Weekly Literature Review

A synthesis of current evidence shaping personalized rehabilitation

Monday: The Broad Evidence Base for Exercise

The week began with a comprehensive overview examining exercise-based interventions across 45 long-term conditions. Dibben et al. (2024) synthesized 42 systematic reviews encompassing over 936,000 participants, revealing that exercise demonstrates beneficial effects across 25 conditions, with evidence particularly strong for health-related quality of life and exercise capacity outcomes. However, the review exposed a critical gap: multimorbidity, the reality for most patients with chronic conditions, received virtually no consideration in intervention design. Most studies actively excluded patients with multiple conditions or failed to document adaptations, highlighting a significant disconnect between research protocols and clinical practice (Dibben et al., 2024).

Citation: Dibben, G. O., Gardiner, L., Young, H. M. L., Wells, V., Evans, R. A., Ahmed, Z., Barber, S., Dean, S., Doherty, P., Gardiner, N., Greaves, C., Ibbotson, T., Jani, B. D., Jolly, K., Mair, F. S., Mcintosh, E., Ormandy, P., Simpson, S. A., Ahmed, S., Krauth, S. J., Steel, L., Singh, S. J., & Taylor, R. S. (2024). Evidence for exercise-based interventions across 45 different long-term conditions: An overview of systematic reviews. eClinicalMedicine, 72, 102599. https://doi.org/10.1016/j.eclinm.2024.102599

Tuesday: Pain Neuroscience Education Beyond Chronic Pain

Louw et al. (2024) challenged the traditional boundaries of Pain Neuroscience Education (PNE), arguing for its application in acute pain scenarios, particularly among athletes. While PNE has established efficacy in chronic pain populations, this commentary presented the Mature Organism Model to demonstrate how biological and psychological factors converge even in acute injuries. The authors emphasized that patients with high fear-avoidance and pain catastrophizing may benefit most from early PNE integration and that combining education with physical interventions (PNE+) produces superior outcomes compared to education alone. Critically, they highlighted how language choices,using "sprain" versus "tear," for example,can either amplify or reduce fear and influence recovery trajectories (Louw et al., 2024).

Citation: Louw, A., Schuemann, T., Zimney, K., & Puentedura, E. J. (2024). Pain neuroscience education for acute pain. International Journal of Sports Physical Therapy, 19(6), 758–767. https://doi.org/10.26603/001c.118179

Wednesday: Phenotyping Chronic Low Back Pain

The BACPAP consortium published international consensus recommendations for identifying dominant pain phenotypes (nociceptive, neuropathic, or nociplastic) in patients with chronic low back pain. The resulting seven-step clinical decision tree provides a structured approach to phenotype classification based on chronicity, pain distribution, evoked hypersensitivity, and comorbid symptoms. While preliminary evidence suggests phenotype-specific treatment responses (such as duloxetine showing enhanced effectiveness in nociplastic low back pain), the authors emphasized that these recommendations are intended to standardize research methodology rather than dictate immediate clinical practice. The consortium acknowledged that mixed phenotypes are common and that no gold standard diagnostic test currently exists, making classification dependent on clustering clinical signs and symptoms (BACPAP Consortium, publication details not provided in original text).

Citation: linkinghub.elsevier.com/retrieve/pii/S2665-9913(23)00324-7 

Thursday: Tailoring Manual Therapy to Pain Mechanisms

Cook et al. (2023) advanced the precision medicine agenda in musculoskeletal care by developing mechanism-specific manual therapy frameworks for nociceptive, nociplastic, and neuropathic pain. Through a hybrid consensus process involving 18 expert clinicians and 96 stakeholders, the study identified one preferred framework for each pain mechanism. All three frameworks shared core principles: manual therapy as part of a biopsychosocial, multimodal approach; treatment modification based on patient response; and patient-centered care. However, mechanism-specific differences emerged. Nociceptive frameworks emphasized targeting peripheral somatic sources with technique variation based on severity and irritability. Nociplastic frameworks prioritized therapeutic alliance and shared decision-making over specific technique parameters, acknowledging that patient response matters more than thrust versus non-thrust distinctions. Neuropathic frameworks proved most complex, with stakeholders preferring mechanism-based descriptions over diagnostic classifications (Cook et al., 2023).

Citation: Cook, C. E., Rhon, D. I., Bialosky, J., Donaldson, M., George, S. Z., Hall, T., Kawchuk, G., Lane, E., Lavazza, C., Lluch, E., Louw, A., Mazzieri, A. M., McDevitt, A., Reed, W. R., Schmid, A. B., Silva, A. G., Smart, K. M., & Puentedura, E. J. (2023). Developing manual therapy frameworks for dedicated pain mechanisms. JOSPT Open, 1(1), 48–62. https://doi.org/10.2519/josptopen.2023.0002

Friday: Implementation Challenges for Pain Neuroscience Education

The week concluded with a pragmatic reality check. Lane et al. (2022) conducted a cluster-randomized trial across 45 outpatient clinics to determine whether training physical therapists in PNE improves patient outcomes for chronic neck or low back pain. While PNE training successfully improved therapists' pain knowledge and attitudes, it failed to produce significant improvements in physical function, the study's primary outcome. Patients in the PNE group showed modest but statistically significant gains in pain self-efficacy at both 2 and 12 weeks. However, treatment fidelity proved problematic; only 44.4% of patients reported receiving key PNE messaging, suggesting a substantial gap between training and implementation. The authors noted that many participating therapists already possessed high baseline pain knowledge, potentially limiting the training's incremental impact (Lane et al., 2022).

Citation: Lane, E., Magel, J. S., Thackeray, A., Greene, T., Fino, N. F., Puentedura, E. J., Louw, A., Maddox, D., & Fritz, J. M. (2022). Effectiveness of training physical therapists in pain neuroscience education for patients with chronic spine pain: A cluster-randomized trial. Pain, 163(5), 852–860. https://doi.org/10.1097/j.pain.0000000000002436

Implications for the Musculoskeletal Industry

This week's literature reveals a musculoskeletal field in transition, moving from one-size-fits-all protocols toward precision rehabilitation while simultaneously confronting implementation barriers that threaten to undermine evidence-based advances.

The Personalization Imperative: Three papers (Wednesday's BACPAP phenotyping, Thursday's mechanism-based manual therapy, and Tuesday's context-sensitive PNE) converge on a single message: generic treatment approaches are becoming obsolete. The field now possesses frameworks for identifying pain phenotypes and matching interventions to mechanisms. However, these frameworks remain largely research tools rather than clinical standards, creating an opportunity gap for organizations that can bridge translation.

The Implementation Challenge: Friday's pragmatic trial delivered a sobering reminder that knowledge does not automatically translate into behavior change or improved outcomes. Even when therapists receive specialized training and demonstrate improved knowledge, treatment fidelity remains inconsistent, and patient outcomes may not improve. This suggests that education alone is insufficient; implementation requires systemic support, workflow integration, clinical decision support tools, and possibly cultural transformation within practices.

The Exercise Foundation: Monday's comprehensive review reinforces exercise as a cornerstone intervention across diverse conditions but exposes how research systematically excludes the multimorbid patients who comprise real-world clinical populations. For the musculoskeletal industry, this creates both a challenge and an opportunity: the challenge of adapting evidence-based protocols for complex patients and the opportunity to generate pragmatic evidence that reflects actual practice.

Strategic Implications: Organizations positioning themselves in value-based musculoskeletal care must address three priorities. First, develop scalable mechanisms for phenotype assessment and mechanism-based treatment matching, moving precision rehabilitation from concept to workflow. Second, invest in implementation science, recognizing that clinician education represents only the first step toward practice transformation. Third, generate real-world evidence addressing the multimorbidity gap, demonstrating how personalized approaches perform with complex patients in community settings.

The convergence of pain phenotyping, mechanism-based treatment frameworks, and expanded applications of pain neuroscience education signals the maturation of precision musculoskeletal care. The question is no longer whether personalization improves outcomes; the evidence increasingly supports this, but rather how to implement these approaches at scale in resource-constrained environments serving multimorbid populations.