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The Musculoskeletal Wrangler

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The Musculoskeletal Wrangler

I am an APA Musculoskeletal Physiotherapist and an emerging APA "Pain" Physio passionate about evidence based practice (EBP).

This page keeps me accountable with EBP, and can hopefully serve as a useful resource for health professionals and consumers.

28/12/2025

Insomnia
Part 4: CBT-insomnia
BACKGROUND:
🔎Cognitive-Behavioural Therapy for Insomnia (CBT-I) is a structured, short-term psychosocial intervention designed to help people with chronic insomnia reduce sleep difficulties by changing the thoughts, behaviours, and habits that keep insomnia going.
COGNITIVE RESTRUCTURING:
🧠 Cognitive restructuring begins to break this cycle by identifying, challenging, and altering the thoughts and beliefs that contribute to insomnia. Common thoughts and beliefs that may be addressed during treatment include anxiety about past experiences of insomnia, unrealistic expectations of sleep time and quality, and worry about daytime fatigue or other consequences of missed sleep.
STIMULUS CONTROL:
🛌 Many people with insomnia begin to dread their bedroom, associating it with wakefulness and frustration. They may also associate their bedroom with habits that make sleeping more difficult, like eating, watching TV, or using a cell phone or computer. Stimulus control attempts to change these associations, reclaiming the bedroom as a place for restful sleep.
SLEEP RESTRICTION:
🕰️ lPeople with insomnia often spend excessive time in bed awake, which weakens the association between the bed and sleep. Sleep restriction therapy addresses this by temporarily limiting time spent in bed to increase homeostatic sleep drive and consolidate sleep, even though this may initially increase daytime sleepiness. Treatment begins with estimating average total sleep time using a sleep diary. Time in bed is then prescribed to closely match this average sleep duration, typically with a minimum buffer of approximately 30 minutes.
❌NOT recommended for people with certain medical conditions that can be made worse by losing sleep, such as bipolar disorder and seizures.
RELAXATION TRAINING
🧘 Breathing exercises: deep, slow breaths to reduce heart rate and promote relaxation
Progressive muscle relaxation (PMR): tensing and relaxing muscles with guided imagery
Autogenic training: body ‘scanning’ to focus on specific sensations (eg: warmth, heaviness etc)
Biofeedback, hypnosis or meditation etc.
SLEEP HYGIENE:
😴 Maintain a sleep schedule: Having a regular, predictable sleep schedule can help your body maintain a rhythm and make it easier to fall asleep. This includes weekends too, which are a common time to forget about the importance of sleep.
❌Don’t lie awake in bed: If you can’t sleep, get out of bed and find something relaxing to do until you feel tired again.
📝Create a nightly routine: Give yourself enough time to get ready for bed. Turn off your electronics early and find some relaxing activities that help you wind down before sleep.
🚴‍♀️ Consider daytime activities: What you do during the day really counts. Even a small amount of exercise can help you sleep better. 🗣️Also try to avoid eating, alcohol, and caffeine too close to bedtime.
CONSIDERATIONS:
👨‍⚕️In order for CBT-I to be effective, it’s important to be open to confronting unhelpful thoughts and behaviours. While the risks of treatment are likely to be mild, it may be uncomfortable at times. Talking about painful experiences, thoughts, and feelings can be challenging and may cause temporary stress and discomfort.
MW
Reference:
https://www.sleepfoundation.org/insomnia/treatment/cognitive-behavioral-therapy-insomnia?utm_source=chatgpt.com

25/12/2025

Insomnia
Part 3: psychological interventions
BACKGROUND:
🔎Given the widespread use of both behavioural and pharmacological treatments, the ACP developed this guideline to provide evidence-based recommendations focused on effectiveness, safety, and long-term outcomes.
📍This ACP clinical practice guideline by Qaseem et al. (2016) is based on systematic reviews of RCTs evaluating non-pharmacological and pharmacological treatments for chronic insomnia in adults. The guideline emphasises patient-centred care, shared decision-making, and prioritisation of treatments with sustained benefit and lower risk of harm.
RECOMMENDATIONS (pictured)
PSYCHOLOGICAL INTERVENTIONS (pictured)
SUMMARY:
📖CBT for insomnia is consistently recommended as the first-line treatment for all adults with chronic insomnia due to its sustained benefits and low risk of harm. Equally, it is widely agreed upon that pharmacological therapy should be considered only when CBT-I is ineffective or unavailable. Medications should be used cautiously, with shared decision-making, short treatment durations, and regular review, as medications provide modest short-term benefit with limited long-term safety evidence.
MW
Reference:
Qaseem A, Kansagara D, Forciea MA, Cooke M, Denberg TD; Clinical Guidelines Committee of the American College of Physicians. Management of chronic insomnia disorder in adults: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2016;165(2):125–133.

25/12/2025

Insomnia
Part 2: pharmacological management cont.
BACKGROUND:
🔎While cognitive behavioural therapy for insomnia (CBT-I) is recommended as first-line treatment, pharmacological therapy remains widely used in clinical practice.
📍CPGs by Sateia et al. (2017) evaluated the efficacy, benefits, and harms of pharmacological treatments for chronic insomnia in adults. They provide clear recommendations based on systematic reviews of RCTs using the GRADE framework. The guideline focuses exclusively on pharmacologic therapy and is intended to guide clinicians when medication is considered appropriate.
WEAK RECOMMENDATIONS:
😴Sleep onset insomnia: eszopiclone, zolpidem, zaleplon, triazolam, ramelteon
😴Sleep maintenance insomnia: eszopiclone, zolpidem, temazepam, suvorexant
⚠️Long-term use of hypnotics should be approached cautiously, with regular review of effectiveness, side effects, and ongoing need.
NOT RECOMMENDED:
❌The guidelines recommend against the routine use of trazodone, tiagabine, diphenhydramine, melatonin (for chronic insomnia), tryptophan, and valerian due to insufficient evidence of benefit.
SUMMARY:
📖The AASM guideline recommends pharmacological treatment for chronic insomnia only when clinically indicated, noting that all recommendations are weak due to modest benefits and potential harms. Many of which are not recommended due to insufficient evidence of efficacy.
MW
Reference:
Sateia MJ, Buysse DJ, Krystal AD, Neubauer DN, Heald JL. Clinical practice guideline for the pharmacologic treatment of chronic insomnia in adults: an American Academy of Sleep Medicine clinical practice guideline. J Clin Sleep Med. 2017;13(2):307–349.

25/12/2025

Insomnia
Part 1: updated assessment and management
BACKGROUND:
🔎Insomnia is a disorder of hyperarousal involving cognitive, behavioural, and physiological mechanisms. Insomnia is often chronic, maintained by maladaptive sleep behaviours and dysfunctional beliefs about sleep. The authors.
📍An overview paper by Krystal et al. (2019) provides an updated, evidence-informed overview of the assessment and management of insomnia, emphasizing a shift away from viewing insomnia solely as a symptom of other conditions toward recognising it as a disorder that warrants direct treatment.
ASSESSMENT:
🔆Detailed sleep history, including timing/schedule, nocturnal symptoms, daytime consequences, PMHx and social history, as well as perpetuating factors
🔆Validated self-report tools (eg: insomnia severity index) or sleep diaries to quantify severity and monitor treatment response
🔆Actigraphy and possible polysomnography if other sleep disorders are indicated (eg: sleep apnoea)
NON-PHARMACOLOGICAL MANAGEMENT:
✅CBT for insomnia as a first-line treatment: stimulus control, sleep restriction, cognitive restructuring, relaxation strategies and sleep education
PHARMACOLOGICAL MANAGEMENT:
⚠️Short-term adjuncts: benzodiazepines, hypnotics (eg: z drugs), melatonin (MT1/MT2) receptor agonists, orexin receptor antagonists, sedating antidepressants, antihistamines
SUMMARY:
📖Insomnia assessment focuses on a detailed sleep history supported by sleep diaries and validated questionnaires, with additional investigations used only when another sleep disorder is suspected. Management prioritises cognitive behavioural therapy for insomnia (CBT-I) as first-line treatment to address behavioural and cognitive contributors, with pharmacological therapies reserved for short-term or adjunctive use and tailored to individual symptoms and comorbidities.
MW
Reference:
Krystal AD, Prather AA, Ashbrook LH. The assessment and management of insomnia: an update. World Psychiatry. 2019;18(3):337–352.

23/12/2025

Pain and sleep
Part 9: non-pharmacological mgmt
BACKGROUND:
🔎It remains unclear whether non-pharmacological interventions can improve sleep outcomes in this population.
📍A recent systematic review by Papaconstantinou et al. (2021) synthesized the data of 2 RCTs (n=467) to investigate the effectiveness of non-pharmacological interventions on sleep characteristics among individuals with musculoskeletal pain and comorbid sleep problems. Both RCTs had a low risk of bias.
INTERVENTIONS:
📝Cognitive behavioural therapy (CBT) for pain and/or sleep
OUTCOMES:
📝Insomnia severity index (ISI) or sleep efficiency (diary)
FINDINGS:
🔆CBT for pain and insomnia was associated with 2–3 times higher odds of clinically meaningful improvement in insomnia severity at 9 months compared with CBT for pain alone or education (OR 2.20–3.21).
🔆CBT for pain significantly improved sleep efficiency compared to education alone
🔆Short-term improvements were linked to later periods of pain reduction.
SUMMARY:
📖CBT for pain and/or insomnia may yield short-to-medium term benefits for sleep characteristics in adults with MSK pain and comorbid insomnia
MW
Reference:
Papaconstantinou E, Cancelliere C, Verville L, Wong JJ, Connell G, Yu H, et al. Effectiveness of non-pharmacological interventions on sleep characteristics among adults with musculoskeletal pain and a comorbid sleep problem: a systematic review. Chiropr Man Therap. 2021;29:23.

23/12/2025

Pain and sleep
Part 8: management framework
BACKGROUND:
🔎Disturbed sleep and pain have a bidirectional relationship: poor sleep heightens pain sensitivity and emotional distress, while pain disrupts sleep initiation and maintenance. Despite this, sleep problems are often overlooked in routine MSK care.
📍A very recent review paper by Shephard et al. (2025) provides a clinician-focused overview of the mechanisms linking sleep disturbance and musculoskeletal pain, highlighting neurophysiological, psychological, and behavioural pathways. The authors emphasize that sleep disturbance is not simply a secondary symptom of pain but an independent and modifiable factor that can influence clinical outcomes. Furthermore, physiotherapists are well placed to identify and address sleep dysfunction as part of holistic pain management.
SCREENING & ASSESSMENT:
🔆Routine screening for sleep problems using validated tools.
🔆Recognise red flags that warrant immediate referral
🔆Differentiate between common sleep disorders
EDUCATION:
🔆Provide clear education on the sleep–pain relationship, and
🔆Set realistic expectations regarding sleep improvement and recovery.
BEHAVIOURAL INTERVENTIONS
🔆Use of behavioural strategies grounded in cognitive behavioural therapy for insomnia (CBT-I), focusing on sleep drive, circadian regulation, pre-sleep arousal, and adaptive sleep behaviours.
🔆Recognise sleep hygiene as a supportive strategy rather than a stand-alone treatment.
INTERDISCIPLINARY COLLABORATION:
🔆Integrate sleep management within broader pain care, with clear referral pathways to sleep or medical specialists when red flags or complex sleep disorders are identified.
SUMMARY:
📖Incorporating sleep assessment and management into MSK care can enhance clinical outcomes, reduce pain severity, and improve function and quality of life. Addressing sleep expands clinical reasoning beyond tissue-based models and supports a biopsychosocial approach.
MW
Reference:
Shepherd MH, Neilson BD, Siengsukon C. The Pain of Poor Sleep: A Clinician’s Guide to Assessing and Addressing Sleep Dysfunction in People With Musculoskeletal Pain Conditions. J Orthop Sports Phys Ther Open. 2025.

22/12/2025

Sleep-wake disorders (insomnia)
Part 4: differential diagnosis (pictured)
📍The Diagnostic and Statistical Manual of Mental Disorders (5th ed.) outlines the major classifications of sleep-wake mental disorders, along with their associated diagnostic criteria. These can be broadly classified into 10 types of disorders, including insomnia disorder.
NORMAL SLEEP VARIATIONS:
😴Sleep duration varies considerably between individuals. Insomnia must be distinguished from age-related sleep changes and sleep deprivation due to circumstances or context.
SITUATIONAL (ACUTE) INSOMNIA:
😴A condition lasting a few days to several weeks, often associated with acute stress due to life events or changes in sleep schedule or environment.
OTHER CLASSIFICATIONS:
🔆Hypersomnolence disorder
🔆Narcolepsy
🔆Breathing-related sleep disorders (eg: sleep apnoea)
🔆Circadian rhythm disorder
🔆Rapid eye movement (REM) sleep behaviour disorder
🔆Non-REM sleep arousal disorders
🔆Nightmare disorder
🔆Restless legs syndrome
🔆Substance/medication-induced sleep disorder
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.

22/12/2025

Sleep-wake disorders (insomnia)
Part 3: risk- and prognostic factors
BACKGROUND:
Risk factors determine who is likely to develop a condition, while prognostic factors determine whether it resolves or becomes chronic.
The Diagnostic and Statistical Manual of Mental Disorders (5th ed.) outlines the major classifications of sleep-wake mental disorders such as insomnia disorder, along with its associated risk- and prognostic factors
RISK FACTORS (increased vulnerability)
Predisposing or individual factors:
Environmental factors
Genetic and physiological factors
Triggering context: major life stressor or event

PROGNOSTIC FACTORS (risk of chronicity)
Perpetuating factors
Cognitive-emotional factors
Course modifiers
SUMMARY:
Risk factors for insomnia are characteristics or conditions that increase an individual’s vulnerability to developing sleep disturbances when exposed to triggers such as stress, illness, or environmental changes.
Prognostic factors, on the other hand, influence the persistence and course of insomnia once it has started.
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.

22/12/2025

Sleep-wake disorders (insomnia)
Part 2: development and course
📍The Diagnostic and Statistical Manual of Mental Disorders (5th ed.) outlines the major classifications of sleep-wake mental disorders such as insomnia disorder, along with its course and development.
DEVELOPMENT:
🔆The onset of insomnia symptoms can occur at any time during life, but the first episode is more common in young adulthood more so than childhood or adolescence.
🔆Late-life onset is often associated with the onset of other health-related conditions.
🔆In women, the incidence of new-onset insomnia increases with menopause and may persist even after other symptoms (e.g., hot flashes) have resolved.
COURSE:
📝Situational (acute) insomnia usually lasts days to weeks and is triggers by life events or changes in sleep schedule or environment. It will often resolve once precipitating factors are addressed, subside or resolve.
📝Persistent insomnia is often maintained by conditioning factors and heightened arousal
PRECIPITATING FACTORS (inciting events):
🔆Acute life stressors, medical conditions or mental health episodes
🔆Rapid changes in sleep schedule or environment
🔆Menopause-related changes
🔆Insidious (unknown)
CONDITIONING FACTORS (learned associations):
🔆Negative sleep associations (eg: bed and wakefulness, pain, stress, frustration etc)
🔆Heightened cognitive and physiological arousal
🔆Increased attention and worry about sleep
🔆Dependence on external cues
🔆Learned “light” sleeping behaviours
PERPETUATING FACTORS (insomnia maintenance):
🔆Ongoing, conditioned hyperarousal
🔆Maladaptive sleep behaviours (excessive bed time, irregular scheduling etc.)
🔆Negative beliefs, perspectives and expectations of sleep
🔆Hypervigilance or hyper-focus on sleep difficulties, reinforcing anxiety and arousal
🔆Psychological comorbidities
🔆Night-to-night variability reinforcing uncertainty and vigilance about sleep
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.

22/12/2025

Sleep-wake disorders (insomnia)
Part 1: DSM-5 classification
BACKGROUND:
🔎Sleep-wake complaints warrant a multidimensional approach with consideration of possibly coexisting clinical conditions such as cardiorespiratory, neurodegenerative, musculoskeletal and mental disorders etc.
📍The Diagnostic and Statistical Manual of Mental Disorders (5th ed.) outlines the major classifications of sleep-wake mental disorders, along with their associated diagnostic criteria. These can be broadly classified into 10 types of disorders, including insomnia disorder.
DIAGNOSTIC CRITERIA (pictured)
PREVALENCE:
📈The most prevalent of all sleep disorders, with 30% of adults report insomnia symptoms world-wide and around 5-20% meeting the DSM-5 diagnostic criteria. 10-15% experience associated daytime impairments
CLINICAL FEATURES:
🔆The essential feature of insomnia disorder is the dissatisfaction with sleep quantity or quality with complaints of difficulty initiating or maintaining sleep, which are accompanied by clinically significant distress and/or impairments in social, occupational or other types of functioning.
🔆Insomnia is often associated with physiological and cognitive arousal that interfere with sleep. This may manifest as fatigue, reduced energy, stress, mood disturbances, musculoskeletal complaints (headache, muscle tension or pain) or gastrointestinal symptoms etc.
🔆During the course of the disorder, individuals may acquire maladaptive sleep habits (excessive bed time, erratic sleep schedules) and cognitions (fear, apprehension etc)
👉🏻In part 2, we will examine the course and development of insomnia disorder along with the associated risk- and prognostic factors
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.

20/12/2025

Clinical reasoning in MSK practice
Part 10: the ‘flag system’
BACKGROUND:
🔎The ‘flag system’ forms part of a multidimensional framework to help classify different types of risk factors by colour to assist clinicians’ recognition, reasoning and management of such factors in their patients.
📍Chapter 4 of Jones and Rivett (2014) provides a comprehensive overview of the assessment, reasoning and management of psychological factors in musculoskeletal practice. The authors differentiate between the unidimensional and multidimensional measures capable of screening and evaluating specific psychological constructs.
FLAG SYSTEM (pictured)
UNIDIMENSIONAL measures:
🔆Fear-avoidance beliefs questionnaire (FABQ)
🔆Pain catastrophizing scale (PCS) or Tampa scale of kinesiophobia (TSK)
🔆Pain anxiety symptoms scale (PASS-20)
🔆Pain self-efficacy questionnaire (PSEQ)
🔆Chronic pain acceptance questionnaire (CPAQ)
🔆Beliefs illness perception questionnaire (IPQ) etc.
MULTIDIMENSIONAL measures:
🔆STarT back screening tool (SBT)
🔆Orebro musculoskeletal pain screening questionnaire (OMPSQ)
SUMMARY:
📖Multidimensional measures provide an avenue to identify patients at high risk for poor clinical outcomes primarily based on the influence of psychological factors.
📚Whereas, utilization of unidimensional measures (if appropriate) provides an avenue to
enhance clinical reasoning regarding psychological (yellow flag) factors.
MW
Reference:
Jones MA, Rivett DA, editors. Clinical reasoning in musculoskeletal practice. 2nd ed. Chatswood (NSW): Elsevier Australia; 2014.

20/12/2025

Clinical reasoning in MSK practice
Part 9: stress-diathesis model
BACKGROUND:
🔎Pain becomes more disabling when combined with pre-existing vulnerabilities such as psychological distress, low self-efficacy, or adverse social contexts.
📍Chapter 3 of Jones and Rivett (2014) examines the ‘stress-diathesis mode’ of pain, which expands on the biopsychosocial framework by explaining how stress (pain impact) interacts with diathesis (vulnerability) to influence disability in chronic pain.
💡The model helps predict which individuals are at higher risk of developing chronic pain and disability based on the presence of vulnerability factors and pain appraisal.
SUMMARY:
📖Clinically, the model highlights that patients with high vulnerability and limited coping resources are more likely to experience persistent pain and greater disability, emphasizing the need for clinicians to assess appraisal, coping capacity, and psychosocial influences to guide management.
MW
Reference:
Jones MA, Rivett DA, editors. Clinical reasoning in musculoskeletal practice. 2nd ed. Chatswood (NSW): Elsevier Australia; 2014.

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The Story

‘Evidence-based practice’ is a cornerstone of good quality physiotherapy practice.

Whilst completing my post-graduate training in musculoskeletal physiotherapy, I had developed a hunger for keeping up to date with good quality contemporary research.

This page is aimed at providing high quality research reviews and summaries on contemporary topics within the field of musculoskeletal physiotherapy.

Posts within this page are structured to provide ‘easy-to-understand’ information for health professionals and health consumers, and will also endeavour to provide the relevant reference(s) for each discussion.

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