Clinical recommendations for chronic musculoskeletal pain in South African primary health care.

BACKGROUND: Chronic musculoskeletal pain (CMSP) is prevalent globally and places a significant burden on individuals, healthcare systems and economies. Contextually appropriate clinical practice guidelines (CPGs) on CMSP are advocated to translate evidence into practice. AIM: This study aimed to investigate the applicability and feasibility of evidence-based CPG recommendations for adults with CMSP in the primary health care (PHC) sector of South Africa (SA). SETTING: The PHC sector in South Africa (SA). METHODS: Consensus methodology was used, comprising two online Delphi rounds and a consensus meeting. A multidisciplinary panel of local healthcare professionals involved in CMSP management was purposefully sampled and invited to participate. The first Delphi survey considered 43 recommendations. In the consensus meeting, the results of the first Delphi round were discussed. The second Delphi round reconsidered the recommendations with no consensus. RESULTS: Seventeen experts participated in the first Delphi round, 13 in the consensus meeting and 14 in the second Delphi round. In Delphi round two, 40 recommendations were endorsed, three were not endorsed and an additional recommendation was added. CONCLUSION: A multidisciplinary panel endorsed 41 multimodal clinical recommendations as applicable and feasible for the PHC of adults with CMSP, in SA. Although certain recommendations were endorsed, they may not be readily implementable in SA because of context factors.Contribution: The study forms the basis of a model of care for contextually relevant PHC of CMSP. Future research should explore factors that could influence the uptake of the recommendations into practice to optimise chronic pain care in SA.

Synthesis of clinical practice guideline recommendations for the primary health care of chronic musculoskeletal pain.

RATIONALE AND AIMS: The prevalence of chronic musculoskeletal pain (CMSP) is high and rising. The multidimensional impact of CMSP on individuals necessitates multidisciplinary evidence-based strategies to prevent and manage chronic pain. Primary health care (PHC) is the first point of care in many healthcare systems and evidence implementation at this point is important. We aim to describe the process of development of a comprehensive list of evidence-based recommendations derived from different high-quality clinical practice guidelines (CPGs) to inform the PHC healthcare of adults with CMSP. METHOD: A systematic review was conducted of CPGs that focussed on PHC management of CMSP in adults. CPGs were identified by searching 13 guideline clearinghouses and five online databases. Eligible CPGs were critically appraised using Appraisal of Guidelines Research and Evaluation, Version II (AGREE II). A stepwise systematic process was followed to identify a core set of recommendations. This process comprised the following: extract recommendations; analyze recommendations; synthesize recommendations by assimilating similar recommendations; determine the strength of the body of evidence underpinning the recommendations and produce a list of synthesized recommendations. RESULTS: Six high-quality CPGs were identified, providing 156 recommendations. These were condensed to 42 statements covering topics about the approach to care, assessment, advice and education, referral, pharmacological management, physical therapy, electrotherapy, psychological therapy, complementary therapy and self-management. The set of recommendations encompasses a person-centered approach, collaborative decision making, a biopsychosocial approach, patient education and empowerment towards self-management. CONCLUSION: The process of developing composite recommendations from multiple CPGs enables end-users to access comprehensive information on managing CMSP in PHC settings that is not available from one singular CPG. The content and evidence base for recommendations varied between CPGs. A similar stepwise process may be used to develop a core set of recommendations for other health conditions, where multiple, diverse CPGs exist.

Clinical practice guidelines for the management of chronic musculoskeletal pain in primary healthcare: a systematic review.

BACKGROUND: Up-to-date, high quality, evidence-based clinical practice guidelines (CPGs) that are applicable for primary healthcare are vital to optimize services for the population with chronic musculoskeletal pain (CMSP). The study aimed to systematically identify and appraise the available evidence-based CPGs for the management of CMSP in adults presenting in primary healthcare settings. METHODS: A systematic review was conducted. Twelve guideline clearinghouses and six electronic databases were searched for eligible CPGs published between the years 2000 and May 2015. CPGs meeting the inclusion criteria were appraised by three reviewers using the Appraisal of Guidelines Research and Evaluation (AGREE) II. RESULTS: Of the 1082 records identified, 34 were eligible, and 12 CPGs were included based on the inclusion and exclusion criteria. The methodological rigor of CPG development was highly variable, and the median domain score was 66%. The median score for stakeholder involvement was 64%. The lowest median score was obtained for the domain applicability (48%). There was inconsistent use of frameworks to aggregate the level of evidence and the strength of the recommendation in the included CPGs. The scope and content of the included CPGs focussed on opioid prescription. CONCLUSION: Numerous CPGs that are applicable for the primary healthcare of CMSP exists, varying in their scope and methodological quality. This study highlights specific elements to enhance the development and reporting of CPGs, which may play a role in the uptake of guidelines into clinical practice. These elements include enhanced reporting of methodological aspects, the use of frameworks to enhance decision making processes, the inclusion of patient preferences and values, and the consideration of factors influencing applicability of recommendations. TRIAL REGISTRATION: PROSPERO CRD42015022098 .