Data were extracted from all trials34, 35, 36, 37 and 38 and tabulated. Means and SDs were provided by the Fulvestrant nmr corresponding author of one trial.35 Mean differences for disability were calculated using estimated SDs at each follow-up point for one trial.36 Only one trial37 reported means and SDs of within-group change and therefore between-group differences at each follow-up point were used to calculate mean differences. Table 4 presents the effect of MDT on pain intensity in comparison to other therapeutic approaches. The between-group comparisons had

95% CI with lower limits that were less than 20 on a scale of 0 to 100. Table 5 presents the effect of MDT on disability in comparison to other therapeutic approaches. The between-group comparisons for disability had 95% CI with upper limits that were less than 20 on a scale of 0 to 100. This review investigated the effectiveness of MDT for pain intensity TGF-beta Smad signaling and disability in comparison to other therapeutic approaches including ‘wait and see’. Five studies

were included in this review. Meta-analysis was undertaken in comparisons between MDT and wait-and-see controls and other comparisons were summarised with mean difference values. Some individual estimates of the effect of MDT in comparison to a wait-and-see control or other therapeutic approaches were statistically significant and in favour of MDT. However, in all studies at all time points, the lower limit of the 95% CI was less than 20 on a scale of 0 to 100. The between-group comparisons for disability also had 95% CI with upper limits that were less than 20 on a scale of 0 to 100. This indicates that any additional reduction in pain intensity due to MDT compared with the Carnitine dehydrogenase wait-and-see approach or other therapeutic approaches

may not be clinically worthwhile. Furthermore, it confirms that any additional reduction in disability from MDT compared with the wait-and-see approach or other therapeutic approaches is not clinically worthwhile. In several of the trials, the results may have been influenced by the use of novice MDT practitioners rather than Diploma MDT therapists. The educational program to become a credentialed MDT therapist does not include direct one-on-one clinical training as well as broader knowledge of physiotherapy evidence. It takes years of intensive MDT training to obtain the MDT Diploma, where candidates learn MDT based on a biopsychosocial framework and obtain substantial experience and skills to apply the MDT algorithm for various musculoskeletal problems. Therefore, it can be assumed that the treatment effect by therapists who only attended some of the MDT curriculum or were only credentialed MDT therapists is less than that of therapists with an MDT Diploma. Evaluation of the potential effectiveness of MDT may therefore require studies to use only therapists with an MDT Diploma. This point should be considered in future research in relation to MDT to avoid misinterpretation of its effectiveness.