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The Musculoskeletal Wrangler, Wonthaggi (2025)

10/11/2025

Chronic pain: a behavioural perspective
Part 3: operant conditioning (positive reinforcement)
📍In an old laboratory study by Linton & Gotestam (1985) healthy participants were exposed to a fixed intensity noxious stimulus asked to rate their pain reports over subsequent trials that involved a verbal form of positive reinforcement.
EXPERIMENT:
🔎Participants underwent a noxious stimulus (a blood pressure cuff inflated to a painful level) whose intensity was held constant (in one condition) or gradually decreased (in another condition).
FINDINGS:
📝Participants who received verbal praise contingent on reporting higher pain tended to increase or maintain their pain reports, even when the actual stimulus was constant or reduced.
IMPRESSION:
📈The praise acted as a rewarding stimulus that encouraged the behaviour of reporting higher pain, demonstrating how environmental feedback can strengthen pain-reporting behaviour.
📉Participants in the non-reinforced condition showed decreases in pain reports, indicating that the absence of reinforcement did not promote the behaviour,
SUMMARY:
📚The study provides experimental support for an operant conditioning model of pain behaviour, suggesting that verbal feedback and reinforcement contingencies can shape how individuals report pain independent of changes in nociceptive input.
⚠️How do these findings align with your clinical practice?
MW
Reference:
Linton SJ, Gotestam KG. (1985). Controlling pain reports through operant conditioning: a laboratory demonstration. Perception and Motor Skills, 60:427-437.

09/11/2025

Chronic pain: a behavioural perspective
Part 2: operant conditioning
REFLECTION:
🔎How do YOUR behaviours and environmental cues influence someone else’s pain experience?
📍An insightful chapter by Nicholas in the Encyclopedia of Pain (2007) describes how operant conditioning helps explain the persistence of pain through learned behavioural patterns influenced by environmental consequences, rather than ongoing tissue damage.
📚In this model, a person’s behaviours, and the way others respond to them, can reinforce or reduce pain-related actions, illustrating how the social and environmental context shapes the pain experience.
POSITIVE REINFORCEMENT:
📖Involves adding a pleasant or rewarding consequence after a behaviour, which increases the likelihood that the behaviour will be repeated.
📝Eg: A person receives sympathy or attention from others when expressing pain, which may unintentionally reinforce pain behaviours.
NEGATIVE REINFORCEMENT:
📖Involves removing or avoiding an unpleasant stimulus after a behaviour, which also increases the likelihood of that behaviour recurring.
📝Eg: Avoiding physical activity to reduce discomfort provides temporary relief, reinforcing avoidance and contributing to ongoing disability.
SUMMARY:
📚Both, positive and negative reinforcement can strengthen another’s pain behaviours. Positive reinforcement adds a rewarding consequence (e.g., attention or support for pain behaviours), while negative reinforcement removes something unpleasant (e.g., relief from pain or effort through avoidance). Together, they help explain how pain behaviours and avoidance can persist over time.
MW
Reference:
Nicholas MK. Operant Perspective of Pain. In: Gebhart GF, Schmidt R, editors. Encyclopedia of Pain. Berlin, Heidelberg: Springer; 2007. p. 1510-1512

09/11/2025

Chronic pain: a behavioural perspective
Part 1: classical conditioning
REFLECTION:
🔎How do behaviours and environmental cues influence the pain experience?
📍An insightful chapter by Nicholas in the Encyclopedia of Pain (2007) provides practical insights into how classical conditioning provides a framework for understanding how pain can become maintained through learned associations rather than ongoing tissue damage.
📚In brief, how one’s behaviour and their environment can influence the pain experience (LBP example pictured)
CLASSICAL CONDITIONING MODEL:
📖Explains how neutral cues that occur alongside pain can become linked to it and later trigger pain-related reactions, even when no actual pain signal is present. Movements, postures, or environments experienced during pain can become conditioned stimuli, so that over time, these cues alone evoke responses like tension, fear, or avoidance, even after healing.
DEFINITIONS:
UNCONDITIONED STIMULUS:
🔆A stimulus that naturally and automatically triggers a response without prior learning
📝e.g., pain causing withdrawal
UNCONDITIONED RESPONSE:
🔆The automatic, natural reaction to the unconditioned stimulus
📝e.g., guarding/bracing, breath holding or fear in response to pain
CONDITIONED STIMULUS:
🔆A previously neutral stimulus that, after being repeatedly paired with the unconditioned stimulus, comes to trigger a learned response
📝e.g., a movement or setting associated with pain
CONDITIONED RESPONSE:
🔆The learned reaction to the conditioned stimulus, similar to the unconditioned response, but now occurring in response to the cue alone
📝e.g., fear or tension when moving, even without pain
SUMMARY:
📚Classical conditioning helps account for how pain can persist through learned associations rather than ongoing injury. Neutral cues experienced during pain, such as movement or environment, can become linked to it and later trigger fear, tension, or avoidance, even after healing.
⚠️Pain serves as the unconditioned stimulus, and over time, these cues become conditioned stimuli that elicit similar responses without actual pain.
MW
Reference:
Nicholas MK. Operant Perspective of Pain. In: Gebhart GF, Schmidt R, editors. Encyclopedia of Pain. Berlin, Heidelberg: Springer; 2007. p. 1510-1512

02/11/2025

Mental disorders
Part 3: other disorders
📍The Diagnostic and Statistical Manual of Mental Disorders (5th ed., Text Revision; American Psychiatric Association, 2022) outlines the major classifications of mood and other mental disorders, along with their associated diagnostic criteria. Detailed below is a broad list of the disorder classifications:
🔆NEURODEVELOPMENTAL: eg: intellectual, ADHD, OCD etc.
🔆NEUROCOGNITIVE: eg: delirium, dementia etc.
🔆SCHIZOPHRENIA SPECTRUM & PSYCHOTIC
🔆BIPOLAR: eg: type I and II, cyclothymic disorder, substance-induced etc.
🔆ANXIETY DISORDERS: eg: social anxiety, panic disorder, selective mutism etc.
🔆OBSESSIVE-COMPULSIVE: eg: OCD, body dysmorphic, hoarding, trichotillomania etc.
🔆PERSONALITY: eg: BPD, narcissistic, histrionic etc.
🔆TRAUMA & STRESS: eg: PTSD, social disengagement, prolonged grief etc.
🔆DISSOCIATIVE: eg: depersonalisation/derealisation disorder, dissociative amnesia etc.
🔆FEEDING & EATING: eg: anorexia or bulimia nervosa, binge-eating etc.
🔆ELIMINATION: eg: enuresis, encopresis.
🔆SLEEP-WAKE: eg: insomnia, hypersomnolence, narcolepsy, sleep behaviour disroders etc.
🔆SEXUAL, GENDER or PARAPHILIC DYSPHORIAS
SUMMARY:
📚It is useful for musculoskeletal practitioners to be aware of mental disorders, as psychological conditions can significantly influence pain perception, treatment response, and overall patient outcomes.
MW
Reference:
American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th ed, text rev. Washington, DC: American Psychiatric Publishing; 2022. Section II: Depressive Disorders.

01/11/2025

Mental disorders
Part 2: somatic symptom disorders
OVERVIEW:
📚All of these disorders are characterised by a prominence of distressing somatic symptoms and/or illness anxiety plus abnormal thoughts, feelings, and behaviours in response to these symptoms associated with significant distress and impairment. Diagnosis tends to be made on the basis of the presence of these symptoms and signs rather than the absence of a medical explanation for somatic symptoms.
📍The Diagnostic and Statistical Manual of Mental Disorders (5th ed., Text Revision; American Psychiatric Association, 2022) outlines the major classifications of mood and other mental disorders, along with their associated diagnostic criteria. Somatic symptom and related disorders encompass conditions where psychological factors significantly influence the perception, persistence, or severity of physical symptoms such as pain.
DIAGNOSTIC CRITERIA (see image):
SUB-CLASSIFICATIONS:
📖Somatic symptom disorders include illness anxiety disorder, functional neurological symptom disorder (conversion disorder), psychological factors affecting other medical conditions, factitious disorder, other specified somatic symptom and related disorder, and unspecified somatic symptom and related disorder.
RISK FACTORS:
⚠️Negative affectivity personality traits (neuroticism)
⚠️Comorbid anxiety or depression
⚠️Low socioeconomic status with stressful and/or health-related life events (incl. abuse)
SUMMARY:
📖Somatic symptom and related disorders are highly relevant in the assessment of individuals with pain conditions, as they highlight the complex interaction between psychological and physiological factors; their presence can influence symptom interpretation, predict poorer prognosis due to heightened distress or maladaptive coping, and necessitate a multidisciplinary management approach that integrates physical rehabilitation with psychological support.
MW
Reference:
American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th ed, text rev. Washington, DC: American Psychiatric Publishing; 2022. Section II: Depressive Disorders.

01/11/2025

Mental disorders
Part 1: depressive disorders
BACKGROUND:
🔎Depressive disorders are characterised by sad, empty, or irritable mood, accompanied by somatic and cognitive changes that significantly affect a person’s functioning. A key feature of which is a persistent disturbance in mood that represents a clear change from an individual’s typical emotional state. Depressive disorders represent an important risk factor, prognostic indicator, and potential confounding variable in musculoskeletal and other pain conditions.
📍The Depressive Disorders chapter of the Diagnostic and Statistical Manual of Mental Disorders (2022, 5th Ed.) outlines this group of conditions that involve five categories with distinct diagnoses that vary in duration, timing, and presumed cause.
DISRUPTIVE MOOD DYSREGULATION DISORDER:
📝Chronic (>12mo) irritability and severe temper outbursts, common in children (between 6 and 10 years old). The etiology of which is thought to be related to developmental dysregulation of emotional control rather than episodic mood shifts.
MAJOR DEPRESSIVE DISORDER (MDD):
📝One or more major depressive episodes (>2 week duration) marked by pervasive low mood, loss of interest, and other cognitive or physical symptoms. The etiology of which is known to be multifactorial in nature, including genetic, neurochemical (e.g., serotonin dysregulation), psychological, and social factors contribute to vulnerability and onset.
PERSISTENT DEPRESSIVE DISORDER (DYSTHYMIA):
📝A chronic form of depression lasting at least two years, often less severe but longer lasting than MDD. The etiology is similar to MDD but with more enduring personality and environmental influences; may involve chronic stress or maladaptive cognitive patterns
PREMENSTRUAL DYSPHORIC DISORDER (PMDD):
📝Mood disturbances linked to the menstrual cycle (luteal phase), with symptoms emerging in the luteal phase and resolving after menstruation. The etiology is linked to hormonal fluctuations and sensitivity to changes in estrogen and progesterone affecting serotonin pathways.
SUBSTANCE/MEDICATION-INDUCED DEPRESSIVE DISORDER:
📝Depressive symptoms arising as a physiological effect of a substance or medication.
DEPRESSIVE DISORDER DUE TO ANOTHER MEDICAL CONDITION:
📝Depression resulting directly from the physiological effects of a medical illness.
CONCLUSION:
📚For practitioners, this underscores the need to consider medication effects, medical comorbidities, and biological contributors to mood, ensuring accurate assessment, interdisciplinary management, and improved rehabilitation outcomes.
MW
Reference:
American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th ed. Washington, DC: American Psychiatric Publishing; 2013. Section II: Depressive Disorders.

30/10/2025

“First, do no harm”
BACKGROUND:
🔎In the field of pain management interventions, the ethical principle of “first, do no harm” (non-maleficence) demands reliable evidence on harms (adverse events, adverse reactions), yet major deficiencies persist.
📍A very recent perspective paper by O’Connell et al. (2025) discuss three main challenges with respect to this ethical principle.
NOMENCLATURE & DEFINITIONS OF HARM:
📖There is inconsistent or ambiguous use of terms like “adverse event”, “adverse reaction”, “serious adverse event” in pain intervention trials. Many frameworks are designed for pharmacologic interventions, and do not adequately cover non drug treatments (e.g., physical, psychological, behavioural, surgical) despite these being commonly used in pain management.
MEASUREMENT OF HARM:
📖Many trials do not systematically measure or capture adverse events associated with interventions for pain, especially non drug treatments. There is often insufficient information about timing (during vs after intervention), causality, grading of severity, and follow up duration. Existing measurement systems may not be well suited to interventions where harms may be subtle, delayed, or unexpected
REPORTING OF HARMS:
📖Even when adverse events are recorded, reporting is inconsistent, incomplete or absent in many publications of randomized controlled trials and systematic reviews in the pain field. These deficiencies hinder balanced assessment of benefits versus harms, which is essential for informed decision making by clinicians, patients and policymakers.
IMPLICATIONS:
⚠️Without reliable data on harms, even interventions assumed to be “low risk”, may carry unrecognised dangers. The absence of reported adverse events may reflect omission rather than true safety.
📚Furture research needs to build mechanisms to anticipate, measure, record and report adverse events.
✅There should be a greater emphasis on harms data, and journals should enforce more consistent reporting standards for adverse events.
✅Patients and clinicians should be aware that benefit only reporting provides an incomplete picture; safety data are often under represented.
MW
Reference:
O’Connell NE, Abdel‐Shaheed C, Qureshi R, Richards G, Soliman N, Fisher E, Cashin AG, Ferraro MC. To do no harm, we must first “know harms”: the challenge of measuring and reporting adverse events in interventions for pain. Pain. E pub ahead of print 26 Aug 2025.

30/10/2025

What Portion of Physiotherapy Treatments’ Effect Is Not Attributable to the Specific Effects in People With Musculoskeletal Pain?
BACKGROUND:
🔎All physiotherapy interventions, and indeed most healthcare treatments, produce a combination of specific effects and non-specific effects (formerly referred to as the “placebo effect”). Understanding how much of an intervention’s outcome is attributable to its specific effects versus its non-specific, contextual influences is essential when evaluating the true usefulness and efficacy of that intervention.
📍A recent meta-analysis by Ezzatvar et al. (2024) investigated how much of the benefit people get from physiotherapy for musculoskeletal pain (like back, neck, or joint pain) is due to the specific treatment itself (e.g., exercise, manual therapy, electrotherapy), and how much comes from non-specific factors, such as patient expectations, therapist interaction, attention, and the natural course of recovery.
STUDIES:
📚The combined data from 68 RCTs, where a physiotherapy intervention was compared to “sham” or placebo versions, in order to compare the “specific” treatment effect/s from the “non-specific” effects.
NON-SPECIFIC EFFECTS:
⚠️Mobilisation & manipulation: 81-88%
⚠️Dry needling: 74%
⚠️Taping: 64%
⚠️Exercise therapy: 46%
SUMMARY:
✅Even when physiotherapy interventions produce a favourable outcome, a major mechanism of the benefit may not be due to the specific therapeutic mechanism, but rather to context, placebo, natural recovery, etc.
📝For practitioners, this highlights the importance of paying attention not just to what treatment is done, but how it is delivered (therapist behaviours, patient expectations, environment).
📝For patients, this doesn’t mean treatment is “just placebo”, it means that many factors (including your own beliefs, the care environment, the therapists’ interaction) matter a lot alongside the technical part of therapy.
MW
Reference:
Ezzatvar Y, Van Oosterwijck J, Lluch E, Pecos-Martín D, Meeus M. Which portion of physiotherapy treatments’ effect is not attributable to the specific effects in people with musculoskeletal pain? A meta-analysis of randomized placebo-controlled trials. J Orthop Sports Phys Ther. 2024;54(5):1–12.

29/10/2025

Correlation vs. causation
BACKGROUND:
🔎In orthopaedic (and broader) observational research, understanding the outcomes of an intervention or experimental condition is essential when evaluating its efficacy. A common pitfall arises however, when ‘correlation’ is mistakenly interpreted as ‘causation’, leading to potentially misleading conclusions.
📍A recent review paper by Zaniletti et al. (2023) outline the major pitfalls when drawing causal conclusions from observational data.
RANDOM CHANCE!
📚Observed associations might simply reflect random variation rather than a true relationship. The role of chance can occur when:
⚠️Sample sizes are too small or samples are not randomised
⚠️Inadequate statistical analysis, incl. significance thresholds and confidence intervals
⚠️Random fluctuations, heterogeneity and individual variability exist in patient characteristics, creating the illusion of a significant effect.
📝An example would be to assume people undergoing a TKR tend to get better outcomes if they have surgery in the morning versus the afternoon, or from on a weekday rather than the weekend.
REVERSE CAUSALITY:
📚Occurs when the direction of cause and effect are opposite to what is assumed. It refers to a situation in which an observed association between two variables arises because the outcome influences the exposure rather than the exposure influencing the outcome.
⚠️To avoid it, research should consist of longitudinal study designs or randomised controlled trials (RCTs).
📝An example would be that people with knee OA are less physically active than those without knee OA. It can be the case however, that the presence of OA is actually the reason why people are less physically active.
CONFOUNDING:
📚Occurs when the apparent relationship between an exposure and an outcome is distorted by the presence of a third variable (a confounder) that is related to both.
📝An example would be to assume patients who attend physiotherapy have better functional outcomes. The relationship between therapy frequency and recovery however is confounded by patient health status, adherence, motivation etc.
SUMMARY:
✅In orthopaedic research, it is crucial to distinguish correlation from causation, as observed associations may arise from random chance, reverse causality, or confounding rather than a true causal effect. Careful study design, including longitudinal studies or RCTs, is needed to draw valid conclusions about intervention efficacy.
MW
Reference:
Zaniletti I, Larson DR, Lewallen DG, Berry DJ, Maradit Kremers H. How to Distinguish Correlation From Causation in Orthopaedic Research. J Arthroplasty. 2023 Apr;38(4):634-637.

27/10/2025

Therapeutic alliance
Part 4: theories, frameworks, themes and characteristics
📍A comprehensive scoping review by Babatunde et al. (2017) collated the data of 130 research papers to examine the theories, frameworks, themes and characteristics of therapeutic alliance (TA) in physiotherapy and occupational therapy (OT).
THEORIES:
🔆Self-determination theory (SDT)
🔆Self-efficacy theory
🔆Social learning theory
FRAMEWORKS:
🔆Health behaviour change
🔆Compliance and satisfaction
🔆Illness perception, self-efficacy and patient beliefs
🔆Patient-centred care, helping and partnership
THEMES (see image)
🔆Communication, congruence, connectedness and partnership
🔆Expectation, roles and responsibilities
🔆Individualised therapy and recognising influencing factors
CHARACTERISTICS (see image)
SUMMARY:
📈The most reported characteristics of therapeutic alliance include, active listening (39%), agreement on goals (32%), therapist skill & confidence (30%), active involvement (28%), encouragement (26%), expectations of therapy (25%) and outcome (22%), clarity of information (26%), non-verbal skills (24%) and friendliness (21%).
✅These are important findings for clinicians when considering the desired characteristics of their therapeutic alliance with patients.
MW
Reference:
Babatunde F, MacDermid J & MacIntyre N. Characteristics of therapeutic alliance in musculoskeletal physiotherapy and occupational therapy practice: a scoping review of the literature. BMC Health Services Research,2017;17:375.

27/10/2025

Therapeutic alliance
Part 3: a mediator of change
BACKGROUND:
🔎The alliance-outcome relationship has long been associated with positive treatment outcomes irrespective of psychotherapy modality.
📍A recent systematic review by Baier et al. (2020) collated the data of 37 relevant articles to examine therapeutic alliance as a potential mediator of symptom change and patient outcome.
FINDINGS:
📈About 70% of the studies reviewed found that the therapeutic alliance mediated treatment outcomes, supporting its role as a mechanism of change in psychotherapy.
LIMITATIONS:
⚠️Although these findings can inform clinical practices and enhance treatment outcomes, further research is required to more precisely estimate how and to what extent the therapeutic alliance drives therapeutic change
CONCLUSION:
✅The strength and quality of this alliance are considered critical factors influencing therapeutic outcomes, with a robust alliance often serving as a mediator for positive change in psychotherapy.
MW
Reference:
Baier AL, Kline AC, Feeny NC. Therapeutic alliance as a mediator of change: A systematic review and evaluation of research. Clin Psychol Rev. 2020 Oct;82:101921. doi: 10.1016/j.cpr.2020.101921.

27/10/2025

Therapeutic alliance (TA)
Part 2: influential factors
📍A recent systematic review by Kinney et al. (2020) collated the data of 7 large studies in part to examine the influential factors (facilitators and barriers) on the TA between clinicians and patients.
FACILITATORS:
🟢Trust, rapport and support
🟢Open communication
🟢Establishing individualised, flexible treatment plans
🟢Identification of patient as a ‘whole person’ encompassing their perspectives, values and potential barriers to compliance
🟢Establish need for active participation
🟢Ability to work through challenges
BARRIERS:
🔴Patient hostility, high anger expression and/or depression scores
🟠Other likely factors include those that either, positively or negatively affect the efficacy of the clinician-patient relationship, such as unfavourable personality traits, lack of clinical competence etc.
RECOMMENDATIONS:
✅The need for continuing education including clinical communication skills or mentorship, and the need for reflective and evidence-based practice.
MW
Reference:
Kinney M, Seider J, Beaty AF, Coughlin K, Dyal M, Clewley D. The impact of therapeutic alliance in physical therapy for chronic musculoskeletal pain: a systematic review of the literature. Physiother Theory Pract. 2020 Aug;36(8):886–98.

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