11 Best Recommendations for your Musculoskeletal Pain and Low Back Pain

It has been all too busy but I thought I will drop by real quick and do a short post on the paper What does best practice care for musculoskeletal pain look like? Eleven consistent recommendations from high-quality CLINICAL PRACTICE GUIDELINES. There are quite a bit of good stuff in there but we will briefly mention on their general recommendations + low back pain recommendation today.  This paper was just published earlier this month and here are the eleven recommendations:

1. Care should be patient centred. This includes care that responds to the individual context of the patient, employs effective communication and uses shared decision-making processes.

2. Screen patients to identify those with a higher likelihood of serious pathology/red flag conditions.

3. Assess psychosocial factors.

4. Radiological imaging is discouraged unless: i. Serious pathology is suspected. ii. There has been an unsatisfactory response to conservative care or unexplained progression of signs and symptoms. iii. It is likely to change management.

5. Undertake a physical examination, which could include neurological screening tests, assessment of mobility and/or muscle strength.

6. Patient progress should be evaluated including the use of outcome measures.

7. Provide patients with education/information about their condition and management options.

8. Provide management addressing physical activity and/or exercise.

9. Apply manual therapy only as an adjunct to other evidence-based treatments.

10. Unless specifically indicated (e.g. red flag condition), offer evidence-informed non-surgical care prior to surgery.

11. Facilitate continuation or resumption of work.

I think #9 is interesting. To offer manual therapy as an adjunct as opposed to not offering it at all.

(I mean, adjunct means it’s supplementary/non-essential right? So, why bother?)

Surprisingly, their low back pain-specific recommendation did not cover the use of manual therapy and largely focused on medical interventions. I would imagine there would be some mention of spinal manipulation, seeing a chiropractor, or even exercise as a viable option for long-term management of low back pain. Either way, their recommendations are:

► Do not offer paracetamol as a single medication.

► Do not offer opioids for chronic LBP.

► Do not offer selective serotonin reuptake inhibitors, serotonin–norepinephrine reuptake inhibitors, tricyclic antidepressants or anticonvulsants for LBP.

► Do not offer rocker shoes or foot orthotics.

► Do not offer disc replacement.

► Only offer spinal fusion if part of a randomised controlled trial.

► Spinal injections (eg, facet joint injections, medical branch blocks, intradiscal injections, prolotherapy and trigger point injections) should not be used for LBP.

I guess that’s something for all of us to think about. We’ll come back again to talk about other recommendations in this paper in more details next week. Are you currently suffering from low back pain? Let us know how these recommendations affect your decision-making process!

p.s. It’s all been really busy for us at Square One. We do have a few more papers that we just got our hands on and we can’t wait to share them with you. Unfortunately, they will have to wait. Current clients: don’t worry, we have already read them and started implementing them in your care 🙂


Frustrated by the lack of results-driven and ethical chiropractic clinics in Singapore, Chiropractor Jesse Cai found Square One Active Recovery to deliver meaningful and sustainable pain solutions.

Our goal? To make our own services redundant to you.

*We do not offer temporary pain relief such as chiropractic adjustments, dry needling, or any form of soft tissue therapy.

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