The role of inference in musculoskeletal pain: an (En)Active Inference Masterclass for clinical reasoning, communication and person-centred care.

INTRODUCTION: Persistent musculoskeletal (MSK) pain is often inadequately explained by tissue findings alone. Reassurance may not resolve fear, while the meaning of an activity may influence how it is experienced. Although widely endorsed, the biopsychosocial model is often applied as a checklist not as a guiding philosophy. Active inference, which describes perception, action and learning as prediction-based processes, may help clinicians connect these observations.

PURPOSE: This Masterclass presents active inference as a conceptual framework and heuristic for person-centred clinical reasoning in MSK pain. Core concepts, including prediction, prediction error, precision and allostasis, are introduced through clinical examples. A five-step clinical reasoning cycle connects the patient's account and priorities with provisional and alternative hypotheses, communication, collaborative movement exploration, and reflection on the patient's response. Evidence for clinical effectiveness, proposed mechanisms and active inference specifically is distinguished throughout.

IMPLICATIONS: Five clinical levers: therapeutic alliance, manual therapy and touch, language, exercise, and context, are presented alongside concrete clinician behaviours, supporting evidence and safeguards against overtreatment, and illustrated through a chronic low back pain vignette. The framework complements differential diagnosis, established approaches such as Cognitive Functional Therapy, and consideration of biological and social contributors. Its additional clinical value remains untested. Falsifiable predictions and priorities for future research are proposed.