Contextual effects in musculoskeletal pain: are we overlooking essential factors?

PainSci » bibliography » Poulter et al 2025
updated Apr 26, 2025

PainSci notes on Poulter 2025:

There is the treatment itself … and then there is the context in which it happens, the messy halo of variables that surround and influence it, the “contextual effects” of the treatment.

All of which is chronically misunderstood and underestimated! For instance, contextual effects are similar to the placebo response, but they aren’t the same thing, and they’re more important. Contextual effects strongly influence how things work out, both in the clinic and the lab — probably more than the placebo response.

This new evidence-based opinion paper tires to clear up four common points of confusion. Nerd factor 8 — not exactly a light read. Fortunately, there’s also a less nerdy version! It’s is also longer, but definitely more readable … about, say, nerd factor 6? Lead author David Poulter published his version of the article before his academic colleagues got to it.

original abstract †Abstracts here may not perfectly match originals, for a variety of technical and practical reasons. Some abstacts are truncated for my purposes here, if they are particularly long-winded and unhelpful. I occasionally add clarifying notes. And I make some minor corrections.

The role of contextual eﬀects in musculoskeletal pain research and clinical practice has garnered growing interest in recent years (Rossettini et al., 2024). While ongoing research has advanced knowledge, it has also sparked debate between clinicians, clinical trialists and other researchers (Saueressig et al., 2024a; Ezzatvar et al., 2024a; Saueressig et al., 2024b; Ezzatvar et al., 2024b). The controversy over contextual eﬀects in musculoskeletal pain research and practice highlights the tension between leveraging their therapeutic potential and minimizing them to preserve treatment specificity (Keter et al., 2025).

Clinicians value any factor that improves patient outcomes, while clinical trialists seek to minimize contextual eﬀects to preserve treatment specificity (Sherriﬀ et al., 2023). Mechanistic researchers, focused on how these factors aﬀect our brain and behavior, struggle to quantify them while excluding them from research protocols and clinical trials (Kamper and Williams, 2013). This tension intensifies in non-pharmacological interventions (Hohenschurz-Schmidt et al., 2023a,b). Additionally, the varying influence of contextual factors on treatment outcomes (Saueressig et al., 2024c), underscores the need for further research to optimize their role across clinical settings and interventions.

Diﬀering perspectives, while enriching scientific debate, may create divisions among professionals, distancing them from the shared goal of leveraging contextual eﬀects to benefit patients with musculoskeletal disorders. Contextual eﬀects are defined as those generated by CFs in clinical practice (Di Blasi et al., 2021). An international consensus recently described CFs as “components of all therapeutic encounters,” including patient, clinician, treatment, patient-clinician relationship, and encounter context characteristics (Cook et al., 2023).

This opinion paper aims to foster dialogue and bridge the gap between clinical practice and research, creating a foundation for collaboration and mutual understanding. First, we examine potential sources of misunderstanding about contextual eﬀects leading to conflicts. Then, we discuss their implications for clinical and research fields. Diﬀerent professionals (clinicians and researchers) from diﬀerent disciplines (nursing, psychology, physical therapy, osteopathy, epidemiology) have been involved to ensure a multidisciplinary, inclusive approach, valuing all perspectives.

original abstract †Abstracts here may not perfectly match originals, for a variety of technical and practical reasons. Some abstacts are truncated for my purposes here, if they are particularly long-winded and unhelpful. I occasionally add clarifying notes. And I make some minor corrections.

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