Can we really be precise with MSK care? (4/3/26)

The MSK world is obsessed with trying to be as precise as possible, we have seen so many methods and systems of the past 30 + years that try to create nice and neat classifications or subgroups that help guide treatment.

This might be mechanically based, like MDT, psychologically based like Start back or more modern attempts with things like pain mechanisms.

This recent paper discusses recent attempts at precision medicine through classification such as pain phenotyping and pain mechanisms.

“Recent highlights in low back pain research, Part I: Diagnosis and Prognosis”

'

“Diagnostic uncertainty has driven interest in evolving approaches. One prominent direction is mechanism-based classification of pain. However, the validation of mechanism-based categories for pain and clinical measures used to discriminate between them are in their infancy and their role in routine care is, for now, largely exploratory

Pain phenotyping has also been proposed to capture the heterogeneity of non-specific LBP.  However, phenotyping faces similar challenges where subgroups often differ between studies, and few have been tested for reproducibility or real-world utility”

It seems that classification systems are much better at the classification part than actually changing the outcomes of treatments by using this process. I think this shows that precision is not quite as precise as some make out! Is it more to give a clinician structure in a murky unclear world than for patients perhaps?

‘Learning styles’ are a great example of this type of thinking in another field. The idea that we can package or classify learning into visual, kinaesthetic, auditory etc. This, of course, turned out to be a bit of a myth, was overly simplistic and did not really improve learning at all!

What if the ultimate sub group is just the patient?

If we listen well enough, there are always opportunities or affordances, if you like a bit of intellectual masturbation, to help or change something. That doesn’t need to be classified or treated through an algorithm, in fact that process may make it less precise and definitely less personalised.

Does this need to be turned into a radar plot highlighting lifestyle or psychological dominance? What does the plot or profile add beyond dealing with the specific issues that often highlight themselves when you listen and act on the patients wider life and journey?

Maybe clinicians need this to become more aware of a world beyond just the biomechanical, in this way I get it. But we could say it’s a lifestyle dominant presentation, whatever that means, without being specific to the person’s actual issue and instead deferring to whatever protocol is dictated by the grouping process

Why do people like the illusion of precision? Does it make people feel more technical or scientific? Like when exercise gets turned into S & C it becomes something better. In reality, the principles are pretty similar between both scenarios.

So, rather than learning some type of grouping to guide you, just let the patient!