Weekly Literature Review: Evolving Paradigms in Musculoskeletal Care

Introduction

This week's literature review explores the dynamic landscape of musculoskeletal healthcare, revealing both the power of evidence-based interventions and the complexity of implementing them effectively in real-world practice. The theme that emerges across these five studies is the evolution from rigid, protocol-driven care toward more nuanced, person-centered approaches that honor both scientific rigor and human experience. From quantitative evidence supporting specific exercise interventions to critical examinations of our theoretical frameworks, this collection challenges healthcare professionals to embrace complexity while maintaining clinical excellence.

Monday: Network Meta-Analysis - Exercise Hierarchy for Chronic Low Back Pain

Fernández-Rodríguez and colleagues delivered robust evidence through their comprehensive network meta-analysis of 118 randomized controlled trials involving 9,710 adults with chronic low back pain. This study provides clear hierarchical evidence that fundamentally challenges traditional approaches to exercise prescription.

The findings are striking in their clarity: Pilates emerged as the superior intervention for both pain reduction (SUCRA: 93%) and disability improvement (SUCRA: 98%). Mind-body approaches and core-based exercises followed as highly effective options, while stretching and McKenzie methods showed limited benefit. The study's strength lies not only in its robust methodology but also in its practical specificity—optimal programs consist of 1-2 sessions per week, lasting under 60 minutes, delivered over 3-9 weeks.

What makes this research particularly valuable is its consistency across diverse populations and settings. The effectiveness remained stable regardless of age, sex, or other participant characteristics, suggesting these findings have broad clinical applicability. However, the authors appropriately acknowledge limitations including high risk of bias in many included studies and potential publication bias, reminding us that even strong evidence requires thoughtful clinical interpretation.

Tuesday: Critical Review - Challenging the Biopsychosocial Orthodoxy

Mescouto and colleagues' critical review presents a provocative challenge to one of healthcare's most accepted frameworks. Through Foucauldian discourse analysis of 66 physiotherapy studies, they expose how the biopsychosocial model—despite widespread theoretical adoption—often remains fragmentary and biomedically dominated in actual practice.

Their identification of four dominant discourses reveals troubling patterns: biological measurements continue to dominate, psychological care is reduced to cognitive-behavioral strategies and yellow flags, social determinants receive only superficial attention, and cultural-ethical dimensions are largely marginalized. This critique goes beyond academic criticism to highlight a fundamental implementation gap that affects patient care quality.

The study's call for "re-theorizing pain care" toward richer contextual frameworks reflects growing recognition that our current models may be insufficiently sophisticated for the complex realities of human suffering. This work challenges the profession to move beyond checkbox approaches to biopsychosocial care toward genuine integration of complexity science, cultural competence, and systems thinking.

Wednesday: Mixed-Methods Study - Implementation Science in Shoulder Pain Care

The 2025 study by Maxwell and colleagues shifts focus from theoretical frameworks to practical implementation, examining what actually drives adherence to evidence-based shoulder pain care. Their concept mapping study with 154 stakeholders across 11 countries provides crucial insights into the gap between evidence and practice.

The research identifies compelling shared priorities between patients and providers: clear education about recovery timelines and treatment options, unified messaging across healthcare providers, and strong therapeutic relationships built on trust and empathy. However, significant gaps emerge in areas like shared decision-making, which was poorly represented despite its theoretical importance.

The study's emphasis on culturally sensitive, tailored messaging reflects evolving understanding that effective implementation requires adaptation to diverse patient contexts rather than one-size-fits-all approaches. The involvement of a Public and Patient Involvement panel in interpreting findings demonstrates commitment to authentic patient partnership in research translation.

Thursday: Qualitative Synthesis - The Lived Experience of Shoulder Pain

Maxwell, Robinson, and McCreesh's meta-ethnographic synthesis brings essential human dimensionality to shoulder pain understanding through 26 high-quality qualitative studies across eight countries. This research illuminates the often-overlooked experiential aspects of musculoskeletal conditions that quantitative studies cannot capture.

The three major themes—life disrupted, searching for a cause, and exercise avoidance versus acceptance—reveal how patients' biomechanical worldviews often conflict with evidence supporting conservative management. Participants expected imaging and surgical solutions while remaining skeptical of exercise-based approaches, creating therapeutic tension that requires skilled navigation.

The study's line-of-argument synthesis suggests that effective care requires bridging belief systems rather than dismissing them. This finding has profound implications for clinical communication, suggesting that educational approaches must honor patient narratives while introducing alternative frameworks for understanding pain and recovery. The research emphasizes that fear of movement and low motivation are significant barriers that must be addressed through empathetic engagement rather than simply providing more information.

Friday: Consensus Statement - Principles Over Protocols in Athletic Care

The 2022 Bern Consensus Statement represents sophisticated evolution in athletic injury management, moving from rigid protocols toward principle-based care that honors sport-specific demands and individual athlete contexts. Developed through expert consensus involving 44 international specialists, this framework exemplifies contemporary understanding of optimal athletic healthcare.

The statement's seven rehabilitation principles—from irritability-driven progression to cognitive-neuroplastic strategies—reflect integrated understanding of tissue healing, motor learning, and psychological factors. Their conceptualization of return-to-sport as a continuum rather than binary outcome demonstrates evolved thinking that balances performance demands with long-term health considerations.

Particularly noteworthy is the emphasis on load management that goes beyond simple volume metrics to consider capacity, biomechanics, and sport-specific demands. The framework's six return-to-sport domains provide comprehensive assessment criteria while maintaining flexibility for individual adaptation. This represents a mature approach that combines evidence-based rigor with clinical wisdom and athlete partnership.

Conclusion

This week's literature reveals a profession in thoughtful transition, moving from reductionist approaches toward more sophisticated, contextually-informed care models. The studies demonstrate that while we have strong evidence for effective interventions, success increasingly depends on our ability to implement them within the complex realities of human experience and healthcare systems.

The common thread across these diverse methodologies is the recognition that technical competence, while necessary, is insufficient without relational skills, cultural awareness, and theoretical sophistication. Whether addressing chronic low back pain through Pilates or managing athletic shoulder injuries, optimal outcomes appear to require healthcare professionals who can navigate multiple paradigms simultaneously—honoring quantitative evidence while integrating qualitative insights, maintaining clinical rigor while embracing relational authenticity.

This evolution represents not a retreat from evidence-based practice, but rather its maturation into a more nuanced approach that serves both clinical effectiveness and human dignity. As musculoskeletal healthcare continues evolving, these studies provide both foundation and direction for practitioners committed to excellence that encompasses technical proficiency and wisdom in its application to the complex realities of healing.

Main Points

• Pilates demonstrates superior effectiveness for chronic low back pain management, outperforming other exercise modalities for both pain reduction (93% SUCRA) and disability improvement (98% SUCRA) with optimal programming of 1-2 sessions weekly

• Biopsychosocial model implementation remains fragmented in clinical practice, with biological factors dominating, psychological care reduced to cognitive-behavioral approaches, and social determinants receiving superficial attention

• Patient experiences reveal biomechanical worldviews that often conflict with conservative management evidence, requiring empathetic navigation and bridge-building between belief systems rather than dismissal

• Shared priorities for evidence-based care adherence include clear education about recovery timelines, unified provider messaging, and strong therapeutic relationships, though shared decision-making remains poorly implemented

• Athletic injury management evolves toward principle-based care emphasizing adaptability, sport-specificity, and multidimensional return-to-sport criteria that balance performance demands with long-term health

• Implementation gaps persist between research and practice, highlighting the need for sophisticated frameworks that integrate quantitative evidence, qualitative insights, and contextual complexity

• Cultural competence and relational skills emerge as essential complements to technical knowledge for effective musculoskeletal care delivery

References

Fernández-Rodríguez, R., Álvarez-Bueno, C., Cavero-Redondo, I., Torres-Costoso, A., Pozuelo-Carrascosa, D. P., Reina-Gutiérrez, S., Pascual-Morena, C., & Martínez-Vizcaíno, V. (2022). Best exercise options for reducing pain and disability in adults with chronic low back pain: Pilates, strength, core-based, and mind-body. A network meta-analysis. Journal of Orthopaedic & Sports Physical Therapy, 52(8), 505–521. https://doi.org/10.2519/jospt.2022.10671

Maxwell, C., Robinson, K., & McCreesh, K. (2020). Understanding shoulder pain: A qualitative evidence synthesis exploring the patient experience. Physical Therapy. https://hdl.handle.net/10344/9797

Maxwell, C., Salsberg, J., Robinson, K., Desmeules, F., Lowry, V., Tetreault, C., & McCreesh, K. (2025). Fostering adherence to evidence-based care in the management of musculoskeletal shoulder pain: A mixed-methods study. Physical Therapy, 105, pzae176. https://doi.org/10.1093/ptj/pzae176

Mescouto, K., Olson, R. E., Hodges, P. W., & Setchell, J. (2022). A critical review of the biopsychosocial model of low back pain care: Time for a new approach? Disability and Rehabilitation, 44(13), 3270–3284. https://doi.org/10.1080/09638288.2020.1851783

Schwank, A., Blazey, P., Asker, M., Møller, M., Hägglund, M., Gard, S., Skazalski, C., Andersson, S. H., Horsley, I., Whiteley, R., Cools, A. M., Bizzini, M., & Ardern, C. L. (2022). 2022 Bern consensus statement on shoulder injury prevention, rehabilitation, and return to sport for athletes at all participation levels. Journal of Orthopaedic & Sports Physical Therapy, 52(1), 11–28. https://doi.org/10.2519/jospt.2022.10952