Weekly Literature Review: Advancing Evidence-Based Practice in Allied Health

Introduction

This week's literature presents a compelling narrative about the evolution of musculoskeletal care, from understanding the neurophysiological mechanisms of pain relief to challenging conventional imaging practices. These five studies collectively emphasize a shift toward personalized, biopsychosocial approaches that prioritize patient beliefs, mechanistic understanding, and judicious clinical decision-making. For allied health professionals in the United States, these findings offer practical insights for optimizing therapeutic outcomes while reducing unnecessary interventions.

Monday: Exercise Intensity and Pain Modulation

Wilson, A. T., Pinette, J., Lyons, K., & Hanney, W. J. (2024). Exercise induced hypoalgesia during different intensities of a dynamic resistance exercise: A randomized controlled trial. PLOS ONE, 19(4), e0299481. https://doi.org/10.1371/journal.pone.0299481

This randomized controlled trial from the University of Central Florida investigated whether exercise intensity influences Exercise-Induced Hypoalgesia (EIH), the temporary reduction in pain sensitivity following physical activity. Sixty healthy adults were randomized to high-intensity (75% 1RM), low-intensity (30% 1RM), or control conditions during single-leg knee extensions.

Contrary to expectations, neither high nor low intensity produced significant differences in pressure pain thresholds compared to rest. However, baseline sensory characteristics, specifically heat pain threshold and temporal summation—predicted hypoalgesic responses during low-intensity exercise. The authors suggest that prior conditioned pain modulation testing may have desensitized participants' inhibitory systems, potentially masking EIH effects.

Clinical Implications: For rehabilitation professionals, this challenges the assumption that "heavier is better" for pain relief. Instead, individual baseline pain processing capacity may determine who benefits most from exercise-induced analgesia, pointing toward precision-based prescription strategies.

Tuesday: Mechanisms of Goal Setting and Pain Education

Walker, E., Jones, M. D., Gibbs, M. T., Gardner, T., Smith, L., Refshauge, K., McAuley, J. H., & Cashin, A. G. (2025). Pain self-efficacy, kinesiophobia and health-related quality of life mediate pain and disability improvements with goal setting and education in people with chronic low back pain: a mediation analysis of a randomised trial. Journal of Physiotherapy, 2025. https://doi.org/10.1016/j.jphys.2025.09.005

This secondary analysis of a randomized controlled trial with 75 participants examined how patient-led goal setting and pain science education reduce chronic low back pain (CLBP) and disability. The study identified four key mediators: pain self-efficacy, kinesiophobia (fear of movement), stress, and health-related quality of life.

For pain intensity, kinesiophobia showed the largest mediating effect (58%), followed by HRQoL (36%). For disability reduction, pain self-efficacy was the dominant mediator (71%). These findings suggest that simply providing exercise or manual therapy is insufficient—clinical success hinges on actively building patient confidence, reframing threat perceptions, and supporting re-engagement in valued activities.

Clinical Implications: Interventions must extend beyond biomechanical correction to address psychological barriers. Clinicians should integrate pain neuroscience education and collaborative goal setting as core, not adjunct, treatment components.

Wednesday: The Tendinopathic Loop

Gehwolf, R., Tempfer, H., Cesur, N. P., Wagner, A., Traweger, A., & Lehner, C. (2025). Tendinopathy: The Interplay between Mechanical Stress, Inflammation, and Vascularity. Advanced Science, 12(e06440). https://doi.org/10.1002/advs.202506440

This comprehensive review introduces the "tendinopathic loop"—a unified model proposing that chronic tendinopathy results from a self-perpetuating cycle involving mechanical stress, inflammation, and pathological vascularity. Aberrant loading triggers maladaptive cellular responses, upregulating pro-inflammatory mediators and vascular endothelial growth factor (VEGF). This leads to hypervascularization, nerve ingrowth, and extracellular matrix (ECM) degradation via matrix metalloproteinases (MMPs).

Critically, inflammation sensitizes mechanoreceptors (e.g., PIEZO1), lowering the mechanical threshold required for tissue damage and accelerating chronicity. The authors argue that single-target treatments (e.g., addressing only load management or inflammation) are insufficient.

Clinical Implications: Effective tendinopathy management requires multi-modal strategies that simultaneously address mechanical loading, reduce inflammation, and potentially target neovascularization. This supports the use of combined interventions such as eccentric exercise, anti-inflammatory modalities, and patient education about progressive load tolerance.

Thursday: Rethinking Shoulder Imaging

Brindisino, F., Salamh, P., Cook, C., Lewis, J., Palese, A., Guerra, G., Bonavita, J., & Rossettini, G. (2025). Shoulder pain: to image or not to image? Frontiers in Rehabilitation Sciences, 6:1624056. https://doi.org/10.3389/fresc.2025.1624056

This opinion piece advocates for a judicious, context-driven approach to shoulder imaging, rejecting both routine screening and blanket avoidance. The authors highlight three critical problems with low-value imaging: (1) structural findings (rotator cuff tears, tendinosis) are common in asymptomatic individuals—akin to wrinkles; (2) imaging rarely changes management in atraumatic cases; and (3) labeling structural abnormalities can trigger nocebo effects, reinforcing catastrophic beliefs and driving patients toward unnecessary injections or surgery.

Imaging is justified when red flags suggest serious pathology, following significant trauma, when conservative care fails after 12 weeks, or when structural confirmation is needed for targeted interventions (e.g., calcific tendinopathy for shockwave therapy).

Clinical Implications: Clinicians must prioritize clinical reasoning and shared decision-making over reflexive imaging orders. Educating patients that structural changes are often normal age-related findings can prevent medicalization of benign conditions and reduce unnecessary downstream interventions.

Friday: Return to Running After Knee Surgery

Alexander, J. L. N., Ezzat, A. M., Culvenor, A. G., De Oliveira Silva, D., Haberfield, M., Esculier, J.-F., & Barton, C. J. (2025). 'The right advice': a qualitative study examining enablers and barriers to recreational running and beliefs about knee health following knee surgery. British Journal of Sports Medicine, 59(ePub ahead of print), 1–11. https://doi.org/10.1136/bjsports-2024-108838

This qualitative study interviewed 17 recreational runners (averaging 7 years post-knee surgery) to identify factors influencing return to running and beliefs about knee health. The primary enabler was receiving "the right advice" from healthcare professionals—specifically, structured return-to-run plans, education on pain monitoring, and challenging unhelpful beliefs within a strong therapeutic alliance. Consistent strength training and effective load management were essential for maintenance.

The most significant barrier was unhelpful professional encounters, including being told they should "never run again" or receiving inadequate rehabilitation structure. This created anxiety, fear of reinjury, and delayed recovery. Interestingly, runners were primarily motivated by psychosocial benefits (mental health, stress management) rather than physical fitness.

Clinical Implications: Clinicians must move beyond pathoanatomical fear-mongering. Providing evidence-based reassurance, structured progression, and addressing psychosocial motivations can empower patients to safely return to valued activities while maintaining long-term knee health.

Cross-Study Themes and Relevance to U.S. Allied Health Practice

1. Personalization Over Protocolization

Monday's EIH study and Tuesday's mediation analysis both emphasize that individual baseline characteristics, whether sensory processing capacity or psychological factors, determine treatment response more than standardized dosage parameters. This challenges one-size-fits-all protocols and supports phenotyping patients based on neurophysiological and psychological profiles.

2. The Biopsychosocial Imperative

Tuesday (goal setting), Thursday (imaging decisions), and Friday (return to running) converge on a unified message: addressing beliefs, fears, and expectations is not optional, it's central to outcomes. The nocebo effects described in Thursday's imaging paper and Friday's "never run again" encounters demonstrate how provider communication can either facilitate or sabotage recovery.

3. Multi-Target Therapeutic Strategies

Wednesday's tendinopathic loop model aligns with the broader theme that complex conditions require comprehensive interventions. Just as tendinopathy cannot be resolved by addressing only load or inflammation, chronic pain (Tuesday) and post-surgical recovery (Friday) require simultaneous attention to physical, psychological, and educational components.

4. Reducing Low-Value Care

Thursday's imaging paper directly addresses healthcare waste, a critical concern in the U.S. system. By reserving imaging for appropriate clinical scenarios and educating patients about the prevalence of asymptomatic findings, allied health professionals can reduce unnecessary costs, downstream interventions, and patient anxiety.

5. The Power of "The Right Advice"

Friday's qualitative findings underscore that clinical expertise extends beyond technical skill to communication, education, and therapeutic alliance. Providers who empower patients with structured plans and challenge catastrophic beliefs enable better outcomes than those who rely solely on passive modalities or restrictive guidance.

Conclusion

This week's literature reinforces a paradigm shift in musculoskeletal rehabilitation: away from reductionist, tissue-focused models toward integrated, person-centered care. For U.S. allied health professionals navigating value-based care models, these studies provide actionable evidence for optimizing outcomes while reducing unnecessary interventions. Whether prescribing exercise intensity, ordering imaging, or counseling post-surgical athletes, the common thread is clear: personalization, education, and addressing the whole person are not just best practices; they are the foundation of effective, efficient, and ethical care.