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The Musculoskeletal Wrangler, Wonthaggi (2026)

16/02/2026

Pain neuroscience education (PNE):
Paradox
PAIN EDUCATION PARADOX:
⚠️While clinicians are increasingly trained to explain that pain does not always reflect tissue damage, this reframing can inadvertently minimise or invalidate a patient’s suffering if poorly delivered.
VALIDATION GAP:
⚠️There is often a clear gap between the provision of scientifically accurate explanations alongside emotional validation. Patients may understand the explanation intellectually but may still feel dismissed, blamed, or not taken seriously. That is, the reconceptualisation of pain has sometimes overshadowed the relational and interpersonal aspects of care. Thus, knowledge does NOT equal validation.
📍A recent editorial by Weisman et al. (2026) argue the above two key concepts pertaining to the uptake and dissemination of PNE, along with the following four recommendations:
SHARED UNDERSTANDING OF TERMINOLOGY:
🔆Clinicians must use precise, contemporary pain terminology and understand key distinctions (e.g., nociception vs pain; mechanisms vs diagnoses) to avoid flawed reasoning. Terminological clarity underpins accurate clinical decisions, even if simplified for patient communication.
CONTEMPORARY NEUROSCIENCE & NEUROIMMUNOLOGY:
🔆Modern pain science shows that pain is not solely a product of tissue damage and may involve immune and neurobiological processes beyond the reach of manual or exercise therapy. This understanding supports appropriate referrals, realistic expectations, and avoidance of outdated structural explanations.
CRITICAL APPRAISAL & EPISTEMIC HUMILITY:
🔆Practitioners must distinguish correlation from causation and recognise the limits of their interventions. Ethical care requires honest communication, reflective practice, and openness to uncertainty.
DISTINGUISHING TREATMENT APPROACHES:
🔆Treating pain mechanisms differs from supporting a person living with pain, and most chronic pain care is supportive rather than curative. Effective practice involves validation, symptom management, education, and coordinated care without oversimplifying causes such as stress.
SUMMARY:
📚Modern pain neuroscience education, while grounded in robust scientific principles, can inadvertently widen a “validation gap” when it does not sufficiently acknowledge the patient’s lived experience. The “pain education paradox” emerges from this tension: reframing pain as a protective, non–damage-based process may help reduce fear and catastrophising, yet—if delivered without empathy—it can unintentionally erode a patient’s sense of legitimacy and being believed.
The authors therefore advocate for a balanced, relational approach in which validation both precedes and accompanies education. High-quality pain care requires more than accurate scientific explanation; it depends equally on compassionate communication, emotional atonement, and a strong therapeutic alliance.
MW
Reference:
Weisman A, Noy M & Masharawi Y. The pain education paradox and validation gap. Musculoskeletal Science and Practice,2026;103476.

15/02/2026

Intervertebral discs (IVDs)
Updating the narrative
BACKGROUND:
🔎For decades, clinicians and researchers have described the IVD as a passive structure that inevitably degenerates with age, loading and stresses — a view that has strongly influenced how back pain and “disc degeneration” are misunderstood and mismanaged. This narrative often leads to fear-based advice to avoid loading the spine, reinforcing inactivity and cautious behaviour.
📍A very recent editoral by Shala (2026) challenges this traditional view by proposing that the disc is a living, mechanoresponsive tissue with adaptive potential. Rather than being doomed to degeneration, the disc uses mechanical loading (eg: compression) to facilitate vital nutrient exchange, maintain hydration, and support cellular health. This reframing emphasizes that appropriate mechanical stimuli, often delivered through movement and controlled loading, are critical to disc physiology
EVIDENCE (see image):
📈Load and movement enhances disc hydration and facilitates nutrient transport, while sedentary behaviour disrupts these processes and may contribute to degenerative changes
⚖️The disc responds and adapts to mechanical loading within an “optimal therapeutic window.” Appropriate loads, such as those generated through low-to-moderate intensity activities (e.g., walking), can promote positive internal changes, whereas excessive mechanical stress may exceed adaptive capacity.
SUMMARY:
📚Emerging evidence proposes a paradigm shift in how intervertebral discs are conceptualised — from degenerative, passive structures to trainable tissues with adaptive potential.
💡Movement and controlled mechanical loading are central to maintaining disc health, challenging long-held narratives that promote spinal protection and avoidance.
👨‍⚕️ Embracing this view encourages clinicians and patients to focus on appropriate loading and movement as strategies for preserving spinal health across the lifespan.
MW
Reference:
Shala R. Rethinking the disc: from degenerative narrative to adaptive potential. Br J Sports Med. 2026. doi: 10.1136/bjsports-2025-110872. Epub ahead of print. PMID: 41490844.2

15/02/2026

Occupational physical activity (OPA):
All-cause mortality
BACKGROUND:
🔎It remains unclear of the independent associations of occupational and leisure-time physical activity (LTPA) with all cause mortality using harmonised individual participant data from multiple cohorts.
📍A large meta-analysis by Andersen et al. (2024) conducted a two stage individual participant data meta analysis using data from the Active Worker consortium, collating the data of 22 prospective cohort studies and 590K working adults over a 23 year follow-up period.
FINDINGS:
📉Among men, higher OPA was associated with only a small increase in all-cause mortality risk (moderate OPA: 1.05; high OPA: 1.12).
⚖️Among women, there was no statistically significant association
📈Among men and women, LTPA was inversely associated with all-cause mortality
SUMMARY
📚While leisure time physical activity was consistently associated with lower all cause mortality, occupational physical activity, did not show these beneficial effects but rather a small association with higher mortality risk in men.
MW
Reference:
Andersen LL, Holtermann A, van der Beek AJ, et al. Associations of occupational and leisure time physical activity with all cause mortality: an individual participant data meta analysis. Br J Sports Med. 2024;58(24):1527 1538.

14/02/2026

Occupational physical activity (OPA):
Paradox
BACKGROUND:
🔎While physical activity is generally promoted as protective against cardiovascular disease and premature mortality, epidemiological findings suggest that high levels of OPA may actually increase these risks — a phenomenon described as the physical activity paradox.
📍An editorial by Holtermann et al. (2018) argue that the paradox reflects differences in the type, pattern, and context of activity rather than total energy expenditure alone.
💡OPA is typically characterised by prolonged duration, repetitive or static tasks, limited worker autonomy, insufficient recovery, and sustained physiological strain. These conditions may lead to chronic cardiovascular stress rather than beneficial adaptation.
IMPLICATIONS:
⚖️More nuanced research is needed to better differentiate physical activity domains and more precisely measure intensity, duration, posture, and recovery. Longitudinal and mechanistic studies are required to clarify how occupational load influences cardiovascular and overall health. Current guidelines may require refinement to account for occupational strain and recovery demands, particularly for workers in physically demanding roles.
SUMMARY:
📚This article challenges the assumption that all physical activity is inherently beneficial. It argues that context, physiological strain, autonomy, and recovery determine whether physical activity promotes health or contributes to risk. Addressing this research gap is essential for developing more accurate, domain-specific physical activity guidelines.
MW
Reference:
Holtermann A, Krause N, van der Beek AJ, Straker L. The physical activity paradox: six reasons why occupational physical activity (OPA) does not confer the cardiovascular health benefits that leisure-time physical activity does. Br J Sports Med. 2018;52(3):149–150.

13/02/2026

Occupational physical activity (OPA):
Umbrella review
BACKGROUND:
🔎OPA, the energy expended during work, may affect health differently from leisure-time physical activity, prompting this umbrella review of systematic reviews to clarify OPA’s impact across multiple health outcomes.
📍An umbrella review by Cillekens et al. (2020) synthesised the data of 17 systematic reviews were synthesised, covering 23 unique health outcomes from 158 observational studies. The overall methodological quality of included reviews was generally low to very low, with none rated as high quality. Evidence certainty was assessed using the GRADE approach.
FAVOURABLE ASSOCIATIONS:
High levels of OPA were associated with reduced risk of:
🟢Cancers
🟢Ischaemic stroke
🟢Coronary heart disease
🟢Mental health outcomes: increased levels of satisfaction and well-being
UNFAVOURABLE ASSOCIATIONS:
High levels of OPA were associated with increased risk of:
🔴All-cause mortality
🔴Osteoarthritis (OA)
🔴Reduced sleep quality and insomnia
🔴Mental health disorders: depression and anxiety
SUMMARY:
📚It may not all be negative, but emerging research increasingly raises concerns about the risks of excessive occupational physical activity compared with moderate levels.
MW
Reference:
Cillekens B, Lang M, van Mechelen W, Verhagen E, Huysmans MA, Holtermann A, van der Beek AJ, Coenen P. How does occupational physical activity influence health? An umbrella review of 23 health outcomes across 158 observational studies. Br J Sports Med. 2020 Dec;54(24):1474–1481.

11/02/2026

Occupational physical activity (OPA):
The ‘Goldilocks principle’
BACKGROUND:
🔎Too much physical strain can cause musculoskeletal injuries and fatigue, while too little can lead to deconditioning and poor cardiometabolic health. At work, traditional job designs often focus on avoiding harm rather than actively promoting health. This has led to interest in a new framework for structuring occupational activity.
📍An editorial paper by Straker et al. (2018) propose the ‘Goldilocks principle’, whereby physical activity at work should be “just right” in its various dimensions and parameters in order to promote health rather than harm it.
WORK DESIGN:
💡Physical activity that is too intense, too prolonged, or too frequent can damage health. Likewise, activity that is too sedentary or infrequent also fails to benefit key health outcomes.Well designed work should include a range of physical demands arranged to stimulate physiological benefits and allow adequate recovery.
HEALTH PROMOTION:
💡By aligning work demands with health promoting physical behaviours, organisations can contribute to improved productivity, prolonged workforce participation (especially in ageing populations), lower chronic disease risk, and reduced healthcare costs.
EQUITY AND REACH:
💡The ‘Goldilocks principle’ applies to all workers and should account for worker capacity, job requirements, and non work physical activity.
SUMMARY:
⚖️The Goldilocks Principle offers a paradigm shift in occupational health, emphasising that physical activity at work should be “just right” — not too little, not too much — to promote rather than impair health.
📚It underscores the need for balanced, varied, and appropriately scheduled physical demands that align with workers’ capacities and broader health goals.
MW
Reference:
Straker L, Mathiassen SE, Holtermann A. The ‘Goldilocks Principle’: designing physical activity at work to be ‘just right’ for promoting health. Br J Sports Med. 2018;52(13):818–819.

11/02/2026

Occupational physical activity (OPA):
The good, the bad, and the ugly
BACKGROUND:
🔎The health effects of OPA can differ markedly from those of leisure time activity, particularly when performed at high intensity. This discrepancy underpins the ‘physical activity paradox,’ whereby high levels of OPA may fail to provide the protective benefits associated with leisure-time PA and, in some cases, could even be detrimental to health
📍A mini review by Jordakieva et al. (2023) explored the evidence underpinning the relationship between OPA intensity, and how this relates to health outcomes. The authors included observational studies comparing high vs low OPA and systematic reviews on related morbidity and mortality.
THE GOOD: moderate OPA
🟢Moderate levels of OPA is broadly considered consistent with moderate leisure-time physical activity. It is considered beneficial in moderation, as it tends to be associated with lower inflammatory markers and lower risks for conditions such as ischemic heart disease, type 2 diabetes, and some cancers.
THE BAD: low OPA
🟠Low or sedentary OPA, especially when combined with low leisure-time PA, is linked to higher proinflammatory markers and increased risks of all-cause mortality and CVD. Some studies show sedentary work correlates with higher inflammation and adverse outcomes compared with more active occupations.
THE UGLY: high OPA
🔴High-intensity OPA such as frequent heavy lifting, prolonged exertion, and limited recovery is associated with elevated inflammatory markers, and tends to correlate with increased CVD risk, elevated blood pressure, and higher mortality, especially among men. Excessive physical strain and stress at work may drive proinflammatory processes.
SUMMARY:
📚While moderate occupational physical activity and an active lifestyle may benefit inflammatory profiles and health, both very low (sedentary) and very high-intensity OPA are linked to proinflammatory markers and elevated risks of morbidity and mortality.
MW
Reference:
Jordakieva G, Hasenoehrl T, Steiner M, Jensen-Jarolim E, Crevenna R. Occupational physical activity: the good, the bad, and the proinflammatory. Front Med (Lausanne). 2023;10:1253951.

07/02/2026

Occupational physics activity (OPA):
Exercise at work: is it enough?
BACKGROUND:
🔎Physical activity is vital for health, reducing chronic disease risk and improving well-being. Guidelines recommend adults complete at least 150 minutes/week of moderate-intensity activity.
EXERCISE DOMAINS:
1️⃣LEISURE-time PA: voluntary exercise outside work (e.g., walking, cycling, running, sport participation etc.).
2️⃣OPA: activity during work (e.g., farming, construction, cleaning etc.).
📍An editorial by Shala (2018) posits that occupational PA does NOT provide the same health benefits as purposeful exercise!
HEALTH RISKS:
⚠️High OPA has been associated with:
⚠️Increased all-cause mortality
⚠️Cardiovascular disease risks
⚠️Musculoskeletal overuse injuries
DIFFERENTIATING FACTORS:
OPA offers different:
❌Intensity and structure: often prolonged low-moderate intensity
❌Lack of recovery: longer work days leading to chronic fatigue and systemic inflammation
❌Limited control: over pace, breaks, workload, stress etc.
❌Socioeconomic factors: jobs with high occupational physical activity is often more common among lower SES populations with additional health burdens
IMPLICATIONS:
🔆Healthier workplaces: redesigning tasks with adequate activity and recovery periods
Structured exercise programs that complement occupational physical activity
🔆Address or mitigate socioeconomic factors/barriers
🔆Further research to identify strategies to improve health outcomes among workers
SUMMARY:
📚Being active at work does NOT substitute for purposeful exercise and may even pose risks such as cardiovascular strain and musculoskeletal injury.
MW
Reference:
Shala R. ‘I’m active enough in my job.’ Why is occupational physical activity not enough? Br J Sports Med. 2018;52(3):149–150.

06/02/2026

Patient safety in telehealth
BACKGROUND:
🔎While synchronous telehealth (real-time interactions like telephone or videoconference consultations) improves access, convenience, and resource use, it may introduce patient safety risks that have been underexplored in research and clinical governance frameworks.
📍A recent scoping review by Oliveria et al. (2025) sought to map existing evidence on these risks by analysing systematic reviews that examined safety concerns arising from synchronous telehealth interactions between healthcare professionals and patients.
PATIENT EXPERIENCE
📚Challenges with factors such as, patient satisfaction, perceived quality of care, and engagement can affect timely reporting of symptoms, adherence, and overall safety outcomes.
MEDICATION & PRESCRIPTION SAFETY:
📚Errors such as incorrect dosing, labelling, and inappropriate prescriptions were reported, though these risks tended to be reduced through video as opposed to telephone consultations.
COMMUNICATION FAILURES:
📚Breakdowns due to connectivity issues, unclear instructions, and loss of non-verbal cues contributed to diagnostic uncertainty and treatment errors
TRAINING & EDUCATION GAPS:
📚Clinicians often lack formal telehealth training, and existing education programs may not include structured safety content, increasing the risk of inappropriate assessment and adverse events
PATIENT IDENTIFICATION ERRORS:
📚Failures in confirming patient identity during virtual encounters can jeopardise clinical decisions, confidentiality, and treatment accuracy.
SUMMARY:
📝Synchronous telehealth offers important benefits but carries distinct patient safety risks across experience, prescribing, communication, training, and identification domains. Addressing these risks requires structured implementation strategies, robust training, and continuous monitoring to ensure safe adoption of telehealth practices alongside further research to better quantify and mitigate harm
MW
Reference:
Oliveira JSR, Fernandez RS, Molina MR, Pinto ACPN, Rocha-Filho CR, Ferreira TM, et al. Patient safety risk associated with synchronous telehealth: A scoping review. PLoS One. 2025;20(12):e0336992

05/02/2026

It’s not all about strengthening
Part 2: clinical implications
BACKGROUND:
🔎Traditionally, exercise-based rehabilitation for musculoskeletal pain incorrectly assumes strengthening muscles (increasing force output) is the key mechanism for reducing pain and improving function.
📍A recent editorial by Powell et al. (2025) challenge the conventional mechanistic assumptions underpinning exercise prescription for musculoskeletal pain, and emphasise the important undelying clinical implications.
CONTEMPORARY & MULTIDIMENSIONAL EXPLANATIONS:
❌Avoid framing strength gains as the primary mechanism through which exercise reduces pain and improves function. Although strength improvements can be beneficial for general physical capacity and long-term health, they do not reliably explain pain relief in musculoskeletal conditions.
❌Refrain from offering simplistic, single-cause explanations (e.g., “this exercise will reduce your pain because it strengthens your muscle”). Instead, they should communicate that exercise may relieve pain through multiple inter-related mechanisms, helping patients develop a more accurate understanding of how rehabilitation works. This can also help counter unhelpful beliefs about pain and tissue damage.
BIOPSYCHOSOCIAL ADOPTION:
✅Incorporate a broader biopsychosocial framework in rehabilitation that acknowledges the broader neurophysiological, psychological, behavioural, and contextual factors that contribute to exercise-induced improvements in pain and function, not just mechanical tissue changes.
INDIVIDUALISED CARE:
❌Don’t merely provide generic strengthening programs, individually-tailor exercise as part of a broader patient-centred approach that considers the individual’s unique pain experience, preferences, expectations, and functional goals, as thie is more likely to engage patients and address the mechanisms relevant to their outcomes.
EMPHASIZE MECHANISM-INFORMED PRACTICE AND EDUCATION:
✅Integrate contemporary pain science and mechanistic insights into clinical practice and education, including patient education that explains the benefits of exercise in terms of nervous system adaptations, behavioural changes, and psychological factors, rather than solely biomechanical strengthening.
RESEARCH:
✅Advocate for research that systematically measures potential mediators (such as self-efficacy, pain-related fear, and other biopsychosocial variables) in clinical practice, and endeavours to identify mechanisms that change alongside clinical improvements can inform better treatment strategies and optimise real-world outcomes.
SUMMARY:
📝While strength training remains a valuable component of rehabilitation, its role should not be overstated as the primary explanation for pain relief. Effective exercise-based rehabilitation requires a multifaceted, individualized, biopsychosocial approach, better communication about mechanisms with patients, and integration of contemporary pain science into both clinical reasoning and practice.
MW
Reference:
Powell J, Wood L, Cashin AG, Lewis JS. It is not all about strength: rethinking mechanistic assumptions in exercise-based rehabilitation for musculoskeletal pain relief. Br J Sports Med. 2025 Dec 31; bjsports-2025-110372. calcaropnpp

05/02/2026

It’s not all about strengthening
Part 1: outcomes and mechanism mismatch
BACKGROUND:
🔎Traditionally, exercise-based rehabilitation for musculoskeletal pain has often been justified primarily on the basis that strengthening muscles (increasing force output) is the key mechanism for reducing pain and improving function. This assumption is deeply embedded in many rehabilitation programs, clinical guidelines, and patient expectations.
📍A recent editorial by Powell et al. (2025) challenge the conventional mechanistic assumptions underpinning exercise prescription for musculoskeletal pain. Contemporary evidence suggests that this strength-centric view oversimplifies how exercise actually alleviates musculoskeletal pain and overlooks important alternative mechanisms.
OUTCOME: MECHANISM mismatch:
📝Traditional mechanistic assumptions in exercise-based rehabilitation propose that increases in strength are the primary causal mechanism underlying pain relief and functional improvement; however, this assumption is not supported by the current evidence.
📚Extensive data from systematic reviews and mediation analyses demonstrate increases in muscle strength rarely explain clinical benefits in pain or function. For example, in knee osteoarthritis, gains in knee extension strength have been shown to account for only a tiny fraction (~2%) of the total benefit of exercise.
PROPOSED MECHANISMS:
🧠 Multiple biopsychosocial and neurophysiological factors are more plausible mechanisms driving exercise-related pain relief and improvements in function, including:
🔆Psychological and behavioural factors such as, changes in pain self-efficacy, reductions in pain-catastrophizing, kinesiophobia and/or pain-related beliefs
🔆Neurophysiological modulation leading to altered pain perception and processing
🔆Contextual factors including therapeutic alliance, recovery expectations, motivation, and engagement etc.
SUMMARY:
📚Current evidence supports a multidimensional picture in which psychological, neurophysiological, and contextual processes contribute substantially to benefits—often more than strength changes themselves.
🗣️By acknowledging this mismatch, clinicians and researchers can better explain, individualise, and optimise exercise-based rehabilitation for musculoskeletal pain.
MW
Reference:
Powell J, Wood L, Cashin AG, Lewis JS. It is not all about strength: rethinking mechanistic assumptions in exercise-based rehabilitation for musculoskeletal pain relief. Br J Sports Med. 2025 Dec 31; bjsports-2025-110372.

04/02/2026

Contextual effects from MSK Rx
BACKGROUND:
🔎When a patient receives a treatment for musculoskeletal pain, the total effect they experience comprises not just the specific effect of the intervention itself, but also non-specific effects, such as natural history of the condition, regression to the mean, and contextual effects related to the treatment setting, expectations and interactions with clinicians. Distinguishing between these components is crucial because some treatments carry potential harm or costs that may not be justified by their specific benefits alone.
📍An editorial by Cashin et al. (2021) explores the challenges involved in identifying and separating contextual effects from the specific effects of musculoskeletal interventions. The authors discuss the methodological challenges, introduce causal mediation analysis and emphasize the importance of acknowledging non-specific or contextual factors when interpreting and applying research findings into clinical practice.
RECOMMENDATIONS:
🔆Contextual effects are often substantial and ubiquitous, and clinical trials (and clinicians) must account for them!
🔆Causal mediation analyses offer an important solution for clarification.
🔆Clear definitions are essential.
SUMMARY:
📝There are inherent difficulties and challenges in separating specific and non-specific (contextual) effects of treatments in pragmatic trials. Causal mediation analysis offers a practical method to estimate contextual contributions.
MW
Reference:
Cashin AG, McAuley JH, Lamb SE, Lee H. Disentangling contextual effects from musculoskeletal treatments. Osteoarthritis and Cartilage. 2021;29(3):297–299.

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