Number of musculoskeletal pain sites leads to increased long-term healthcare contacts and healthcare related costs, 2021, Mose et al

[Andy]

Abstract

Background
People with musculoskeletal pain seek more healthcare than the general population, however little is known about the long-term effect on healthcare use. The aim of this study was to examine the consequences of number of musculoskeletal pain sites on long-term care-seeking and healthcare-related costs and explore how health anxiety influences this relationship.

Methods
We conducted a Danish population-based longitudinal cohort study of 4883 participants combining self-reported survey data from 2008 with ten-year follow-up data from national health registers. Using a causal inference framework, we examined associations between number of pain sites (range 0–7)/level of health anxiety (high/low level) and face-to-face healthcare contacts/healthcare-related costs. Data were analyzed using negative binomial regression with generalized estimating equations. Regression models were adjusted for sex, age, duration of pain, level of education, comorbidity, personality traits, risk of depression, marital status, physical job exposure, and previous healthcare utilization.

Results
For each additional pain site general healthcare contacts (Incidence Rate Ratio (IRR): 1.04 (95% CI: 1.03–1.05)), healthcare-related costs (IRR: 1.06 (95% CI: 1.03–1.08) and musculoskeletal healthcare contacts (IRR: 1.11 (95% CI:1.09–1.14) increased. Those with high levels of health anxiety at baseline had a slightly higher number of general healthcare contacts (IRR 1.06 (1.01–1.11), independent of number of pain sites. However, level of anxiety did not influence the effect of number of pain sites on any healthcare use or cost outcomes.

Conclusions
We found evidence for a causal association between increasing number of pain sites and greater healthcare use and cost, and high levels of health anxiety did not increase the strength of this association. This suggests that number of pain sites could be a potential target for biopsychosocial interventions in order to reduce the need for future care-seeking.

Open access, https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-021-06994-0

 

[Trish]

Another contender for dumbest research idea, providing yet another conclusion that BPS interventions are the answer. A conclusion based on no evidence.

 

[Mithriel]

We need a strong intervention to teach psychologists that association is not CAUSALITY!!!!!

The number of web sites may have gone up alongside health care use because people can't get painkillers.

The fact they state that people with musculoskeletal pain seek more healthcare than the general population is so inane it caught my breath. This is what they call science? Musculoskeletal pain used to be called disease so it was treated just like all the other diseases.

What do they think doctors are paid to do?

 

[rvallee]

This suggests that number of pain sites could be a potential target for biopsychosocial interventions in order to reduce the need for future care-seeking.

Wat? How high are these people? That sentence makes no sense.

 

[Hoopoe]

Reducing the number of pain sites seems to be a convoluted way to say medical treatment.

 

[JemPD]

I dont know why, because it's just more of the same. But i'm as always incredulous that this is actual research!

People with musculoskeletal pain seek more healthcare than the general population

Well no sh*t Sherlock!

Money has been spent to 'discover' that people who have pain seek more healthcare than those who dont. And those who have a lot of pain, in several sites, seek more than those who have only a small amount - in one site.

This is on the level of funding studies to discover that people who are very hungry because they didnt eat for 24hrs, eat a lot more than those who are just a little peckish because it's only 2hrs since they had their dinner.

For Gods sake. I just despair.



The next thing will be an abstract conclusion which says

"we found that 98% of people who die of cancer confined themselves to bed in the 48hrs before they died. This could be a novel target for psychotheraputic & physiotherapy interventions to help people remain upright. Thus possibly saving many lives"

 

[Remain in Light]

What is it about today and releasing the dumbest "research". Is it like certain times of year when film companies release their crappiest movies, between blockbusters.
We aren't meant to read this stuff , they're just talking amongst themselves. There really are too many psychologists in the world.
I don't mean that sinisterly

 

[rvallee]

I dont know why, because it's just more of the same. But i'm as always incredulous that this is actual research!



Well no sh*t Sherlock!

Money has been spent to 'discover' that people who have pain seek more healthcare than those who dont. And those who have a lot of pain, in several sites, seek more than those who have only a small amount - in one site.

This is on the level of funding studies to discover that people who are very hungry because they didnt eat for 24hrs, eat a lot more than those who are just a little peckish because it's only 2hrs since they had their dinner.

For Gods sake. I just despair.



The next thing will be an abstract conclusion which says

"we found that 98% of people who die of cancer confined themselves to bed in the 48hrs before they died. This could be a novel target for psychotheraputic & physiotherapy interventions to help people remain upright. Thus possibly saving many lives"

"Shocking study finds that restaurant-goers are more hungry than the average population, we discuss the groundbreaking implications and how the restaurant industry still has massive growth opportunity if it can figure out who is hungry and how to get them near restaurants at the time their hunger is highest, with the novel implication that being near a restaurant may be the main driving factor behind hunger. Have we found a solution to hunger in the world? Some experts say: 'maybe, why not? which one pays me the most? wait don't quote me on that!'"

 

[lunarswirls]

I read this paper very differently. Not sure if it's because I'm missing something due to major brain fog but I skimmed through past publications for each author and I didn't notice any red flags suggesting they're a part of the BPS cult of idiocy.

When it comes to ME and other unexplained illnesses, BPS is often used to mean: ignore the "bio", focus exclusively on the "psycho", then claim psychological therapies = biological treatments because ~mind and body are one~ while blaming the patient for the social when they don't get better.

I don't think that's the BPS model the authors are following...

Care-seeking could be viewed as a process that involves personality, psychological factors and beliefs/knowledge (e.g. fear avoidance, health anxiety, risk perceptions, stress, self-efficacy), comorbidity, type/nature of symptoms/diagnosis (e.g. location, duration, intensity, disability), and social factors.

And their conclusion was:

Our findings show that increasing number of pain sites is associated with higher number of general healthcare contacts, higher healthcare-related costs and higher number of musculoskeletal healthcare contacts over a subsequent ten-year period. We found a weak association between health anxiety and higher number of general healthcare contacts and no evidence that level of health anxiety influences the effect of number of pain sites on healthcare utilization outcomes.

In this context, our results add knowledge about drivers of care-seeking and may assist healthcare professionals in formulating patient communication and clinical decision-making in order to optimize healthcare utilization. This study is also a step towards better understanding of a population of patients that might not benefit from current clinical pathways and the organization of healthcare systems in most Western countries.

The comorbid nature of pain characterized by multiple pain sites calls for comprehensive collaboration across disciplines which can be a challenge within the silo-organization of most healthcare systems and healthcare sectors. In order better embrace this population of patients in the healthcare system and avoid healthcare overuse, we need more knowledge about the healthcare pain management trajectories across sectors and disciplines. Such knowledge could potentially highlight management gaps or specific patient groups in high risk of non-guideline-adherent clinical pathways.

Another important knowledge gap for future research projects of health care service use is the perspective of the health care user. Such knowledge could also guide healthcare providers in their communication with people with multi-site pain in order optimize patient-centered healthcare pain management.

(emphasis mine, paragraph broken up for easier reading)

I didn't look at the methodology but this all seems pretty reasonable to me. I've always wanted researchers who are seen as neutral tell the rest of the scientific/medical community, "Hey, we have no horse in this race and we believe the biopsychosocial model can be a useful way to explain illness in general if used properly. Previous studies have pointed to health anxiety as the main driver of increased healthcare usage and therefore costs. In this paper, we put that hypothesis to the test and could not find any evidence to support it. Rather, it seems like patients with musculoskeletal pain seek more healthcare than the general population because they have more pain due to biological factors, and most healthcare systems in Western countries do a poor job of providing relief. Maybe we should focus on fixing that instead of blaming and gaslighting the patients."

I feel like that's what these authors tried to do here. The way I read it, they seem to be advocating for a more patient-centered approach to healthcare with multidisciplinary teams, where our input as patients is valued instead of being seen as false illness beliefs which need to be corrected.

Am I being too generous? Is there a reason to be suspicious of these authors' motives?

 

[Sean]

The next thing will be an abstract conclusion which says

"we found that 98% of people who die of cancer confined themselves to bed in the 48hrs before they died. This could be a novel target for psychotheraputic & physiotherapy interventions to help people remain upright. Thus possibly saving many lives"

Shh. Don't give them any ideas.

 

[Milo]

Head-desk, head-desk

 

[Trish]

Thank you @lunarswirls for taking a closer look at the paper and giving a different perspective. I admit my initial comment was based solely on the abstract which seemed to make a sweeping conclusion about biopsychsocial interventions that did not follow logically from the reported outcomes.

I have now skimmed through the whole paper, and I stand by my original comment. It was a large study with a huge number of variables from which, for this paper, they have focused on number of pain sites, number of doctor visits and health anxiety. They also did a huge mass of other statistical tests with different variables. Perhaps these will be discussed in different papers.

I agree it was useful that they found only a weak correlation with health anxiety, but they seem to treat number of pain sites as useful, but don't factor into it pain severity. Why not test whether those with more severe pain at fewer sites had more doctor visits etc.

Anyway, my main criticism still stands. Why conclude that more BPS interventions are needed? The data don't explore or show any evidence of the effectiveness of any psychological or social interventions, nor, indeed of any biological interventions. The study simply did not investigate the effectiveness of any intervention as far as I can see, except in the crude sense that if an intervention had been effective, the number of doctor visits might decrease over time.

 

[Mithriel]

You may have noticed that I thought they meant increase of the number of sites on the web to talk about pain. It was only when I read what other people wrote that I realised they meant pain sites on the body.

That makes it even worse! And did I have an ME moment or is it shocking that I assumed this was the latest way of saying the biggest risk factor is to talk about your symptoms with someone else or join an association?

What if you have more than 7 painful bits? And how can you reduce pain in one part of the body without another? Obviously not by taking painkillers. Today we will give your knee a severe talking to to stop it hurting but your ankle can have a week off.

 

[JemPD]

I feel like that's what these authors tried to do here. The way I read it, they seem to be advocating for a more patient-centered approach to healthcare with multidisciplinary teams, where our input as patients is valued instead of being seen as false illness beliefs which need to be corrected.

Really? I didnt read in that way, but i must admit i only skim read. It's possible i fell into the trap i criticise Drs of doing... and interpreting what i think is being said rather than whats actually being said.
If thats what i've done then i apologise to the researchers unreservedly. Unfortunately i dont have the energy spare to spend reading it fully/properly to find out, so will keep an open mind for now.

Today we will give your knee a severe talking to to stop it hurting but your ankle can have a week off.

 

[Jonathan Edwards]

I feel like that's what these authors tried to do here. The way I read it, they seem to be advocating for a more patient-centered approach to healthcare with multidisciplinary teams, where our input as patients is valued instead of being seen as false illness beliefs which need to be corrected.

Am I being too generous? Is there a reason to be suspicious of these authors' motives?

I am afraid so.

I am fairly sure that this is a group of physios who have had the brilliant idea that what patients need is more physio: lots of nice exercises taught by terribly nice physios who really care for the patients. They know nothing about the causes of joint pain and have no idea why physio should be good except that they are physios and like to be told they are nice and helpful.

These are exactly the people who are causing the problems we are having over the NICE guidelines. People who think their job is to be told how nice they are by patients. It does not enter their head that it might matter whether or not the patients have a problem that they can help with.

 

[Creekside]

You may have noticed that I thought they meant increase of the number of sites on the web to talk about pain.

When I saw the thread title, I checked to see whether they meant that the more pain relief web sites available, the more people would seek medical help for pain. The actual research finding was no less silly.

 

[lunarswirls]

Thank you for taking the time to add some crucial context, @Jonathan Edwards. I had a feeling I was missing something but couldn't figure out what.

Affiliations

1. Department of Occupational Medicine, University Research Clinic, Danish Ramazzini Centre, Herning, Denmark
   S. Mose, J. H. Andersen & D. H. Christiansen
2. VIA University College, School of Physiotherapy, Holstebro, Denmark
   S. Mose
3. Curtin School of Allied Health, Curtin University, Perth, WA, Australia
   P. Kent & A. Smith
4. Center for Muscle and Joint Health, University of Southern Denmark, Odense, Denmark
   P. Kent

I also missed some red flags in the references section.

So they're just a group of physios whose idea of listening to patients and focusing on biological factors is finding a more palatable way to tell us musculoskeletal pain with no known cause can be fixed with more exercise. No wonder they're calling for "comprehensive collaboration across disciplines" - can't risk having GPs divert patients away from their services if the GP chooses to follow actual evidence-based guidelines! As usual, it's all about them and not about the patients.

I agree it was useful that they found only a weak correlation with health anxiety, but they seem to treat number of pain sites as useful, but don't factor into it pain severity. Why not test whether those with more severe pain at fewer sites had more doctor visits etc.

I think you'll find your answer in this excerpt from another study by many of the same authors:

Musculoskeletal disorders are one of the leading causes of long-term sickness absence and health-related early retirement pension. High level of musculoskeletal pain intensity is strongly associated with impaired function and a prognostic factor for long-term sickness absence. However, until recently, prognostic factors for poor outcomes have often been studied in relation to localized musculoskeletal pain or one clinical disorder (e.g. low back pain, shoulder pain), even though several recent studies have shown that localized pain is relatively rare, and musculoskeletal pain often occurs in various body regions simultaneously.

Furthermore, pain in multiple body regions (widespread pain) are substantially differently associated with other risk factors than localized pain. Gender, age, symptoms of stress and physical strain have demonstrated significantly stronger association with widespread pain compared to localized pain and functional consequences increase proportionally with the number of body regions with musculoskeletal pain. This indicates that studies analyzing musculoskeletal pain should take number of body regions with pain as well as pain intensity into account. However, the association between pain intensity and the number of body regions with pain has not been thoroughly studied, even though a recent study indicates that these factors increase proportionally.​

Anyway, my main criticism still stands. Why conclude that more BPS interventions are needed? The data don't explore or show any evidence of the effectiveness of any psychological or social interventions, nor, indeed of any biological interventions. The study simply did not investigate the effectiveness of any intervention as far as I can see, except in the crude sense that if an intervention had been effective, the number of doctor visits might decrease over time.

Indeed it does. I think they're trying to make the case for why referring patients with widespread musculoskeletal pain to mental health services like CBT is the wrong approach, and that these patients would be better served by physios like themselves who take our pain very seriously because they care so very, very much. And it would be even better if the clinical pathways for these patients were more streamlined so physios like them are consulted right from the get-go instead of being forced to wait for those know-nothing GPs to refer patients with MSK pain to them after performing a bunch of useless investigations.

They didn't say any of that explicitly, of course. They're trying hard to appear neutral and objective (sure fooled me) but I suspect that's where they're trying to steer the debate.

What if you have more than 7 painful bits? And how can you reduce pain in one part of the body without another? Obviously not by taking painkillers. Today we will give your knee a severe talking to to stop it hurting but your ankle can have a week off.

Their position is probably that all 7 pain sites are false alarms and we should target the brain with exercise. Or maybe it's inflammation making the nerves overly sensitive which can be cured with... exercise again. The rationale doesn't really matter - the important thing is that the solution is always exercise.

Really? I didnt read in that way, but i must admit i only skim read. It's possible i fell into the trap i criticise Drs of doing... and interpreting what i think is being said rather than whats actually being said.
If thats what i've done then i apologise to the researchers unreservedly. Unfortunately i dont have the energy spare to spend reading it fully/properly to find out, so will keep an open mind for now.

Yeah, I tried to give them the benefit of the doubt and be open-minded because I hate hypocrisy. Huge mistake.