Weekly MSK Literature Review

Monday: Economic Analysis and Cost Drivers in MSK Primary Care Main Points

• Systematic review of 22 economic analyses (2008-2018) revealed moderate to high methodological quality overall, though with recurring gaps in perspective justification and cost categorization

• Hospital admissions, outpatient visits, and imaging represent the highest unit costs in MSK care, but GP visits, outpatient visits, and physiotherapy sessions drive total spending due to high utilization volume

• Resource use capture was generally strong (often via patient cost diaries), and unit costs were typically derived from national reference sources

• Critical methodological gaps included: almost no studies distinguished short- vs long-run costs (despite stating perspective), inconsistent clarity on fixed cost allocation and staff time, and limited transparency in cost justification

• The review demonstrates that utilization volume, not unit price alone, is the primary determinant of MSK costs in community settings

Clinical Significance This work provides essential clarity for value-based MSK care redesign: understanding that high-volume, lower-cost services (GP visits, physiotherapy) matter more than isolated high-cost events should shift attention toward optimizing access, efficiency, and appropriateness of front-line services. Standardized costing frameworks would enable meaningful service benchmarking, identification of unwarranted variation, and evidence-based resource allocation decisions across primary and community MSK programs.

Citation Burgess, R., Hall, J., Bishop, A., Lewis, M., & Hill, J. (2020). Costing methodology and key drivers of health care costs within economic analyses in musculoskeletal community and primary care services: A systematic review of the literature. Journal of Primary Care & Community Health, 11, 1–13. https://doi.org/10.1177/2150132719899763

Tuesday: Prescription and Delivery Variability in Graded Motor Imagery Main Points

• Scoping review of 32 RCTs (38 intervention arms) using graded motor imagery (GMI) for chronic pain revealed striking consistency in full GMI protocols, with all 8 full-protocol arms adhering to the original 2004 Moseley framework

• Full GMI consistently involves three sequential phases (left/right judgments, imagined movements, mirror therapy), typically 2 weeks per phase (6 weeks total), with high-frequency home practice (often every waking hour)

• Component-only interventions (30 arms) showed substantial variability: duration ranged 5-70 days, session length 10-60 minutes, with inconsistent frequency, instructions (first- vs third-person imagery), and delivery modes (apps, software, printed materials)

• Reporting quality assessed via TIDieR framework revealed gaps: only 48% clearly reported intensity/dose, 29% described adaptations/personalization, and 42% documented fidelity/adherence strategies

• Despite 20 years since initial protocol publication, no consensus exists on optimal dose, sequence, or delivery method for component-only approaches, limiting meta-analysis and clinical translation

Clinical Significance This review clarifies why GMI research appears heterogeneous and difficult to synthesize: while full protocols are standardized, the majority of trials test isolated components with wide methodological variation and incomplete reporting. For clinicians implementing GMI, this suggests the complete protocol may be more evidence-based than cherry-picking components, while highlighting the urgent need for standardized reporting to enable knowledge translation and identify which adaptations improve outcomes.

Citation Williams, S. A., Cashin, A. G., Ferraro, M. C., Devonshire, J. J., Leake, H., Linke, J., Wallwork, S., Pinto, R. Z., Moseley, G. L., & McAuley, J. H. (2026). Prescription of graded motor imagery for people with chronic pain: A scoping review. European Journal of Pain, 30, e70220. https://doi.org/10.1002/ejp.70220

Wednesday: Cultural Context as Essential Element of Biopsychosocial MSK Care Main Points

• Masterclass argues that culture fundamentally shapes pain experience, expression, interpretation, and management, yet remains systematically undisintegrated in physical therapy despite widespread endorsement of the biopsychosocial model

• Cultural beliefs about pain causation vary dramatically: Mexican-American communities may view pain as God's will, Aboriginal Australians may interpret it as spiritual dysfunction, Zulu communities may attribute it to bewitching, and rural vs urban Nepalese show divergent medicalization patterns

• These culturally influenced beliefs directly affect disability levels, catastrophizing, help-seeking behavior, and treatment engagement, making cultural assessment not optional but essential for effective care

• Culturally sensitive pain neuroscience education requires shifting from clinician-centered teaching to patient-centered learning, using culturally relevant metaphors and examples, validating rather than confronting beliefs, and adapting delivery methods to local contexts

• Combining culturally adapted PNE with cognition-targeted exercise and graded activity yields medium to large improvements in fear, hypervigilance, and catastrophizing when delivered with cultural congruence

Clinical Significance This work challenges the field to operationalize the "social" in biopsychosocial care by recognizing that culturally incongruent interventions risk ineffectiveness or harm. For health systems serving diverse populations, developing culturally adapted materials, training clinicians in cultural humility, and embedding cultural assessment into standard practice represents not just an equity imperative but a clinical effectiveness strategy essential for optimizing MSK outcomes across all populations.

Citation Reis, F. J. J., Nijs, J., Parker, R., Sharma, S., & Wideman, T. H. (2022). Culture and musculoskeletal pain: Strategies, challenges, and future directions to develop culturally sensitive physical therapy care. Brazilian Journal of Physical Therapy, 26, 100442. https://doi.org/10.1016/j.bjpt.2022.100442

Thursday: Contextual Factors as Active Ingredients in Conservative Low Back Pain Care Main Points

• Systematic review of 21 studies (N=3,075) examining whether interventions that explicitly modify contextual factors improve pain intensity and physical functioning in adults with chronic low back pain

• Eight studies showed significant improvements in pain intensity and seven showed improvements in physical functioning when contextual factors were intentionally modified (not merely present)

• The most influential modifiable contextual factors included: addressing maladaptive illness beliefs (fear, catastrophizing, biomedical misconceptions), positive verbal suggestions that shape treatment expectations, visual/physical cues signaling therapeutic benefit, and empathetic communication with strong therapeutic alliance

• Studies modifying multiple contextual factors simultaneously showed stronger effects than single-factor interventions, suggesting synergistic benefit

• Most included studies rated Excellent or Good quality (modified Downs & Black scale), though heterogeneity in intervention design, dose, and theoretical grounding limits firm conclusions about optimal CF modification strategies

Clinical Significance This review provides systematic evidence that contextual factors are not peripheral "soft skills" but measurable, modifiable contributors to clinical outcomes in chronic low back pain. For clinicians, this means intentionally shaping patient expectations, addressing beliefs, optimizing communication, and creating therapeutic environments should be viewed as core clinical competencies, available at no cost in every encounter and capable of amplifying the effectiveness of standard conservative treatments.

Citation Sherriff, B., Clark, C., Killingback, C., & Newell, D. (2022). Impact of contextual factors on patient outcomes following conservative low back pain treatment: Systematic review. Chiropractic & Manual Therapies, 30, 20. https://doi.org/10.1186/s12998-022-00430-8

Friday: Fear of Movement and Reinjury in Sports Medicine Rehabilitation Main Points

• Perspective article argues that fear of movement and reinjury is central to sports injury recovery, influencing treatment decisions, rehabilitation progress, and return-to-sport outcomes more powerfully than many physical impairments

• In ACL injury, fear is often highest early post-surgery and predicts poorer functional outcomes; high fear at return-to-sport clearance increases risk of second ACL injury, and fear is a primary reason athletes do not return to sport despite adequate physical function

• Acute Achilles tendon rupture involves sudden trauma and high fear of reinjury influencing return-to-sport decisions, while Achilles tendinopathy shows up to 38% prevalence of high kinesiophobia despite lower actual rupture risk

• Fear follows a "U-shaped" trajectory: high immediately after injury, decreases during rehabilitation as confidence builds, then rises again when approaching return to sport, exactly when athletes need maximum support

• Current assessment tools (TSK, ACL-RSI) may not fully capture sport-specific fear nuances, as athletes may fear performance loss, specific movements, or future disability rather than general movement or immediate reinjury

Clinical Significance This work challenges the field to recognize psychological readiness as inseparable from physical readiness in sports rehabilitation. Fear assessment and management must be integrated throughout the entire care continuum, from treatment decision-making to return-to-sport clearance, using graded exposure, strength testing to rebuild trust, clear communication about risks, and explicit acknowledgment of the emotional load athletes carry. Treating fear as a core rehabilitation component, not an afterthought, may be essential for successful return not just to sport but to confidence.

Citation Kvist, J., & Grävare Silbernagel, K. (2022). Fear of movement and reinjury in sports medicine: Relevance for rehabilitation and return to sport. Physical Therapy, 102(2), pzab272. https://doi.org/10.1093/ptj/pzab272

Weekly Themes & Strategic Insights

1. Value in MSK Care Requires Understanding True Cost Drivers, Not Just Unit Prices The Burgess et al. costing review demonstrates that high-volume, lower-cost services (GP visits, physiotherapy) drive total MSK spending far more than isolated high-cost events. This aligns conceptually with the contextual factors work by Sherriff et al., which shows that optimizing the "how" of care delivery, through communication, expectation management, and therapeutic alliance, can enhance outcomes at minimal cost. Together, these papers suggest value improvement requires attending to the high-frequency touchpoints and relational elements of care, not just reducing expensive procedures.
   

2. Intervention Fidelity and Reporting Quality Remain Persistent Barriers to Knowledge Translation Both the Williams et al. GMI review and the Reis et al. cultural care masterclass highlight that incomplete reporting and lack of standardization prevent effective synthesis and implementation. Williams found that only 48% of GMI trials clearly reported dose/intensity, while Reis documented the absence of culturally adapted materials and protocols. This pattern suggests the field needs not just more research, but more rigorous description of what was actually delivered, to whom, how, and with what adaptations, enabling replication and quality improvement.
   

3. Psychological and Contextual Factors Are Not "Soft", They Are Measurable, Modifiable Clinical Targets Three papers (Sherriff, Kvist, Reis) converge on the evidence that beliefs, expectations, fear, communication quality, and cultural congruence meaningfully influence MSK outcomes. Sherriff shows contextual factor modification improves pain and function in chronic low back pain, Kvist demonstrates that fear predicts return-to-sport outcomes more strongly than physical measures in ACL and Achilles injuries, and Reis documents how cultural beliefs shape disability and engagement. These are not peripheral concerns, they are central determinants of recovery that demand systematic assessment and intervention.
   

4. The Biopsychosocial Model Requires Operationalization Beyond Lip Service Despite widespread endorsement of biopsychosocial care, the Reis masterclass reveals that clinical practice remains disproportionately biological, while the Kvist perspective shows psychological readiness is often treated as secondary to physical clearance criteria. The Sherriff review offers evidence that intentional modification of psychosocial elements improves outcomes, but the field lacks standardized frameworks for integrating these factors into routine care. Moving from conceptual acceptance to systematic implementation remains an urgent challenge.
   

5. Standardization and Personalization Are Not Opposing Goals, Both Are Necessary The Williams GMI review shows that full standardized protocols are consistently delivered while component-only approaches vary wildly, suggesting standardization supports fidelity. Yet the Reis cultural care work demonstrates that rigid, one-size-fits-all approaches fail when cultural context is ignored. The solution is not choosing between standardization and personalization, but building protocols with clearly defined core elements (dose, sequence, key components) that allow culturally and individually appropriate adaptations within evidence-based parameters.
   

6. Fear Assessment and Management Must Be Integrated Throughout the MSK Care Continuum The Kvist sports medicine perspective shows fear is highest at injury onset and again at return-to-sport, while the Sherriff contextual factors review demonstrates that addressing maladaptive beliefs improves outcomes in chronic low back pain. Together, these suggest fear assessment cannot be a one-time screening but must be ongoing, with interventions (graded exposure, expectation management, communication strategies) embedded at every care transition point, from initial injury through treatment decisions, rehabilitation progression, and return-to-activity clearance.
   

Implications for MSK Care Delivery, Technology, and Strategy

Economic Models and Value-Based Contracts: Costing frameworks must focus on high-utilization services (GP, physiotherapy, outpatient visits) rather than just high-unit-cost events. Value-based payment models should incentivize optimization of front-line care quality and access, not solely reduction of imaging or procedures.

Digital Therapeutics and Remote Monitoring: Technologies implementing GMI, PNE, or graded exposure must prioritize complete reporting of dose, sequence, and delivery parameters to enable evidence synthesis. Digital tools offer opportunity for standardized core protocols with culturally adaptive interfaces and personalized progression algorithms.

Workforce Development: Clinician training must explicitly include cultural humility, contextual factor optimization (communication, expectation management, therapeutic alliance), and fear assessment/management. These are not "soft skills" but core clinical competencies with direct outcome effects.

Clinical Protocols and Care Pathways: Standardized MSK pathways should embed psychological and cultural assessment at all care transitions, with decision support for when and how to integrate culturally adapted education, graded exposure, and contextual factor enhancement. Return-to-activity criteria must include validated psychological readiness measures, not just physical function tests.

Health Equity and Population Health: Culturally incongruent care is not just inequitable, it's clinically ineffective. Health systems must develop culturally adapted materials, multilingual resources, and community-specific care pathways. Cultural sensitivity is a quality metric, not optional cultural competence training.

Research Priorities: Future trials must meet higher reporting standards (TIDieR framework) with clear documentation of dose, fidelity, adaptations, and contextual elements. Research funding should prioritize culturally tailored interventions, standardized contextual factor protocols, and psychologically informed rehabilitation models. The field needs less duplication of underpowered, poorly reported trials and more rigorous implementation science.

Measurement and Outcomes: Current patient-reported outcome measures may not capture sport-specific fear, cultural variations in pain expression, or contextual factor effects. Outcome measurement must expand beyond pain and function to include psychological readiness, patient expectations, treatment credibility, and culturally relevant quality-of-life domains.

Bottom line: Effective MSK care requires understanding that the context, culture, and psychological dimensions of care delivery are not peripheral, they are measurable, modifiable determinants of outcome that demand the same systematic attention we give to exercise prescription, manual therapy technique, or surgical indications. Value improvement lies not in eliminating high-cost events but in optimizing high-volume interactions and integrating biopsychosocial care beyond conceptual endorsement into operational reality.