Best Practice & Research Clinical RheumatologyVol. 22, No. 3, pp. 385–386, 2008

doi:10.1016/j.berh.2008.03.001

available online at http://www.sciencedirect.com

Preface

Principles of managing musculoskeletal

conditions

The management of musculoskeletal diseases remains one of the great challenges forthe health professions. The diseases themselves are very varied in their presentationand pathology, but we have deliberately focussed on arthritis and its consequences.Therapeutic approaches also cover a vast spectrum of opportunities. We have notbeen able to cover all aspects of management but hope that this volume will providea reasonable overview of the major principles of most of the different modalities oftreatment available to practitioners in the ‘art’ of managing musculoskeletal disease.We have drawn our authorship from those who we believed could present an evi-dence-based approach and feel that they have succeeded admirably. We have includeda wide range of clinicians to emphasise the multidisciplinary effort required for optimalmanagement of these conditions. The primary care perspective (Chapter 12) is partic-ularly important as this is where the majority of people with musculoskeletal problemswill have first contact and undergo treatment. Readers will also note that we havepredominantly focussed this text on non-pharmacological management strategies.

Basic principles of clinical medicine are emphasised. We have stressed the impor-tance of taking an extensive history and carrying out a careful examination as the cor-nerstone of management. Many musculoskeletal conditions are self limiting and do notrequire exhaustive and often expensive investigations at the outset; this is highlightedin Chapter 7 with respect to the common problems of neck and lower back pain.However patients have to be reassured that something is being provided for themin terms of education and a management plan, and if the symptoms do not settlequickly then further investigation and review will be undertaken. The patient educationchapter (Chapter 2) stresses the importance of self efficacy and chronic disease selfmanagement and raises some interesting questions about the decreasing number ofpatients accessing arthritis self management programs exploring why this might be so.

A number of authors in this volume have stressed the importance of communica-tion between the patient and the health professional, and also the importance ofimpressing on that patient the ‘‘uncertainty’’ of health science – that in many situationswe cannot make a firm diagnosis at initial presentation. We also stress however theimportance of making that diagnosis as quickly as possible and starting treatmentthat will make a difference in terms of the long term outcomes, either curing thecondition or at least significantly reducing long term disability.

Chapters 3 and 4 cover the highly important areas of exercise and physical thera-pies, with practical tips on how to maintain compliance. Rehabilitation in its broadestcontext as it relates to people with musculoskeletal disease is reviewed in detail inChapter 5 and we have included a comprehensive review of surgical management of

1521-6942/$ - see front matter ª 2008 Elsevier Ltd. All rights reserved.

386 Preface

important musculoskeletal conditions in Chapter 8. We must remember that arthro-plasty remains one of the most cost effective treatments available and has revolution-ised the lives of many patients with painful joints. On the other hand it is important tolook at surgery from an evidence based context because there are many conditionssuch as back pain where it is largely inappropriate except for very specific conditions.

People with musculoskeletal disease are great users of complimentary therapies,and Chapter 9 provides an overview of the evidence base that has been somewhatlacking until recently in this area of musculoskeletal medicine (and one that certainlyneeds expanding in the future). Dietary issues (Chapter 11) are also assuming greaterimportance with increasingly overweight Western populations who are at increasedrisk for osteoarthritis, especially if successful weight reduction strategies are not im-plemented in this population.

Pain remains the most important symptom of these conditions and management ofthat pain requires a multidisciplinary approach. This requires taking a biopsychosocialapproach as highlighted in Chapter 6, looking at all the factors in the patients’ life thatmight impact on their perception of pain, and the way they handle it. Again this high-lights the importance of communication with the patient and the issue of goal settingand continuing review of the patient.

Given the ageing health workforce and the global shortage of health professionals(the most recent WHO health workforce report predicts a shortage of 4.3 millionover the next decade) we have also included a discussion in Chapter 10 of differentways of delivering musculoskeletal health services using physician assistants (a dele-gated model) or nurse practitioners. These models may well provide opportunitiesto reach wider populations and allow rheumatologists and orthopaedic surgeons toconcentrate on ‘‘high end’’ diagnosis and management planning.

What we have tried to do in the volume is stimulate some broader thinking abouthow we can best provide care to as many people with musculoskeletal disease as pos-sible without compromising the quality of that care and at the same time encourage anexpansion of the evidence base for the management of these conditions. The Bone andJoint Decade has been a significant influence in focussing our attention on these impor-tant and common conditions and we hope this volume will be a useful aid tomanagement.

Peter Brooks

Philip G. Conaghan