[Analgesics, chronic pain and musculoskeletal rehabilitation]. / Médicaments antalgiques, douleur chronique et réadaptation de l'appareil locomoteur.

The majority of patients following musculoskeletal rehabilitation are taking painkillers. However, apart from one recent observational study, there is a lack of data. The use of analgesics, particularly opioids, is associated with higher scores for pain, anxiety, depression, catastrophizing and disability, as well as poorer results in functional tests. Prescribing analgesic treatment with precise objectives (improving pain and function) should also include identifying psychosocial factors associated with a poor prognosis. Regular reassessment of the treatment should make it possible to limit side-effects and the risk of misuse and help patients to engage in an active rehabilitation programme and resume regular physical activity.

La majorité des patients effectuant une réadaptation musculosquelettique consomme des antalgiques. Cependant, en dehors d'une étude observationnelle récente, les données manquent. La prise d'antalgiques, en particulier les opioïdes, est associée à des scores de douleur, d'anxiété, de dépression, de catastrophisme et de handicap élevés, ainsi qu'à des résultats plus faibles aux tests fonctionnels. La prescription d'un traitement antalgique avec des objectifs précis (amélioration de la douleur et de la fonction) doit également comporter une détection des facteurs psychosociaux de mauvais pronostic. Une réévaluation régulière de la prescription devrait permettre de limiter les effets secondaires, les risques de mésusage et aider les patients à s'engager dans un programme de réadaptation actif et à reprendre une activité physique régulière.

Effectiveness of manual therapy interventions in cystic fibrosis care: a pilot study.

BACKGROUND: Cystic fibrosis (CF) is a severe genetic condition that affects multiple organ systems and imposes a substantial treatment burden. Regarding the lungs and airways, the progressive pathophysiological changes place a significant strain on the musculoskeletal components of the respiratory system for people with CF. This pilot study investigated the effectiveness of manual therapy interventions (MTIs) on thoracic mobility, respiratory muscle strength, lung function, and musculoskeletal pain. METHOD: A study with a pretest-posttest design was conducted with 15 eligible people with CF at the Sahlgrenska University Hospital CF Centre. After an initial set of diagnostic tests at baseline, the participants underwent eight weekly 30-min MTIs. The MTIs included passive joint mobilisation and soft tissue manipulation of primary and secondary anatomical areas of the musculoskeletal respiratory system. On the day of the final intervention, the baseline measurements were repeated. RESULTS: Trends of increased thoracic mobility were observed following the intervention, with a statistically significant increase in respiratory muscle strength. No change in lung function was observed. Musculoskeletal pain before and after the intervention showed a significant decrease in tender points, and all participants reported positive experiences with MTIs. CONCLUSION: MTIs may improve thoracic mobility, alleviate pain, and enhance respiratory muscle strength in people with CF. Further research is needed to confirm their potential role as a CF physiotherapy supplement. CLINICAL TRIAL ID: NCT04696198.

Empowering patients with persistent pain: The potential of cognitive functional therapy in interdisciplinary care: A single-case experimental design.

INTRODUCTION AND PURPOSE: Persistent musculoskeletal pain (PMP) is multifactorial and causes both societal and financial burdens. Integration of multifactorial management in patients with PMP remains challenging. A single-case experimental design was performed on three patients suffering from high impact PMP (lumbar spine, shoulder and knee) to i) assess the potential for Cognitive Functional Therapy (CFT) in interdisciplinary care, ii) describe in detail the clinical journey patients experienced during the intervention, and iii) evaluate the changes and associations in relation to the outcome measures of pain, disability, maladaptive movement behavior, subjective overall improvement, health related quality of life and work status. These were monitored over one year, at the end of each of the six intervention modules. RESULTS: After introducing the intervention systematic changes were seen, with medium to large changes (Non-overlap of All Pairs 0.67-1) for all outcome measures. Associations between changes of the outcome measures were large (r ≥ 0.50) and changes occurred concurrently. Minimally clinically important difference thresholds were exceeded for all outcome measures and two patients achieved relevant improvements related to work reintegration. DISCUSSION: The positive results of this study are comparable with recent CFT studies. However, the difference regarding the number of sessions and duration of the intervention is evident. The length of the intervention in this study seemed to enable continuous significant improvements up until 12 months post onset and follow-up. CONCLUSION: CFT in interdisciplinary care was effective for all measures. The detailed descriptions of the clinical processes aim to improve clinical care.

Through the Lens of Movement-Evoked Pain: A Theoretical Framework of the "Pain-Movement Interface" to Guide Research and Clinical Care for Musculoskeletal Pain Conditions.

Over 120 million Americans report experiencing pain in the past 3 months. Among these individuals, 50 million report chronic pain and 17 million report pain that limits daily life or work activities on most days (ie, high-impact chronic pain). Musculoskeletal pain conditions in particular are a major contributor to global disability, health care costs, and poor quality of life. Movement-evoked pain (MEP) is an important and distinct component of the musculoskeletal pain experience and represents an emerging area of study in pain and rehabilitation fields. This focus article proposes the "Pain-Movement Interface" as a theoretical framework of MEP that highlights the interface between MEP, pain interference, and activity engagement. The goal of the framework is to expand knowledge about MEP by guiding scientific inquiry into MEP-specific pathways to disability, high-risk clinical phenotypes, and underlying individual influences that may serve as treatment targets. This framework reinforces the dynamic nature of MEP within the context of activity engagement, participation in life and social roles, and the broader pain experience. Recommendations for MEP evaluation, encompassing the spectrum from high standardization to high patient specificity, and MEP-targeted treatments are provided. Overall, the proposed framework and recommendations reflect the current state of science in this emerging area of study and are intended to support future efforts to optimize musculoskeletal pain management and enhance patient outcomes. PERSPECTIVE: Movement-evoked pain (MEP) is a distinct component of the musculoskeletal pain experience and emerging research area. This article introduces the "Pain-Movement Interface" as a theoretical framework of MEP, highlighting the interface between MEP, pain interference, and activity engagement. Evaluating and treating MEP could improve rehabilitation approaches and enhance patient outcomes.

Which Remote Rehabilitation Interventions Work Best for Chronic Musculoskeletal Pain and Depression? A Bayesian Network Meta-Analysis.

OBJECTIVE: To evaluate the effectiveness of remote rehabilitation interventions for people living with chronic musculoskeletal pain and depression. DESIGN: A systematic review with network meta-analysis (NMA) of randomized controlled trials. LITERATURE SEARCH: We searched the Cochrane Central Register of Controlled Trials, CINAHL, EMBASE, LILACS MEDLINE, PSYNDEX, and PsycINFO databases from inception to May 2023. STUDY SELECTION CRITERIA: Randomized controlled trials that evaluated the effectiveness of remote rehabilitation interventions in people with chronic musculoskeletal pain and depression. DATA SYNTHESIS: We used Bayesian random-effects models for the NMA. Effect estimates were comparisons between rehabilitation interventions and waitlist. We performed a sensitivity analysis based on bias in the randomization process, large trials (>100 patients per arm) and musculoskeletal condition. RESULTS: Fifty-eight randomized controlled trials involving 10 278 participants (median sample size: 137; interquartile range [IQR]: 77-236) were included. Interactive voice response cognitive behavioral therapy (CBT; standardized mean difference [SMD] -0.66, 95% credible interval [CrI] -1.17 to -0.16), CBT in person (SMD -0.50, 95% CrI -0.97 to -0.04), and mobile app CBT plus exercise (SMD -0.37, 95% CrI -0.69 to -0.02) were superior to waitlist at 12-week follow-up for reducing pain (> 98% probability of superiority). For depression outcomes, Internet-delivered CBT and telecare were superior to waitlist at 12-week follow-up (SMD -0.51, 95% CrI -0.87 to -0.13) (> 99% probability of superiority). For pain outcomes, the certainty of evidence ranged from low to moderate. For depression outcomes, the certainty of evidence ranged from very low to moderate. The proportion of dropouts attributed to adverse events was unclear. No intervention was associated with higher odds of dropout. CONCLUSION: Interactive voice response CBT and mobile app CBT plus exercise showed similar treatment effects with in-person CBT on pain reduction among people living with chronic musculoskeletal pain and depression had over 98% probability of superiority than waitlist control at 12-week follow-up. Internet-delivered CBT and telecare had over 99% probability of superiority than waitlist control for improving depression outcomes at 12-week follow-up. J Orthop Sports Phys Ther 2024;54(6):1-16. Epub 26 February 2024. doi:10.2519/jospt.2024.12216.

Intervención fisioterapéutica en fibromialgia / Physiotherapeutic intervention in fibromyalgia

Introducción: La fibromialgia afecta el movimiento corporal. Provoca dolor en puntos claves, causa molestias musculoesqueléticas y limita la actividad de las personas. Se ha descrito que la fisioterapia mejora de calidad de vida de estos pacientes. Objetivo: Identificar los test de evaluación y los procesos de intervención fisioterapéutica utilizados en la fibromialgia. Métodos: Se realizó una revisión de literatura en PubMed, ScientsDirect, SciELO y LILLACS, con la terminología MeSH y DeCS, entre 2017 y 2022. Resultados: La escala visual análoga y la algometría por presión son los test utilizados para el dolor. La hidroterapia, el cupping, la punción seca, el masaje sueco, los ejercicios respiratorios y los aeróbicos resultan los métodos de intervención con más uso. Conclusiones: Los procesos de intervención se deben plantear según las evaluaciones del dolor y la funcionalidad en la persona. El tratamiento fisioterapéutico de la fibromialgia debe tener un componente de ejercicio físico aérobico y fuerza para disminuir la fatiga; devolverle al músculo su funcionalidad y aumentar la capacidad aeróbica(AU)

Introduction: Fibromyalgia affects body movement. It causes pain in key points, it causes musculoskeletal discomfort and it limits the persons's activity. It has been described that physiotherapy improves the quality of life of these patients. Objective: To identify the evaluation tests and physiotherapy intervention processes used in fibromyalgia. Methods: A literature review was carried out in PubMed, ScientsDirect, Scielo and LILLACS, with the terminology MeSH and DeCS, from 2017 to 2022. Results: The visual analogue scale and pressure algometry are the tests used for pain. Hydrotherapy, cupping, dry needling, Swedish massage, breathing exercises and aerobics are the most commonly used intervention methods. Conclusions: Intervention processes should be planned according to the evaluations of pain and functionality in the person. The physiotherapy treatment of fibromyalgia must have a component of aerobic physical exercise and strength to reduce fatigue, to return the muscle to its functionality and increase aerobic capacity(AU)

Efficient Screening for Fear of Movement in Outpatient Settings: Short Form and Computer Adaptive Tests for Fear Avoidance and Negative Pain Coping.

OBJECTIVE: The purpose of this study was to develop screening measures using item response theory (IRT) for 2 factors highly relevant to fear of movement (FoM): fear avoidance and negative pain coping. METHODS: A total of 431 patients with neck (n = 93), shoulder (n = 108), low back (n = 119), or knee (n = 111) conditions seeking physical therapy completed 8 validated psychological questionnaires measuring fear avoidance and negative pain coping, resulting in 97 candidate items for IRT analysis. Unidimensionality and local independence were assessed using exploratory factor analyses followed by confirmatory factor analyses. Items were assessed for model fit to the graded response model for ordinal items. Using the final item bank, a computer adaptive test (CAT) administration mode was constructed, and reduced item sets were selected to create short forms (SFs), including items with highest information (reliability) at the different levels of the trait being measured while also considering clinical content. RESULTS: The results supported a 28-item bank for fear avoidance and 16-item bank for negative pain coping. A 10-item and 8-item SF were developed for fear avoidance and negative pain coping, respectively. Additionally, 4-item form versions were created to provide options with lower administrative burden. CAT administration used a mean (median) of 7.7 (8) and 7.0 (7) items for fear avoidance and negative pain coping, respectively. All factors demonstrated construct validity by discriminating patient groups in expected clinical patterns. CONCLUSION: These newly derived SFs and CAT administration modes provide reliable, valid, and efficient options to screen for fear avoidance and negative pain coping in populations with musculoskeletal pain. IMPACT: These tools, collectively referred to as the Screening for Pain Vulnerability and Resilience tools, address a critical need for standard FoM screening processes that aid in clinical decision-making to identify who might benefit from psychologically informed approaches.

Usefulness and feasibility of comprehensive and less comprehensive vocational rehabilitation for patients with chronic musculoskeletal pain: perspectives from patients, professionals, and managers.

PURPOSE: To explore the usefulness and feasibility of a comprehensive vocational rehabilitation (C-VR) program and less comprehensive (LC-VR) program for workers on sick leave due to chronic musculoskeletal pain, from the perspective of patients, professionals, and managers. MATERIALS AND METHODS: Semi-structured interviews were held with patients, professionals, and managers. Using topic lists, participants were questioned about barriers to and facilitators of the usefulness and feasibility of C-VR and LC-VR. Thirty interviews were conducted with thirteen patients (n = 6 C-VR, n = 7 LC-VR), eight professionals, and nine managers. All interviews were transcribed verbatim. Data were analyzed by systematic text condensation using inductive thematic analysis. RESULTS: Three themes emerged for usefulness ("patient factors," "content," "dosage") and six themes emerged for feasibility ("satisfaction," "intention to continue use," "perceived appropriateness," "positive/negative effects on target participants," "factors affecting implementation ease or difficulty," "adaptations"). The patients reported that both programs were feasible and generally useful. The professionals preferred working with the C-VR, although they disliked the fixed and uniform character of the program. They also mentioned that this program is too extensive for some patients, and that the latter would probably benefit from the LC-VR program. Despite their positive intentions, the managers stated that due to the Dutch healthcare system, implementation of the LC-VR program would be financially unfeasible. CONCLUSIONS: The main conclusion of this study is that it is not useful to have one VR program for all patients with CMP and reduced work participation, and that flexible and tailored-based VR are warranted.Implications for rehabilitationBoth comprehensive and less comprehensive vocational rehabilitation are deemed useful for patients with chronic musculoskeletal pain and reduced work participation. Particular patient factors, for instance information uptake, discipline, willingness to change, duration of complaints, movement anxiety, obstructing thoughts, and willingness to return to work might guide the right program for the right patient.Both comprehensive and less comprehensive vocational rehabilitation are deemed feasible in practice. However, factors such as center logistic (schemes, rooms, professionals available) and country-specific healthcare insurance and sickness compensation systems should foster the implementation of less comprehensive programs.

Measurement Properties of the Work Ability Score in Sick-Listed Workers with Chronic Musculoskeletal Pain.

Purpose Chronic musculoskeletal pain can have a major impact on ability to work. The work ability score is a commonly used single-item question to assess work ability but has not been fully validated yet. The aim of the present study was to evaluate test-retest reliability, agreement, construct validity, and responsiveness of the work ability score among sick-listed workers with chronic musculoskeletal pain. Methods Data of sick-listed workers with chronic musculoskeletal pain was routinely collected at seven rehabilitation centres in the Netherlands. Assessments included a set of questionnaires, administered at admission and discharge from a fifteen-week vocational rehabilitation program. Test-retest reliability was determined with the intraclass correlation coefficient. For agreement, the standard error of measurement and smallest detectable changes were calculated. Construct validity was assessed by testing hypotheses regarding Spearman rank correlation coefficient. Area under the curve obtained from the receiver operating characteristic curve and minimal clinically important change were determined for the total sample and work ability score baseline tertile groups to assess responsiveness. Results In total, 34 workers were analyzed for reliability and agreement, 1291 workers for construct validity, and 590 responded to the responsiveness questionnaire. Reliability reached an intraclass correlation coefficient of 0.89; 95% CI 0.77-0.94, a standard error of measurement of 0.69 points, and the smallest detectable change of 1.92 points. For construct validity, six of the seven predefined hypotheses were not refuted. The area under the curve was 0.76 (95% CI 0.71-0.81) allowing for discrimination between stable and improved workers, with a minimal clinically important change of 2.0 points for the total sample. Conclusion The work ability score showed good measurement properties among sick-listed workers with chronic musculoskeletal pain.

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.

Effectiveness of rehabilitation on pain and function in people affected by hemophilia.

INTRODUCTION: Literature provides unclear evidence of the effectiveness of many physiotherapy interventions on pain intensity, quality of life, and functional ability in hemophilic patients, and suggests that rehabilitation programs should be focused on functional goals and the disability of patients. AIM: The aim of the present study is to present the outcome of a case series of patients with hemophilia in which a rehabilitation program has been carried out on the basis of a specific individual patient's functional impairment. METHODS: Fifty-one patients were enrolled: 32 patients (Rehab Group) received a rehabilitative treatment, 19 patients for different reasons (living far from the hospital, family problems) did not receive rehabilitation (Control Group). The rehabilitation program was planned with respect to the emergent problems: musculoskeletal pain, joint range of motion limitation, muscle flexibility, walking difficulties, the appearance of hematomas/hemartro, and postural problems. All the patients were assessed at baseline (T0), after 1 month (T1), and after 3 months (T2) through visual analogic scale for musculoskeletal pain, the Hemophilia Joint Health Score for joint range of motion, the Functional Independence Score in Hemophilia for disability, and postural assessment by visual inspection. RESULTS: A significant reduction of pain and improvement of Hemophilia Joint Health Score and Functional Independence Score in Hemophilia score was found in the Rehab Group along with the follow-up. Pain in the Control Group was lower with respect to the other group at baseline and significantly decreased after 1 month. CONCLUSION: A rehabilitation program focused on individual impairment of patients with hemophylia determined satisfying results in terms of pain control, functional, and disability improvement in 3 months follow-up.

Chronic musculoskeletal pain, catastrophizing, and physical function in adult women were improved after 3-month aerobic-resistance circuit training.

Although exercise is beneficial for chronic musculoskeletal pain (CMP), the optimal type and amount of exercise are unclear. This study aimed to determine the impact of circuit training that combines aerobic and resistance exercises on adult women with CMP. A total of 139 women with CMP underwent circuit training for 3 months and were asked to complete the following questionnaires at baseline and 3 months later: Numeric Rating Scale (NRS), Pain Catastrophizing Scale (PCS), Roland-Morris Disability Questionnaire (RDQ), Shoulder36, and Knee injury and Osteoarthritis Outcome Score (KOOS). Significant improvements were observed in NRS, PCS, RDQ, and KOOS activities of daily living (ADL) scores after the intervention relative to baseline (p < 0.0001, p = 0.0013, 0.0004, and 0.0295, respectively), whereas shoulder function did not improve. When considering the impact of exercise frequency, NRS scores improved regardless of exercise frequency. Furthermore, PCS, RDQ, and KOOS scores improved in participants who exercised at least twice a week (24 sessions over the course of 3 months). In conclusion, CMP, pain catastrophizing, and physical function in adult female fitness club participants with CMP of NRS 4 or higher improved after 3 months of aerobic-resistance circuit training.

Long-term follow-up of patients with chronic musculoskeletal pain attending interdisciplinary pain rehabilitation: outcomes and predictive factors.

The long-term outcomes of interdisciplinary pain rehabilitation (IPR) in patients with chronic musculoskeletal pain (CMP) and its predictors has been studied to a limited extent. In this historical cohort study, functioning, satisfaction with life domains, and pain were assessed at baseline, discharge, and at 6-15 years follow-up. At follow-up, most patients (77%) rated the effects of the IPR as temporarily or persistently positive. The gains in functioning, satisfaction with life domains, and pain made during IPR remained for 6-15 years after the IPR. Patients who were single, retired, or not in work, and those having higher pain and lower functioning at baseline, had lower functioning at follow-up, while patients with traumatic pain disorders had higher functioning at follow-up. Gains made during IPR, particularly gains in social and mental functioning and in pain predicted functioning at follow-up. Treatments and events between discharge and follow-up also influenced the long-term outcome. In conclusion, on average, outcomes achieved during IPR persisted at long-term follow-up. Predictors of a better long-term outcome were mainly baseline characteristics.

Predictors of Sickness Absence in a Clinical Population With Chronic Pain.

Chronic pain-related sickness absence is an enormous socioeconomic burden globally. Optimized interventions are reliant on a lucid understanding of the distribution of social insurance benefits and their predictors. This register-based observational study analyzed data for a 7-year period from a population-representative sample of 44,241 chronic pain patients eligible for interdisciplinary treatment (IDT) at specialist clinics. Sequence analysis was used to describe the sickness absence over the complete period and to separate the patients into subgroups based on their social insurance benefits over the final 2 years. The predictive performance of features from various domains was then explored with machine learning-based modeling in a nested cross-validation procedure. Our results showed that patients on sickness absence increased from 17% 5 years before to 48% at the time of the IDT assessment, and then decreased to 38% at the end of follow-up. Patients were divided into 3 classes characterized by low sickness absence, sick leave, and disability pension, with eight predictors of class membership being identified. Sickness absence history was the strongest predictor of future sickness absence, while other predictors included a 2008 policy, age, confidence in recovery, and geographical location. Information on these features could guide personalized intervention in the specialized healthcare. PERSPECTIVE: This study describes sickness absence in patients who visited a Swedish pain specialist interdisciplinary treatment clinic during the period 2005 to 2016. Predictors of future sickness absence are also identified that should be considered when adapting IDT programs to the patient's needs.

Many physiotherapists lack preparedness to prescribe physical activity and exercise to people with musculoskeletal pain: A multi-national survey.

OBJECTIVES: Determine physiotherapists' (i) awareness of physical activity, and exercise prescription guidelines; (ii) perceived role, knowledge, confidence, skills and training in prescribing and progressing aerobic exercise and resistance training to people with musculoskeletal pain; (iii) professional development preferences; and (iv) perceived influences of external factors on exercise prescription for people with musculoskeletal pain. DESIGN: Multi-national cross-sectional survey. METHODS: An open online survey was developed specifically for this study. RESULTS: 1,352 physiotherapists from 56 countries participated. The majority of respondents correctly stated physical activity guidelines for adults (60%) and children (53%), but only 37% correctly stated guidelines for older adults. Eleven percent and 16% could name an accepted guideline for aerobic exercise and resistance training, respectively. Most agreed their role included prescribing aerobic exercise (75%) and resistance training (89%). Fewer reported they had the confidence, training or skills to prescribe aerobic exercise (38-50%) and resistance training (49-70%). Workshops were the most preferred (44%) professional development option. Most respondents believed appointment scheduling and access to equipment and professional development (62-79%) affected their ability to prescribe effective exercise. CONCLUSION: Many physiotherapists lack knowledge and training to provide physical activity advice, and to prescribe aerobic exercise and resistance training to people with musculoskeletal pain.

The Use of Acupuncture in the Management of Patients With Humeral Fractures: A Systematic Review and Meta-analysis.

OBJECTIVE: The purpose of this study was to conduct a systematic review and meta-analysis of the effects of acupuncture on humeral fractures. METHODS: Randomized controlled trials were searched systematically from inception to January 2020 using the Cochrane Central Register of Controlled Trials, Embase, PubMed, Web of Science, China National Knowledge Infrastructure, and 7 Korean databases. Pain scale and Japanese Orthopaedic Association scores were the primary and secondary measurements. A risk-of-bias assessment and meta-analysis were conducted. RESULTS: Seven randomized controlled trials were included in the systematic review; the quality of the studies was ambiguous. The meta-analysis showed that acupuncture improved the pain severity score compared with conventional therapies (standard mean difference = -4.55, 95% confidence interval, -7.48 to -1.61, I2 = 98%, P < .00001) but did not improve the Japanese Orthopaedic Association score (standard mean difference = 4.99, 95% confidence interval, -0.31 to 10.30, I2 = 99%, P < .00001). CONCLUSION: Our meta-analysis shows that acupuncture reduced pain after proximal humeral fracture, in addition to common rehabilitative modalities. However, the conclusion of this review should be cautiously applied in clinical practice owing to the low quality of the included studies.

Inter-Individual Differences in the Responses to Pain Neuroscience Education in Adults With Chronic Musculoskeletal Pain: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

Pain neuroscience education (PNE) is an approach used in the management of chronic musculoskeletal pain. Previous reviews on PNE and other pain interventions, have focused on mean treatment effects, but in the context of "precision medicine," any inter-individual differences in treatment response are also important to quantify. If inter-individual differences are present, and predictors identified, PNE could be tailored to certain people for optimizing effectiveness. Such heterogeneity can be quantified using recently formulated approaches for comparing the response variance between the treatment and control groups. Therefore, we conducted a systematic review and meta-analysis on the extracted standard deviations of baseline-to-follow up change to quantify the inter-individual variation in pain, disability and psychosocial outcomes in response to PNE. Electronic databases were searched between January 1, 2002 and June 14, 2018. The review included 5 randomized controlled trials (n = 428) in which disability outcomes were reported. Using a random effects meta-analysis, the pooled SD (95% confidence interval) for control group-adjusted response heterogeneity to PNE was 7.36 units /100 (95% confidence interval = -3.93 to 11.12). The 95% prediction interval for this response heterogeneity SD was wide (-10.20 to 14.57 units /100). The control group-adjusted proportion of "responders" in the population who would be estimated to exceed a clinically important change of 10/100 ranged from 18 to 45%. Therefore, when baseline-to-follow up random variability in disability is taken into account (informed by the control arm), there is currently insufficient evidence for the notion of clinically important inter-individual differences in disability responses to PNE in people with chronic musculoskeletal pain. The protocol was published on PROSPERO (CRD42017068436). PERSPECTIVE: We bring a novel method to pain science for calculating inter-individual differences in response to a treatment. This is conductedwithin the context of a systematic review and meta-analysis on PNE. We highlight how using erroneous methods for calculating inter-individual differences can drastically change conclusions when compared to appropriate methods.

The Effectiveness of Strategies to Promote Walking in People With Musculoskeletal Disorders: A Systematic Review With Meta-analysis.

OBJECTIVE: To evaluate the effect of walking promotion strategies on physical activity, pain, and function in people with musculoskeletal disorders. DESIGN: Intervention systematic review with meta-analysis. LITERATURE SEARCH: We performed the searches in MEDLINE, Embase, the Cochrane Central Register of Controlled Trials, and the Physiotherapy Evidence Database (PEDro) from inception to August 2019. STUDY SELECTION CRITERIA: We included randomized controlled trials evaluating interventions that promote walking in people with musculoskeletal disorders. DATA SYNTHESIS: We used the PEDro scale for assessing risk of bias and the Grading of Recommendations Assessment, Development and Evaluation approach to evaluate the quality of evidence. We expressed pooled effects for between-group differences as mean differences or standardized mean differences and 95% confidence intervals, or as risk ratios and 95% confidence intervals, using random-effects meta-analyses. RESULTS: Twelve eligible trials (n = 1456 participants) were identified. There was moderate- to very low-quality evidence of no difference in physical activity levels for walking promotion interventions when compared to minimal interventions, and a significant effect favoring walking promotion when compared with usual care in the short term. There was moderate-quality evidence that walking promotion was modestly effective for reducing pain and improving function compared with minimal intervention and usual care. There was no difference in pain and function for walking promotion compared to supervised exercise. Walking promotion was not associated with different rates of adverse events compared to control conditions. CONCLUSION: Strategies to promote walking did not increase physical activity in people with musculoskeletal disorders. Walking promotion was associated with small improvements in pain and function compared to minimal intervention and usual care. J Orthop Sports Phys Ther 2020;50(11):597-606. doi:10.2519/jospt.2020.9666.