Remote management of musculoskeletal pain: a pragmatic approach to the implementation of video and phone consultations in musculoskeletal practice

Introduction: Remote consultations through phone or video are gaining in importance for the treatment of musculoskeletal pain across a range of health care providers. However, there is a plethora of technical options for practitioners to choose from, and there are various challenges in the adaptation of clinical processes as well as several special considerations regarding regulatory context and patient management. Practitioners are faced with a lack of high-quality peer-reviewed resources to guide the planning and practical implementation of remote consultations. Objectives: This Clinical Update seeks to provide practical guidance for the planning and implementation of remote consultations for the management and treatment of people with musculoskeletal pain. Methods: Recommendations are based on a brief overview of the relevant research regarding phone and video consultations for musculoskeletal practice and derived from the literature, relevant guidelines, and practical experience. Results: The technical feasibility of remote consultations for musculoskeletal complaints is good, patient satisfaction is high, and a growing body of evidence supports its comparative effectiveness to in-person consultations in some circumstances for improving pain and functioning. We consider in detail practical aspects such as the choosing of hardware and software, we touch on the legal and regulatory context, and we focus on the adaptation of clinical processes and communication. Conclusion: This Clinical Update draws together best-practice evidence in a practically applicable format, enabling therapists who are working with people with pain to directly apply this knowledge to their individual clinical settings and the requirements of their patients. Keywords: Telehealth, Video consultation, Musculoskeletal pain, Physiotherapy, Exercise, Manual therapy, Psycholog

Avoiding nocebo and other undesirable effects in chiropractic, osteopathy and physiotherapy: An invitation to reflect

Introduction While the placebo effect is increasingly recognised as a contributor to treatment effects in clinical practice, the nocebo and other undesirable effects are less well explored and likely underestimated. In the chiropractic, osteopathy and physiotherapy professions, some aspects of historical models of care may arguably increase the risk of nocebo effects. Purpose In this masterclass article, clinicians, researchers, and educators are invited to reflect on such possibilities, in an attempt to stimulate research and raise awareness for the mitigation of such undesirable effects. Implications This masterclass briefly introduces the nocebo effect and its underlying mechanisms. It then traces the historical development of chiropractic, osteopathy, and physiotherapy, arguing that there was and continues to be an excessive focus on the patient's body. Next, aspects of clinical practice, including communication, the therapeutic relationship, clinical rituals, and the wider social and economic context of practice are examined for their potential to generate nocebo and other undesirable effects. To aid reflection, a model to reflect on clinical practice and individual professions through the ‘prism’ of nocebo and other undesirable effects is introduced and illustrated. Finally, steps are proposed for how researchers, educators, and practitioners can maximise positive and minimise negative clinical context

Pragmatic trials of pain therapies

Pragmatic randomised clinical trials aim to directly inform clinical or health policy decision-making. Here, we systematically review methods and design of pragmatic trials of pain therapies to examine methods, identify common challenges, and areas for improvement. Seven databases were searched for pragmatic randomised controlled clinical trials which assessed pain treatment in a clinical population of adults reporting pain. All screening steps and data extractions were performed twice. Data were synthesised descriptively and correlation analyses between pre-specified trial features and PRECIS-2 (PRagmatic – Explanatory Continuum Indicator Summary 2) ratings and attrition were performed. Protocol registration: PROSPERO-ID CRD42020178954. Of 57 included trials, only 21% assessed pharmacological interventions, the remainder physical, surgical, psychological or self-management pain therapies. Three-quarters of the trials were comparative effectiveness designs, often conducted in multiple centres (median: 5; Q1/3: 1, 9.25) and with a median sample size of 234 patients at randomization (Q1/3: 135.5; 363.5). Although most trials recruited chronic pain patients, reporting of pain duration was poor and not well described. Reporting was comprehensive for most general items, while often deficient for specific pragmatic aspects. Average ratings for pragmatism were highest for treatment adherence flexibility and clinical relevance of outcome measures. They were lowest for patient recruitment methods and extent of follow-up measurements and appointments. Current practice in pragmatic trials of pain treatments can be improved in areas such as patient recruitment and reporting of methods, analysis and interpretation of data. These improvements will facilitate translatability to other real-world settings – the purpose of pragmatic trials

Blinding and sham control methods in trials of physical, psychological, and self-management interventions for pain (article II): a meta-analysis relating methods to trial results

Sham interventions in randomised clinical trials (RCTs) of physical, psychological, and self-management (PPS) therapies for pain are highly variable in design and thought to contribute to poor internal validity. It has, however, not been formally tested whether the extent to which sham controls resemble the treatment under investigation consistently affects trial outcomes, such as effect sizes, differential attrition, participant expectancy, and blinding effectiveness. Placebo or sham-controlled RCTs of PPS interventions of clinical pain populations were searched in twelve databases. The similarity of control interventions to the experimental treatment was rated across 25 features. Meta-regression analyses assessed putative links between employed control interventions, observed effect sizes in pain-related outcomes, attrition, and blinding success. The sample included 198 unique control interventions, dominated by manual therapy and chronic musculoskeletal pain research. Meta-analyses indicated small to moderate benefit of active treatments over control interventions, across subgroups of manual therapies, exercise, and rehabilitation, and psychological intervention trials. Multiple meta-regression modelling demonstrated that similarity between sham control and tested interventions predicted variability in pain-related outcomes, attrition, and blinding effectiveness. Influential were differences relating to the extent of intervention exposure, participant experience, and treatment environments. The results support the supposed link between blinding methods and effect sizes, based on a large and systematically sourced overview of methods. Challenges to effective blinding are, however, complex, and often difficult to discern from trial reports. Nonetheless, these insights have the potential to change trial design, conduct, and reporting and will inform guideline development

Research objectives and general considerations for pragmatic clinical trials of pain treatments: IMMPACT statement

Many questions regarding the clinical management of people experiencing pain and related health policy decision-making may best be answered by pragmatic controlled trials. To generate clinically relevant and widely applicable findings, such trials aim to reproduce elements of routine clinical care or are embedded within clinical workflows. In contrast with traditional efficacy trials, pragmatic trials are intended to address a broader set of external validity questions critical for stakeholders (clinicians, healthcare leaders, policymakers, insurers, and patients) in considering the adoption and use of evidence-based treatments in daily clinical care. This article summarizes methodological considerations for pragmatic trials, mainly concerning methods of fundamental importance to the internal validity of trials. The relationship between these methods and common pragmatic trials methods and goals is considered, recognizing that the resulting trial designs are highly dependent on the specific research question under investigation. The basis of this statement was an Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT) systematic review of methods and a consensus meeting. The meeting was organized by the Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks (ACTTION) public-private partnership. The consensus process was informed by expert presentations, panel and consensus discussions, and a preparatory systematic review. In the context of pragmatic trials of pain treatments, we present fundamental considerations for the planning phase of pragmatic trials, including the specification of trial objectives, the selection of adequate designs, and methods to enhance internal validity while maintaining the ability to answer pragmatic research questions

Discrimination, bullying or harassment in undergraduate education in the osteopathic, chiropractic and physiotherapy professions: a systematic review with critical interpretive synthesis

The objective of this review was to chart, appraise and synthesise the available evidence regarding the experience of discrimination, bullying or harassment in undergraduate manual therapy (MT) education. We systematically searched 9 databases in accordance with our prospectively registered protocol (PROSPERO CRD42021249305). English language primary research papers relevant to concepts of discrimination, bullying or harassment in undergraduate MT education, published between 2010 and 2021, were sought. Two independent reviewers screened all titles and abstracts against inclusion criteria, full texts were then retrieved and independently screened and assessed for risk of bias and data extraction. Disagreements were resolved by discussion and the use of a third reviewer. Data were synthesised using a critical interpretive synthesis method. We identified 407 records in our search, 17 full text articles were included in our final synthesis. We highlighted that bullying is prevalent within undergraduate MT education. This is reported to have a large impact upon learners' wellbeing and attainment. Attainment gaps and higher attrition rates for students from ethnic minority groups and students with disabilities in UK physiotherapy were noted in our review, this may not be applicable to other contexts. Our review was limited to English language and a lack of available primary data may be a limitation of our review. This is the first systematic review on this topic and followed best available methodological guidance

Tensegrity and manual therapy practice: a qualitative study

Background Tensegrity has been proposed as a unifying mechanism between structures at cellular, connective tissue and whole body level. Originating in the fields of sculpture and architecture, tensegrity has recently received increasing attention from practitioners and researchers of manual therapy. Notwithstanding this, evidence regarding the role of the tensegrity principle to manual therapy practice is lacking. Objective This qualitative study explored the conception of tensegrity amongst manual therapy practitioners and how knowledge of the physical principle of tensegrity may influence manual therapy practitioners' clinical decision-making. Methods Eight semi-structured interviews were conducted with participants from manual therapy, fascia research and/or manual therapy education fields, and analysed using grounded theory methods. Results Data from this study indicates that tensegrity may inform clinical decision-making in manual therapy. A theory has been constructed that may help to explain aspects of manual therapy practitioners' approaches to tensegrity. Four such approaches to tensegrity were identified and elaborated on. Conclusion This study suggests that apart from being of importance as a scientific model in the fields of architecture, engineering and biology, tensegrity may also be useful to the practice of manual therapy. Here, tensegrity may serve as a theoretical underpinning of previously conceived clinical models and subjective clinical experience, and may also inform decision-making processes by providing a biomechanical model of the human body. © 2016 Elsevier Lt