Archives of Rehabilitation Research and Clinical Translation (2023) 5, 100258

Archives of Rehabilitation Research and Clinical Translation

Archives of Rehabilitation Research and Clinical Translation 2023;5:100258
Available online at www.sciencedirect.com

Special Communication

Musculoskeletal Pain: Current and

Future Directions of Physical Therapy
Practice
Brona M. Fullen, PhD a, Harriet Wittink, PhD b,
An De Groef, PhD c,d,e, Morten Hoegh, PhD f,
Joseph G. McVeigh, PhD g, Denis Martin, PhD h,i,
Keith Smart, PhD a

a
UCD School of Public Health, Physiotherapy and Sports Science, University College Dublin,
Ireland
b
Research Centre Healthy and Sustainable Living Utrecht University of Applied Sciences, The
Netherlands
c
Department of Rehabilitation Sciences, Leuven, Belgium
d
Department of Rehabilitation Sciences and Physiotherapy MOVANT, University of Antwerp,
Antwerp, Belgium
e
Pain in Motion International Research Group, www.paininmotion.be
f
Aalborg University, Faculty of Medicine, Department of Health Science and Technology,
Denmark
g
Discipline of Physiotherapy, School of Clinical Therapies, College of Medicine and Health,
University College Cork, Ireland
h
Centre for Rehabilitation, School of Health and Life Sciences, Teesside University, United
Kingdom
i
NIHR Applied Research Collaborative North East and North Cumbria, Cumbria,
Northumberland, United Kingdom

KEYWORDS Abstract Musculoskeletal (MSK) pain is 1 of the most common problems managed by clinicians
Biopsychosocial model; in MSK care. This article reviews current frameworks for the assessment and management of
Musculoskeletal pain; MSK pain within evidence-based physical therapy practice. Key considerations related to the
Physical therapy biopsychosocial model of pain, evidence-based practice, assessment, treatment, physical activ-
modalities; ity/movement behavior, risk stratification, communication as well as patient education and self-
Rehabilitation; management skills within physical therapy and physical and rehabilitation medicine are
Therapeutics addressed. The future direction of MSK pain management is also discussed, including strategies
to promote evidence-based practice, behavior change, social prescribing, and the use of

List of abbreviations: BPS, biopsychosocial; EBP, evidence-based practice; LBP, low back pain; MSK, musculoskeletal; NICE, National Institute
for Health and Care Excellence; PA, physical activity; TENS, transcutaneous electrical nerve stimulation.
Disclosures: none.
Cite this article as: Arch Rehabil Res Clin Transl. 2023;000:100258

https://doi.org/10.1016/j.arrct.2023.100258
2590-1095/© 2023 The Authors. Published by Elsevier Inc. on behalf of American Congress of Rehabilitation Medicine. This is an open access
article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
2 B.M. Fullen et al.

technologies.
© 2023 The Authors. Published by Elsevier Inc. on behalf of American Congress of Rehabilitation
Medicine. This is an open access article under the CC BY license (http://creativecommons.org/
licenses/by/4.0/).

Introduction The biopsychosocial model

Physical therapy is clinically and cost effective in the assess- EBP within MSK care has been informed and shaped, in part,
ment and management of musculoskeletal (MSK) disorders.1 by the BPS model of illness and pain. The BPS model was pre-
Current MSK practice typically involves 3 components: edu- sented in 1977 in response to perceived shortcomings of the
cation, exercise, and physical therapy. Evidence for each of biomedical model and as a means of acknowledging the bio-
the 3 component is limited, including the best way to pro- logical, psychological, and social factors determinants of
vide them, and the emphasis that should be placed on each. health and disease. It was proposed as “a blueprint for
An evidence-based biopsychosocial (BPS) approach with the research, a framework for teaching, and a design for action
active engagement of the patient in their own care is advo- in the real world of health care”.8 Crucially, it acknowledged
cated. the reality that illnesses and diseases are human experien-
This article reviews current frameworks such as evi- ces as much as pathologic entities.
dence-based practice (EBP), the BPS model, risk stratifica-
tion, and psychologically-informed physical therapy for the Application of the biopsychosocial model in clinical
assessment and management of MSK pain. practice

MSK pain disorders are no longer considered a purely bio-

medical problem, but considered a complex problem which
Evidence-based practice
can be influenced by a wide range of other factors. These
include cognitive, psychological, social, as well as biomedi-
EBP has been defined as “the conscientious, explicit, and
cal factors. Assessing and treating patients according to the
judicious use of current best evidence in making decisions
BPS model has been recommended in a number of pain-
about the care of individual patients” which includes the
related clinical guidelines relevant to clinicians.9 The BPS
integration of best research evidence, clinical expertise,
model also forms the basis of the World Health Organiza-
and patient values.2 It was subsequently pointed out that
tion’s International Classification of Functioning, Disability
this definition did not include any reference to ethical prin-
and Health,10 suggesting widespread endorsement of the
ciples. A definition of EBP for physiotherapists was suggested
model. However, there seems to be varying levels of confi-
as “an area of study, research, and practice in which clinical
dence and proficiency among clinicians regarding psychoso-
decisions are based on the best available evidence, integrat-
cially oriented clinical knowledge and practice.11
ing professional practice and expertise with ethical
principles.”3
Clinicians are in favor of EBP and research; however, it Psychologically informed treatment in physical
is not always used in clinical practice.4 Barriers to clini- therapy
cal use of EBP include lack of time and workload pres-
sures, access to research, and difficulty translating A range of psychologically informed physical therapy inter-
research in to practice.4 Therefore, understanding, pro- ventions have been developed and evaluated.12 This
moting, and maximizing the facilitators of EBP (postgrad- approach blends conventional physical therapy treatments
uate education, skills to engage in self-directed learning, with cognitive-behavioral therapies, that acknowledge the
beliefs that research and clinical guidelines can usefully influence of a person’s thoughts, feeling and behaviors
inform clinical decision-making, and a willingness to together with wider socio-economic contextual factors.13
change and adopt more effective methods) could be used Examples of such approaches include graded activity/expo-
to enhance clinical practice.5 Engaging in such strategies sure, cognitive-behavioral therapy and acceptance, and
(educational interventions,6 training and education of commitment interventions where the patient is facilitated
stakeholders, adapting and tailoring the context, and to use acceptance as a way to deal with negative thoughts
supporting clinicians) have been shown to improve guide- and feelings and commits to positive values-based goals.14
line adherence and knowledge. However, when evaluat- Reviews show that the clinical effects of such interventions
ing resultant changes in patient-reported outcomes, the on pain-related outcomes are inconsistent.12,14
literature is very limited. A recent systematic review on
allied health care professionals EBP training included 6
studies, of which only 3 including patient reported out-
comes, with no significant changes reported. The authors Musculoskeletal pain assessment
conclude that either that the outcome measures were
not sensitive, that different intervention strategies are Physical therapists and physical and rehabilitation medicine
needed to change patient outcomes, and that more physicians are frequently consulted for their assessment and
research is needed in this area.7 treatment of disorders of which pain is often the dominant
Musculoskeletal pain and physical therapy 3

feature, and of course pain may be considered a disease in choices a person makes in whether to move and how to
its own right.15 move (frequency intensity, etc). Consequently, there is a
need for objective measurement of movement behavior in
Palpation, structural integrity, serious pathology people in pain. Considering the factors that modulate PA,
including the quantity, type, psychosocial, and lifestyle fac-
Assessment of low back pain (LBP) and MSK disorders in gen- tors, will help in the diagnosis and in the development of
eral should exclude specific pathologies (eg, fracture, infec- individualized treatment planning. It will also help in the
tion, malignancy),16 Assessment of “red flags” is essential in monitoring and assessment of the effect of physical therapy
many pain conditions and is used to identify risk of serious treatment over time.
pathology,17 although individual red flags cannot reliably
predict pathology.18,19 As an alternative or complementary Risk stratification
approach to the use of nominal patho-anatomic diagnoses,20
mechanism-based approaches to the management of pain Management of LBP should include stratifying patients into
have been advocated.21 According to the International Asso- homogenous groups based on risk stratification and offering
ciation for the Study of Pain (IASP), there are 3 broad cate- targeted treatment, which results in better outcomes, and
gories of pain mechanisms (nociceptive, neuropathic, and is now specifically recommended in the United Kingdom’s
nociplastic) that may occur alone or in combination.21 Noci- National Institute for Health and Care Excellence (NICE)
ception provides a means of neural feedback that allows the guidelines.33 The most widely known tool for this approach
central nervous system to detect and avoid noxious and is the STarT Back Screening tool that allows clinicians to
potentially damaging stimuli in both active and passive set- identify those who are at a low, medium, or high risk of
tings. Neuropathic pain is caused by a lesion or disease of poorer clinical outcomes due to potentially modifiable physi-
the somatosensory system, including peripheral fibers (Ab, cal and psychological prognostic indicators (low mood, anxi-
Ad, and C fibers) and central neurons. Nociceptive mecha- ety, catastrophizing, and fear avoidance) for persistent
nisms are assumed to drive the pain experience during and disabling symptoms.34 Management of low-risk patients con-
immediately after acute injuries. Likewise, nociceptive and sists of advice (pamphlets, information video) and PA with
neuropathic mechanisms are dominant in pathologies such an emphasis on promoting appropriate levels of activity,
as cancer and neuropathic pain, and nociplastic may be the including return to work. For medium-risk patients, manage-
dominant mechanism in some nonspecific and chronic pain ment should consist of referral for standardized physical
presentations, such as chronic non-specific LBP and chronic therapy, to address symptoms and function. High-risk
widespread pain/fibromyalgia. patients should be referred for psychologically informed
physical therapy, again to address symptoms and functional
Physical activity/movement behavior impairment in addition to psychosocial issues that may pres-
ent a barrier to recovery.34 The efficacy of this approach has
been established in Europe but has not been replicated in
Guidelines for the assessment and management of MSK pain
the US, illustrating successful implementation may vary in
recommend the promotion of active lifestyles with regular
different health service settings.35 Given that up to one-
physical activity (PA) as a first line treatment.9 Both short
third of primary care patients with LBP have dominant psy-
and long-term benefits on the pain experience have been
chosocial risk factors,34 identifying and implementing an
reported22,23 as well as positive effects on cardiovascular
early effective care to patients’ level of risk of poorer out-
health, mood, stress, sleep quality of life, and sexual
comes is important.36
function.24,25
Within the BPS assessment of a person in pain an assess-
ment of their PA levels should be undertaken in order to Communication skills
develop the most appropriate intensity and targeted individ-
ualized exercise programme.26 Subjective measures such as Clear communication between clinicians and their patients
PA questionnaires, for example, Baecke physical activity is essential to facilitate active patient involvement in the
questionnaires,27 electronic diaries28 have been commonly assessment and management process. Patient-centered
used, although more recently objective measures, such as communication, including motivational interviewing skills,
accelerometers, are increasingly used to objectively mea- have been shown to improve patient satisfaction, build con-
sure performance of activities in people with LBP.29,30 Stud- fidence, and improved health-related knowledge in those
ies show only a weak31 to moderate correlation32 between with chronic MSK pain.37,38,39
self-reported PA and objectively measured PA (accelerome- A patient-centered communication style is fundamental
try) in individuals with chronic pain. Most people with to achieving active patient engagement.40,41 Communicat-
chronic pain underestimate their level of PA. There is also a ing with empathy, developing congruence of the clinician’s
discrepancy between the association between subjectively and patient’s goals and taking a positive approach to build a
or objectively measured PA and important outcome meas- therapeutic alliance and facilitate shared-decision making
ures such as pain intensity, anxiety, and disability.30,31 are all essential.42,43 Adapting the communication style to
An international consensus on the term “movement the individual patient, having the ability to communicate
behavior” has been reached, which includes sedentary using plain language, being cognizant of their health literacy
behavior, PA, and exercise.32 Movement behavior describes level, speaking directly to the patient, listening actively,
the 24-hour pattern of movement and non-movement pat- and asking appropriate questions are important features of
terns (including sleep). The term behavior refers to the patient-centered communication.41 Health literacy is the
4 B.M. Fullen et al.

degree to which individuals have the capacity to obtain, pro- of benefit), ultrasound (no evidence), and interferential
cess, and understand basic health information needed to therapy (no evidence). The most recent Cochrane review on
make appropriate health decisions. Research indicates that TENS (an overview of systematic reviews including 9 reviews
health literacy in general in Europe may be inadequate44 and 51 TENS-related randomized controlled trials, n=2895)
and hamper effective self-management in patients with equally is unable to conclude with any confidence that, in
chronic pain.45 Barriers to effective communication such as people with chronic pain, TENS is harmful, or beneficial, for
demographic characteristics (socio-economic background, pain control, disability, health-related quality of life, use of
age, education level) should also be considered. Patient- pain-relieving medicines, or global impression of change.54
centered communication requires the time to implement; With regard to transcranial magnetic stimulation, the
however, the investment will result in increased effective- findings from a Cochrane systematic review (38 trials,
ness of the applied pain management strategies.46,47 n=1225) indicates that repetitive transcranial magnetic
stimulation of the motor cortex, but not the dorsolateral
prefrontal cortex, may provide short term, but likely clini-
Musculoskeletal pain management cally unimportant improvements in chronic pain and quality
of life (low to very low quality evidence).55
Following a thorough BPS assessment, a number of evi-
denced-based treatments and approaches may be used to Physical activity and exercise
manage MSK problems.
Evidence supports the use of exercise and PA in the manage-
Manual therapy ment of chronic diseases including painful conditions such as
osteoarthritis, rheumatoid arthritis, and fibromyalgia.56
Manual therapy has been a core intervention for physical Incorporation of exercise and PA and their importance are
therapists treating patients with MSK complaints and is rec- usually introduced during initial individual appointments
ommended as an adjunct or second line treatment in clinical and continued through to structured exercise classes or as a
guidelines for non-specific LBP.48 However, the rationale component of a chronic pain rehabilitation program. Despite
underpinning manual therapy has changed from a strict bio- the physical, psychosocial, and social benefits achieving the
mechanical paradigm (changing or influencing somatic tis- PA guideline goal of 30 minutes of moderate PA, a day is chal-
sues) to a neurophysiological one.49 In this paradigm, lenging for patients living with pain. Although the frequency,
manual therapy may provide its pain-relieving effects via intensity, type, and time (duration) parameters (F.I.T.T.) for
the well-established descending modulatory pathways in the specific conditions are known, there is increasing awareness
central nervous system.49 While the exact mechanisms by that adherence long-term to exercise programs are affected
which manual therapies affect the nociceptive system are by other factors including depression and other physical
unknown, it is clear that moderately painful pressure can health problems.57 Evidence suggests that exercise behav-
lead to short-lasting pain inhibition (sometimes referred to iors are modifiable; therefore, motivational/behavioral
as pain-inhibits-pain) in both humans and rodents.50 Further- change strategies should be incorporated into exercise inter-
more, manual therapy is likely to have an influence on pain ventions to enhance patients’ motivation and longer-term
via more cognitive and contextual factors.49,51 These adherence.58,59 The choice of exercise therapy should be
include the clinician’s professionalism, mindset, and appear- closely aligned with patients’ preferences and goals as
ance; the patient’s beliefs, experiences, and expectations enjoyment in and commitment to the type of exercise will
about their diagnosis and treatment, the physiotherapist- help with long-term adherence.
patient relation during the appointment, the application of Feedback on PA and exercise levels is a powerful behav-
the manual therapy technique, even the overall impression ioral change tool,60 and the use of technologies such as
of the clinic/hospital department.51 Viewing manual therapy wearable biosensors integrated into clothing, shoes,
through the lens of neuroscience not only provides a likely watches, and smart phones that acquire, transmit, store,
mechanism but may explain why different manual therapies and retrieve health-related data could be used to monitor
appear to have similar effects on MSK problems such as and augment individualized rehabilitation.61 A recent sys-
LBP.52 Manual therapy may also provide the skilled clinician tematic review of controlled trials reported that these devi-
with a tool to engage non-verbally with the patient.53 ces have promise in relation to increasing PA participation62
or to maintain PA levels after structured lifestyle interven-
Electro-physical modalities tions.63 Going forward this technology may also reduce tra-
ditional health care usage of face-to-face appointments for
providing ongoing support.64,65
NICE33 reports that most of the evidence for the use of elec-
tro-physical modalities for chronic primary pain is of low to
very low quality. The committee’s view is that there was Self-management skills
considerable uncertainty in the data, with little evidence of
long-term outcomes, and much heterogeneity in practice. Facilitating the development of self-management skills and
While laser therapy has the strongest preliminary evidence building self-efficacy is a core feature of chronic pain man-
of benefit (quality of life and pain), it is not recommended agement.66 Self-management is a difficult to measure com-
until further research is undertaken. plex concept,67 but typically involves the key skills of
The NICE committee also does not recommend transcuta- problem solving, decision making, seeking, and using
neous electrical nerve stimulation (TENS) (lack of evidence resources, forming partnerships with their health care
Musculoskeletal pain and physical therapy 5

providers and taking action.68 Acceptance of the persistent Implementing patient-centered care
nature of pain is a key step in moving from a search for a
diagnosis and medical solution to an individualized self-man- Patient centeredness in MSK care includes effective commu-
agement approach. nication, individualized treatment, working with patient-
A recent randomized controlled trial (n=102) of patients defined goals, education, and information sharing during all
with chronic pain incorporated pain neurophysiology educa- aspects of treatment that facilitates decision making, along
tion, cognitive behavioral principles, and individualized, with self-management support.43
goal-oriented exercises with the type and amount of exer-
cise was based on the participants’ goals, abilities, and pain Behavioral change
sensitivity.69 Results showed improved function, pain inten-
sity, pain knowledge, catastrophizing, self-efficacy, satisfac- A process of behavioral change is the key to successful man-
tion with health care, and global rating of change, but no agement of MSK conditions including pain.37 Several behav-
improvement in pain interference, work status, fatigue, ioral change models such as Bandura’s self-efficacy theory.
depressive symptoms, or health care utilization in compari- Self-efficacy is a person’s particular set of beliefs that deter-
son with usual care. By contrast, generic self-management mine how well one can execute a plan of action in prospec-
interventions have been shown to have limited effectiveness tive situations.76 People’s beliefs in their efficacy are
for patients with chronic MSK pain.70 developed by 4 main sources of influence: (i) mastery expe-
riences (performance outcomes), (ii) vicarious experiences
Patient education (social role models), (iii) social persuasion, and (iv) emo-
tional states. If patients and health care professionals con-
Patient education is a core component of the management tribute to this process and agree on treatment decisions, the
of MSK pain. Patient education often reflects that pain is not process of behavior change is enhanced, and the likelihood
a true representation of the actual state of the tissues, but of improving pain-related outcomes increases.37
it is the nervous system’s interpretation of the threat of In a systematic review on behavior change techniques
their injury, which in turn is subject to modulation by various (BCTs) associated with adherence to prescribed exercise in
psychological factors, including fear avoidance, catastroph- patients with persistent MSK pain, a moderate level of evi-
izing, expectations, cognitions, and beliefs. Systematic dence to support adherence for 5 BCTs was found including
reviews and meta-analyses on pain science education in (i) social support (unspecified), (ii) goal setting (behavior),
chronic MSK pain populations have reported evidence for (iii) instruction of behavior, (iv) demonstration of behavior,
improving pain ratings, pain knowledge, disability, pain cat- and (v) behavior practice/rehearsal.77 For exercise or PA
astrophizing, kinesiophobia, attitudes regarding pain, and interventions to have a longer-term effect, they need to be
physical movement.71 However, to achieve clinically impor- enjoyable and meaningful to the individual.78,79
tant improvements, education should be combined with It is also suggested that a pain neuroscience education
physical interventions.72 Less research has been undertaken program may be needed to prime patients for an active life-
on those with acute pain; 1 systematic review reported style, remove barriers, and bridge the intention-behavior
inconclusive evidence for the benefits of perioperative pain gap to actively self-manage their problem through a tailored
science education on post-operative pain, which can be programme.38
influenced by health care professionals’ beliefs.72
Self-management
Managing comorbidities
Successful self management including the ability to man-
Patient assessment and management for MSK conditions age symptoms, treatment, physical, psychological and social
should always be considered within the context of their gen- consequences, and lifestyle changes related to one’s chronic
eral health. By mid-century, 1 in 6 people globally will be condition is essential in MSK care. There is evidence to sup-
aged 65 years or older,73 with the prevalence of comorbid- port self-management interventions for a variety of differ-
ities increasing with age. In addition to aging, several other ent pain conditions80 and the use of digital communication-
important risk factors are associated with the development based technology (internet based, telephone supported, vir-
of chronic disease, such as lifestyle factors (smoking, alco- tual reality) may provide innovative options for patients liv-
hol, lack of PA). Many of these factors can cause multiple ing with chronic pain.81 Several mobile-health applications
diseases and many symptoms may have shared underlying also show promise for (cognitive) treatment82 and relapse
neurobiology.74 For instance, depression is a common comor- prevention.83
bidity in patients with chronic pain and depression itself is People who are knowledgeable about their condition are
associated with a higher incidence of co-morbid somatic ill- better able to self-manage and also deal with others who do
nesses, especially cardiovascular diseases, type 2 diabetes, not understand their condition;84 however, this requires a
and metabolic syndrome. In the future, it will be necessary good level of health literacy. Incorporating effective health
to accommodate, and potentially treat, such comorbidities literacy strategies into treatment, for example, offering
within pain-related rehabilitation approaches. Systematic information in bit-size chunks, using plain language and
reviews and meta-analyses have provided strong evidence techniques such as the Teach Back methods, have been
for the efficacy of therapeutic exercise for a range of out- shown to be effective.85
comes in patients with a broad range of long-term Patients with chronic pain experience exacerbations of
conditions.75 their pain problems and relapses may be due to an individual
6 B.M. Fullen et al.

physical event, or it may result from cumulative physical and in physical health, increased self-esteem and confidence,
psychological stresses that challenge patients’ coping and a reduction in visits to general practitioners.94
resources. Rehabilitation professionals can help to identify This article has reviewed current concepts in the man-
situations that are challenging and help patients develop agement of MSK pain. EBP remains the underlying approach
strategies to cope with them. Strategies may include setting of course, and new evidence is emerging. The BPS model
criteria to visit health professionals, using pain medication, underpins the need to address all aspects of the patient’s
or briefly resting and relaxing. Plans for resuming activity problem, biomedical issues, psychosocial issues, and the
following an exacerbation are critical.86 Technological appli- context and environment in which the patient lives and
cations, such as apps, virtual reality, or telephone-based works are all equally important. Reflecting a greater aware-
interventions may help patients maintain the skills they ness of the BPS approach to MSK issues, psychological
learned in their pain management programs and prevent informed physical therapy is an emerging area of practice
relapse. and there is a growing body of evidence to support this prac-
tice, particularly within a risk stratification approach to
assessment and treatment. Some fundamentals of MSK care
Future directions remain unchanged, effective communication with the
patient as a partner in care is critical. PA and exercise inter-
The evolving biopsychosocial model ventions in MSK care remain a core intervention; however,
there is a greater awareness of the need to support behav-
ioral change and the techniques required to do this. Like-
Although not specific to pain, variations and updates of the
wise, there is a greater awareness of the role of supported
BPS model have recently been described in light of new
self-management and the use of technology as an adjunct to
knowledge. The “holistic biopsychosocial model of illness”
treatment. Public approaches and social prescribing inter-
makes explicit the range of factors that may influence
ventions in MSK care are in their infancy, but given the chal-
behavior and disability and aims to provide a comprehensive
lenges of access to services and treatment no doubt these
understanding of illness and a rational approach to rehabili-
approaches will grow and develop.
tation.87 The “Biopsychosocial-Pathways model” describes
causal pathways among biological, psychological, and social
factors.88 Aside from integrating newer interpretations of
Musculoskeletal care in 2050
the BPS model, addressing the many barriers to the adoption
of existing methods, such as those linked to the professional
The basic International Classification of Functioning, Disabil-
knowledge and skills of clinicians (eg, a perceived lack of
ity and Health (ICF) is robust enough to imagine it could still
knowledge of psychosocial factors and/or how to identify or
be relevant in 2050 as a framework for defining needs of the
manage them), may promote improved understanding and
individual across the lifespan. Perhaps there will be a more
application of BPS approaches in future clinical practice and
widespread understanding of the influence of environmental
education.89
factors that could focus attention on new ways of addressing
people’s needs. For example, attention to the importance of
Focusing on the social perspective societal attitudes and norms about chronic pain may lead to
more public education campaigns like pain revolution (pain-
Social prescribing initiatives are viewed as a way of revolution.org) and flippin pain (flippinpain.co.uk).
addressing the wider social determinants of health and tar- The expanding influence of social media as a source of
geting those most socially disadvantaged.90 The negative information in society may become increasingly important.
physical and psychological effect of chronic pain is well Selective use of social media and information sources can
established, and there is evidence that chronic pain is asso- create “echo chambers”, magnify the problem and spread-
ciated with loneliness and perceived insufficiency of social ing false/inaccurate information that reinforce attitudes
support.91 The use of non-drug, community-based, non- and beliefs, potentially hindering successful pain manage-
clinical interventions has been proposed as a cost-effective ment. A growing challenge therefore is to ensure that evi-
alternative to help those with long-term conditions, dence-based messages and information achieve cut-through
including chronic pain, to manage their symptoms and to the public consciousness.
improve their health and well-being.92 Social prescription The ubiquity of digital technology in health care has been
is widely promoted as a way of targeting socioeconomically accelerated by the COVID-19 pandemic and will influence
deprived populations in need of direct health care inter- patient care in the future.66 The enforced shift to virtual
vention by linking patients in primary care with support consultation and treatment, while previously available, was
services embedded within the community.93 There are a not widely used in clinical practice. However, for many peo-
range of social prescription initiatives widely used such as ple with chronic pain the logistical benefits of this approach
“Arts on Prescription”; “Books on Prescription”; “Educa- may remain attractive, and the use of virtual appointments
tion on Prescription”, but “exercise prescription” is 1 of may be more desirable. As these solutions lead to great
the most used social prescription interventions for the pro- improvements in patient care, the health and wellbeing
motion of PA.94 While more development in this area is effects for patients will change the profession. The chal-
needed, participants in social prescribing programs have lenge going forward will be to optimize the important ele-
reported improvement in outcomes relevant to those with ments of the skilled clinical encounter (communication,
chronic pain such as psychological well-being and positive empathy, therapeutic touch, and therapeutic alliance).
mood; reduction in anxiety and depression, improvements Other technological advances including virtual reality,
Musculoskeletal pain and physical therapy 7

artificial intelligence, and machine learning will also deepen 12. Archer KR, Coronado RA, Wegener ST. The role of psychologi-
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