










































MANUSCRIPT TYPE


EVIDENCE-TO-PRACTICE REVIEW  

 

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All rights reserved. ISSN Online 2577-8188                                                                              Volume 5 – Issue 1 – April 2022 

 
 

Recommendation for Best Practices in the Management of 
Musculoskeletal Pain: An Evidence-To-Practice Review  
Laura M. Kehr, MS, ATC*; Dylan C. Rowe, MS, ATC*; Rylee M. Learn, MS, ATC*; Allison B. Smith, PhD, SCAT, ATC†; Zachary K. 
Winkelmann, PhD, SCAT, ATC* 
*University of South Carolina, Columbia, SC; †University of Louisiana at Lafayette, Lafayette, LA 
  

 
ABSTRACT 
While musculoskeletal (MSK) pain conditions are some of the most common health issues faced internationally, the quality of patient 
care with MSK pain is lacking. Problems with MSK care include the overuse of imaging, surgery, opioids, and failure to educate 
patients. Improving the quality of care for MSK conditions is considered a priority for all involved healthcare clinicians. The 2019 
guiding systematic review addressed the concerns of MSK management by identifying common recommendations for high-quality 
care through appraisals of clinical practice guidelines (CPGs). Data was extracted from four databases and included articles 
examining the most common sites of MSK pain in adults. Selected articles were appraised using the AGREE II instrument that provided 
scores to indicate the level of quality. Researchers in the guiding systematic review then classified the CPGs to determine consistent 
recommendations. The results from the guiding manuscript identified eleven common and consistent recommendations for MSK pain 
management that focused on a comprehensive approach to address the overall well-being of the individual to ensure patient-
centered care. The recommendations should be incorporated into healthcare and clinical practices to give healthcare professionals 
patient-centered outcomes for MSK pain management and improve the quality of care. 
 
 
Correspondence 
Dr. Zachary Winkelmann, 1300 Wheat Street, Columbia, SC 29208. 
E-mail: winkelz@mailbox.sc.edu   
Twitter: @zachwinkelmann 
  
Full Citation 
Kehr LM, Rowe DC, Learn RM, Smith AB, Winkelmann ZK. Recommendation for best practices in the management of musculoskeletal 
pain: An evidence-to-practice review. Clin Pract Athl Train;5(2): 24-31. https://doi.org/10.31622/2022/0005.02.5.  
 
Submitted: December 2, 2020 Accepted: August 24, 2021. 

 
ORIGINAL REFERENCE 
Lin I, Wiles L, Waller R, et al. What does best practice care for musculoskeletal pain look like? 
Eleven consistent recommendations from high-quality clinical practice guidelines: systematic review. Br 
J Sports Med. 2020;54(2):79-86. doi:10.1136/bjsports-2018-099878. 

SUMMARY 
 
CLINICAL PROBLEM AND QUESTION 
 
Some of the leading causes of disability worldwide are musculoskeletal pain (MSK) conditions.1 A lack of 
quality healthcare and a lack of universally agreed-upon treatment plans for these MSK conditions, are two 
primary reasons for the MSK related disability. A lack of quality healthcare results in the overuse of 
imaging,2,3 unnecessary surgeries,4,5 use of opioids.6,7 and a failure to properly educate and advise patients 
about their conditions.8 In order to combat quality of care issues and improve healthcare, clinicians can utilize 
clinical practice guidelines (CPGs), which are ‘statements that include recommendations intended to optimize 
patient care that are informed by a systematic review of evidence and an assessment of the benefits and 
harms of alternative care options’.9 Patient care that follows CPG recommendations typically results in 
improved patient outcomes and lower costs to the consumer, especially with the management of low back 
pain (LBP).10,11  These CPGs can also help ease transitions between different healthcare in terms of treatment 
options and care plans.  Unfortunately, there are also many shortcomings with CPGs, creating discourse and 
criticism in the literature. Criticisms include the use of various guidelines for the same conditions having 

mailto:winkelz@mailbox.sc.edu
https://doi.org/10.31622/2022/0005.02.5


Recommendation for Best Practices in The Management of Musculoskeletal Pain: An Evidence-To-Practice Review 
 

 

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inconsistent terminology, having too much or too little representation of certain conditions, and a lack of 
instruction for implementation into practice.12 Despite criticisms, high quality CPGs may be effective methods 
for shaping how MSK conditions are treated in the healthcare system. MSK pain conditions in different body 
areas may share similarities in regard to mechanisms and clinical courses.13,14 However, there is inconsistent 
evidence that CPGs share similarities for how best to treat MSK pain or that the recommendations can be 
applied across levels of healthcare. Therefore, the purpose of the reviewed study was to establish 
recommendations to better assess and manage MSK pain conditions based on available CPGs.  

SUMMARY OF LITERATURE 

The authors of the guiding systematic review conducted a literature search of four databases that included 
MEDLINE, CINAHL, Embase, Physiotherapy Evidence Database, and four unnamed guideline repositories to 
evaluate MSK pain CPGs. The search terms and methods used in this study are the same as a previously 
published study.12 For a CPG to be included in the systematic review, it had to meet certain criteria including: 
1) published no earlier than 2011, 2) focused on adults, 3) described pain development processes, and 4) 
had to be written in English. The guidelines that only focused on traumatic MSK pain, single modalities, 
specific disease processes, and those that required payment were excluded from the systematic review.  

The authors’ initial search resulted in 6,232 CPGs, and after screening those results using their inclusion 
criteria, 44 guidelines were remaining for further appraisal. Appraisal was completed by three independent 
investigators using the Appraisal of Guidelines for Research and Evaluation II (AGREE-II) instrument, which 
resulted in eleven CPGs that were considered high quality. The AGREE-II instrument was utilized as it is the 
most widely used tool to obtain overall rating scores and identify high-quality CPGs.15,16 Of the eleven CPGs 
that were high-quality and used in the systematic review, four of them evaluated low back pain, four 
investigated osteoarthritis pain, two evaluated neck pain, and one evaluated shoulder pain. After the 
appraisal, the CPGs were synthesized in four steps: extracting the CPG recommendations, classifying these 
recommendations, creating a narrative summary, and identifying common recommendations among MSK 
conditions when possible. The authors were able to use the information from their extensive search and 
evaluation to produce the following outcomes and results. 

SUMMARY OF OUTCOMES 

The CPGs were classified according to “should do,” “could do,” “do not do,” and “uncertain” guidelines to 
help identify consistent recommendations which are defined in Table 1. The guidelines that were assigned 
either “should do'' or “do not do” classifications and did not have conflicting evidence were considered 
consistent recommendations. Following the appraisal and classification process, only 44 CPGs of the 6232 
identified records met the inclusion criteria. The 44 included CPGs applied to various MSK conditions which 
are specified in Figure 1. From the 44 CPGs, 11 common and consistent recommendations were chosen to 
be applied across MSK pain conditions. The guiding systematic review suggested that these recommendations 
could guide healthcare providers with a clear and simple consensus of current MSK pain priorities and, as a 
result, may help address the variations in the quality-of-care patients receive.2,17,8 One intervention not listed 
in the systematic review was a consensus for CPGs related to opioid prescription. This is due to conflicting 
recommendations and the potential for harm; however, the only consistent view was to urge caution and 
discouraged the use of opioids.  

Figure 1. Number of appraised CPGs and their specific musculoskeletal conditions. 



Recommendation for Best Practices in The Management of Musculoskeletal Pain: An Evidence-To-Practice Review 
 

 

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All rights reserved. ISSN Online 2577-8188                                                                     Volume 5 – Issue 2 – September 2022 
  

 
 
Table 1. Classification system the guiding systematic review used to determine consistent 
recommendations from relevant CPGs. 

Classification Definition 

Should Do 

Recommendations that could be applied in all circumstances of 
musculoskeletal pain unless contraindications are present. These ‘should do’ 
recommendations are based on strong evidence such as having high-quality 
evidence of positive clinical effects or that the benefits of following the 
recommendations outweigh the risks. 

Could Do 

Recommendations that could be applied in individual circumstances 
depending on the patient. These ‘could do’ recommendations are based on 
lesser quality studies with consistent evidence and where the benefits 
outweigh the harms. 

Do Not Do Recommendations with strong evidence of no benefits and/or the harms 
outweigh the benefits. 

Uncertain 
‘Uncertain’ classification was applied because of incomplete or inconsistent 
findings and could not give a recommendation for or against a clinical 
practice. 

 

 

 

0 2 4 6 8 10 12 14 16

Other

Neck Conditions

Shoulder Conditions

Osteoarthritis

Low Back Pain

Number of Identified CPGs



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FINDINGS AND CLINICAL IMPLICATIONS 

The appraisal and classification process in the guiding systematic review revealed 11 consistent 
recommendations for health care providers to incorporate into their practice. Recommendations are 
summarized in Table 2. The 11 recommendations may be used in a variety of ways to improve patient care. 
The reviewed article provided three examples of improvement. First, the recommendations may assist 
patients in making more informed decisions about their healthcare and help them recognize that some care 
they are receiving may be suboptimal. Second, the recommendations can guide clinicians in their decision 
making for the best course of action for their patients. Clinicians may also use them to identify areas where 
continued professional development is needed to improve their patient care. Third, with continued 
development of the recommendations, a set of indicators could be used as a benchmark of quality care or 
as minimum standards.  

Limitations of the article were also addressed. The AGREE II instrument that scored the CPGs reflects 
processes and reporting of guidelines, not necessarily the quality of that content; therefore, high quality 
trials could have been excluded. Also, the investigators created their own criteria for appraising CPGs based 
on the AGREE II instrument which has the potential for bias. The study only reviewed CPGs in English, leaving 
out other relevant guidelines; however, the article is confident that, through their appraisal process, all 
relevant CPGs were included.  

CLINICAL BOTTOM LINE 

MSK pain can greatly impact the quality of life for affected individuals. Furthermore, variation in healthcare 
makes receiving care difficult for patients, as there are no common recommendations for the treatment of 
MSK conditions. The assessment and management of MSK conditions is the most effective way to improve the 
overall well-being of patients, and the lack in quality of care from the healthcare system is the largest 
problem faced by patients. The CPG recommendations were developed to address the shortcomings of the 
assessment and management of MSK pain conditions, and implementation of the recommendations may 
begin to fix this problem. After reviewing this article, all members of the healthcare team should utilize the 
recommendations put forth by the guiding systematic review to provide measurable, impactful care.  

Athletic trainers are included in the healthcare team and are no exception when it comes to following the 
guidelines presented by the reviewed article. Athletic trainers have primary roles involving prevention, 
emergency care, assessment, and therapeutic interventions for illnesses and injuries, specifically with 
orthopedic and musculoskeletal care.18 Athletic trainers also work with a variety of patients in various settings 
that can affect MSK health. One of the eleven recommendations suggests completing an inclusive exam which 
may include neurological screenings and mobility and strength testing, which all athletic trainers are already 
trained to do during patient evaluations. Athletic trainers already incorporate some of the CPG 
recommendations into practice by providing mobility, strength, and flexibility exercises and conservative 
management into rehabilitation therapy for their patients. However, even though this approach is already 
practiced, athletic trainers are still not perfect in their care. A study from 2016 indicated athletic trainers 
have knowledge about using evidence-based care, such as the CPG recommendations, in clinical settings, 
but less than 30% actually implemented evidence-based healthcare into practice.19 Constant awareness, 
intentional implementation, and daily practice of the 11 recommendations is necessary to improve patient 
care in patients with MSK pain conditions. 



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Table 2. Recommendations and examples to improve patient care 
Recommendation Examples Classification of 

Recommendations 
Care should be patient 
centered 

• Viewing the patient holistically 
• Viewing each patient as an individual 
• Allowing the patient to be involved 

with the decision-making process 
• Using effective communication 
• Base context on patient’s preferences 

Categorized as “should do” 
for osteoarthritis (4/4), low 
back pain (4/4), neck pain 
(2/2), and shoulder pain 
(1/1) 

Practitioners should 
screen patients for 
serious pathological 
conditions 

• Suspected infections, malignancy, 
fracture, inflammatory causes of pain, 
or neurological deficits 

• Serious conditions that present as MSK 
pain but are not (aortic aneurysm) 

• Gout  
• Other arthritis or malignancy (bone 

pain) 

Categorized as “should do” 
for osteoarthritis (1/1), low 
back pain (3/3), neck pain 
(2/2), and shoulder pain 
(1/1) 

Assess psychosocial 
factors which can be 
affected by their 
injuries/illnesses 

• Emotions/moods such as depression 
and anxiety 

• Fear/kinesiophobia (irrational fear of 
physical movement due to injury or 
reinjury) 

Categorized as “should do” 
for osteoarthritis (2/2), low 
back pain (4/4), neck pain 
(2/2), and shoulder pain 
(1/1) 

Only use radiological 
imaging in specific 
situations  

• Suspecting serious pathology 
• Conservative care is not working 
• Unexplained progression of signs and 

symptoms occurs  
• Imaging is likely to change 

management 

Categorized as “do not do” 
routine use of radiological 
imaging for osteoarthritis 
(1/1), low back pain (4/4), 
and shoulder pain (1/1) 

Assessments should be 
complete and all 
inclusive 

• Physical exams 
• Neurological screening 
• Mobility 
• Muscle strength testing 

Categorized as “should do” 
for osteoarthritis (2/2), low 
back pain (3/3), neck pain 
(1/1), and shoulder pain 
(1/1) 

Use validated patient-
oriented outcome 
measures to evaluate 
patient progress 

• Patient self-rated recovery questions 
• Pain intensity measures 
• Functional capacity or activities of 

daily living  
• Quality of life questionnaires 

Categorized as “should do” 
for osteoarthritis (2/2), low 
back pain (1/1), neck pain 
(1/1), and shoulder pain 
(1/1) 

Educate patients about 
their conditions and the 
management options  

• To encourage self-management of 
their conditions 

• Inform and reassure patients 

Categorized as “should do” 
for osteoarthritis (3/3), low 
back pain (4/4), neck pain 
(2/2), and shoulder pain 
(1/1) 



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Management options 
should address physical 
activity and exercise 

• Strengthening  
• Flexibility 
• Mobility exercises (range of motion 

and stretching)  
• Water-based exercises 
• Neuromuscular education 

Categorized as “should do” 
for osteoarthritis (4/4), low 
back pain (2/4), neck pain 
(2/2), and shoulder pain 
(1/1) 
 
Categorized as “could do” 
for low back pain (2/4) 

Use manual therapy 
only in combination with 
other evidence-based 
treatments 

• Used with other management 
strategies like: 

o Exercise 
o Psychological therapy 
o Information/education 
o Activity advice 

Categorized as “should do” 
with other modalities for 
osteoarthritis (1/1), low back 
pain (4/4), and shoulder 
pain (1/1) 

Offer non-surgical 
treatments before 
considering surgery 
unless “red flag” 
conditions are present  

• Conservative treatment yields no 
progress or makes the conditions 
worse 

Categorized as “should do” 
for osteoarthritis (1/1), low 
back pain (2/2), and 
shoulder pain (1/1) 

Facilitate continuation 
or resumption of work 
after MSK injury 

• Avoid inactivity  
• Gradually increase normal daily 

activity levels 
• Return to work and while continuing 

rehabilitation services 
• Communication between workers, 

employers, and health providers 

Categorized as “should do” 
for osteoarthritis (1/1), low 
back pain (2/3), neck pain 
(1/1), and shoulder pain 
(1/1) 
 
Categorized as “could do” 
for low back pain (1/3) 

Numbers provided in the classification of recommendation column refer back to the 11 CPGs 
(osteoarthritis=4, low back pain=4, neck pain=2, shoulder pain=1) 

  

Athletic trainers also have a unique role in the healthcare team, as they practice in collaboration with other 
healthcare professionals, such as physicians, physical therapists, nurses, dietitians and pharmacists.18 If all of 
the healthcare professionals follow the recommendations of the guiding systematic review, the transfer of 
patient care will be seamless, the overall quality of care will increase, and better outcomes can occur for the 
patient in the event of a patient transfer between collaborating healthcare professionals. This holds true for 
athletic trainers when they perform an initial evaluation but must refer the patient to a physician for further 
testing or a physical therapist for a more focused rehabilitation plan. Following the guidelines will allow for 
referrals to be smooth and will benefit the patient in the end. Healthcare services can also use the CPG 
recommendations as benchmarks or minimum standards for documentation, reporting, or clinical audit 
purposes. For example, athletic trainers may base performance evaluation criteria on the CPG 
recommendations to evaluate the staff’s clinical performances and ensure patient-centered care is being 
practiced.  

In conclusion, MSK pain conditions are common issues in various populations. Unfortunately, the treatment and 
management of MSK conditions can be inconsistent and suboptimal. Treatment options and plan of care for 
patients can be lost during the transition between different healthcare providers and professions. Improving 



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patient-oriented quality of care for MSK conditions also poses a challenge in healthcare; fortunately, the 
CPG recommendations provide simple and direct guidelines to implement into practice. The eleven 
recommendations can serve as an educational tool and reference for all healthcare professionals who 
provide care for MSK pain conditions, as well as a benchmark for comparing the quality of care between 
health services and minimum standards during reporting or clinical audits. The healthcare team, including 
athletic trainers, should be able to implement the eleven recommendations with ease which would in turn 
improve care for MSK patients. The recommendations can be applied with minimal or no resources as several 
of the recommendations require the clinician to be patient-centered in their exam and delivery of 
information. Examples of implementation without resources including assessing psychosocial factors, using 
validated outcome measures, and providing clear patient education. 

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14. Henschke N, Ostelo RW, Terwee CB, Van Der Windt DA. Identifying generic predictors of outcome in 
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https://doi.org/10.4085/1062-6050-51.2.11.  

 

 

https://doi.org/10.1002/acr.21665
https://doi.org/10.1503/cmaj.091716
https://doi.org/10.1503/cmaj.091714
https://doi.org/10.1371/journal.pone.0061243
https://doi.org/10.3109/13561820.2014.942778
https://doi.org/10.4085/1062-6050-51.2.11

	ABSTRACT

