Management of chronic musculoskeletal pain in Hong Kong

Chronic musculoskeletal pain is a common and disabling condition, with significant physical, psychological, and social impairments.¹ According to the Census and Statistics Department of the Hong Kong Special Administrative Region, it is estimated that the number of Hong Kong residents aged [greater than or equal to]65 years will increase from 0.9 million in 2011 (13% of the population) to around 2.6 million in 2041 (30% of the projected population).² A local study in 2016 reported the prevalence of chronic pain of 28.7% in the general population; 83.1% reported more than one site of pain, and 5.8% reported eight or more sites of pain around the body.³ The prevalence is higher in the older population, with 70% adults aged [greater than or equal to]60 years reported having chronic pain of moderate intensity; the most common sites were the knee (48.3%), back (34.7%), and shoulder (28.1%).⁴ It is expected that individual and socio-economic burdens of chronic musculoskeletal pain will increase with the ageing population in Hong Kong, requiring a multi-level integrated response.

Management of chronic musculoskeletal pain in Hong Kong

Chronic musculoskeletal pain is commonly encountered in primary care.⁵ The role of primary care physicians is to assess, to diagnose and to manage treatable and modifiable causes. They also act as gatekeepers, identifying suitable candidates for secondary care. More importantly, primary care physicians help individuals with chronic pain to maintain the optimal quality of life.⁶Chronic musculoskeletal pain, whether a result of trauma, infection, tumours, or other orthopaedic conditions with surgical implications, is managed by orthopaedic surgeons. For refractory pain, patients will be referred to pain clinics for more invasive interventions such as nerve blocks or spinal injections.⁷ The majority of residents in Hong Kong have Chinese ethnicity, so traditional Chinese medicine also plays an important role in the care of chronic musculoskeletal pain with treatments such as acupuncture and joint manipulation.⁸ Other allied health professionals, such as physiotherapists, occupational therapists, pain nurses, dietitians, psychologists, pharmacists, prosthetists, and orthotists also contribute substantially to the management and rehabilitation of various chronic musculoskeletal pain conditions. Despite having groups of experts in different fields in Hong Kong, there are major challenges to pain care, including over-reliance on the biomedical view of pain, inadequate emphasis on the biopsychosocial approach, a lack of service models to streamline communication, and a lack of cooperation and collaboration among disciplines.

Multidisciplinary care for chronic musculoskeletal pain

As healthcare systems internationally and in Hong Kong shift from promoting biomedical models of chronic pain to biopsychosocial models, multidisciplinary or interdisciplinary pain management models are encouraged.⁹ The team consists of multiple health providers from different disciplines with sufficient professional breadth that integrates through frequent communication and common goals to comprehensively address the biopsychosocial model of pain.¹⁰ The treatment- and cost-effectiveness of such pain management programmes have been well documented in the scientific literature, and their implementations have been successful.¹¹ However, most of these programmes have been operated either in secondary or even tertiary care, where pain conditions are already chronic, complicated, and refractory. Therefore, we believe effective models of care should also be implemented in primary care. Timely and comprehensive management initiated in primary care can potentially avoid the course of development into chronicity. One example is “Turning Pain into Gain”,¹² a multidisciplinary chronic pain programme implemented in one of the Primary Health Network in South East Queensland, Australia. This programme resulted in significant improvements in medication management, participant self-efficacy, and self-reported hospitalisations.¹²

Newer concepts for model development

The traditional model of medicine and medical science, which attempts to attribute musculoskeletal symptoms to a pathological diagnosis, has hindered the development of a more rational and effective approach to chronic pain care. This approach considers pain as the only guide to the underlying pathology and overemphasises diagnosis and attempts at cure. This approach ignores the status of pain and its related disability which warrant assessment and management of its own.¹³ There is a conceptual shift to place symptoms and their impact on daily life at the centre of primary care management.¹⁴ Furthermore, care should focus on individuals with co-morbidity rather than a distinctive single musculoskeletal diagnosis, incorporating psychological and social context in the management.¹⁵ Musculoskeletal pain is almost inevitable in the lifetime of an individual,¹⁶ and the resulting disability may diminish the opportunity for active and positive approaches to care. Therefore, promotion of active self-management, exercise and positive thinking are essential in supporting individuals with chronic pain.^{17 18} Platforms that facilitate communication between physicians, surgeons, and allied healthcare professionals enhance knowledge exchange and ultimately improve chronic pain care.¹⁹ Because managing chronic musculoskeletal pain is one of the largest workloads in primary care, knowledge, training, and enthusiasm must be strengthened.^{6 14} Other directions are possible alternatives, such as supporting and training healthcare professionals other than doctors to undertake the role of gatekeeper, such as permitting direct access for patients to advice from physiotherapists and pharmacists. These could be especially effective in areas where access to medical care is difficult.^{20 21}

References

1. Cimmino MA, Ferrone C, Cutolo M. Epidemiology of chronic musculoskeletal pain. Best Pract Res Clin Rheumatol 2011;25:173-83.

2. Hong Kong Population Projections 2015-2064. Census and Statistics Department, Hong Kong SAR Government; 2015.

3. Cheung CW, Choi SW, Wong SS, Lee Y, Irwin MG. Changes in prevalence, outcomes, and help-seeking behavior of chronic pain in an aging population over the last decade. Pain Pract 2017;17:643-54.

4. Sit RW, Zhang D, Wang B, et al. Sarcopenia and chronic musculoskeletal pain in 729 community-dwelling Chinese older adults with multimorbidity. J Am Med Dir Assoc 2019;20:1349-50.

5. Mose S, Kent P, Smith A, Andersen JH, Christiansen DH. Trajectories of musculoskeletal healthcare utilization of people with chronic musculoskeletal pain—a population-based cohort study. Clin Epidemiol 2021;13:825-43.

6. Mills S, Torrance N, Smith BH. Identification and management of chronic pain in primary care: a review. Curr Psychiatry Rep 2016;18:22.

7. Chu MC, Law RK, Cheung LC, et al. Pain management programme for Chinese patients: a 10-year outcome review. Hong Kong Med J 2015;21:304-9.

8. Vickers AJ, Vertosick EA, Lewith G, et al. Acupuncture for chronic pain: update of an individual patient data meta-analysis. J Pain 2018;19:455-74.

9. Gatchel RJ, McGeary DD, McGeary CA, Lippe B. Interdisciplinary chronic pain management: past, present, and future. Am Psychol 2014;69:119-30.

10. Stanos S, Houle TT. Multidisciplinary and interdisciplinary management of chronic pain. Phys Med Rehabil Clin N Am 2006;17:435-50.

11. Kamper SJ, Apeldoorn AT, Chiarotto A, et al. Multidisciplinary biopsychosocial rehabilitation for chronic low back pain: Cochrane systematic review and meta-analysis. BMJ 2015;350:h444.

12. Joypaul S, Kelly FS, King MA. Turning pain into gain: evaluation of a multidisciplinary chronic pain management program in primary care. Pain Med 2019;20:925-33.

13. Clauw DJ, Essex MN, Pitman V, Jones KD. Reframing chronic pain as a disease, not a symptom: rationale and implications for pain management. Postgrad Med 2019;131:185-98.

14. Croft P, Peat GM, Van Der Windt DA. Primary care research and musculoskeletal medicine. Prim Health Care Res Dev 2010;11:4-16.

15. Bergman S. Management of musculoskeletal pain. Best Pract Res Clin Rheumatol 2007;21:153-66.

16. Walsh NE, Brooks P, Hazes JM, et al. Standards of care for acute and chronic musculoskeletal pain: the Bone and Joint Decade (2000-2010). Arch Phy Med Rehabil 2008;89:1830-45.

17. Du S, Yuan C, Xiao X, Chu J, Qiu Y, Qian H. Self-management programs for chronic musculoskeletal pain conditions: a systematic review and meta-analysis. Patient Educ Couns 2011;85:e299-310.

18. Reid MC, Papaleontiou M, Ong A, Breckman R, Wethington E, Pillemer K. Self-management strategies to reduce pain and improve function among older adults in community settings: a review of the evidence. Pain Med 2008;9:409-24.

19. Gordon DB, Watt-Watson J, Hogans BB. Interprofessional pain education—with, from, and about competent, collaborative practice teams to transform pain care. Pain Rep 2018;3:e663.

20. Bury TJ, Stokes EK. A global view of direct access and patient self-referral to physical therapy: implications for the profession. Phys Ther 2013;93:449-59.

21. Hadi MA, Alldred DP, Briggs M, Munyombwe T, José Closs S. Effectiveness of pharmacist-led medication review in chronic pain management: systematic review and meta-analysis. Clin J Pain 2014;30:1006-14.