Is it time to reframe how we care for people with non-traumatic musculoskeletal pain?

Psychosocial Factors, Sleep, and Central Pain Processing for Making a Prognosis About Recovery of Pain, Function, and Quality of Life After Rotator Cuff Repair: An Exploratory Longitudinal Study

OBJECTIVE: To explore modifiable psychosocial factors, sleep-related variables, indices of central pain processing and patients' characteristics as potential prognostic factors for pain, shoulder function, and quality of life (QoL) 1 year after rotator cuff repair. DESIGN: This observational longitudinal study included 142 patients who were undergoing rotator cuff repair. All measures took place pre-rotator cuff repair (T0), and 12 weeks (T1) and 12 months (T2) after rotator cuff repair. METHODS: Mixed-effects linear regression modeled relationships between the Western Ontario Rotator Cuff Index (WORC, model A), the Subjective Shoulder Value (SSV, model B), and EuroQol's EQ-5D-5L for QoL (model C), and potential prognostic factors over time. Factors included psychosocial variables, sleep-related indices, and proxies of central pain processing. Patients' age, sex, and body mass index complemented the analyses. RESULTS: At follow-up (T2), data from 124 participants were available for analysis. Five prognostic factors were identified for the 1-year outcome. Better expectations for symptom reduction (P<.0001, -1.4 mm) and an increase in Douleur Neuropathique 4 score (P = .0481, -0.9 mm) affected the evolution of WORC over time (model A). An increase in injury perception subscale consequence (P = .0035, 0.04%) influenced the SSV trajectory (model B). In addition, when sleep quality (P = .0011, -0.13%) and sleep efficiency (P = .0002, 0.005%) improved, the EQ-5D-5L slope was affected (model C). CONCLUSION: Addressing cognitions, pain mechanisms and sleep behavior prior to rotator cuff repair can identify people who are at risk of a poor outcome after surgery. J Orthop Sports Phys Ther 2024;54(8):530-540. Epub 4 July 2024. doi:10.2519/jospt.2024.12398.

Association between perception of harm and valence of shoulder movement images with disability levels related to chronic shoulder pain

ABSTRACT

Recent studies highlight an interplay between pain perception and emotional responses. This necessitates a thorough investigation into how beliefs and motivational influences respond to visual stimuli of movements. Such an analysis is crucial for understanding the extent to which these factors contribute to disability levels associated with shoulder pain. We aimed to investigate the relationship between the perception of harm and the valence in images depicting shoulder movements and determine how these perceptions are linked to disability levels associated with shoulder pain. This cross-sectional study recruited 42 individuals with chronic shoulder pain. Participants were presented with 58 shoulder movements images. Each participant evaluated these images for emotional valence and arousal using the self-assessment manikin. For every image, they provided their level of avoidance, fear, and perception of harm in a numerical scale. We measured disability levels and pain catastrophizing using the Shoulder Pain and Disability Index and the Pain Catastrophizing Scale. A direct acyclic graph was used. Multiple linear regression analysis was conducted with shoulder disability as the dependent variable and perception of harm and valence as independent variables, adjusted for the confounders catastrophizing and arousal. This analysis resulted in a significant model (F4,37 = 11.44; adjusted R2 = 0.547; P < 0.01). The perception of harm to shoulder movement (β = 0.11; P < 0.001; 95% confidence interval = 5.6-11.8) was significantly associated with the level of shoulder disability, whereas valence did not show a significant association (β = 0.26; P = 0.15; 95% confidence interval = 1.7-10.8). The perception of harm associated with shoulder movements images during daily activities was associated with disability. Individuals who believe that shoulder movements are harmful have greater disability.

One and Done? The Effectiveness of a Single Session of Physiotherapy Compared With Multiple Sessions to Reduce Pain and Improve Function and Quality of Life in Patients With a Musculoskeletal Disorder: A Systematic Review With Meta-analyses

OBJECTIVE

To compare single and multiple physiotherapy sessions to improve pain, function, and quality of life (QoL) in patients with musculoskeletal disorders (MSKDs).

DATA SOURCES

AMED, Cinahl, SportsDiscus, Medline, Cochrane Register of Clinical Trials, Physiotherapy Evidence Database, and reference lists.

STUDY SELECTION

Randomized controlled trials (RCTs) comparing single and multiple physiotherapy sessions for MSKDs.

DATA EXTRACTION

Two reviewers extracted data and assessed risk of bias and certainty of evidence using Cochrane Risk of Bias tool 2.0 and Grading of Recommendation Assessment, Development, and Evaluation.

DATA SYNTHESIS

Six RCTs (n=2090) were included (conditions studied: osteoporotic vertebral fracture, neck, knee, and shoulder pain). Meta-analyses with low-certainty evidence showed a significant pain improvement at 6 months in favor of multiple sessions compared with single session interventions (3 RCTs; n=1035; standardized mean difference [SMD]: 0.29; 95% CI: 0.05 to 0.53; P=.02) but this significant difference in pain improvement was not observed at 3 months (4 RCTs; n=1312; SMD: 0.39; 95% CI: -0.11 to 0.89; P=.13) and at 12 months (4 RCTs; n=1266; SMD: -0.05; 95% CI: -0.49 to 0.39; P=.82). Meta-analyses with low-certainty evidence showed no significant differences in function at 3 (4 RCTs; n=1583; SMD: 0.05; 95% CI: -0.11 to 0.21; P=.56), 6 (4 RCTs; n=1538; SMD: 0.06; 95% CI: -0.12 to 0.23; P=.53) and 12 months (4 RCTs; n=1528; SMD: 0.08; 95% CI: -0.08 to 0.25; P=.30) and QoL at 3 (4 RCTs; n=1779; SMD: 0.08; 95% CI: -0.02 to 0.17; P=.12), 6 (3 RCTs; n=1206; SMD: 0.03; 95% CI: -0.08 to 0.14; P=.59), and 12 months (4 RCTs; n=1729; SMD: -0.03; 95% CI: -0.12 to 0.07; P=.58).

CONCLUSIONS

Low certainty meta-analyses found no clinically significant differences in pain, function, and QoL between single and multiple physiotherapy sessions for MSKD management for the conditions studied. Future research should compare the cost-effectiveness of those different models of care.

Qualitative study exploring the views of patients and healthcare providers on current rehabilitation practices after lumbar fusion surgery

OBJECTIVES

To explore the views of patients and healthcare providers on current rehabilitation after lumbar fusion surgery (LFS) to fuel the development of a novel rehabilitation care pathway.

DESIGN

A cross-sectional, qualitative study with an interpretive descriptive design.

SETTING

Academic and non-academic hospital setting in Belgium.

PARTICIPANTS

31 caregivers from (non)-academic settings and 5 patients with LFS were purposefully sampled and in-depth interviewed.

RESULTS

Out of the data of all interviews, participants reported opinions on 23 thematic clusters that were expressed in a time-contingent manner from the preoperative, perioperative to postoperative phase. Afterwards, themes were mapped to the Consolidated Framework for Implementation Research, with a larger role for concepts related to the innovation, inner and individual domain. As an overarching theme, the importance of an 'individualised, patient-centred rehabilitation built on a strong therapeutic alliance with an accessible interprofessional team' was stressed for patients undergoing LFS. Specifically, participants stated that a biopsychosocial approach to rehabilitation should start in the preoperative phase and immediately be continued postoperatively. No consensus was observed for movement restrictions postoperatively. Uniform communication between the involved caregivers was considered essential for optimal therapeutic alliance and clinical outcome. The precise role and competence of each member of the interprofessional team needs, therefore, to be clearly defined, respected and discussed. An accessible case manager to guide the patient trajectory and tackle problems could further support this. Interestingly, only patients, psychologists and physiotherapists addressed return to work as an important outcome after LFS.

CONCLUSIONS

This qualitative study identified key experiences and points to consider in the current and future rehabilitation pathway for LFS. Future research should incorporate these findings to build a novel rehabilitation pathway for LFS and evaluate its feasibility and cost-effectiveness.

TRIAL REGISTRATION NUMBER

This study was registered at clinicaltrials.gov (NCT03427294).

A modern way to teach and practice manual therapy

BACKGROUND

Musculoskeletal conditions are the leading contributor to global disability and health burden. Manual therapy (MT) interventions are commonly recommended in clinical guidelines and used in the management of musculoskeletal conditions. Traditional systems of manual therapy (TMT), including physiotherapy, osteopathy, chiropractic, and soft tissue therapy have been built on principles such as clinician-centred assessment, patho-anatomical reasoning, and technique specificity. These historical principles are not supported by current evidence. However, data from clinical trials support the clinical and cost effectiveness of manual therapy as an intervention for musculoskeletal conditions, when used as part of a package of care.

PURPOSE

The purpose of this paper is to propose a modern evidence-guided framework for the teaching and practice of MT which avoids reference to and reliance on the outdated principles of TMT. This framework is based on three fundamental humanistic dimensions common in all aspects of healthcare: safety, comfort, and efficiency. These practical elements are contextualised by positive communication, a collaborative context, and person-centred care. The framework facilitates best-practice, reasoning, and communication and is exemplified here with two case studies.

METHODS

A literature review stimulated by a new method of teaching manual therapy, reflecting contemporary evidence, being trialled at a United Kingdom education institute. A group of experienced, internationally-based academics, clinicians, and researchers from across the spectrum of manual therapy was convened. Perspectives were elicited through reviews of contemporary literature and discussions in an iterative process. Public presentations were made to multidisciplinary groups and feedback was incorporated. Consensus was achieved through repeated discussion of relevant elements.

CONCLUSIONS

Manual therapy interventions should include both passive and active, person-empowering interventions such as exercise, education, and lifestyle adaptations. These should be delivered in a contextualised healing environment with a well-developed person-practitioner therapeutic alliance. Teaching manual therapy should follow this model.

Altered upper limb motor behavior in breast cancer survivors and its relation to pain: A narrative review

Breast cancer is the most commonly diagnosed cancer among women and many women suffer from persistent physical and psychological complaints following their cancer treatment. Altered motor behavior at the shoulder region and upper limb, that is, alterations in movement patterns, spatiotemporal movement characteristics and muscle activation patterns, is a common physical consequence of breast cancer treatment, that can have a clear impact on daily life functioning and quality of life. Furthermore, altered upper limb motor behavior is suggested to relate to upper limb pain, which is very commonly reported in breast cancer survivors (BCS). This review, prepared according to the SANRA guidelines, looks into the current understanding of alterations in motor behavior at shoulder and upper limb in BCS, by discussing the factors related to this altered behavior. In this, we specifically focus on the relation between motor behavior and pain. Results of our search show that cancer treatment modality is predictive for shoulder range of motion. Furthermore, single prospective studies show depressive symptoms, living alone, being non-white and low physical activity levels as predicting factors for reduced shoulder range of motion. Pain as factor related to altered motor behavior is only assessed in cross-sectional research, limiting its interpretation in context of being cause or consequence of motor behavioral adaptations, and on the underlying mechanism explaining their relation. It is concluded that studies which explain the mechanisms how and in which subgroup of BCS motor behavioral alterations are associated with pain at the upper limb, are necessary in future.

Improving general practice management of patients with chronic musculoskeletal pain: Interdisciplinarity, coherence, and concerns

OBJECTIVES

Management of patients with chronic musculoskeletal pain (CMP) remains a challenge in general practice. The general practitioner (GP) often experiences diagnostic uncertainty despite frequently referring patients with CMP to specialized departments. Therefore, it remains imperative to gain insights on how to optimize and reframe the current setup for the management of patients with CMP. The objective was to explore GP's perspectives on the challenges, needs, and visions for improving the management of patients with CMP.

METHODS

A qualitative study with co-design using the future workshop approach. Eight GPs participated in the future workshop (five females). Insights and visions emerged from the GP's discussions and sharing of their experiences in managing patients with CMP. The audio-recorded data were subjected to thematic text analysis.

RESULTS

The thematic analysis revealed four main themes, including (1) challenges with current pain management, (2) barriers to pain management, (3) the need for a biopsychosocial perspective, and (4) solutions and visions. All challenges are related to the complexity and diagnostic uncertainty for this patient population. GPs experienced that the patients' biomedical understanding of their pain was a barrier for management and underlined the need for a biopsychosocial approach when managing the patients. The GPs described taking on the role of coordinators for their patients with CMP but could feel ill-equipped to handle diagnostic uncertainty. An interdisciplinary unit was recommended as a possible solution to introduce a biopsychosocial approach for the examination, diagnosis, and management of the patient's CMP.

CONCLUSIONS

The complexity and diagnostic uncertainty of patients with CMP warrants a revision of the current setup. Establishing an interdisciplinary unit using a biopsychosocial approach was recommended as an option to improve the current management for patients with CMP.

Association of meeting 24-hour movement guidelines with low back pain among adults

Background

According to recently published 24-hour movement guidelines, adults should spend: ≥150 minutes/week in moderate-to-vigorous physical activity (MVPA); <8 hours/day in sedentary behaviour (SB); and 7-9 hours/day sleeping.

Objective

We explored the association between meeting these recommendations and low back pain (LBP)-the most common musculoskeletal disorder.

Methods

We collected self-reported data from 2333 adults about: MVPA, SB and sleep duration; frequency and intensity of LBP; and sociodemographic and lifestyle characteristics.

Results

Meeting a combination of SB and sleep recommendations was associated with lower odds of LBP in the past week and past month (adjusted odds ratio [OR]: 0.64 and 0.52, respectively; p < 0.05 for both). Among LBP sufferers, meeting any combination of recommendations that includes sleep was associated with lower odds of frequent (OR range: 0.49-0.61; p < 0.05 for all) and intense (OR range: 0.39-0.66; p < 0.05 for all) LBP in the past week, while meeting a combination of SB and sleep recommendations or all three recommendations was associated with lower odds of intense LBP in the past month and past year (OR range: 0.50-0.68; p < 0.05 for all). The likelihood of experiencing higher frequency and intensity of LBP decreased with the number of recommendations met (p for linear trend < 0.05).

Conclusion

Meeting the SB and sleep recommendations in combination is associated with a lower likelihood of LBP, while adhering to the overall 24-hour movement guidelines or any combination of recommendations that includes sleep is associated with lower frequency and intensity of LBP among LBP sufferers.

'Making every contact count' with patients with musculoskeletal conditions: a qualitative exploration of acceptability to physiotherapists

AIM

To qualitatively explore physiotherapists' experiences and acceptability of implementing 'Making Every Contact Count Healthy Conversation Skills' (MECC HCS) in routine practice with patients with musculoskeletal (MSK) conditions.

METHODS

This article reports the second phase of a mixed method, sequential explanatory study. Physiotherapists trained in and delivering MECC HCS in their practice were invited to take part in semi-structured interviews. We hoped to develop a rich, in-depth understanding of their use and perceptions of the brief intervention and to contextualise findings from the first phase of the study. Qualitative data were analysed using Reflexive Thematic Analysis.

RESULTS

Physiotherapists valued MECC HCS as being integral to their practice, promoting a person-centred approach to supporting behaviour change and enhancing self-management in patients with MSK conditions and pain. It was believed that this brief intervention could reduce workload pressure for physiotherapists and have significant wider benefits for health services. Time limitations associated with appointments did, however, pose as a challenge to MECC HCS delivery, and it was felt that more organisational-level support was needed to sustain it.

CONCLUSIONS

These findings support our quantitative data, collected in the first phase of this study. MECC HCS is a highly acceptable brief intervention that can be delivered in physiotherapy care to support behaviour change in patients with MSK conditions. Future roll-out may be optimised within organisations by providing regular refresher training and adopting a MECC champion.

The feasibility, facilitators, and barriers in the initial implementation phase of 'good life with osteoarthritis in Denmark' (GLA:D®) in Switzerland: a cross-sectional survey

BACKGROUND

The guideline-based, conservative, non-pharmacological management of hip and knee osteoarthritis in clinical practice has been insufficient in Switzerland until now. The implementation of "Good Life with Osteoarthritis in Denmark" (GLA:D®), a programme designed to address this evidence-performance gap, was started in 2019 in Switzerland. This study investigated the acceptance and practicality of the GLA:D® Switzerland programme and identified the facilitators and barriers to its implementation, to support the development of tailored implementation strategies.

METHODS

This is a non-experimental observational study. A cross-sectional survey was performed among the physiotherapists (PTs) of the first five GLA:D® Switzerland certification courses, using the Measurement Instrument for Determinants of Innovations (MIDI) to identify the facilitators and barriers. Descriptive statistics were calculated, and qualitative content analysis was used for open-ended questions.

RESULTS

In the online survey, 86 GLA:D® certified PTs participated (response rate: 61%). The majority of 51 PTs (63.7%) worked in private practices. Of the responding PTs 58 (78.4%) were satisfied with the general concept of the GLA:D® Switzerland programme. Practicality was evaluated positively, particularly the second and third individual session (n = 40 PTs, 83.3%), the 40 m Fast-paced Walk Test (43, 89.6%), the 30 s Chair Stand Test (45, 93.8%), and the exercise programme (40, 83.3%). The marketing (12, 15%), the 'data entry' (5, 10.4%), 'register the patient' (7, 14.6%), and the digital patient questionnaire (9, 14.2%) were rated less positively. In total, 12 facilitators and 12 barriers were identified. The barriers were mainly related to adopting user, e.g., perceived personal disadvantages. Barriers were also found in the organisational context, e.g., time available. Facilitators were associated with the GLA:D® Switzerland programme itself, e.g., completeness, relevance for patients, and the adopting user, e.g., self-efficacy, and in the organisational context, e.g., material resources and facilities. Topics related to the socio-political context were raised in the answers to the open-ended questions, e.g., general awareness level of the GLA:D® Switzerland programme and patient recruitment.

CONCLUSION

The acceptance, practicality and facilitators identified from the initial implementation are encouraging. However, the identified barriers and activities rated with low practicality require tailored strategies to support a successful implementation of the GLA:D® Switzerland programme.

Affordance-based practice: An ecological-enactive approach to chronic musculoskeletal pain management

BACKGROUND

The biomedical understanding of chronic musculoskeletal pain endorses a linear relationship between noxious stimuli and pain, and is often dualist or reductionist. Although the biopsychosocial approach is an important advancement, it has a limited theoretical foundation. As such, it tends to be misinterpreted in manners that lead to artificial boundaries between the biological, psychological, and social, with fragmented and polarized clinical applications.

OBJECTIVE

We present an ecological-enactive approach to complement the biopsychosocial model. In this approach, the disabling aspect of chronic pain is characterized as an embodied, embedded, and enactive process of experiencing a closed-off field of affordances (i.e., shutting down of action possibilities). Pain is considered as a multi-dimensional, multicausal, and dynamic process, not locatable in any of the biopsychosocial component domains. Based on a person-centered reasoning approach and a dispositional view of causation, we present tools to reason about complex clinical problems in face of uncertainty and the absence of 'root causes' for pain. Interventions to open up the field of affordances include building ability and confidence, encouraging movement variability, carefully controlling contextual factors, and changing perceptions through action according to each patient's self-identified goals. A clinical case illustrates how reasoning based on an ecological-enactive approach leads to an expanded, multi-pronged, affordance-based intervention.

CONCLUSIONS

The ecological-enactive perspective can provide an overarching conceptual and practical framework for clinical practice, guiding and constraining clinicians to choose, combine, and integrate tools that are consistent with each other and with a true biopsychosocial approach.

Physiotherapists' perceptions on using a multidimensional clinical reasoning form during psychologically informed training for low back pain

PURPOSE

Building clinical reasoning skills is important to effectively implement psychologically informed practice. We developed a multidimensional clinical reasoning form (CRF) to be used by physiotherapists in a psychologically informed practice training programme for low back pain. In this paper we describe the development of the CRF, how the CRF was used in the training, and present an evaluation of physiotherapists' perceptions of the CRF.

METHODS

Qualitative semi-structured interviews were conducted with ten physiotherapists purposively sampled in primary care. Data were gathered through pre, and post training focus group interviews and a secondary analysis of individual physiotherapist interviews conducted after the training. Thematic analysis was used to analyse the data and capture the emergent themes.

RESULTS

Two main themes emerged before the training: (1) the CRF 'needs formal training' and (2) 'lacked instruction'. Three main themes emerged after the training (1) it provided 'a helpful framework for multidimensional clinical reasoning' (2) the CRF, and accompanying operational definitions, helped physiotherapists 'elicit information, with 'question prompts' helpful in facilitating patient disclosure (3) 'Utility' - although the CRF was not formally used by the physiotherapists it provided a conceptual reasoning framework to work from with more challenging patients.

CONCLUSION

The CRF was not designed to be used in isolation by clinicians without training. However, when used as a training adjunct it appears to be valued by physiotherapists to help develop their critical thinking and better characterise patients' presentations in order to personalise care from a bio-psychosocial perspective.

Evaluation of a blended learning approach on stratified care for physiotherapy bachelor students

BACKGROUND

Stratified models of care are valuable for addressing psychosocial factors which influence the outcome of patients with musculoskeletal disorders. Introducing such models in undergraduate training has the potential to propagate this knowledge with evidence and foster its implementation. The objective of this paper is to explore the perception and changes in the fear-avoidance beliefs of physiotherapy students participating in a developed blended learning course on stratified care.

METHODOLOGY

A mixed-methods with a convenient sample of two consecutive cohorts were given a blended learning course on stratified care for patients with low back pain. The blended learning course comprised scientific rudiments and application of stratified care in clinical practice conceptualised using the KERN' 6-step approach. The exam scores, perceptions, performance on self-reflection-tests and pre- and post-scores on The Tampa Scale for Kinesiophobia for Physiotherapists' (TSK-PT) were obtained. After gaining clinical experience, participants were invited to discuss their clinical experiences and perceptions in workshops. The quantitative data was analysed explorative-descriptively. The qualitative data was analysed following an inductive coding system with constant comparisons.

RESULTS

Ninety-one participants consented to the evaluation (mean age = 22.9 ± 1.6 years), 66% were female. Exam scores correlated with time spent in training (r = 0.30) and scores on self-reflection-tests 1 and 2 (r = 0.40 and r = 0.41). Participants in both cohorts described the learning resources as promoting their interest in the subject (72% and 94%), up-to-date (91% and 93%) and helpful (91% and 97%). The fear-avoidance scores for participants decreased from 53.5 (± 9.96) to 40.1 (± 12.4) with a large effect size (d = 1.18). The regression model [F (2, 49) = 1151.2, p < 0.001] suggests that pre-TSK-PT and the interest of participants in the training predicted post-TSK-PT. The workshop participants (n = 62) all worked in clinical practice. Emerging from the analysis were 4 categories (evolving to maturity in practice, perceiving determinants of stratified care, strategising for implementation and adopting an outlook for future practice).

CONCLUSION

The quality of engagement in learning, training strategy and interest in the subject contributes immensely to learning outcomes. This blended learning course was successful in reducing kinesiophobia and influencing the participants' attitude towards care with the potential of being translated into long-term practice.

Consideration of Psychosocial Factors in Acute Low Back Pain by Physical Therapists

Clinical guidelines consistently recommend screening psychosocial (PS) factors in patients with low back pain (LBP), regardless of its mechanical nature, as recognized contributors to pain chronicity. However, the ability of physiotherapists (PTs) in identifying these factors remains controversial. This study aimed to assess the current identification of psychosocial risk factors by physical therapists (PTs) and which characteristics of PTs are associated with the identification of the main risk for chronicity (physical or psychosocial). A cross-sectional descriptive study surveying Spanish PTs in public and private health services was conducted, including questions on PT characteristics and three low back pain (LBP) patient vignettes with different biopsychosocial (BPS) clinical presentations. From 484 respondents, the majority of PTs agreed regarding the main risk for chronicity for each vignette (PS 95.7% for vignette A, PS and physical 83.5% for vignette B and PS 66% for vignette C). Female PTs were more likely to rate psychosocial compared with males (p < 0.05). PTs with higher levels of social and emotional intelligence (both, p < 0.05) were more likely to identify the main risk for chronicity. However, only gender and social information processing for vignette A (p = 0.024) and emotional clarity for vignette B (p = 0.006) were able to predict the identification of psychosocial and physical risk, respectively. The main risk for chronicity was correctly identified by a large majority of PTs through patient vignettes. Gender, social and emotional intelligence played a relevant role in the recognition of psychosocial risk and biopsychosocial factors.

Virtual reality in the management of patients with low back and neck pain: a retrospective analysis of 82 people treated solely in the metaverse

BACKGROUND

Clinically, neck pain disorders (NPD) and non-specific low back pain (NS-LBP) are respectively the fourth and first most common conditions associated with the greatest number of years lived with disability. Remote delivery of care may benefit healthcare sustainability, reduce environmental pollution, and free up space for those requiring care non-virtual care.

METHODS

A retrospective analysis was performed on 82 participants with NS-LBP and/or NPD who received exercise therapy delivered solely in the metaverse using virtually reality. The study was to determine if this was achievable, safe, had appropriate outcome measures that could be collected, and if there was any early evidence of beneficial effects.

RESULTS

The study demonstrated that virtual reality treatment delivered via the metaverse appears to be safe (no adverse events or side effects). Data for more than 40 outcome measures were collected. Disability from NS-LBP was significantly reduced (Modified Oswestry Low Back Pain Disability Index) by 17.8% (p < 0.001) and from NPD (Neck Disability Index) by 23.2% (p = 0.02).

CONCLUSIONS

The data suggest that this method of providing exercise therapy was feasible, and safe (no adverse events reported), that complete reports were obtained from a large selection of patients, and that software acquired outcomes were obtainable over a range of time points. Further prospective research is necessary to better understand our clinical findings.

Understanding Discrepancies in a Person's Fear of Movement and Avoidance Behavior: A Guide for Musculoskeletal Rehabilitation Clinicians Who Support People With Chronic Musculoskeletal Pain

BACKGROUND: Generic self-report measures do not reflect the complexity of a person's pain-related behavior. Since variations in a person's fear of movement and avoidance behavior may arise from contextual and motivational factors, a person-centered evaluation is required-addressing the cognitions, emotions, motivation, and actual behavior of the person. CLINICAL QUESTION: Most musculoskeletal rehabilitation clinicians will recognize that different people with chronic pain have very different patterns of fear and avoidance behavior. However, an important remaining question for clinicians is "How can I identify and reconcile discrepancies in fear of movement and avoidance behavior observed in the same person, and adapt my management accordingly?" KEY RESULTS: We frame a clinical case of a patient with persistent low back pain to illustrate the key pieces of information that clinicians may consider in a person-centered evaluation (ie, patient interview, self-report measures, and behavioral assessment) when working with patients to manage fear of movement and avoidance behavior. CLINICAL APPLICATION: Understanding the discrepancies in a person's fear of movement and avoidance behavior is essential for musculoskeletal rehabilitation clinicians, as they work in partnership with patients to guide tailored approaches to changing behaviors. J Orthop Sports Phys Ther 2023;53(5):1-10. Epub: 9 March 2023. doi:10.2519/jospt.2023.11420.

'I can feel myself coming out of the rut': a brief intervention for supporting behaviour change is acceptable to patients with chronic musculoskeletal conditions

AIM

To a) understand the perceptions and experiences of patients with musculoskeletal (MSK) conditions in relation to their physiotherapy care and their acceptability of 'Making Every Contact Count Healthy Conversation Skills' (MECC HCS) as a brief intervention within this care and, b) explore the mechanisms through which MECC HCS might facilitate behaviour change and enhance self-management in patients with MSK conditions.

METHODS

This study adopted an exploratory qualitative design, in which individual, semi-structured interviews with participants were conducted. Eight participants were interviewed. Five had been engaging with physiotherapists trained in and delivering MECC HCS within their routine physiotherapy appointments and three had been engaging with physiotherapists who had not received this training and were instead delivering usual care. MECC HCS is a person-centred approach to behaviour change that aims to empower individuals to take control of their health behaviours by building self-efficacy. The MECC HCS training programme helps healthcare professionals to develop skills in i) using 'open discovery' questions to explore context and allow patients to identify barriers and generate solutions; ii) listening more than giving information/ making suggestions; iii) reflecting on practice and iv) supporting Specific, Measurable, Action-oriented, Realistic, Timed, Evaluated, Reviewed (SMARTER) goal setting.

RESULTS

Those who had engaged with MECC HCS trained physiotherapists found their physiotherapy care highly acceptable and felt that their physiotherapist listened to them, tried to understand their context and world, and helped them plan for change. These individuals experienced increases in self-efficacy and motivation for self-managing their MSK conditions. A need for continued support following physiotherapy treatment was, however, emphasised for long-term self-management.

CONCLUSIONS

MECC HCS is highly acceptable to patients with MSK conditions and pain and may successfully facilitate health-promoting behaviour change and enhance self-management. Providing opportunities to join support groups following physiotherapy treatment may promote long-term self-management and provide social and emotional benefits for individuals. The positive findings of this small qualitative study warrant further investigation on the differences in experiences and outcomes between patients engaging with MECC HCS physiotherapists and those receiving treatment as usual during routine physiotherapy care.

Comprehensive assessment and classification of upper and lower limb pain in athletes: a scoping review

BACKGROUND

Upper and lower limb (peripheral) pain is prevalent in athletes. Contemporary research prioritises multidimensional pain assessment and classification. This study aims to review comprehensive athlete pain assessment practices against the reference standard (International Olympic Committee, IOC Athlete Pain framework), identifying trends and highlighting gaps.

METHODS AND ANALYSIS

Six databases were searched using a comprehensive search strategy. This review followed the Joanna Briggs Institute standardised methodology for scoping reviews and is reported in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews. Title and abstract, full-text screening and data charting were completed by two independent reviewers.

INCLUSION CRITERIA

Original research, systematic reviews and clinical practice guidelines reporting assessment or classification of pain in athletes of any age with chronic or acute peripheral pain in English on human participants from database inception.

RESULTS

470 studies with 175 different pain assessment tools were mapped against the IOC Athlete Pain Framework. Papers included tools from neurophysiological (470/100%), biomechanical (425/90%), affective (103/22%), cognitive (59/13%) and socioenvironmental (182/39%) domains. Pain classification was included in 108 studies (23%). 4 studies (0.85%) defined pain. Athletes with physical disability were included in 13 (3%) studies and no studies included athletes with intellectual disabilities. Socioeconomic factors were addressed in 29 (6%) studies.

DISCUSSION

Neurophysiological and biomechanical domains are frequently addressed. Affective, socioenvironmental and cognitive tools are under-represented. Potential tools for use by researchers and clinicians are highlighted. Defining and classifying pain and determining predominant pain mechanisms is needed in both research and clinical practice. More work on underrepresented populations is needed.

CONCLUSION

This review informs researchers and clinicians working with athletes in pain how pain assessment and classification is currently conducted and highlights future priorities.

Experiences and needs of physiotherapists and exercise therapists regarding the management of working people with complaints of the arm, neck and shoulder (CANS): A focus group study

BACKGROUND

Non-traumatic complaints of the arm, neck and/or shoulder (CANS) are difficult-to-treat musculoskeletal conditions. CANS treatment has varying degrees of success, particularly in the working population.

OBJECTIVES

To evaluate the experiences and needs of physiotherapists (PTs) and exercise therapists (ETs) regarding the treatment of working patients with CANS.

DESIGN

An exploratory qualitative focus group study was conducted.

METHOD

Qualitative data were collected from 27 therapists who were purposefully recruited for their broad range of experience and qualifications. The data was analysed using thematic analysis.

RESULTS

Both PTs and ETs assess CANS extensively by exploring their patients' psychosocial factors, work-related factors, illness beliefs, and working conditions. Therapists apply hands-off treatment interventions, such as coaching the patient to make behavioural changes and providing self-management support. However, therapists experience many difficulties in these areas, resulting in a need to learn more about coaching techniques for behavioural change, engaging in meaningful conversations about the patient's perspective, supporting patients in building a strong social network in the workplace, and creating a professional network for collaboration.

CONCLUSIONS

The treatment of working people with CANS is difficult for PTs and ETs. Therapists express a need to learn more about supporting self-management, applying coaching techniques and engaging in meaningful conversations. Moreover, therapists indicate a need to establish a professional multidisciplinary network to support collaborations with other disciplines to treat working patients with CANS.

Patient perspectives of care pathways for people with low back pain: A qualitative study

BACKGROUND

Low back pain (LBP) care pathways aim to enhance health outcomes through patient-clinician mutual decision-making and care coordination. However, challenges to successful translation into practice include patients' understanding, expectation, and acceptance of treatment and management strategies for LBP. This study explored patients' perspectives and/or experience of care pathways and their involvement in decision-making in primary care.

METHODS

A qualitative descriptive design was adopted. Semi-structured interviews were conducted with 14 participants with LBP recruited from the community. Inductive thematic analysis of the qualitative data was conducted within the design framework to enable a systematic comparison of experiences across participants and within individual cases.

RESULTS

Five themes described participant perspectives and understanding of care pathways: i) care pathways can guide decision-making; ii) familiarity with no and/or stepped care pathway, but preference for matched or blend of care pathways; iii) engaging in shared decision-making; iv) patient-related barriers to implementation; v) patient-related facilitators to implementation.

CONCLUSIONS

Participants felt that existing care pathways did not meet their needs when pain persisted. Participants preferred matched or hybrid care pathways and suggested that implementation of such pathways should focus on addressing an individual's needs. Adopting a holistic approach, and clarity in shared decision-making, were deemed crucial for effective implementation of LBP pathways in practice. Consumer (patient) engagement in the design of LBP care pathways is recommended.

Are psychosocial variables, sleep characteristics or central pain processing prognostic factors for outcome following rotator cuff repair? A protocol for a prospective longitudinal cohort study

INTRODUCTION

Prognosis following surgical rotator cuff repair (RCR) is often established through the assessment of non-modifiable biomedical factors such as tear size. This understates the complex nature of recovery following RCR. There is a need to identify modifiable psychosocial and sleep-related variables, and to find out whether changes in central pain processing influence prognosis after RCR. This will improve our knowledge on how to optimise recovery, using a holistic rehabilitation approach.

METHODS AND ANALYSIS

This longitudinal study will analyse 141 participants undergoing usual care for first time RCR. Data will be collected 1-21 days preoperatively (T1), then 11-14 weeks (T2) and 12-14 months (T3) postoperatively. We will use mixed-effects linear regression to assess relationships between potential prognostic factors and our primary and secondary outcome measures-the Western Ontario Rotator Cuff Index; the Constant-Murley Score; the Subjective Shoulder Value; Maximal Pain (Numeric Rating Scale); and Quality of Life (European Quality of Life, 5 dimensions, 5 levels). Potential prognostic factors include: four psychosocial variables; pain catastrophising, perceived stress, injury perceptions and patients' expectations for RCR; sleep; and four factors related to central pain processing (central sensitisation inventory, temporal summation, cold hyperalgesia and pressure pain threshold). Intercorrelations will be assessed to determine the strength of relationships between all potential prognostic indicators.Our aim is to explore whether modifiable psychosocial factors, sleep-related variables and altered central pain processing are associated with outcomes pre-RCR and post-RCR and to identify them as potential prognostic factors.

ETHICS AND DISSEMINATION

The results of the study will be disseminated at conferences such as the European Pain Congress. One or more manuscripts will be published in a peer-reviewed SCI-ranked journal. Findings will be reported in accordance with the STROBE statement and PROGRESS framework. Ethical approval is granted by the Ethical commission of Canton of Zurich, Switzerland, No: ID_2018-02089 TRIAL REGISTRATION NUMBER: NCT04946149.

Reconfiguring the biomedical dominance of pain: time for alternative perspectives from health promotion?

Strategies to reduce the burden of persistent pain in society are rooted in a biomedical paradigm. These strategies are located downstream, managing persistent pain once it has become a problem. Upstream activities that create social conditions to promote health and well-being are likely to help, yet health promotion discourse and research are lacking in pain literature. In this article, we argue that the subjective nature of pain has not sat comfortably with the objective nature of medical practice. We argue that the dominance of the biomedical paradigm, with a simplistic 'bottom-up' model of pain being an inevitable consequence of tissue damage, has been detrimental to the health and well-being of people living with persistent pain. Evidence from neuroscience suggests that bodily pain emerges as a perceptual inference based on a wide variety of contextual inputs to the brain. We argue that this supports community, societal and environmental solutions to facilitate whole-person care. We call for more salutogenic orientations to understand how people living with persistent pain can continue to flourish and function with good health. We suggest a need for 'upstream' solutions using community-based approaches to address cultural, environmental, economic and social determinants of health, guided by principles of equity, civil society and social justice. As a starting point, we recommend appraising the ways human society appreciates the aetiology, actions and solutions towards alleviating persistent pain.

Management of Chronic Musculoskeletal Disorders in the Workplace from the Perspective of Older Employees: A Mixed Methods Research Study

(1) Background: This mixed methods research (MMR) study explored older employees’ experiences of chronic musculoskeletal disorders (CMSDs) in relation to their employment, their perspectives on managing these conditions in the workplace and the strategies used to facilitate and maintain their roles and responsibilities. The services offered to them were also identified. (2) Methods: A mixed methods exploratory sequential design was implemented. In the first qualitative phase, 16 semi-structured interviews gathered in-depth information from older employees. The findings informed the development of an online questionnaire in the survey phase, which was administered to older employees (N = 107). Both sets of findings were then integrated using a narrative joint display. (3) Results: The phenomena of presenteeism and leaveism were important components of employees’ strategies for managing their condition. The integrated findings highlighted the roles of employers, managers and social support in encouraging disclosure and supporting the management of CMSDs. The results also emphasised how self-management and professional health services are crucial for sustaining employability. (4) Conclusions: Current challenges call for employers to identify effective ways to support the ageing workforce and invest in training opportunities for managers and collaborative opportunities with healthcare professionals and other stakeholders. A flexible, empathetic and resourceful work environment is optimal for supporting sustained employability for an ageing workforce.

‘I am the educator and the learner at the same time’: a qualitative survey of the knowledge and use of adult learning theory in UK musculoskeletal physiotherapists' patient education

Background/Aims

Patient education is a core component of musculoskeletal care, yet broad definitions exist and effective delivery methods are unclear. Musculoskeletal physiotherapists' use of patient education has been described as individualised and collaborative, reflecting a person-centred model of care. However, discrepancies between perceived and actual practice, and therapist-centred approaches to education, have been observed. Little is known about the theoretical basis of musculoskeletal physiotherapists' patient education practice, yet the adult learning theory frames how adults interact with education and echoes the principles of person-centred care. The aim of this study was to analyse the use of adult learning theory to inform patient education practice among UK musculoskeletal physiotherapists.

Methods

This study used a novel, online questionnaire to collect quantitative and qualitative data from a self-selecting sample of UK musculoskeletal physiotherapists, using a multimodal recruitment strategy. Complete responses were provided by 66 participants. Categorical and narrative data were collected and descriptive and thematic analyses undertaken.

Results

Participants generally self-rated their educational competencies highly, with the exception of evaluating patient education. Participants were more familiar with reflective and self-directed learning than with other adult learning theories. Two main themes were described: implicit adult learning theory knowledge and challenges in applying adult learning theory.

Conclusions

The results suggest that musculoskeletal physiotherapists may have implicit knowledge of adult learning theory, yet challenges exist in applying them. This finding supports the establishment of ongoing training in educational skills for physiotherapists and could be used as a catalyst for musculoskeletal physiotherapists to reflect on their knowledge and use of adult learning theory.

Patients' and physiotherapists' perspectives on implementing a tailored stratified treatment approach for low back pain in Nigeria: a qualitative study

BACKGROUND

Stratified care has the potential to be efficient in addressing the physical and psychosocial components of low back pain (LBP) and optimise treatment outcomes essential in low-income countries. This study aimed to investigate the perceptions of physiotherapists and patients in Nigeria towards stratified care for the treatment of LBP, exploring barriers and enablers to implementation.

METHODS

A qualitative design with semistructured individual telephone interviews for physiotherapists and patients with LBP comprising research evidence and information on stratified care was adopted. Preceding the interviews, patients completed the Subgroups for Targeted Treatment tool. The interviews were recorded, transcribed and analysed following grounded theory methodology.

RESULTS

Twelve physiotherapists and 13 patients with LBP participated in the study (11 female, mean age 42.8 (SD 11.47) years). Seven key categories emerged: recognising the need for change, acceptance of innovation, resistance to change, adapting practice, patient's learning journey, trusting the therapist and needing conviction. Physiotherapists perceived stratified care to be a familiar approach based on their background training. The prevalent treatment tradition and the patient expectations were seen as major barriers to implementation of stratified care by the physiotherapists. Patients see themselves as more informed than therapists realise, yet they need conviction through communication and education to cooperate with their therapist using this approach. Viable facilitators were also identified as patients' trust in the physiotherapist and adaptations in terms of training and modification of the approach to enhance its use.

CONCLUSION

Key barriers identified are the patients' treatment expectations and physiotherapists' adherence to the tradition of practice. Physiotherapists might facilitate implementation of the stratified care by communication, hierarchical implementation and utilisation of patients' trust. Possibilities to develop a consensus on key strategies to overcome barriers and on utilisation of facilitators should be tested in future research.

Effects of Gaming on Pain-Related Fear, Pain Catastrophizing, Anxiety, and Depression in Patients with Chronic Musculoskeletal Pain: A Systematic Review and Meta-Analysis

The aim was to systematically review the effects of gaming on pain-related fear, pain catastrophizing, anxiety, and depression in patients with chronic musculoskeletal pain. Databases (Medline, EMBASE, PsycInfo, CINAHL, Cochrane Central Register for Controlled Trials [CENTRAL], Web of Science, and SCOPUS) were searched from inception up to October 2021. Two reviewers independently selected randomized controlled trials that compared the effects of any gaming modality with other interventions or no treatment on pain-related fear, pain catastrophizing, anxiety, and depression. For data synthesis, Standardized Mean Differences (SMDs) and 95% confidence interval (CI) were calculated using a random-effects inverse variance model for meta-analysis according to the outcome of interest, comparison group, and follow-up period. The level of evidence was synthesized using Grading of Recommendations, Assessment, Development, and Evaluations (GRADE). Thirteen studies were included with a total sample of 680 patients. Gaming was superior to other treatments and no treatment on reducing pain-related fear (SMD: -1.23; 95% CI: -2.02 to -0.44) and anxiety (SMD: -0.55; 95% CI: -1.01 to -0.09), respectively. Gaming was not superior to other treatments on reducing pain catastrophizing, anxiety, and depression, and it was not superior to no treatment on reducing pain-related fear, pain catastrophizing, and depression. Those findings were based on very low or low-quality evidence. In a conclusion, gaming modalities may have positive effects on some mental health outcomes. However, there were conflicting results with low-quality evidence, which indicates that more high-quality randomized controlled trials are needed.

The prevalence of musculoskeletal pain and therapy needs in adults with Osteogenesis Imperfecta (OI) a cross-sectional analysis

BACKGROUND

Osteogenesis Imperfecta affects approximately 1 in every 10,000 people. Musculoskeletal disorders and pain are common in adults with Osteogenesis Imperfecta, but specific knowledge of the problems people have is lacking. Access to therapy services for adults with Osteogenesis Imperfecta is variable. We designed this analysis to better understand the musculoskeletal disorders and consequent therapy needs for adults with Osteogenesis Imperfecta.  METHODS: This study was a cross-sectional analysis of outpatients with Osteogenesis Imperfecta. Adults attending a newly established multidisciplinary clinic at a tertiary centre in 2019 were included. A highly specialist physiotherapist worked within the clinic to offer therapy input if required and to refer patients to appropriate therapy as needed. People over the age of 18 were included if they had a diagnosis of Osteogenesis Imperfecta. Data were collected over a five month period using routinely collected clinical information and patient reported outcomes.

RESULTS

Over five months 50 patients attended the clinic. Musculoskeletal pain was a significant feature reported by 84% of patients. Over 50% of patients reported persistent pain for longer than one year duration and the most common site of pain was in the spine (46%). No difference in pain between types of OI and age. Forty five per cent (n = 19) of patients reported moderate to severe problems with mobility on the EQ-5D with over half reporting problems with self-care and ability to carry out usual activities. Over 50% of patients in clinic also reported anxiety (EQ-5D). During the consultation 70% of patients received therapy input which was either advice in clinic or an onward referral to the appropriate service. The referral rate to specialist out-patient rehabilitation services at a tertiary centre was 30%.

CONCLUSIONS

This analysis highlights the high prevalence of MSK pain in adults with OI and the effect on physical function and emotional wellbeing. This study demonstrates the diverse needs of the adult Osteogenesis Imperfecta population and the need for suitable multidisciplinary therapy services.

Unraveling Negative Expectations and Nocebo-Related Effects in Musculoskeletal Pain

This Perspective adapts the ViolEx Model, a framework validated in several clinical conditions, to better understand the role of expectations in the recovery and/or maintenance of musculoskeletal (MSK) pain. Here, particular attention is given to the condition in which dysfunctional expectations are maintained despite no longer being supported by confirmatory evidence (i.e., belief-lifting the arm leads to permanent tendon damage; evidence-after the patient lifts the arm no tendon damage occurs). While the ViolEx Model suggests that cognitive immunization strategies are responsible for the maintenance of dysfunctional expectations, we suggest that such phenomenon can also be understood from a Bayesian Brain perspective, according to which the level of precision of the priors (i.e., expectations) is the determinant factor accounting for the extent of priors' updating (i.e., we merge the two frameworks, suggesting that highly precise prior can lead to cognitive immunization responses). Importantly, this Perspective translates the theory behind these two frameworks into clinical suggestions. Precisely, it is argued that different strategies should be implemented when treating MSK pain patients, depending on the nature of their expectations (i.e., positive or negative and the level of their precision).

Needs assessment for health service design for people with back pain in a hospital setting: A qualitative study

BACKGROUND

There is a need for effective health service solutions to provide greater structure and support for implementing evidence-based practice in back pain care. Patient involvement in developing these solutions is crucial to increase relevance, acceptability and uptake.

OBJECTIVES

To determine patients' perceived needs and barriers to best-practice back pain care, and potential solutions to better address care needs. The study is the third in a series of needs assessment studies feeding into the 'idea generation' for service design in a large teaching hospital in a culturally and linguistically diverse community in metropolitan Sydney, Australia.

DESIGN

We conducted a combination of focus groups and in-depth interviews using an interpretive description approach. We used inductive thematic analysis to identify the main themes.

SETTING AND PARTICIPANTS

We purposively sampled patients with diverse characteristics from the neurosurgery and physiotherapy outpatient clinics, in particular those whose primary language was English, Arabic, Persian or Mandarin. Non-English audio recordings were translated and transcribed by bilingual researchers.

RESULTS

There were 24 participants (focus groups = 9; individual interviews = 15) when data saturation was reached. The analysis identified three key themes with several subthemes around what service designers needed to understand in helping people with back pain in this setting: (1) This is who I am; (2) It's not working for me; and (3) What I think I need.

DISCUSSION AND CONCLUSION

This study highlights that perceived unmet needs of patients are underpinned by unhelpful beliefs about the causes of and solutions for back pain, misaligned care expectations, unclear expectations of the hospital role and fragmentations in the health system. To design and implement a service that can deliver better back pain care, several solutions need to be integrated around: developing new resources that challenge unhelpful beliefs and set realistic expectations; improving access to education and self-management resources; focusing on individualized care; using a collaborative multidisciplinary approach within the hospital; and better connecting with and directing primary health care services.

PATIENT OR PUBLIC CONTRIBUTION

A consumer representative of the Western Sydney Local Health District provided input during study conceptualisation and is duly recognized in the Acknowledgements section.

From Fear to Safety: A Roadmap to Recovery From Musculoskeletal Pain

Contemporary conceptualizations of pain emphasize its protective function. The meaning assigned to pain drives cognitive, emotional, and behavioral responses. When pain is threatening and a person lacks control over their pain experience, it can become distressing, self-perpetuating, and disabling. Although the pathway to disability is well established, the pathway to recovery is less researched and understood. This Perspective draws on recent data on the lived experience of people with pain-related fear to discuss both fear and safety-learning processes and their implications for recovery for people living with pain. Recovery is here defined as achievement of control over pain as well as improvement in functional capacity and quality of life. Based on the common-sense model, this Perspective proposes a framework utilizing Cognitive Functional Therapy to promote safety learning. A process is described in which experiential learning combined with "sense making" disrupts a person's unhelpful cognitive representation and behavioral and emotional response to pain, leading them on a journey to recovery. This framework incorporates principles of inhibitory processing that are fundamental to pain-related fear and safety learning.

At my own pace, space, and place: a systematic review of qualitative studies of enablers and barriers to telehealth interventions for people with chronic pain

ABSTRACT

Telehealth is a promising approach to support self-management with the potential to overcome geographical barriers. Understanding patient perspectives will identify practical challenges to delivering self-management strategies by telehealth. The aim of this study was to synthesize the perceptions of people with chronic musculoskeletal pain for engaging in interventions delivered using telehealth. We searched MEDLINE, Embase, CINAHL, LILACS, and PsycINFO databases. We included qualitative studies that explored perceptions or experiences or attitudes of people with chronic musculoskeletal pain engaging with telehealth. We assessed the methodological quality using the Critical Appraisal Skills Programme checklist. Meta-synthesis was guided by a thematic synthesis approach. The level of confidence of review findings was assessed using the Confidence in the Evidence from Reviews of Qualitative Studies (GRADE-CERQual). Twenty-one studies were included (n = 429). Telehealth comprised web-based, videoconference-based, telephone-based, video-based, and smartphone app-based programs delivered solely or combined. Chronic musculoskeletal conditions included people with knee or hip osteoarthritis, chronic low back pain, persistent pain (chronic joint pain or nonspecific chronic musculoskeletal pain), rheumatoid arthritis, and functional fatigue syndrome. The enablers for engaging in telehealth interventions were as follows: (1) "at my own pace, space, and place" and (2) empowered patient. Barriers to engaging in telehealth interventions were as follows: (1) impersonal, (2) technological challenges, (3) irrelevant content, and (4) limited digital (health) literacy. Telehealth interventions with well-designed interactive platforms, flexibility to fit patients' routine, and the broad availability of material may favor better engagement. Encouragement of self-efficacy is linked to successful telehealth-delivered self-management programs.

Patient-centered care in musculoskeletal practice: Key elements to support clinicians to focus on the person

Musculoskeletal rehabilitation, including physiotherapy, needs to move towards a broader biopsychosocial understanding of musculoskeletal conditions and the delivery of high-value care for people with persistent pain conditions, in which a patient-centered approach is a key feature. However, it has been reported that clinicians experience difficulties with integrating patient-centered care principles into their clinical practice. Based on a focused symposium about patient-centered care for patients with musculoskeletal conditions, held during the online 2021 World Physiotherapy Congress, the purpose of this article is to share key elements of the content of this symposium with a wider audience, aimed at enabling clinicians to enhance patient-centeredness in their current practice. These key elements include establishing meaningful connections, deciding together and self-management support. Moreover, challenges on patient-centered care in low/middle income countries will be discussed and recommendations to implement patient-centered care in clinical practice will be provided.

Physiotherapist beliefs and perspectives on virtual reality-supported rehabilitation for the assessment and management of musculoskeletal shoulder pain: a focus group study protocol

Shoulder pain accounts for a large proportion of musculoskeletal disorders and years lived with disability. Musculoskeletal shoulder pain is challenging to manage and while research evidence suggests that exercise should be a cornerstone of shoulder pain rehabilitation, the exact type and dosage of exercise is unclear. Adherence is a barrier to successful outcomes with exercise-based management of musculoskeletal pain, especially for those with co-morbidities, high pain levels and reported boredom associated with competing prescribed exercise. Virtual reality (VR) may offer an effective platform for rehabilitation of musculoskeletal shoulder pain. Virtual Reality has been shown to be effective for management of acute and chronic pain conditions, for delivering education around various health conditions, and for supporting rehabilitation of neurological conditions. Therefore, it is possible that VR may have a role in the delivery of exercise and education for individuals with musculoskeletal shoulder pain. VR intervention design should involve several steps and begin with establishing early acceptability from users as to the suitability of the technology in clinical practice as well as potential barriers and facilitators to using the technology successfully. This study will therefore aim to explore physiotherapists beliefs and perspectives of immersive VR as a platform for assessment and rehabilitation in patients with musculoskeletal shoulder pain. Further, this study will inform the development of a VR intervention for use in the rehabilitation of musculoskeletal shoulder pain. A series of online focus groups will be conducted with physiotherapists in Ireland using a qualitative descriptive approach to data analysis. A six-phase process of data analysis will be carried out to identify important patterns and themes within the data. The current study will be the first to explore clinician's perspectives on the role of VR in musculoskeletal practice.

Experiences, barriers and needs of physiotherapists with regard to providing self-management support to people with low back pain: A qualitative study

BACKGROUND

A person-centred, biopsychosocial approach focused on self-management and a healthy lifestyle is recommended for managing non-specific low back pain (LBP).

OBJECTIVE

What are the experiences of physiotherapists with regard to providing self-management support to people with non-specific LBP?

DESIGN

Exploratory qualitative.

METHODS

Fourteen semi-structured interviews were conducted with physiotherapists in the Netherlands using a semi-structured and pilot tested interview guide. Data were analysed using inductive thematic analysis.

RESULTS

Physiotherapists believe that self-management has added value in the management of people with non-specific LBP. Motivational interviewing, providing advice and exercise were most frequently used to facilitate behaviour change aimed at enhancing patients' self-management. Support regarding self-management skills was not frequently mentioned. Physiotherapists are not fully aware of and do not fully integrate support with regard to important self-management skills. The most important barrier participants experienced with regard to integrating self-management was patient expectations. Another important barrier was addressing psychosocial factors. Most participants expressed a need to better integrate self-management support in their treatment. They explained that they needed more knowledge (courses, knowledge clips), opportunities to exchange experiences (peer review group) and tools for patients (app).

CONCLUSIONS

Physiotherapists do not fully integrate support with regard to important self-management skills in people with non-specific LBP. We recommend that physiotherapists address the identified barriers and needs and better include self-management support in their treatment of people with non-specific LBP. We recommend important stakeholders to collectively work on diminishing barriers to integrating self-management support.

Therapists' experiences and needs with regard to providing work-focused care: a focus group study

BACKGROUND

Musculoskeletal disorders (MSDs) can create a temporary or permanent disability that reduce a person's ability to work. Physiotherapists (PTs), occupational therapists (OTs) and exercise therapists (ETs) are often involved in the early management of MSDs. There is a need for additional insights into therapists' experiences, barriers and needs to work-focused care. Moreover, there is no evidence on how OTs and ETs address work participation. Therefore, the aim of this qualitative study was 1) to investigate how generalist PTs, OTs and ETs provide work-focused healthcare and 2) to obtain insight into their perceived barriers and needs that affect their ability to address occupational factors.

METHODS

An exploratory qualitative study using three focus groups. Generalist PTs, OTs and ETs were eligible to participate if they treated working patients with MSDs. A semi-structured interview guide with open-ended questions was developed. Two moderators facilitated each focus group using the interview guide, and all the groups were audio recorded. Data were analysed using inductive thematic analysis.

RESULTS

Sixteen therapists (mean age 44 years, range 25-59) participated in this study. Participants were aware of the importance of taking occupational factors into account. Whether they address occupational factors is largely dependent on the patient's request for help. However, ETs and OTs consider it normal to ask about occupational factors during the diagnostic process, while PTs often address this in later consultations. Almost all participants were unaware of the existence of PTs, OTs or ETs who are specialised in occupational health. Moreover, almost all participants struggled with when to refer a patient to other (occupational) healthcare professionals. This study identified several needs of therapists. These included knowledge about laws and legislation and skills for identifying and addressing work-related or work-relevant complaints.

CONCLUSIONS

Participants in this qualitative study were aware of the importance of taking occupational factors into account. However, how PTs, OTs and ETs address work participation and the extent to which they do so can be improved. There was a lack of knowledge about and cooperation with occupational health professionals, including PTs, OTs or ETs specialised in occupational health.

Taking patients to the ice cream shop but telling them that they cannot have ice cream: a qualitative study of orthopaedic spine clinicians' perceptions of persistent low back pain consultations

OBJECTIVE

This study aimed to explore the perceptions of orthopaedic clinicians about consultations for people with persistent musculoskeletal low back pain (PMLBP) in which surgery is not recommended. Surgery is not recommended for the majority of PMLBP consulting in secondary care settings.

SETTING

Secondary care sector in the UK.

PARTICIPANTS

Semi-structured qualitative interviews were conducted with 24 orthopaedic team clinicians from 17 different hospitals in the UK and Ireland. Interviews explored clinicians' perceptions of the challenges in consultations where surgery is not indicated. Interviews were transcribed verbatim and analysed using thematic analysis.

RESULTS

Two meta-themes, Difficulties and Enablers, each consisting of several subthemes were identified. Difficulties included challenges around the choice of appropriate terminology and labels for PMLBP, managing patients' expectations, working with mentally vulnerable patients and explaining imaging findings. Enablers included early management of expectations, use of routine imaging, triaging, access to direct referral elsewhere, including other non-surgical practitioners in the team, training to improve communication skills and understanding of psychological issues.

CONCLUSION

The findings highlight clinicians' perceived need for concordance in messages delivered across the care pathway and training of orthopaedic clinicians to deliver effective reassurance and address patients' needs in circumstances where surgery is not indicated.

Chronic pain: good management of practical pain control strategies is associated with being older, more health activated and having better mental health

INTRODUCTION Chronic pain affects a large proportion of the adult population and people in pain need to learn how to manage it in order to maintain quality of life. AIM This study aimed to examine how well people with long-term conditions make use of self-management strategies to control their pain, and to identify personal attributes associated with a higher degree of success. METHODS People with chronic pain who participated in the first phase of a longitudinal long-term conditions study in the MidCentral region made up the study sample (N=326, response rate 21%). They completed a questionnaire by mail or online, which included items on pain management, general health, patient activation, experiences with general practice and demographics. RESULTS Pain control strategies were managed fairly well overall. Taking pain medication and avoiding caffeine, alcohol, heavy meals and exercise before bed were managed best, whereas sleep, relaxation breathing and remaining socially active were managed least well. A multiple regression analysis found higher scores on patient activation, self-rated overall pain management at home, mental health and older age (≥75 years) to be associated with better management. DISCUSSION This study identified pain control strategies that are managed well, and less well, outside of a specific intervention. Results highlight topics for discussion in consultations and identify areas where general practice could provide better self-management support, such as sleep and exercise. Better overall pain control strategy management was most strongly associated with patient activation; that is, a combination of knowledge, skills and confidence to manage health and health care that is amenable to intervention. Improving the level of activation in people with long-term conditions may enhance their use of pain control strategies.

Unintended consequences: quantifying the benefits, iatrogenic harms and downstream cascade costs of musculoskeletal MRI in UK primary care

OBJECTIVES

The largest proportion of general practitioner (GP) magnetic resonance imaging (MRI) is musculoskeletal (MSK), with consistent annual growth. With limited supporting evidence and potential harms from early imaging overuse, we evaluated practice to improve pathways and patient safety.

METHODS

Cohort evaluation of routinely collected diagnostic and general practice data across a UK metropolitan primary care population. We reviewed patient characteristics, results and healthcare utilisation.

RESULTS

Of 306 MSK-MRIs requested by 107 clinicians across 29 practices, only 4.9% (95% CI ±2.4%) appeared clearly indicated and only 16.0% (95% CI ±4.1%) received appropriate prior therapy. 37.0% (95% CI ±5.5%) documented patient imaging request. Most had chronic symptoms and half had psychosocial flags. Mental health was addressed in only 11.8% (95% CI ±6.3%) of chronic sufferers with psychiatric illness, suggesting a solely pathoanatomical approach to MSK care. Only 7.8% (95% CI ±3.0%) of all patients were appropriately managed without additional referral. 1.3% (95% CI ±1.3%) of scans revealed diagnoses leading to change in treatment (therapeutic yield). Most imaged patients received pathoanatomical explanations to their symptoms, often based on expected age or activity-related changes. Only 16.7% (95% CI ±4.2%) of results appeared correctly interpreted by GPs, with spurious overperception of surgical targets in 65.4% (95% CI ±5.3%) who suffered 'low-value' (ineffective, harmful or wasteful) post-MRI referral cascades due to misdiagnosis and overdiagnosis. Typically, 20%-30% of GP specialist referrals convert to a procedure, whereas MRI-triggered referrals showed near-zero conversion rate. Imaged patients experienced considerable delay to appropriate care. Cascade costs exceeded direct-MRI costs and GP-MSK-MRI potentially more than doubles expenditure compared with physiotherapist-led assessment services, for little-to-no added therapeutic yield, unjustifiable by cost-consequence or cost-utility analysis.

CONCLUSION

Unfettered GP-MSK-MRI use has reached unaccceptable indication creep and disutility. Considerable avoidable harm occurs through ubiquitous misinterpretation and salient low-value referral cascades for two-thirds of imaged patients, for almost no change in treatment. Any marginally earlier procedural intervention for a tiny fraction of patients is eclipsed by negative consequences for the vast majority. Only 1-2 patients need to be scanned for one to suffer mismanagement. Direct-access imaging is neither clinically, nor cost-effective and deimplementation could be considered in this setting. GP-MSK-MRI fuels unnecessary healthcare utilisation, generating nocebic patient beliefs and expectations, whilst appropriate care is delayed and a high burden of psychosocial barriers to recovery appear neglected.

The Challenges and Perspectives of the Integration Between Virtual and Augmented Reality and Manual Therapies

Virtual reality (VR) and augmented reality (AR) have been combined with physical rehabilitation and psychological treatments to improve patients' emotional reactions, body image, and physical function. Nonetheless, no detailed investigation assessed the relationship between VR or AR manual therapies (MTs), which are touch-based approaches that involve the manipulation of tissues for relieving pain and improving balance, postural stability and well-being in several pathological conditions. The present review attempts to explore whether and how VR and AR might be integrated with MTs to improve patient care, with particular attention to balance and to fields like chronic pain that need an approach that engages both mind and body. MTs rely essentially on touch to induce tactile, proprioceptive, and interoceptive stimulations, whereas VR and AR rely mainly on visual, auditory, and proprioceptive stimulations. MTs might increase patients' overall immersion in the virtual experience by inducing parasympathetic tone and relaxing the mind, thus enhancing VR and AR effects. VR and AR could help manual therapists overcome patients' negative beliefs about pain, address pain-related emotional issues, and educate them about functional posture and movements. VR and AR could also engage and change the sensorimotor neural maps that the brain uses to cope with environmental stressors. Hence, combining MTs with VR and AR could define a whole mind-body intervention that uses psychological, interoceptive, and exteroceptive stimulations for rebalancing sensorimotor integration, distorted perceptions, including visual, and body images. Regarding the technology needed to integrate VR and AR with MTs, head-mounted displays could be the most suitable devices due to being low-cost, also allowing patients to follow VR therapy at home. There is enough evidence to argue that integrating MTs with VR and AR could help manual therapists offer patients better and comprehensive treatments. However, therapists need valid tools to identify which patients would benefit from VR and AR to avoid potential adverse effects, and both therapists and patients have to be involved in the development of VR and AR applications to define truly patient-centered therapies. Furthermore, future studies should assess whether the integration between MTs and VR or AR is practically feasible, safe, and clinically useful.

Cognitive biases cloud our clinical decisions and patient expectations: a narrative review to help bridge the gap between evidence-based and personalized medicine

In sports medicine and rehabilitation of musculoskeletal conditions, training, knowledge and expertise of clinicians are the guarantors of good clinical practice. But are they really? Since the 1970s, a growing body of sociological and behavioral science has developed the concepts of cognitive biases and thinking errors. In a nutshell, it tries to explain how we approach decision-making using shortcuts, or heuristics. Our brains will alternatively use 2 systems to think and decide: system 1 is fast, intuitive and emotional, whereas system 2 is slow, logical and conscious. We may think clinicians use the latter systematically, but they actually use system 1 in many situations. Whether due to intrinsic thinking errors or external forces that cloud our judgment, we are under unconscious influences and so are all the stakeholders in the rehabilitation setting, including the patient/athlete. We present some of the most prevalent biases that pervade clinical decision-making and attempt to give a bit of background context starting from the typical tension between academic authority and personal experience. The field of sports performance is also riddled with beliefs, egocentrism and a general tendency to search for magic bullets that will bring the marginal gains and edge over the competition. This plays into the rehabilitation of patient-athletes in different ways. Finally, there are ways to mitigate the effect of cognitive biases to improve decision-making. This must include better communication, shared decisions and ultimately the understanding that we should drive our profession to deliver high-value care tailored to the patients, in line with the best evidence at the best possible cost. Hopefully, we can shed some light without too many of our own biases on the complexities of thinking in sports medicine and rehabilitation.

Anxiety sensitivity, pain severity and co-use of cigarettes and e-cigarettes among adults with chronic pain

Anxiety sensitivity (fear of potential negative consequences of anxiety-related symptoms/sensations) has been identified as a transdiagnostic factor in comorbid pain and nicotine dependence and evidence suggests that anxiety sensitivity may be indirectly associated with nicotine use via greater pain severity. Therefore, this study tested the hypothesis that anxiety sensitivity is associated with cigarette and e-cigarette use/co-use directly and indirectly via greater pain severity. Participants included 273 online survey respondents with chronic musculoskeletal pain (34% female; Mage = 32.9). Anxiety sensitivity was positively associated with cigarette smoking, e-cigarette use and cigarette/e-cigarette co-use (ps < .05). Furthermore, anxiety sensitivity was indirectly and positively associated with cigarette smoking, e-cigarette use and co-use via greater chronic pain severity. Pain severity may play an important role in associations between anxiety sensitivity and nicotine dependence and prospective research should examine temporal/causal effects of anxiety sensitivity in relation to pain severity and nicotine/tobacco use.

This is the day your life must surely change : Prioritising behavioural change in musculoskeletal practice

Behavioural change is the modification or transformation of behaviour. Health behaviour has been defined as, 'any activity undertaken for the purpose of preventing or detecting disease or for improving health and wellbeing' (Bennell et al., 2019 [1]). For a smoker it is acting on the decision to stop or reduce the number of cigarettes smoked, for someone with a higher than ideal body mass index, it is acting to reduce weight and for someone who isn't achieving ideal levels of exercise (Briggs et al., 2020 [2]) it is the decision and action to increase metabolic activity. With increased understanding of the importance of self-management and impact of lifestyle, clinicians supporting people presenting with musculoskeletal symptoms have recognized that behavioural change is an essential component of the care we need to prioritize. It is about sharing the benefits of lifestyle choices that promote health, discussing how to introduce and maintain them, and supporting people through their journey of change, so the change becomes the new normal. Behavioural change science assumes that (i) morbidity and mortality are due in part to certain behaviours and (ii) these behaviours are modifiable. The aim of this debate article is to discuss reasons why clinicians must include long term behavioural change into their management plan and methods they may use to facilitate the change ensuring recipients are empowered to act and make today the day their 'lives will surely change'.

A Novel Biopsychosocial Approach to Neck Pain in Military Helicopter Aircrew

INTRODUCTION: Flight-related neck pain (FRNP) is a frequently reported musculoskeletal complaint among military helicopter aircrew. However, despite its prevalence and suspected causes, little is known of the underpinning pain mechanisms or the impact of neck pain on aircrews in-flight task performance. The biopsychosocial (BPS) approach to health, combined with the contemporary conceptualization of musculoskeletal pain, in which injury and pain are not necessarily synonymous, provides a relatively new holistic framework within which to consider the problem of FRNP in military helicopter aircrew. Combining these concepts, a new conceptual model is proposed to illustrate how biopsychosocial factors may influence pain perception, potentially affecting aircrews capacity to process information and, therefore, threatening in-flight task performance. Recommendations are made for considering the underlying pain mechanisms of FRNP to aid prognoses and guide the development of holistic evidence-based countermeasures for FRNP in military helicopter aircrew. Development of instruments able to measure psychosocial factors, such as self-efficacy and functional ability, validated in the military helicopter aircrew population, would assist this task.Vail RE, Harridge SDR, Hodkinson PD, Green NDC, Pavlou M. A novel biopsychosocial approach to neck pain in military helicopter aircrew. Aerosp Med Hum Perform. 2021; 92(5):333341.

Schlüsselregion Becken

Hintergrund

Beckenringdysfunktionen sind eine der häufigsten Ursachen für Arbeitsausfälle weltweit. Neben muskuloskeletalen können viszerale Beschwerden der Beckenorgane auftreten. Der Beitrag erläutert den aktuellen Wissensstand zur funktionellen Anatomie des Beckens, beschreibt einige typische Beschwerdebilder aus gynäkologischer/geburtshilflicher Sicht sowie eine manuelle Methode zur nachhaltigen Beschwerdelinderung.

Fragestellung

Welche viszeralen Beschwerdebilder werden durch eine Beckenringdysfunktion (mit)verursacht? Wie kann eine manuelle Methode aussehen, die nachhaltig zur Verminderung der Beschwerden und Verbesserung der Lebensqualität beiträgt?

Methode

Der heutige Wissensstand der funktionellen Anatomie des Beckens wird mit den entsprechenden Beschwerdebildern bei Beckenringdysfunktionen dargelegt. Der Fokus liegt neben muskuloskeletalen speziell auch auf viszeralen Problemen wie vorzeitige Kontraktionen, Geburtsproblemen, Dysmenorrhö, Obstipation, Harndrang, Dyspareunie und Fertilitätsprobleme.

Ergebnisse

Beschwerdelinderung, Zunahme der Lebensqualität und bessere Funktion der Beckenorgane nach manueller Therapie und Stabilisierung des Beckenrings zeigen sich in einzelnen Fallbeispielen und insgesamt bei der Klientel der Grundversorgerpraxis.

Schlussfolgerung

Das Becken ist eine Schlüsselregion für die manuelle Medizin. Verschiedenste Beschwerdebilder können durch eine manuelle Behandlung deutlich reduziert werden.

Physiotherapist beliefs and perspectives on virtual reality-supported rehabilitation for the assessment and management of musculoskeletal shoulder pain: a focus group study protocol

Shoulder pain accounts for a large proportion of musculoskeletal disorders and years lived with disability. Musculoskeletal shoulder pain is challenging to manage and while research evidence suggests that exercise should be a cornerstone of shoulder pain rehabilitation, the exact type and dosage of exercise is unclear. Adherence is a barrier to successful outcomes with exercise-based management of musculoskeletal pain, especially for those with co-morbidities, high pain levels and reported boredom associated with competing prescribed exercise. Virtual reality (VR) may offer an effective platform for rehabilitation of musculoskeletal shoulder pain. VR has been shown to be effective for management of acute and chronic pain conditions, for delivering education around various health conditions, and for supporting rehabilitation of neurological conditions. Therefore, it is possible that VR may have a role in the delivery of exercise and education for individuals with musculoskeletal shoulder pain. VR intervention design should involve several steps and begin with establishing early acceptability from users as to the suitability of the technology in clinical practice as well as potential barriers and facilitators to using the technology successfully. This study will therefore aim to explore physiotherapists beliefs and perspectives of immersive VR as a platform for assessment and rehabilitation in patients with musculoskeletal shoulder pain. Further, this study will inform the development of a VR intervention for use in the rehabilitation of musculoskeletal shoulder pain. A series of online focus groups will be conducted with physiotherapists in Ireland using a qualitative descriptive approach to data analysis. A six-phase process of data analysis will be carried out to identify important patterns and themes within the data. The current study will be the first to explore clinician's perspectives on the role of VR in musculoskeletal practice.

Reframing how we care for people with persistent non-traumatic musculoskeletal pain. Suggestions for the rehabilitation community

There have been repeated calls to re-evaluate how clinicians provide care for people presenting with persistent non-traumatic musculoskeletal conditions. One suggestion is to move away from the 'we can fix and cure you' model to adopting an approach that is more consistent with approaches used when managing other persistent non-communicable diseases; education, advice, a major focus on self-management including lifestyle behavioural change, physical activity and medications as required. Currently the global delivery of musculoskeletal care has many of the elements of a 'super wicked problem', namely conflict of interest from stake-holders due to the consequences of change, prevailing expectation of a structural diagnosis and concomitant fix for musculoskeletal pain, persistent funding of high risk, more expensive care when low risk more economic viable options that don't impact on the quality of outcome exist, and an unquestionable need to find a solution now with the failure resulting in a growing social and economic burden for future generations. To address these issues, 100 participants included clinicians, educators and researchers from low-, middle- and high-income countries, eight presenters representing the physiotherapy, sport medicine and the orthopaedic professions and the insurance industry, together with three people who shared their lived experiences of persistent musculoskeletal pain, discussed the benefits and barriers of implementing change to address this problem. This paper presents the results from the stakeholders' contextual analysis and forms the basis for the proposed next steps from an action and advocacy perspective.

Knowledge and attitudes toward musculoskeletal pain neuroscience of manual therapy postgraduate students in the Netherlands

BACKGROUND

Health care practitioners' knowledge and attitudes influence patients' beliefs and health outcomes in musculoskeletal (MSK) pain. It is unclear to what extent physiotherapists undertaking a postgraduate master in manual therapy (MT students) possess the knowledge and attitudes toward pain neuroscience to be able to apply the biopsychosocial model in patients with MSK pain.

OBJECTIVES

The aim of this study was to assess the knowledge and attitudes toward pain neuroscience in MT students.

DESIGN

A cross-sectional study.

METHOD

Self-reported knowledge and attitudes were measured among students (n = 662) at baseline and in all years of the MT postgraduate programs in the Netherlands. The Knowledge and Attitudes of Pain questionnaire (KNAP) was used as a primary measure. Difference in KNAP-scores between baseline (0), year 1, year 2 and year 3 was tested using a one-way ANOVA (hypothesis: 0 < 1<2 < 3). A two factor ANOVA was used to determine the interaction effect of focused pain education and year in the curriculum with KNAP.

RESULTS

There was an overall significant difference of KNAP scores with a medium effect size (F(3, 218.18) = 13.56, p < .001, ω² = 0.059). Differences between years ranged from small to medium. Interaction effect of knowledge and attitudes and focused pain education was significant with a small effect size (F(6) = 2.597, p = .017, ω² = 0.012). Sensitivity analyses were consistent with the main results.

CONCLUSIONS

Positive differences in knowledge and attitudes toward pain neuroscience in MT students occur between the progressing years of the curriculum. Differences may be related to the provision of focused pain education.

"You'd be better off to do the keyhole and make a good job of it" a qualitative study of the beliefs and treatment expectations of patients attending secondary care with degenerative meniscal tears

BACKGROUND

Current clinical practice guidelines for degenerative meniscal tears recommend conservative management yet patients are frequently referred to the consultant orthopaedic surgeon despite a lack of evidence for the use of arthroscopy.

OBJECTIVES

To explore the beliefs about their condition and treatment expectations of patients referred to a secondary care orthopaedic clinic with a degenerative meniscal tear.

DESIGN AND METHODS

Design and MethodsThis qualitative study involved ten patients who participated in semi-structured telephone interviews. Data were subjected to thematic analysis and findings were reported in accordance with the Consolidated Criteria for Reporting Qualitative Studies.

RESULTS

Analysis identified five themes. Participants described beliefs, strongly influenced by magnetic resonance imaging (MRI) results, that damaged structures were causing their knee problems ("The meniscus is busted"), and expected their knee problems to inevitably worsen over time ("It's only going to get worse"). Participants were hopeful the orthopaedic consultation would clarify their problem and lead to a subsequent definitive intervention ("Hopefully they will give me answers"). Most participants viewed surgery as "the quick and straightforward solution" necessary to repair faulty cartilage. Exercise was not seen as compatible with the recovery process by most ("Would I make it worse?").

CONCLUSIONS

How participants understand their knee problem contributes to surgical expectations and perceptions that it is not amenable to conservative management. Findings suggest a need to educate both patients and primary care clinicians about the safety and efficacy of exercise as first-line therapy for degenerative meniscal tears. The negative role of MRI in promoting surgical expectations needs further consideration.

Musculoskeletal Physical Therapy After COVID-19: Time for a New "Normal"

In late 2019, a previously unknown coronavirus, SARS-CoV-2 (the coronavirus that causes COVID-19), was reported in Wuhan, China. Similar to the polio virus epidemic, the fear, uncertainty, and collective response associated with COVID-19 have disrupted daily life on a global scale. In this editorial, we argue that it is time for musculoskeletal physical therapists to grasp the opportunity provided by the COVID-19 pandemic to provide care that is (1) primarily active, (2) focused on self-efficacy and self-management, and (3) far less reliant on passive therapies. J Orthop Sports Phys Ther 2021;51(1):5-7. doi:10.2519/jospt.2021.0102.