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The Musculoskeletal Wrangler, Wonthaggi (2025)

29/11/2025

Shoulder pain: phenotyping
Part 2: clinical features
BACKGROUND:
🔎Identifying pain phenotypes may allow clinicians to tailor treatment—whether pharmacological, surgical, exercise-based, or psychologically informed—toward the underlying mechanisms driving a patient’s pain.
📍A recent narrative review by De Baets et al. (2025) argues that accurately phenotyping a patient’s shoulder pain is essential for targeted assessment and more effective, mechanism-informed management.
NOCICEPTIVE PAIN:
📚Typically linked to a clear onset, with symptoms that are proportionate, predictable, and mechanically provoked.
🕵️‍♂️Pain follows an anatomically logical pattern and usually responds to NSAIDs.
👨‍⚕️Clinical tests that load or stress the injured tissues reproduce symptoms, while irrelevant tests remain negative.
👨‍🔬Quantitative sensory testing (QST) may show local hypersensitivity (ie: peripheral sensitisation).
NEUROPATHIC PAIN:
📚Arises from nerve injury or disease and follows a neuroanatomically consistent distribution.
🕵️‍♂️Pain is often severe, irritable, spontaneous, and may disturb sleep. Sensory changes such as numbness, tingling, or allodynia are common, and NSAIDs are generally ineffective.
👩‍⚕️Clinical examination reveals pain with neural tension or compression tests and sensory abnormalities along the nerve.
🧑🏼‍🔬QST may show reduced thermal or pressure thresholds and localized hyperalgesia.
NOCIPLASTIC PAIN:
📚Features unclear onset, disproportionate and inconsistent pain that is widespread and not mechanically driven.
🕵️‍♂️Symptoms fluctuate and are often influenced by psychosocial factors, with frequent comorbidities such as sleep disturbance or obesity.
👨‍⚕️Examination shows inconsistent responses and widespread hypersensitivity, including static and dynamic allodynia.
👨‍🔬QST commonly demonstrates generalized sensory dysfunction, including widespread hyperalgesia, enhanced temporal summation, and reduced conditioned pain modulation (i.e.: central sensitisation)
SUMMARY:
💡Clinicians should consider incorporating diagnostic labels based on pain mechanisms in an attempt to improve and streamline clinical reasoning for musculoskeletal pain conditions.
MW
Reference:
De Baets L, Kuppens K, Labie C, Haik MN, Kapreli E, Bilika P, Struyf F, Borms D, Fernández-de-Las-Peñas C, Kosek E, Lluch E, Testa M, Lewis J, Goossens Z, Schilz M, Bonneux I, Nijs J. Shoulder pain phenotyping: A guide for clinicians to determine predominant nociceptive, neuropathic, or nociplastic shoulder pain. Brazilian Journal of Physical Therapy,2025;19:10240.

29/11/2025

Shoulder pain: phenotyping
Part 1: pain mechanisms
BACKGROUND:
🔎Persistent shoulder pain is common, and it is associated with substantial morbidity and healthcare costs. Approximately 21 to 50 % of people with shoulder pain treated in primary healthcare recover within 6 months. It is not known why at least half do not recover.
📍A recent narrative review by De Baets et al. (2025) argues that accurately phenotyping a patient’s shoulder pain is essential for targeted assessment and more effective, mechanism-informed management.
🟢NOCICEPTIVE PAIN is described as localised, proportionate to movement or mechanical loading, and associated with clear aggravating/relieving factors.
🟠NEUROPATHIC PAIN is characterised by burning, electric, or shooting qualities, sensory loss or gain, and positive neurological findings consistent with nerve involvement.
🔵NOCIPLASTIC PAIN presents with disproportionate, diffuse, non-mechanical pain, hypersensitivity, inconsistent patterns, and may co-occur with fatigue, sleep disturbance, and other central sensitisation features.
CLINICAL DECISION-MAKING ALGORITHM (pictured)
💡The authors outline the 7 step decision-making pathway and clinical indicators to help clinicians stratify patients based on the dominant pain mechanism.
SUMMARY:
📖Identifying the predominant pain phenotype(s) contributing to persistent shoulder pain—and tailoring treatment accordingly—is an increasingly important focus in contemporary practice.
MW
Reference:
De Baets L, Kuppens K, Labie C, Haik MN, Kapreli E, Bilika P, Struyf F, Borms D, Fernández-de-Las-Peñas C, Kosek E, Lluch E, Testa M, Lewis J, Goossens Z, Schilz M, Bonneux I, Nijs J. Shoulder pain phenotyping: A guide for clinicians to determine predominant nociceptive, neuropathic, or nociplastic shoulder pain. Brazilian Journal of Physical Therapy,2025;19:10240.

27/11/2025

“Person-centred” manual therapy
Part 3: factors moderating clinical analgesia
BACKGROUND:
🔎Clinical analgesia refers to the reduction of pain experienced by a patient during or after a therapeutic intervention. In the context of manual therapy, it describes the decrease in pain that occurs as a result of the combined effects of the technique, the patient’s expectations and beliefs, the therapeutic relationship, and the surrounding clinical context.
💡It reflects a real, perceived reduction in pain, regardless of whether the mechanism is biomechanical, neurological, immune-related, or psychological.
📍A recent clinical commentary by Keter et al. (2024) argue the need for clinicians to integrate a “person-centred care” approach into the practice of manual therapy (MT) for musculoskeletal pain. Here they discuss the broad factors that can moderate the analgesic effects of MT.
CLINICAL ANALGESIA through manual therapy is not solely driven by the technique itself but by a range of patient-, provider-, and context-dependent factors that can either strengthen or weaken the therapeutic effect.
PATIENT FACTORS:
📝Include expectations, prior experiences, beliefs about pain, emotional state, and current levels of fear, anxiety, or confidence.
✅Positive expectations, therapeutic alliance, and readiness to engage in active care can enhance analgesic response, whereas fear, catastrophizing, or negative beliefs can diminish it.
PROVIDER FACTORS:
📝Communication style, empathy, confidence, and the ability to tailor explanations and touch to the individual also affect outcomes.
✅A supportive, collaborative approach can amplify analgesia, while overly biomedical or prescriptive communication may undermine it.
CONTEXTUAL FACTORS:
📝The environment, perceived safety, cultural meaning of touch, and overall therapeutic setting—further shape how the nervous system interprets the intervention.
✅A calming, reassuring context can promote down-regulation of pain, whereas a rushed or impersonal environment may inhibit benefits.
SUMMARY:
📖An individual’s analgesic response to manual therapy emerges from the interaction between technique, patient, provider, and context. These factors collectively determine whether MT facilitates meaningful pain relief, underscoring that clinical analgesia is individualised, variable, and highly dependent on the unique circumstances surrounding each patient encounter.
MW
Reference:
Keter D, Hutting N, Vogsland R, Cook CE. Integrating person-centered concepts and modern manual therapy. JOSPT Open,2024;2(1):60-70.

27/11/2025

“Person-centred” manual therapy
Part 2: traditional vs. contemporary approach
📍A recent clinical commentary by Keter et al. (2024) argue the need for clinicians to integrate a “person-centred care” approach into the practice of manual therapy (MT) for musculoskeletal pain.
HISTORICAL vs. PATIENT-CENTRED DIFFERENCES (pictured)
🔆Treatment planning, goals, focus and follow-up
🔆Proposed mechanisms of action
🔆How outcomes are attributed and interpreted incl. lack of improvement or non-responders
🔆Assessment strategies
🔆Education focus
SUMMARY:
⚠️Historical manual therapy tends to centre around identifying and “fixing” a painful tissue through specific techniques based on mechanical and pathoanatomical explanations, with education focused on structural issues and repeated hands-on care when symptoms recur.
✅Person-centred manual therapy considers biological, psychological, and social contributors to pain, uses shared decision making, and applies MT to build confidence and support active self-management.
✅Pain relief and patient responses are viewed as multifactorial, success depends on context and patient fit, and non-response leads to reassessing the role of MT, with follow-up aimed at empowerment rather than ongoing passive treatment.
MW
Reference:
Keter D, Hutting N, Vogsland R, Cook CE. Integrating person-centered concepts and modern manual therapy. JOSPT Open,2024;2(1):60-70.

26/11/2025

“Person-centred” manual therapy
Part 1: overview
BACKGROUND:
🔎Traditional manual therapy has often emphasized structural diagnosis and clinician-led interventions, yet research increasingly shows that outcomes are strongly influenced by patient expectations, beliefs, psychosocial factors, and the therapeutic relationship.
📍A recent clinical commentary by Keter et al. (2024) argue the need for clinicians to integrate a “person-centred care” approach into the practice of manual therapy (MT) for musculoskeletal pain.
RATIONALE:
🕵️‍♂️In order for manual therapy to remain contemporary and relevant, there needs to be a shift in musculoskeletal care from traditional, technique-driven manual therapy toward a more person-centred, biopsychosocial approach.
🕵️‍♂️An individual’s response to manual therapy is multifactorial, and influenced not only by biomechanical factors but also by psychological, social, and contextual elements.
PERSON-CENTRED FRAMEWORK:
🔆Thorough subjective assessment exploring beliefs, expectations, psychosocial contributors, sleep, coping, activity, and life context;
🔆Objective assessment that prioritizes function and relevance rather than “correcting abnormalities”
🔆Shared decision-making that integrates patient values and preferences
🔆Combining MT with education, movement, exercise, and self-management, reducing reliance on passive care.
🔆The therapeutic alliance—communication, trust, empathy, and rapport—plays a meaningful role in outcomes and should be considered a clinical skill equal to manual techniques.
SUMMARY:
📖Modern manual therapy is most effective when grounded in person-centred care, integrating patient values, psychosocial context, and collaborative decision-making with skilled hands-on treatment.
💡Rather than focusing on technique specificity or structural correction, clinicians are encouraged to use MT as one component of a holistic, individualized treatment plan that promotes self-efficacy and active recovery. Integrating these concepts supports evidence-based practice and improves quality of care in musculoskeletal rehabilitation.
MW
Reference:
Keter D, Hutting N, Vogsland R, Cook CE. Integrating person-centered concepts and modern manual therapy. JOSPT Open,2024;2(1):60-70.

26/11/2025

Manual therapy framework for pain mechanisms.
Part 6: neuropathic framework
📍A recent report by Cook et al. (2023) aimed to develop consensus frameworks that show how manual therapy (MT) should be adapted for each pain mechanism to support more consistent, mechanism-informed, and evidence-aligned care.
TECHNIQUES (space)
📝Nerves require adequate space within their surrounding “containers” (muscles, fascia, canals). Reduced space is linked to neuropathic pain (e.g., foraminal stenosis, carpal tunnel syndrome).
🗣️Treatments aim to restore space: surgical decompression or therapeutic interventions such as manual therapy and exercises (e.g., cervical lateral glides, median nerve glides).
🕵️‍♂️Container-focused treatments are recommended before neural mobilization to optimize nerve movement and reduce entrapment risk.
TECHNIQUES (movement)
📝Neural tissue must move freely to support normal function. Reduced neural mobility is associated with neuropathic pain and mechanosensitivity.
🗣️Neurodynamic techniques (sliders, tensioners) restore mobility and reduce pain; progression is usually from sliders (acute/subacute) to tensioners.
🕵️‍♂️Pain is approached with graded exposure rather than avoidance or forcing.
Pins and needles during treatment are expected; numbness should be avoided.
TECHNIQUES (blood flow)
📝Decreased circulation increases neuropathic pain; improved blood flow decreases nerve sensitivity.
🗣️Neurodynamic treatments and exercises focus on repeated movement rather than sustained stretches to enhance blood flow.
INTEGRATION:
📖Effective neuropathic pain management integrates space optimization, neural mobility, blood flow, and psychosocial interventions, with treatment progression guided by tissue and patient tolerance.
📖Psychosocial considerations: Fear avoidance and pain catastrophizing can limit neural mobility and exacerbate pain.
📚Education, particularly Pain Neuroscience Education (PNE), reduces fear, improves mobility, increases pressure pain thresholds, and may precede neurodynamic or container treatments.
MW
Reference:
Cook CE, Rhon DI, George SZ, Hall T, Lavazza C, Lluch E, McDevitt A, Reed WR, Bialosky J, Donaldson M, Kawchuk G, Lane E, Louw A, Mazzieri AM, Schmid AB, Silva AG, Smart KM, Puentedura EJ. Developing manual therapy frameworks for dedicated pain mechanisms. J Orthop & Sports Phys Ther Open. 2023;1(1):48–62.

25/11/2025

Manual therapy framework for pain mechanisms.
Part 5: nociplastic framework
📍A recent report by Cook et al. (2023) aimed to develop consensus frameworks that show how manual therapy (MT) should be adapted for each pain mechanism to support more consistent, mechanism-informed, and evidence-aligned care.
TECHNIQUES:
📝Specific techniques (joint, soft tissue, nerve; thrust vs non-thrust; superficial vs deep; sliding vs tensioning) are LESS critical and should align with patient/provider preference and response.
🔆Treatment can be applied at the primary pain site or remotely.
TREATMENT GOALS:
📖Improve pain-related domains such as activity interference, mood, fear avoidance, unpleasantness, suffering, and fatigue rather than pain itself initially. Pain reduction may not be achievable on its own and often does not occur until improvements are seen in other domains.
🕵️‍♂️Track patient responses carefully, especially since nociplastic pain may temporarily increase with MT, and provide supportive communication to reduce fear and negative emotions.
INTEGRATION:
🗣️MT should be combined with exercise, possibly at lower intensity than for nociceptive or neuropathic pain. Exercise can target the primary region or be performed remotely.
🗣️Important to integrate with pain education, explaining nociplastic pain as maladaptive nervous system activity without tissue damage, and frame MT as “desensitizing” the nervous system rather than correcting a structural issue.
MW
Reference:
Cook CE, Rhon DI, George SZ, Hall T, Lavazza C, Lluch E, McDevitt A, Reed WR, Bialosky J, Donaldson M, Kawchuk G, Lane E, Louw A, Mazzieri AM, Schmid AB, Silva AG, Smart KM, Puentedura EJ. Developing manual therapy frameworks for dedicated pain mechanisms. J Orthop & Sports Phys Ther Open. 2023;1(1):48–62.

25/11/2025

Manual therapy framework for pain mechanisms.
Part 4: nociceptive framework
📍A recent report by Cook et al. (2023) aimed to develop consensus frameworks that show how manual therapy (MT) should be adapted for each pain mechanism to support more consistent, mechanism-informed, and evidence-aligned care.
TECHNIQUES:
📝MT techniques are applied with variable force, speed, intensity, frequency, and repetitions tailored to the patient’s clinical presentation, including severity, irritability, stage, and stability of pain.
🔆May include passive or active-assisted joint mobilization, soft-tissue mobilization, nerve mobilization, and thrust or non-thrust manipulations.
TREATMENT GOALS:
📖Pain reduction, improved mobility, and enhanced function. MT may also be applied to adjacent of neighbouring regions other than the primary pain site when appropriate.
🕵️‍♂️Patient response is continuously monitored during and between sessions; success is defined by pain reduction and/or functional improvement.
INTEGRATION:
🗣️MT should not be integrated as a stand-alone intervention. It should be part of a comprehensive, evidence-based approach including education, exercise therapy, and a biopsychosocial, patient-centered framework.
MW
Reference:
Cook CE, Rhon DI, George SZ, Hall T, Lavazza C, Lluch E, McDevitt A, Reed WR, Bialosky J, Donaldson M, Kawchuk G, Lane E, Louw A, Mazzieri AM, Schmid AB, Silva AG, Smart KM, Puentedura EJ. Developing manual therapy frameworks for dedicated pain mechanisms. J Orthop & Sports Phys Ther Open. 2023;1(1):48–62.

24/11/2025

Manual therapy framework for pain mechanisms.
Part 3: recommendation overview
📍A recent report by Cook et al. (2023) aimed to develop consensus frameworks that show how manual therapy (MT) should be adapted for each pain mechanism to support more consistent, mechanism-informed, and evidence-aligned care.
📚Table 4 illustrates the unique and overlapping aspects of the MT treatment framework relating to each dominant pain mechanism.
NOCICEPTIVE PAIN:
📝Strong focus on forceful, variable techniques (e.g., heavier force, different speeds) to directly address tissue-level nociceptive drivers.
🗣️Success is closely tied to repeated assessments (within- and between-session) to adjust dose and technique
NOCIPLASTIC PAIN:
📝Emphasize the use of pain interference (how much pain limits activity) rather than pain intensity as a guide for MT.
🗣️Techniques are gentler, with lower force/speed, and there is significant emphasis on reconceptualisation education(explaining pain mechanisms).
NEUROPATHIC PAIN:
📝Unique recommendation around improving “space, movement, and blood flow” for neural structures to support nerve health and reduce sensitivity.
🗣️There is a graded application strategy, with early sessions being more conservative to monitor neural tolerance.
SUMMARY:
All three frameworks:
🔆Emphasise individualised, patient-centred care (not a “one-size-fits-all” approach).
🔆Require ongoing modification of MT based on patient response.
🔆Position MT within a multimodal biopsychosocial approach, not as a standalone treatment.
🔆Support shared decision-making and adapting techniques to the person’s presentation.
MW
Reference:
Cook CE, Rhon DI, George SZ, Hall T, Lavazza C, Lluch E, McDevitt A, Reed WR, Bialosky J, Donaldson M, Kawchuk G, Lane E, Louw A, Mazzieri AM, Schmid AB, Silva AG, Smart KM, Puentedura EJ. Developing manual therapy frameworks for dedicated pain mechanisms. J Orthop & Sports Phys Ther Open. 2023;1(1):48–62.

24/11/2025

Manual therapy framework for pain mechanisms.
Part 2: treatment framework components
📍A recent report by Cook et al. (2023) aimed to develop consensus frameworks that show how manual therapy (MT) should be adapted for each pain mechanism to support more consistent, mechanism-informed, and evidence-aligned care.
📖Table 1 defines and details the manual therapy (MT) treatment framework components, which form the building blocks for describing how MT can be tailored to different pain mechanisms (nociceptive, nociplastic, neuropathic).
IMPLICATIONS:
🗣️These components provide a structured way to define and compare different manual therapy frameworks by systematically varying these dimensions (force, duration, technique, intent, etc.), clinicians can more precisely tailor manual therapy to a patient’s dominant pain mechanism.
💡These treatment framework components support mechanism-based reasoning: rather than applying manual therapy uniformly, therapists can design interventions that reflect theoretical and clinical reasoning about how the manual therapy works in different contexts.
MW
Reference:
Cook CE, Rhon DI, George SZ, Hall T, Lavazza C, Lluch E, McDevitt A, Reed WR, Bialosky J, Donaldson M, Kawchuk G, Lane E, Louw A, Mazzieri AM, Schmid AB, Silva AG, Smart KM, Puentedura EJ. Developing manual therapy frameworks for dedicated pain mechanisms. J Orthop & Sports Phys Ther Open. 2023;1(1):48–62.

24/11/2025

Manual therapy framework for pain mechanisms.
Part 1: pain definitions
BACKGROUND:
🔎Although clinicians routinely treat people with nociceptive, nociplastic, and neuropathic pain, manual therapy is rarely guided by pain-mechanism–specific frameworks. Instead, practice has traditionally been technique-driven or tissue-based.
📍A star-studded report by Cook et al. (2023) aimed to develop consensus frameworks that show how manual therapy (MT) should be adapted for each pain mechanism to support more consistent, mechanism-informed, and evidence-aligned care.
NOCICEPTIVE PAIN:
📝Pain that arises from actual or potential damage to non-neural tissue due to the activation of nociceptors.
Eg: acute pain, strains and sprains etc.
NOCIPLASTIC PAIN:
📝Pain that arises from altered nociception despite no clear evidence of actual or potential tissue damage causing the activation of peripheral nociceptors or evidence of a lesion or disease of the somatosensory system causing pain.
Eg: chronic pain alongside unhelpful coping strategies and/or psychosocial risk factors
NEUROPATHIC PAIN:
📝Pain that is caused by a lesion or disease of the somatosensory nervous system.
Eg: neuropathy, radiculopathy etc.

SUMMARY:
📖Throughout this series we will delve into concepts of how the identification of mechanism-specific frameworks can support a shift toward precision manual therapy.
📚Understanding a patient’s dominant pain mechanism or phenotype can allow clinicians to select and dose MT more effectively, reducing variability in care and promoting more targeted, mechanism-informed practice.
MW
Reference:
Cook CE, Rhon DI, George SZ, Hall T, Lavazza C, Lluch E, McDevitt A, Reed WR, Bialosky J, Donaldson M, Kawchuk G, Lane E, Louw A, Mazzieri AM, Schmid AB, Silva AG, Smart KM, Puentedura EJ. Developing manual therapy frameworks for dedicated pain mechanisms. J Orthop & Sports Phys Ther Open. 2023;1(1):48–62.

23/11/2025

Unhelpful imaging beliefs
BACKGROUND:
🔎Many patients with musculoskeletal disorders believe that imaging (e.g., MRI, X-rays) is necessary to diagnose their condition, “rule out serious problems,” guide treatment, or validate their symptoms despite clinical practice guidelines often recommend AGAINST routine imaging, especially when there is no “red flag/s”. ⚠️Over-imaging does NOT improve outcomes and can drive unnecessary interventions.
📍A recent prospective cohort study by Plante et al. (2025) aimed to explore the imaging beliefs of 152 participants with a variety of musculoskeletal disorders to determine if they correlate with, or predict pain interference and physical function outcomes.
FINDINGS:
📈Maladaptive imaging beliefs were positively correlated with pain interference and negatively correlated with physical function.
🧠The primary maladaptive beliefs encompassed the need to “rule out serious conditions” and to use imaging to “validate symptoms”
🕵️‍♂️These beliefs demonstrate a weak association with poorer pain and functional outcomes.
👨‍⚕️ Less relevant beliefs included the need for imaging to “guide treatment plan” or to “determine diagnosis”
IMPLICATIONS:
📚Maladaptive beliefs about imaging may influence recovery: believing one needs imaging to diagnose or “prove” the condition might lead to poorer outcomes.
📚The authors speculate this may relate to less engagement in active therapies (e.g., exercise), more worry, or lower self-efficacy – more research required to investigate these mechanisms.
SUMMARY:
📖Maladaptive or unhelpful beliefs about the necessity of imaging (e.g., needing scans to rule out serious illness or validate pain) are modestly but significantly associated with worse pain interference and lower physical function in people with musculoskeletal disorders.
MW
Reference:
Plante J, Kucksdorf J, Ruzich J, Young JL, Rhon DI. Do Maladaptive Imaging Beliefs Predict Self-Reported Pain Interference and Physical Function in Patients With Musculoskeletal Disorders? J Orthop Sports Phys Ther.2024;54(9):608–617.

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