Neuromuscular exercise for chronic musculoskeletal pain in older people: a randomised controlled trial in primary care in Hong Kong

I read with interest the randomised controlled trial (RCT) by Sit et al proposing neuromuscular (NM) exercise training as a management option in chronic musculoskeletal (MSK) pain.¹

RCTs have traditionally been hailed as the ‘gold-standard’ for studying treatment effects.² However, the article in question provides a good example as to why a reader should look beyond the basic study design, into the detail.

When investigating a new treatment, a useful RCT will compare the proposed intervention with the current gold-standard treatment. In the case of chronic MSK pain it would have been useful to see how NM exercise training compares to another form of exercise training. In reality, the authors have compared their intervention to a ‘waiting list’ control group.

Not only does this design introduce the ‘nocebo effect’ into the equation as a huge potential confounder, but it also means that the study does little to help guide clinical practice. Although the authors point this out as a limitation of their study towards the end of their paper, the importance of this is vastly understated in my opinion.

The authors defend their use of a ‘waiting list’ control group by referencing a ‘Personal View’ paper.³ In the current research climate, it is easy to draw on papers that defend various viewpoints - such as the RCT by Cunningham et al that demonstrated that trials with ‘waiting list’ control conditions may significantly overestimate treatment effects.⁴

With this in mind, one must take a common-sense approach in interpreting findings from studies such as this.

References
1. Sit R, Choi S, Wang B et al. Neuromuscular exercise for chronic musculoskeletal pain in older people: a randomised controlled trial in primary care in Hong Kong. Br J Gen Pract 2020;71(704): e226-e236.
2. Gosall N, Gosall G. The doctor's guide to critical appraisal. Knutsford: PasTest; 2015.
3. Gold S, Enck P, Hasselmann H et al. Control conditions for randomised trials of behavioural interventions in psychiatry: a decision framework. Lancet Psychiatry 2017; 4(9):725-732.
4. Cunningham J, Kypri K, McCambridge J. Exploratory randomized controlled trial evaluating the impact of a waiting list control design. BMC Med Res Methodol 2013; 13(1).