Boosting treatment outcomes via the patient-practitioner relationship, treatment-beliefs or therapeutic setting: A systematic review with meta-analysis of contextual effects in chronic musculoskeletal pain.

Objective:
To ascertain whether manipulating contextual effects (e.g. interaction with patients, or beliefs about treatments) boosted the outcomes of non-pharmacological and non-surgicaltreatments for chronic primary musculoskeletal pain.

Design:
Systematic review of randomized controlled trials.

Data Sources:
We searched for trials in six databases, citation tracking, and clinical trials registers. We included trials that compared treatments with enhanced contextual effects with the same treatments without enhancement in adults with chronic primary musculoskeletal pain.

Data synthesis:
The outcomes of interest were pain intensity, physical functioning, global ratings of improvement, quality of life, depression, anxiety, and sleep. We evaluated risk of bias and certainty of the evidence using Cochrane Risk of Bias tool 2.0 and the GRADE approach, respectively.

Results:
Of 17637 records, we included 10 trials with 990 participants and identified 5 ongoing trials. The treatments were acupuncture, education, exercise training, and physical therapy. The contextual effects that were improved in the enhanced treatments were patient-practitioner relationship, patient beliefs and characteristics, therapeutic setting/environment, and treatment characteristics. Our analysis showed that improving contextual effects in non-pharmacological and non-surgical treatments may not make much difference on pain intensity (mean difference [MD] : -1.77, 95%-CI: [-8.71; 5.16], k = 7 trials, N = 719 participants, Scale: 0-100, GRADE: Low)) or physical functioning (MD: -0.27, 95%-CI: [-1.02; 0.49], 95%-PI: [-2.04; 1.51], k = 6 , N = 567, Scale: 0-10, GRADE: Low) in the short-term and at later follow-ups. Sensitivity analyses revealed similar findings.

Conclusion:
Whilst evidence gaps exist, per current evidence it may not be possible to achieve meaningful benefit for patients with chronic musculoskeletal pain by manipulating the context of non-pharmacological and non-surgical treatments.