Half of patients with musculoskeletal pain not treated

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Rheumawire

Mar 30, 2004

Half of patients with musculoskeletal pain not treated

Cornwall, UK - An extensive European survey, based on telephone

interviews with 6000 people with musculoskeletal pain and almost 1500

primary-care physicians, has found that half of these patients are not

being treated. The findings are reported in the April 2004 issue of the

ls of the Rheumatic Diseases [1].

Between 60% and 75% of patients said they suffered from pain on a

constant or daily basis, to the extent that it limited routine

activities. However, around 1 in 4 did not seek medical help for this

pain. Those who did seek help had often waited for several months or

years before doing so, and around half the patients who consulted a

doctor said they were not currently being treated for their pain.

Yet the doctors felt they were managing the condition well, the survey

found. Doctors said that they offered all patients some form of

treatment, and virtually all of them said they were trying to improve

patients' quality of life.

" There is a discordance between physician and patient perspectives of

care, " conclude the authors, headed by Dr Woolf (Royal Cornwall

Hospitals Trust, Treliske, UK). They suggest that the discrepancy may be

attributable, in part, to the fact that family doctors generally

underestimate the impact or severity of patients' pain and the

consequent disability and psychological distress.

" The gap is of concern, as it means there are a lot of people who are

not getting the best quality of life when they have these

musculoskeletal problems, " Woolf tells rheumawire in an interview. " But

their quality of life could be better if they got better advicefor

example, on exercise and weight loss, reassurance about what they can

and can't do, and what awaits them in the future, as well as a better

understanding of using analgesics to control their pain. "

The survey has highlighted a need for more education and awareness, of

both the general public and family doctors, he says. " A common message

that came through is that musculoskeletal pain is what happens when you

get older and that you just have to live with it, whereas we want to get

across the message that you can live despite it, rather than with it. "

The survey was devised and conducted by the Arthritis Action Group

(AAG), a collaboration set up as part of the Bone and Joint Decade to

advance awareness of rheumatic conditions and choices of management.

Conducted in 8 countries (France, Germany, Ireland, Italy, Spain,

Sweden, Switzerland, and the UK), it involved telephone interviews with

1483 primary-care physicians and 5803 patients and people not seeking

help. Most people with musculoskeletal pain who had seen a physician had

a self-reported diagnosis (given by their physician) of " arthritis " or

" wear and tear. "

The survey found that the impact of musculoskeletal pain and perceptions

of treatment were similar across the 8 countries studied, but the

management of pain differed.

More than half the respondents (57%) said they were in constant pain.

Around 15% to 22% reported daily pain, and a similar proportion said the

pain limited their ability to perform moderate tasks such as vacuuming

or playing golf. Between 27% and 56% rated their health as poor or fair.

In all of the countries, most of these people (73%-88%) had sought

medical help and been given a diagnosis (45%-75%). However, up to a

quarter (12%-27%) had never sought medical help, despite the fact that

38% to 57% of these individuals were in constant or daily pain.

Why these people in pain are not seeking medical help is unclear, the

authors comment, but perhaps thinking that these symptoms are normal

with aging is one explanation. Woolf comments further that some patients

see pain as a natural warning sign that shouldn't be suppressed, while

others feel they should be able to manage the pain without becoming

reliant on medications.

Nearly all of the physicians (90%) reported a real interest in trying to

improve patients' quality of life and offered patients some form of

treatment. However, few routinely provided written information about the

condition or about the treatment options (16%-17% of physicians in all

the countries except for Germany and Spain, in which these percentages

were much higher [25%-34%]).

" Generally, the management that the doctors said they were giving was

good, " Woolf comments. Although there are no guidelines for management

of musculoskeletal pain, they do exist for osteoarthritis, and overall

they are being followed, he says.

The most frequently used nonphamacological approaches were advice on

exercise and referrals to physiotherapy, and in some countries

physicians also recommended herbal products (Germany, France, Spain, and

Switzerland) and acupuncture (Germany, Spain, Italy, and Switzerland).

However, pharmacological management differed between the countries, the

authors note. The highest use of drugs was in the UK (64% of

respondents) and the lowest in Italy (34%), with the majority of these

(>61%) taking a prescription drug, most often a nonsteroidal

anti-inflammatory drug (NSAID). In every country, most of these patients

(43%-65%) had a self-reported diagnosis of osteoarthritis, " arthritis, "

or " wear and tear, " while a further 4% to 24% had a self-reported

diagnosis of rheumatoid arthritis. A small proportion of patients in

each country who were taking a prescription drug (4%-17%) had not seen

their doctor for at least 2 years.

Woolf et al comment that use of prescription drugs was low, ranging from

28% to 54% of patients. They also emphasize that many of the patients

who are not taking drugs are in constant/daily pain (50%-66%).

They suggest that one explanation for this low use of prescription drugs

may be that patients are ill informed about them. The survey showed up

misunderstandings about risks and fears about addiction and tolerance

among both patients and their doctors.

Among the patients who were taking NSAIDs, 23% to 47% thought that the

treatment was very effective in managing their pain, and the physicians'

perceptions of treatment efficacy were similar. However, there was a

marked difference in the perception of risk. Most physicians (67%-94%)

were very or somewhat concerned about the risks associated with NSAID

treatment (except in Italy, where only 28% were worried), while among

the patients the figure was 37% or less.

There was also a lack of knowledge about side effects among the

patientsonly 19% of patients in Spain were aware of any side effects

associated with NSAIDs, although this figure was much higher in other

countries (45%-51% in Sweden, Ireland, Germany, France, and the UK and

up to 69%-75% in Switzerland and Italy).

Many of the physicians felt it best to tell patients only about the most

common side effects (40%-64% in all countries except for Italy, where

the figure was only 26%). Around a quarter of both patients and

physicians believed that warning signs would always precede serious

gastrointestinal events such as ulcers.

In addition to worries about the side effects, most patients reported

fears about addiction and tolerance in relation to NSAIDs, and these

views were shared by some of the physicians.

" There appears to be an imbalance in the perception of risk vs benefit, "

comments Woolf. It appears that patients are underaware of the benefits

of these drugs, while the doctors are overaware of the risks and are

putting across a negative message along the lines of " don't take these

drugs until you really need to. " This can lead to the impression that

the side effects of treatment can be worse than the condition itself, he

commentsand the survey showed this opinion is held by a large proportion

of both patients and doctors (more than 50% and 60%, respectively, in

nearly all of the countries studied).

One message that needs to get across to both patients and their doctors

is that careful use of analgesics to relieve the pain can be beneficial,

Woolf says. For example, a patient who likes walking may stop the

activity because it leads to joint pain, he explains. Reassuring the

patient that this doesn't mean that the joint is being damaged, along

with appropriate analgesia to relieve the pain, can make walking

enjoyable again, with many benefits for overall health and well being

(eg, weight control, cardiovascular health, etc).

The authors conclude that the responses from the general public

collected in this survey do not paint an optimistic picture. Patients

delay seeking medical help for their pain, and many do not take

treatment. They also lack information about their condition and

treatment, and as a result, are unlikely to participate in their care in

an informed way. " These combined factors are likely to adversely affect

their outcome, " they say.

" Although many primary-care physicians are providing good clinical care,

the effectiveness of treatment they offer could be maximized by changes

in the ways in which they communicate information about the condition

and treatment options, improved assessment of patients' risk,

elicitation of patients' perceptions and priorities for treatment, and

more appropriate use of available treatments, " Woolf et al conclude.

In an editorial in the same issue of the journal [2], the current

president of EULAR, Dr ph Smolen (University of Vienna, Austria),

says the findings of the survey are " worrisome. " These observations call

for actions to improve awareness and information among both the

population in general and among physicians, he says. " But they also

confirm our realization that despite major advances in some areas . . .

we need more research and better transposition of research achievements

into practice. "

Zosia Chustecka

Sources

1. Woolf AD, Zeidler H, Haglund U, et al. Musculoskeletal pain in

Europe: its impact and a comparison of population and medical

perceptions of treatment in eight European countries. Ann Rheum Dis 2004

Apr; 63(4):342-347.

2. Smolen JS. Combating the burden of musculoskeletal conditions. Ann

Rheum Dis 2004 Apr; 63(4):329.

I'll tell you where to go!

Mayo Clinic in Rochester

http://www.mayoclinic.org/rochester

s Hopkins Medicine

http://www.hopkinsmedicine.org