Chronic musculoskeletal pain (CMP) refers to ongoing pain felt in the bones, joints and tissues of the body that persists longer than 3 months. For these conditions, it is widely accepted that secondary pathologies or the consequences of persistent pain, including fear of movement, pain catastrophizing, anxiety and nervous system sensitization appear to be the main contributors to pain and disability. While exercise is a primary treatment modality for CMP, the intent is often to improve physical function with less attention to secondary pathologies. Exercise interventions for CMP which address secondary pathologies align with contemporary pain rehabilitation practices and have greater potential to improve patient outcomes above exercise alone. Biopsychosocial treatment which acknowledges and addresses the biological, psychological and social contributions to pain and disability is currently seen as the most efficacious approach to chronic pain. This clinical update discusses key aspects of a biopsychosocial approach concerning exercise prescription for CMP and considers both patient needs and clinician competencies. There is consensus for individualized, supervised exercise based on patient presentation, goals and preference that is perceived as safe and non-threatening to avoid fostering unhelpful associations between physical activity and pain. The weight of evidence supporting exercise for CMP has been provided by aerobic and resistance exercise studies, although there is considerable uncertainty on how to best apply the findings to exercise prescription. In this clinical update, we also provide evidence-based guidance on exercise prescription for CMP through a synthesis of published work within the field of exercise and CMP rehabilitation.
and the AGReMA group IMPORTANCE Mediation analyses of randomized trials and observational studies can generate evidence about the mechanisms by which interventions and exposures may influence health outcomes. Publications of mediation analyses are increasing, but the quality of their reporting is suboptimal.OBJECTIVE To develop international, consensus-based guidance for the reporting of mediation analyses of randomized trials and observational studies (A Guideline for Reporting Mediation Analyses; AGReMA). DESIGN, SETTING, AND PARTICIPANTSThe AGReMA statement was developed using the Enhancing Quality and Transparency of Health Research (EQUATOR) methodological framework for developing reporting guidelines. The guideline development process included (1) an overview of systematic reviews to assess the need for a reporting guideline; (2) review of systematic reviews of relevant evidence on reporting mediation analyses; (3) conducting a Delphi survey with panel members that included methodologists, statisticians, clinical trialists, epidemiologists, psychologists, applied clinical researchers, clinicians, implementation scientists, evidence synthesis experts, representatives from the EQUATOR Network, and journal editors (n = 19; June-November 2019); (4) having a consensus meeting (n = 15; April 28-29, 2020); and (5) conducting a 4-week external review and pilot test that included methodologists and potential users of AGReMA (n = 21; November 2020). RESULTSA previously reported overview of 54 systematic reviews of mediation studies demonstrated the need for a reporting guideline. Thirty-three potential reporting items were identified from 3 systematic reviews of mediation studies. Over 3 rounds, the Delphi panelists ranked the importance of these items, provided 60 qualitative comments for item refinement and prioritization, and suggested new items for consideration. All items were reviewed during a 2-day consensus meeting and participants agreed on a 25-item AGReMA statement for studies in which mediation analyses are the primary focus and a 9-item short-form AGReMA statement for studies in which mediation analyses are a secondary focus. These checklists were externally reviewed and pilot tested by 21 expert methodologists and potential users, which led to minor adjustments and consolidation of the checklists. CONCLUSIONS AND RELEVANCEThe AGReMA statement provides recommendations for reporting primary and secondary mediation analyses of randomized trials and observational studies. Improved reporting of studies that use mediation analyses could facilitate peer review and help produce publications that are complete, accurate, transparent, and reproducible.
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