Rheumatology Advance Access originally published online on August 9, 2006
Rheumatology 2006 45(10):1321; doi:10.1093/rheumatology/kel185
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Primary care guidelines in rheumatology
University of Sheffield Medical School, Institute of General Practice and Primary Care and 1University of Sheffield, Division of Genomic Medicine, Academic Rheumatology Group, Sheffield, South Yorkshire, UK
Correspondence to: A. Adebajo. E-mail: a.o.adebajo{at}sheffield.ac.uk
SIR, The recent editorial by Wise et al. [1] accurately reflects the literature on guideline implementation and highlights the challenges inherent in seeing undifferentiated medical problems at an early stage in primary care. Such guidelines need to be understood in the context of general practitioners having short consultations, limited access to investigations and usually some prior knowledge of the patient based on a healthcare record from birth; guidelines need to fit this primary care model of clinical assessment.
We believe that back pain provides a case in point. The effective dissemination of evidence-based guidelines for back pain brought about a paradigm shift in management, and general practitioners no longer send people with back pain to bed for days with drugs such as diazepam, advice to avoid activity and a sick note for a month. Similarly, we believe that there are now opportunities to develop evidence-based primary care guidelines for other common musculoskeletal problems such as knee pain [2] and shoulder pain [3], appropriate for a ‘10 min consultation’. The consultation guidelines would ideally incorporate a ‘red flag’ system similar to that available for back pain so as to identify potentially serious disease and assess important psychosocial factors (occupation, psychological distress and illness, disability and home situation), the patients’ views about the cause of symptoms and expectations of further management. We believe that although radiographic and blood tests are commonly requested in primary care for knee and shoulder pain, these tests are rarely indicated in either of these two conditions unless potentially serious pathology is suspected.
We are concerned that the majority of the available guidelines are difficult to adhere to in primary care as many of the treatments assessed in randomized controlled trials are not readily available in primary care, for example, acupuncture for knee osteoarthritis [4]. We feel that treatment choices for common musculoskeletal problems should be based on a holistic approach, which might more often emphasize conservative interventions such as advice about footwear, physiotherapy treatments, exercise and weight loss programmes rather than emphasizing expensive and potentially harmful non-steroidal inflammatory drugs. Guidelines reflecting a multidisciplinary approach is, in our view, particularly important, more so with developments such as extended scope physiotherapists who can independently assess and treat patients and primary care nurse practitioners who are increasingly the first point of patient contact for musculoskeletal problems in primary care. We hope that future guideline developments will take account of these issues and pay full recognition to the context within which these guidelines will need to operate.
The authors have declared no conflicts of interest.
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- Wise E, Kumar N, Walker D. (2006) Primary care guidelines in rheumatology. Rheumatology 1:6–8.
- Underwood MR. (2004) Community management of knee pain in older people: is knee pain the new back pain? Rheumatology 43:2–3.
[Free Full Text] - Mitchell C, Adebajo A, Hay E, Carr A. (2005) Shoulder pain: diagnosis and management in primary care. Br Med J 331:1124–8.
[Free Full Text] - MacAuley D. (2004) Managing osteoarthritis of the knee. Br Med J 329:1300–1.
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