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Ernstzen D.V.1, Louw Q.A.1, Hillier S.L.1,2
1Stellenbosch University, Division Physiotherapy, Cape Town, South Africa, 2University of South Australia, International Centre for Allied Health Evidence, Sansom Institute for Health Research, Adelaide, Australia
Background: Chronic musculoskeletal pain is a global health care concern, and is a major cause of disability and morbidity in sub-Saharan Africa. High-quality, evidence-based clinical practice guidelines can enable quality health care for chronic musculoskeletal pain. Clinical guidelines developed in developed nations may not be appropriate in resource-constrained environments, due to differences in socio-cultural, societal and policy contexts. The contextualisation of clinical guidelines is an option to provide guidance for resource-constrained environments.
Purpose: The overall aim of the study was to develop a contextualised evidence-based, multimodal clinical guideline for the primary healthcare of adults with chronic musculoskeletal pain in the Western Cape Province of South Africa.
Methods: Mixed methods in three parts were conducted. The three parts consisted of a contextual analysis, evidence synthesis and contextualisation. In part 1, qualitative methodology was used to investigate the context factors that influence the care of patients with chronic musculoskeletal pain. Semi-structured interviews were conducted with a sample of patients with chronic musculoskeletal pain and their healthcare providers. In part 2, a systematic review was conducted to identify current, high-quality clinical guidelines about the primary healthcare of chronic musculoskeletal pain; and a core set of evidence-based recommendations were extracted from the guidelines. In part 3, consensus methodology was used and a multi-disciplinary panel of experts evaluated, authenticated and contextualized the clinical recommendations for the intended context.
Results: A core set of 43 multimodal, evidence-based clinical recommendations for the management of chronic musculoskeletal pain were identified through the evidence synthesis process. The content of the core set were focussed on: approach to care, assessment, advice and education, referral, pharmacological management, physical therapy, electrotherapy, psychological therapy, complimentary therapy and self-management. The 20 patients and 21 clinicians that participated in the contextual analysis agreed on the context factors that influence care. These context factors were the personal characteristics of the patient and clinician, the social and environmental circumstances within which the patient lives, the healthcare interventions received and healthcare system factors. In part 3 of the study, the multidisciplinary panel validate the recommendations, and developed and practice points for implementation, using the contextual analysis (part 1).
Conclusion(s): The end-product of the study was a contextualised, evidence-based and multimodal clinical guideline for the primary healthcare of chronic musculoskeletal pain in the Western Cape province of South Africa. The guideline indicates the importance of an inter- or multi-disciplinary approach, focussed on patient empowerment within a supportive environment. Modifications in practice patterns, healthcare system organization and governance will contribute to the successful implementation of the guideline.
Implications: Chronic musculoskeletal pain is a multidimensional phenomenon and requires a multi-disciplinary approach. Care should include attention to physical, psychological, social and environmental domains. Patient empowerment through contextually relevant education plays a vital role in quality care of patients with chronic musculoskeletal pain. The physical therapist is an important member of the pain care team.
Funding acknowledgements: Stellenbosch University Rural Medical Education Partnership Initiative, Stellenbosch University, National Research Foundation of South Africa, South African Medical Research Council.
Topic: Globalisation: health systems, policies & strategies
Ethics approval: The Health Research Ethics Committee of Stellenbosch University, South Africa (S14/01/018).
All authors, affiliations and abstracts have been published as submitted.
