Thomas Baster: Pain options

MUSCULOSKELETAL conditions — both acute and chronic — have become a significant case load in general practice and are linked to much pain and disability in the community. They are also a significant component of health expenditure.
    
According to the Australian Institute of Health and Welfare musculoskeletal conditions were the fourth leading contributor to direct health expenditure in Australia in 2004–2005, at a cost of $4 billion.

The management of some of these cases can be both frustrating and difficult. Many of these patients have already seen physiotherapists, chiropractors and other allied health professionals without much benefit before they end up back on the GP’s doorstep. What options are then available to the GP?

Pain clinics and pain specialists are one option but are usually difficult to access in a timely manner.

Another option is to refer problem musculoskeletal pain cases to a non-specialist medical colleague with an interest in musculoskeletal problems for assessment and treatment.

A group of such doctors — mostly GPs — with an interest in treating acute and chronic musculoskeletal conditions has been active in Australia for more than 40 years under an incorporated organisation known as the Australian Association of Musculoskeletal Medicine (AAMM).

Prominent members of AAMM have included Australian general practice’s leading light, Professor John Murtagh, and pain specialist and researcher, Professor Nik Bogduk, who have contributed much to the development of treatments and the use of evidence-based medicine in the musculoskeletal field. Many AAMM members have postgraduate qualifications such as a diploma in musculoskeletal medicine available in Australia and New Zealand.

Ongoing education is an important part of the association, including an annual scientific conference, with members encouraged to upgrade skills and knowledge so they can provide superior patient outcomes.

AAMM is also active in research and is partly funding a current musculoskeletal research project through Griffith University in Queensland on the treatment of lateral epicondylosis. As detailed in last week’s MJA and reported in MJA InSight, attracting funding for musculoskeletal research is an ongoing problem.

While the most common conditions seen in musculoskeletal medicine are spinal, the discipline also covers a wide range of other conditions including arthritides, tendinopathies, neuropathic pain and regional pain syndromes. Assessment and treatment are multifaceted with consideration of both the biomechanical and the psychosocial factors. They are also carried out with an awareness of the strengths and limitations of clinical assessment and investigations.

Treatments can include evidence-based patient education, manual therapies, specific exercises and a range of injection therapies including trigger point injections, joint and bursa injections of local anaesthetic and steroids (if appropriate), and prolotherapy injections of ligaments and entheses. Dry needling and acupuncture may also be used.

AAMM members also have expertise in the appropriate use of opiates, as a significant number of chronic musculoskeletal pain patients often require such medications. Judicious use of imaging is also emphasised to reduce patient exposure to radiation and cost to Medicare.

Many members have a close working relationship with interventional radiologists, pain specialists, rheumatologists and neurosurgeons/orthopaedic specialists for particularly difficult musculoskeletal cases.

With the prevalence of musculoskeletal conditions in the general population and the burden on the health care system, access to a colleague who has a special interest and skill in this area of medicine to assist with diagnosis, pain and other management is a cost effective and useful option for GPs to consider.

Dr Thomas Baster is the president of the Australian Association of Musculoskeletal Medicine and a GP practising in Brisbane.