Demographic and participants characteristics
Three hundred thirty-two physicians with a mean age of 47.5 ± 9.6 years (85 female, 25.6%, 43.6 ± 9.2 years; 235 male, 70.8%, 48.8 ± 9.4 years) responded to the questionnaire. Among all physicians, 146 (44.0%) were orthopaedists, 97 (29.2%) internists and 63 (19.0%) anaesthetists. Out of these groups, 90 (27.1%) were sub-specialised in rheumatology and 50 (15.1%) in pain therapy. Thirty-seven (11.1%) doctors worked at a university hospital, 113 (34.0%) at a county hospital, 160 (48.2%) in a private clinic, 2 (0.6%) in a pain centre and 20 (6.0%) did not specify their place of work. Forty-one (12.3%) physicians were residents and 281 (84.6%) consultants. The detailed affiliations and professional status of the respondents are shown in Table S1 (additional file 2).
Congress groups showed differences regarding age, gender and the work centre. Female rheumatologists were younger than male rheumatologists. In general, women were not only younger but also differently distributed within the groups of specialisation and subspecialisation when compared to men. There were less female surgeons than female rheumatologists or anaesthetists. Physicians working in a hospital were younger than those in a private clinic.
When asked for the number of myofascial pain patients treated, 163 (48.9%) of all physicians attended more then four patients a week, 87 (26.1%) between one and three patients a week, 39 (11.7%) between one and three patients per month, 36 (10.8%) up to ten patients a year and 6 (1.8%) physicians never saw myofascial pain patients. There were no intergroup differences regarding those distributions (p = 0.801).
When we asked how often patients were referred to special pain centres, we found the following distribution: 82 (24.6%) of physicians never did, 89 (26.7%) up to ten patients per year, 96 (28.8%) up to three patients per month, 25 (7.5%) between one and three patients a week and 26 (7.8%) referred more than four patients a week to a specialised pain centre. Pain therapists rarely refer their patients to another centre (p < 0.001). For detailed information see Table S1 (additional file 2).
Estimated importance of myofascial pain syndrome and prevalence of myofascial trigger points
When asked for the importance of myofascial pain the physicians mean score was 2.5 ± 1.4 (n = 330). There were no significant differences among the respective groups (p = 0.803), specialities (p = 0.578), genders (p = 0.294) or other demographic data.
Physicians estimated the prevalence of active trigger points to 46.1 ± 27.4% (n = 329) in the overall population and 52.8% ± 26.9 (n = 330) in their own patients. Subjects from the pain congress rated these frequencies higher than other physicians; 55.4 ± 22.2% in the overall population (p < 0.001) and 63.4 ± 21.7% in their own patients (p = 0.001). For detailed information see Table S2 (additional file 3).
Prescription Rates of treatment options
Analgesics
Pharmacological approaches were the most common treatment (1525 choices, i.e. a mean of 4.5 analgesics evaluated per physician). Non steroidal anti-inflammatory drugs or coxibs were the main analgesics (n = 304, 91.6%), followed by metamizol and paracetamol (n = 289, 87.0%), weak opioids (n = 271, 81.6%), antidepressants (n = 240, 72.3%), strong opioids (n = 190, 57.2%) or anticonvulsants (n = 175, 52.7%). Other drugs were rarely used (n = 56, 16.9%), physicians named especially muscle relaxants (n = 17, 5.1%) and flupirtine (n = 16, 4.8%). Detailed intra- and inter-group values are shown in Figure 1 and Table S3 (additional file 4).
Physical therapy
Physical therapies were prescribed one-third less often than analgesics (1118 choices, i.e. a mean of 3.4 physical therapies evaluated per physician). Manual therapy was prescribed most often, i.e. by 270 (81.1%) of all physicians, followed by TENS (n = 242, 72.9%) and acupuncture (n = 200; 60.2%). Ultrasound (n = 132, 39.8%), percussion waves (n = 106, 31.9%) or dry needling (n = 96, 28.9%) were prescribed less often. Additional treatments were chosen by 72 (21.7%) of all physicians. These treatments were rather specified e.g. chiropractics (n = 8), cryotherapy (n = 3) and osteopathy (n = 3) as other physical therapy. Detailed intra- and inter-group values are shown in Figure 1 and Table S3 (additional file 4).
Injections
The use of injection techniques is less important in the overall therapeutic concept (390 choices, i.e. a mean of 1.2 injections evaluated per physician). Injection of local anaesthetics was mainly used (n = 236; 71.1%). Spinal interventions (e.g. spinal cord stimulation, epidural injection) was used by 102 (30.7%) whereas injection of botulinum toxin was used by 41 (12.3%) of physicians. Additional techniques (n = 11, 3.3%) were not specified. Detailed intra- and inter-group values are shown in Figure 1 and Table S3 (additional file 4).
Rating of treatment approaches
A 6-point scale (with 1 being excellent effective and 6 being worst) allowed physicians to rate the effectiveness of the used treatment approaches. 54.3% of all physicians surveyed stated current symptom-based treatment options being insufficient. This opinion was more pronounced in the rheumatologists group (77.3%) than anaesthetists (49.2%) or orthopaedists (45.8%).
Analgesics
Muscle relaxants (2.1 ± 0.5) and flupirtine (1.6 ± 0.7) are estimated as most effective analgesics. They form part of additional assignable drugs (overall 2.3 ± 1.1 points). They were followed by antidepressants (2.6 ± 1.0), non-steroidal anti-inflammatory drugs or coxibs (2.7 ± 1.0), metamizol or paracetamol (3.1 ± 1.0), weak opioids (3.1 ± 1.1), strong opioids (3.2 ± 1.5) and anticonvulsants (3.2 ± 1.2). Detailed intra- and intergroup data are shown in Figure 2 and Table S4 (additional file 5).
There were significant intragroup differences regarding the rating of treatment options for non-steroidal anti-inflammatory drugs or coxibs (p = 0.002), weak and strong opioids (p < 0.001), anticonvulsants (p = 0.024) and additional pharmacologic approaches (p = 0.006). Non-steroidal anti-inflammatory drugs or coxibs were rated better by orthopaedists when compared to pain therapists (p = 0.018) or to rheumatologists (p = 0.001); weak and strong opioids were rated less effective by pain therapists than orthopaedists (p < 0.001) or rheumatologists (p < 0.01); pain therapists rated anticonvulsants worse than orthopaedists (p = 0.008); Other pharmacologic treatments scored better in the pain group then with orthopaedists (p = 0.007) or rheumatologists (p = 0.018).
Physical therapies
Manual therapy was rated with an average of 2.3 ± 0.9. Dry needling (2.4 ± 1.1) and acupuncture (2.4 ± 1.0) were estimated with a similar effectiveness. TENS (2.6 ± 0.9) scored better than percussion waves (2.8 ± 1.2). Ultrasound techniques were estimated being the less effective therapeutic option (3.0 ± 1.2). Additional treatments (e.g. chiropractics, osteopathy) were rated 2.0 ± 0.9. Detailed intra- and intergroup data are shown in Figure 2 and Table S4 (additional file 5).
There were intragroup differences regarding the rating of TENS (p = 0.001), manual therapy (p = 0.002) and acupuncture (p = 0.006). TENS got a better ranking by orthopaedists (p = 0.001) and pain therapists (p < 0.001) when compared to rheumatologists. The same held for manual therapy (p = 0.001, p = 0.1) and acupuncture (p = 0.008, p = 0.002). Ultrasound was rated better by orthopaedists than pain therapists (p = 0.033); Dry needling was rated better by pain therapists than orthopaedists (p = 0.039) or rheumatologists (p = 0.044).
Injections
Injection of local anaesthetics was rated with an average of 2.3 ± 1.0 and injection of botulinum toxin scored 2.8 ± 1.4. Spinal interventions scored worst (2.9 ± 1.8). Additional but unspecified injections scored 1.9 ± 0.5. Detailed intra- and intergroup data are shown in Figure 2 and Table S4 (additional file 5).
There were intragroup differences regarding the rating of injection of local anaesthetics (p = 0.008). This concerned the rheumatologists group when compared to pain therapists (p = 0.032) or orthopaedists (p = 0.002). Injections were rated differently by orthopaedists and rheumatologists (p = 0.021).
Correlations between participant characteristics and treatment approaches
A gender effect could be demonstrated for the use of spinal interventions (p = 0.049), which is rarely used by women, while they prefer manual therapy (p = 0.019).
Physicians younger than 35 years rated the use of weak (p = 0.002) and strong opioids (p = 0.009) less effective than those older than 65 years.
Working place-related effects appeared different: physicians employed at district hospitals (n = 113) estimated non-steroidal anti-inflammatory drugs or coxibs more effective than physicians working in a private practice (n = 160, p = 0.018).
Comparing the ratings of residents and consultants, it became evident that residents evaluated weak (p = 0.004) and strong opioids (p = 0.001), antidepressants (p = 0.049) and dry needling (p = 0.042) less effective.