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.

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.

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.

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.

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.

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.

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.

The (cost-)effectiveness and cost-utility of a novel integrative care initiative for patients with chronic musculoskeletal pain: the pragmatic trial protocol of Network Pain Rehabilitation Limburg.

BACKGROUND: Rehabilitation care for patients with chronic musculoskeletal pain (CMP) is not optimally organized. The Network Pain Rehabilitation Limburg 2.0 (NPRL2.0) provides integrated care with a biopsychosocial approach and strives to improve the Quadruple Aim outcomes: pain-related disability of patients with CMP; experiences of care of patients with CMP; meaning in the work of healthcare professionals; and healthcare costs. Firstly, in this study, the effectiveness (with regard to the functioning and participation of patients) of primary care for patients with CMP will be assessed, comparing care organized following the NPRL2.0 procedure with usual care. Secondly, the cost-effectiveness and cost-utility with regard to health-related quality of life and healthcare costs will be assessed. And thirdly, the effect of duration of participation in a local network in primary care will be studied. METHODS: In this pragmatic study, it is expected that two local networks with 105 patients will participate in the prospective cohort study and six local networks with 184 patients in the stepped-wedge based design. Healthcare professionals in the local networks will recruit patients. INCLUSION CRITERIA: age ≥ 18 years; having CMP; willing to improve functioning despite pain; and adequate Dutch literacy. EXCLUSION CRITERIA: pregnancy; and having a treatable medical or psychiatric disease. Patients will complete questionnaires at baseline (T1), 3 months (T2), 6 months (T3), and 9 months (T4). Questionnaires at T1 and T4 will include the Pain Disability Index and Short Form Health Survey. Questionnaires at T1, T2, T3, and T4 will include the EQ-5D-5L, and iMTA Medical Consumption and Productivity Cost Questionnaires. Outcomes will be compared using linear mixed-model analysis and costs will be compared using bootstrapping methods. DISCUSSION: NPRL2.0 is a multidimensional, complex intervention, executed in daily practice, and therefore needing a pragmatic study design. The current study will assess NPRL2.0 with respect to the Quadruple Aim outcomes: patient health and costs. This will provide more information on the (cost-) effectiveness of the organization of care in a network structure regarding patients with CMP. The other two Quadruple Aim outcomes will be examined alongside this study. Trial registration Netherlands Trial Register: NL7643. https://www.trialregister.nl/trial/7643 .

Development and validation of a method to screen for co-morbid depression by non-behavioral health practitioners treating musculoskeletal pain.

BACKGROUND: Although diagnosis and treatment of depressive illness is outside the scope of practice for non-behavioral health practitioners such as occupational therapists, physical therapists, kinesiotherapists, and chiropractors, it frequently is comorbid with painful musculoskeletal disorders such as low back pain and it negatively affects outcomes, including return to work. As psychologically-informed practice becomes more widely implemented without the immediate availability of behavioral health practitioners, safe and effective methods to screen for and appropriately triage depressive illness by nonbehavioral health practitioners are necessary. OBJECTIVES: To demonstrate the efficacy and validity of a method employed by non-behavioral health practitioners to screen for and appropriately triage musculoskeletal pain patients who also are experiencing depressive illness. METHODS: As part of a previously-published psychometric research study conducted in a community-based musculoskeletal pain rehabilitation program, a method was developed for nonbehavioral health practitioners to screen for and appropriately triage patients for co-morbid depressive illness, thus providing the current opportunity to examine the effects of depressive illness on work outcomes. The first step in the two-step process involves a 22-item questionnaire, providing scores used in the second step to triage for outside consultation with behavioral health practitioners. This paper describes the screening method and its application in an observational study of the impact of depressive illness on work outcomes. RESULTS: Among 156 consecutive patients who were presenting with musculoskeletal pain disorders to an outpatient rehabilitation program, 22.3% also were identified to have co-morbid clinical depression. The screening process allowed all patients to continue in the rehabilitation program. Those who were already receiving behavioral health care were encouraged to inform care providers of their participation in the program. Those who were not receiving behavioral health care were successfully triaged to care outside of the clinic. Depressive illness was found to affect success in the program, confirming the validity of the screening process for outpatient rehabilitation program participants experiencing chronic pain. CONCLUSIONS: A simple and effective depression screening process that triages patients without interruption of musculoskeletal treatment can be employed by nonbehavioral health practitioners. Because return to work outcomes were found to be negatively affected by depressive illness, this approach has the potential to improve overall program efficacy.

Capacitive and resistive electric transfer therapy in rehabilitation: a systematic review.

Capacitive and resistive electric transfer (CRET) therapy is a physical treatment modality commonly used to treat musculoskeletal pain. It normally uses a longwave radiofrequency of ~0.5 MHz. The system consists of a neutral plate and two different electrodes that can transfer energy in two modalities: capacitive and resistive. The aim of this systematic review was to identify and summarize the available data in the literature on this physical modality. From a search of articles published before December 2019 in MEDLINE and Scopus indexed journals, we retrieved 276 articles, 13 of which met the inclusion criteria for this review. Most articles dealt with musculoskeletal disorders, mainly spine disorders and knee osteoarthritis. More than 75% of the studies used a similar range of frequency (440-600 KHz). Almost all described an improvement in strength and function and reduced pain intensity after the treatment. Although nine of the 13 studies (70%) were randomized controlled trials, only two had a low risk of bias according to the Cochrane library assessment tool. CRET seems to be an effective therapy to decrease pain, and improve the quality of life and disability of patients affected by musculoskeletal disorders. There is no study on symptoms of patients with neurological disorders. Further research is necessary to standardize the therapeutic protocols across different orthopedic diseases, and to assess the benefits of CRET in other fields such as neurological or rheumatologic disorders.

Rising incidence of musculoskeletal discomfort in the wake of the COVID-19 crisis.

The COVID-19 pandemic has led to the shutdown of much of the world's economic and social operations. Given shutdown of exercise facilities, there has been a sharp uptick in a sedentary lifestyle. As people have lost their normal daily activity patterns, it is reasonable to assume that musculoskeletal pain-related syndromes will consequently begin to increase. In addition, there has been a rise in social network, television, and online home-based workouts. In the wake of the COVID-19 pandemic, it is unclear whether previous recommendations for physical activities will remain sufficient, given cessation of normal physical activities from day-to-day life. We raise a variety of questions in dealing with the potential fallout of the COVID-19 shutdown from a musculoskeletal standpoint.

The Evidence for Common Nonsurgical Modalities in Sports Medicine, Part 1: Kinesio Tape, Sports Massage Therapy, and Acupuncture.

OBJECTIVE: There are a number of nonsurgical modalities used by athletes in attempts to improve performance or prevent, treat, and rehabilitate musculoskeletal injuries. A concise review of available evidence on common nonsurgical modalities used today is necessary so that practitioners may appropriately counsel patients. METHODS: A comprehensive review of relevant publications regarding Kinesio taping, sports massage therapy, and acupuncture from 2006 through 2019 was completed using PubMed and Google Scholar. RESULTS: There have been numerous investigations evaluating the efficacy of nonsurgical modalities for a myriad of musculoskeletal conditions. There is some low level evidence to suggest the use of Kinesio tape for athletes with acute shoulder symptoms and acupuncture for carpal tunnel syndrome and as an adjunct treatment for low back pain. There is a need for higher quality research to better elucidate the effect of sports massage therapy on sports performance, recovery, and musculoskeletal conditions in general. CONCLUSIONS: Nonsurgical modalities are low-cost treatment strategies with very few reported adverse outcomes that will likely continue to increase in popularity. High-quality studies are needed to effectively evaluate these treatments, so that care providers can provide appropriate guidance based on evidence-based medicine.

The Evidence for Common Nonsurgical Modalities in Sports Medicine, Part 2: Cupping and Blood Flow Restriction.

OBJECTIVE: There are a number of nonsurgical modalities used by athletes in attempts to improve performance or prevent, treat, and rehabilitate musculoskeletal injuries. A concise review of available evidence on common nonsurgical modalities used today is necessary, so that practitioners may appropriately counsel patients. METHODS: A comprehensive review of relevant publications regarding cupping and blood flow restriction (BFR) from 2006 through 2019 was completed using PubMed and Google Scholar. RESULTS: There have been numerous investigations evaluating the efficacy of nonsurgical modalities for a myriad of musculoskeletal conditions. Cupping may be an effective option with low risk in treating nonspecific, musculoskeletal pain. Studies comparing BFR with non-BFR controls suggest that it may increase muscle strength and endurance for individuals undergoing rehabilitation or sport-specific training by mimicking the low oxygen environment during exercise. CONCLUSIONS: Nonsurgical modalities are low-cost treatment strategies with rates of adverse outcomes as low as 0.008% that will likely continue to increase in popularity. Despite the paucity of recent research in cupping and BFR, evidence suggests benefits with use. High-quality studies are needed to effectively evaluate these treatments, so that care providers can provide appropriate guidance based on evidence-based medicine.