Musculoskeletal disorders account for more people with disabilities than any other single organ system, probably excepting psychological illness. Competence in musculoskeletal (MSK) rehabilitation is essential because many patients seen in all other condition-specific domains will also have joint problems. Two features stand out as crucial. Pain is a central feature of most musculoskeletal conditions. The rehabilitation expert must feel confident analysing pain and understanding its multifactorial nature. This competency is closely linked to being competent in managing patients with chronic pain (competency E-22). Second, the expert must feel confident identifying, analysing, and managing psychological factors contributing to a person’s problems. This is essential because many patients seen will have conditions where psychological factors are the main component, conditions such as fibromyalgia, hypermobility syndrome, and chronic pain. This competency will also link closely with trauma rehabilitation because it will take on the post-acute management of people with significant fractures.
F-31 Musculoskeletal rehabilitation
Table of Contents
Musculoskeletal rehabilitation competency
The rehabilitation expert is “Able to assess rehabilitation needs of, give rehabilitation advice about, and take rehabilitation responsibility for any patient presenting with any acute or longer-term musculoskeletal condition.” This includes responsibility for people with congenital and generically determined conditions or chronic musculoskeletal or spinal pain. A document listing the expected knowledge, skills, behavioural indicators, and some relevant references can be downloaded.
Introduction
The musculoskeletal system is the basis for all behaviours and activities. The nervous system may generate and coordinate actions, but muscles, usually acting on bony structures, execute all plans, including speaking. Most behaviours also involve joints, where two bones meet. Therefore, the musculoskeletal system is always active and often generates and experiences significant forces. Disorders are common and will usually impact behaviours and activities.
In some countries, musculoskeletal rehabilitation is the predominant rehabilitation activity and area of interest. This extends to undertaking neurophysiological nerve conduction studies and electromyography, ultrasound examinations, joint injections, and, in some countries, massage. Other countries, such as the UK, consider it more appropriate for different specialists, such as clinical neurophysiologists or radiologists, or other professionals, such as physiotherapists, to undertake this work.
The competency given here excludes these areas and focuses on the rehabilitation aspects. Anyone interested in the details required in other countries should look at the curriculum in the United States.
Musculoskeletal rehabilitation; a challenge.
Jeremy Lewis and Peter O'Sullivan asked, is it time to reframe how we care for people with non-traumatic musculoskeletal pain? They start by saying, “The majority of persistent non-traumatic musculoskeletal pain disorders do not have a pathoanatomical diagnosis that adequately explains the individual’s pain experience and disability.”
Their first crucial observation is that many symptoms are attributed to minor changes or features, scarcely worthy of the descriptor abnormalities, that are common in the healthy population without good evidence to justify the attribution. This leads to surgical and other treatments that are rarely successful. For example, evidence does not support radiofrequency denervation or spinal cord stimulation, and any benefit from surgery is usually short-lived. A recent review reports that 20% to 40% of patients develop a ‘failed back surgery syndrome’ after back surgery, with pain that is intractable and often severe, with ongoing pain.
The second equally essential observation is that many musculoskeletal diagnostic labels, such as trigger points and treatments, such as correction of trunk posture, are invalid; treatments have been invented for conditions without evidence to support them.
These observations do not imply that the authors or anyone else disbelieve the patient’s report of their experience. The authors specifically refer to the disabilities these patients have.
They make some points that are based on rehabilitation thinking.
First, the person’s complaints and experiences are always multifactorial, influenced by the whole biopsychosocial model of illness. There is never a single cause, and rarely will one factor be pre-eminent.
Next, clinicians must abandon the medical model’s approach of attempting a cure; once the clinical team accepts that no single cure exists, they can educate the patient and their family.
This leads to an educational and self-management approach, usually centred on adapting the person’s lifestyle and beliefs.
They speculate that, “Reframed in this manner, patients would no longer be led to expect a ‘magic’ manipulation or other passive approach to ‘cure’ their condition, and this in turn may reduce stress and burnout experienced by many clinicians who are unable to deliver on such unsubstantiated promises.”
Thus, musculoskeletal rehabilitation’s challenge is abandoning the medical model and its associated approach of biomedical interventions and adopting a complete rehabilitation approach. This still allows biomedical interventions provided:
- They are supported by significant evidence of long-term effectiveness
- The clinician is explicit that it is not a cure, and it must be seen as a small part of the overall approach
- The patients accepts this fully, undertaking the many other actions recommended.
Disease management.
Many rheumatological conditions have been transformed over the last 30 years with very effective treatments. Nonetheless, musculoskeletal rehabilitation services will still see patients with these conditions as some people will still develop some disabilities.
Patients attending for advice and therapy may be on potent drugs and may develop side effects or have questions about the disease and its treatment. Any rehabilitation expert working in a musculoskeletal service should acquire a good understanding of the drugs, their characteristics, benefits, and risks so that they can support their patients.
Surgery benefits many more significant musculoskeletal conditions; replacing major joints is an outstanding healthcare intervention. Rehabilitation services will almost always see such patients before surgery and will do so after surgery.
The rehabilitation expert must understand what surgery offers when to suggest it, and the risks. This ensures that all appropriate patients are referred at the proper time. Furthermore, the patient must be given realistic expectations, including awareness of post-surgical self-management.
As in all other organ-specific rehabilitation specialities, there will be many patients with rare conditions, either a rare disease or a rare manifestation of a common disease. It is best to acquire knowledge about these when encountering the condition, using the first competency, research and learning (A-1).
Sports and Exercise Medicine
Sports and Exercise Medicine was separated from Rehabilitation Medicine in the UK for political reasons associated with the Olympic games. Both specialities are very small, which has consequences. However, the Faculty of Sports and Exercise Medicine probably has many more members than the British Society for Physical and Rehabilitation Medicine.
Sports and Exercise Medicine expressly undertakes musculoskeletal rehabilitation in the UK. Their curriculum's second capability in practice is the “Ability to develop, lead and deliver a comprehensive musculoskeletal service that spans community and hospital settings for adults.” However, they cover areas rehabilitation services do not cover, such as involvement in public health and providing safe and practical advice and support to professional athletes.
In the United States, Sports Medicine is also separate. A suggested curriculum for people training in Physical Medicine and Rehabilitation interested in Sports Medicine has been published. Its content illustrates again the vast difference between the American and British approaches to training curriculums.
Rehabilitation experts can learn much about musculoskeletal competency from Sports and Exercise Medicine. One critical area is exercise, its physiology and how to optimise exercise for the person and their condition. Only a few rehabilitation clinicians know much about exercise. Therefore, anyone training should seek experience with a Sports and Exercise service, if available, to “ deliver exercise medicine services for adults, encompassing both prevention and management of chronic disease.” This is the fourth capability in the Sports and Exercise Medicine curriculum.
Exercise is a vital part of all rehabilitation. Cardiovascular exercise is one of the most important and effective interventions in almost all rehabilitation. Exercise is precisely part of most cardiac and pulmonary rehabilitation, and a review of the role of resistance training in musculoskeletal rehabilitation found it is effective in several musculoskeletal conditions.
In summary, gaining experience in a sports and exercise service will give you a different perspective on musculoskeletal rehabilitation and increase your ability to recommend exercise as a rehabilitation intervention.
Conclusion
Musculoskeletal conditions may significantly impact disabilities arising from other conditions. They are also common so that they will be present in many people in all specialist rehabilitation services. Therefore, whatever your interests, achieving competency in musculoskeletal rehabilitation will enable you to manage patients more effectively. Three specialities link closely with musculoskeletal rehabilitation: rheumatology, orthopaedic surgery, and Sports and Exercise Medicine. Gaining experience in the latter will teach a different approach, emphasising exercise. More importantly, it will enable you to learn more about the safe and effective use of exercise in many other rehabilitation areas.
