Patients with Musculoskeletal Pain Stress Multimodal Care in Emergency Department

Stephanie Eucker, MD, PhD

Although common, effective musculoskeletal pain management in the emergency department (ED) remains a challenge, with patients reporting choice of pain treatment is often based on provider-specific practice, rather than patient preference.

A recent study evaluated new approaches to efficiently identify patient expectations and preferences in care of the patient population, with an analysis of the Patient-Centered Outcomes Questionnaire (PCOQ).

Investigators, led by Stephanie Eucker, MD, PhD, Department of Surgery and Department of Orthopedic Surgery, Division of Emergency Medicine, Duke University, observed most patients in the ED who presented with musculoskeletal pain reported moderately high levels in pain, function, emotional distress, and fatigue, with expectations of substantial (40 - 60%) reductions in each domain following treatment.

Study

The team performed a cross-sectional survey of demographic, clinical, and psychosocial characteristics of adult ED patients who were admitted with musculoskeletal pain between June 2018 - October 2019.

Patients were aged ≥18 years, with a triage level of 3 - 5 and presented with a chief complaint of neck, back, or extremity pain determined by the ED provider to be musculoskeletal.

The PCOQ was considered the primary measure for patient-reported outcomes in order to quantify levels of pain (usual, desired, expected, and successful), and interference with daily activities, fatigue, and emotion from 0 - 100 (worst imaginable).

Further, the PCOQ scale used 0 (not important) - 100 (most important) in determining importance of improvement with each domain.

The PCOQ included demographics include age, sex, and race, as well as pain characteristics, including location of pain, duration of current pain episode, and history of prior episodes of musculoskeletal pain.

The analysis questioned patients on their willingness to try pharmacologic, such as ibuprofen, naproxen, and aspirin, or non-pharmacologic treatments including deep breathing, physical therapy, meditation, or exercise.

Investigators identified subgroups through cluster analysis and determined PCOQ domains of importance in improvement.

Results

After screening, 210 patients were enrolled in the study with a median age of 44 years with 52.3% (n = 91) patients were female and 56.9% (n = 95) Black/African-American.

Data show patients reported moderate usual severity levels in each PCOQ domain, including pain (mean = 67), interference (median = 66), fatigue (median = 51), and emotion (mean = 50).

In addition, most patients wanted 100% resolution within each domain, defining treatment success as substantial with a median of 63.2% - 76.5%. However, they expected moderate improvements across all domains with a median of 45% - 53.7%.

For patients with previous episodes of pain, desired levels were similar, but the team noted they had less strict definitions of success.

Furthermore, investigators noted cluster analysis of the 4 PCOQ domain had no conclusive statistical solution, but the 3-cluster was selected for further analysis due to clear definitions between subgroups.

In the 3-cluster solution, the team identified 3 patient subgroups through importance ratings of each domain.

The first considered multiple domains important (n = 118) with higher importance in all 4 domains, while the second was pain and function important (n = 34) with increased importance for pain and interference with daily activity and the third was considered only pain important (n = 22).

The team also observed the majority of patients had a high willingness to use medications for pain (96%), including non-steroidal anti-inflammatory drug (NSAIDs; 74.7%) and opioids (67.2%). They found fewer patients were willing to try acetaminophen (50.6%) or medical marijuana (21.3%).

In addition, the majority of patients (94.3%) were willing to try non-pharmacologic treatments, including passive modalities (84.5%), physical therapy (73%) and psychosocial modalities including prayer (74.1%).

Conclusion

The team concluded that understanding patient expectation, goal, and priority are essential factors in patient-centered care in patients with musculoskeletal pain in the ED.

"Our findings highlight the importance of addressing a range of functional outcomes when managing musculoskeletal pain in ED patients,” investigators wrote. “Similar to other patient populations, ED patients have a broad set of treatment goals that include addressing pain-related impairments in function and quality of life as much as the pain itself.”

The study, “Moving toward patient-centered care in the emergency department: Patient-reported expectations, definitions of success, and importance of improvement in pain-related outcomes,” was published online in Academic Emergency Medicine.