Best Practice & Research Clinical Rheumatology

Vol. 22, No. 3, pp. 419–433, 2008

doi:10.1016/j.berh.2008.01.001
available online at http://www.sciencedirect.com

Non-exercise physical therapies

for musculoskeletal conditions

Michael V. Hurley * PhD, MCSP

Professor of Physiotherapy

Lindsay M. Bearne PhD, MSc, MSCP

Lecturer in Physiotherapy
Academic Department of Physiotherapy, Kings College London, Rehabilitation Research Unit,
Dulwich Community Hospital, East Dulwich Grove, London SE22 8PT, UK

Management of musculoskeletal conditions by physiotherapy delivers a package of health care

designed to reduce pain and improve function. Health-care interventions should be safe, effec-
tive, acceptable to patients, deliverable by clinicians, and affordable by health-care providers.
Physiotherapy is very safe and popular with patients. While there is good evidence that exercise
relieves pain, improves function, and is cost-effective, evidence supporting the use of non-
exercise physiotherapeutic interventions is much weaker. There is some support for the efficacy
of thermotherapy, transcutaneous electrical neuromuscular stimulation, and massage, all of
which are relatively inexpensive and easy to self-administer. There is little evidence to support
the efficacy of electrotherapy, acupuncture or manual therapy, which need to be delivered by
a therapist, making them expensive and encouraging long-term reliance on others. Despite
lack of efficacy, the popularity and powerful placebo effects of physiotherapeutic modalities
may have some utility in making more burdensome physiotherapeutic interventions (exercise
and self-management advice) more acceptable.

Key words: non-exercise physical therapy; musculoskeletal conditions.

Physiotherapy forms a major component in management of musculoskeletal condi-

tions.1 For any health-care intervention to be clinically useful it must be safe, effective,
acceptable (to patients), deliverable (by clinicians) and affordable (by health-care pro-
viders, policy makers and taxpayers). There is strong evidence that exercise – regarded
as the province of physiotherapists – fulfils many of these criteria (see Chapter 2 for
more details). This chapter reviews the evidence supporting the safety, efficacy,

* Corresponding author. Tel.: +44 203 299 6022; Fax: +44 203 299 6358.
E-mail address: [email protected] (M.V. Hurley).
1521-6942/$ - see front matter ª 2008 Elsevier Ltd. All rights reserved.
420 M. V. Hurley and L. M. Bearne

acceptability, deliverability and affordability of ‘non-exercise’ physiotherapeutic inter-

ventions commonly used in the management of musculoskeletal conditions.
We define each modality, briefly present the reported potential or probable ratio-
nale for its use, the evidence supporting short- and long-term efficacy, adverse effects,
costs, and the practicality of delivering each modality. Where possible, we have relied
on well-conducted systematic reviews rather than individual trials. Unfortunately,
despite their ubiquitous use, there is a paucity of research on physical therapies.
Old, poorly designed and poorly reported studies, with methodological heterogeneity
or flaws, produce equivocal evidence, with convoluted, speculative explanations as to
why an intervention may be effective for some pathologies but not others (e.g. inflam-
matory conditions but not ‘non-inflammatory’ conditions), even though the underlying
pathological mechanisms may be very similar: e.g. effective for rheumatoid arthritis
(RA) but not ankylosing spondylitis (AS). Where little information exists, we are
forced to rely on opinion, speculation and plausibility.
We also consider the utility of non-exercise physical therapies as part of a complex
package of health care in the biopsychosocial model of chronic ill health.

THE AIMS AND RATIONALE OF PHYSIOTHERAPY IN

MUSCULOSKELETAL CONDITIONS

The main aims of physiotherapy are to reduce pain, to maintain/regain joint movement,
and to maximize function and health-related quality of life without adverse effects, en-
abling people to cope better with chronic ill health. The general assumption is that
relieving pain will result in spontaneous improvement in functioning and quality of life.
The best conceptual physiological mechanism for pain relief for physiotherapeutic
modalities is the ‘pain gate theory’ proposed by Melzack and Wall.2 This concept
posits that pain perception is modulated (‘gated’) in the dorsal column of the spinal
cord by competing inputs from large-diameter non-nociceptive Ab nerves (transmit-
ting information from cutaneous thermal, mechanical or electrical stimulation) and
smaller-diameter nociceptive C-nerves (transmitting painful stimulation). Since nerve
conduction is much faster in the larger-diameter nerve fibres of non-nociceptive
nerves, impulses from these fibres arrive in the spinal cord before impulses from
the smaller-diameter nociceptor nerves, ‘closing the pain gate’ and blocking the
perception of pain.
Other possible ways in which physiotherapeutic modalities might relieve pain
include release of endogenous opioids (e.g. encephalins and endorphins) that inhibit
nociceptors, or via stimulation of the descending inhibitory pathways

THERMOTHERAPY

Thermotherapy is the application of heat or cold to alter cutaneous, intra-articular tem-

perature and core temperature.3 In addition to ‘shutting the pain gate’, thermotherapy
may relieve pain by increasing tissue temperature, which increases blood flow, meta-
bolic rate and tissue extensibility, whereas cooling tissue initially decreases tissue
blood flow by causing vasoconstriction followed by vasodilatation to prevent hypoxic
damage (the ‘hunting reflex’), reducing tissue metabolism, neuronal excitability and
conduction rate, inflammation, and tissue extensibility. Since heating and cooling can
relieve pain, patient preference can be taken into consideration when deciding which
to use.
 Non-exercise physical therapies 421

Heating of superficial tissues can be achieved using heat packs, wax baths, infrared
radiation, sunlight, sauna or steam room. Cooling of tissues is achieved using ice packs,
ice baths, commercially available coolant gel packs and sprays (Figure 1). Simple forms
of thermotherapy (heat/ice packs) are safe for people with normal cutaneous sensa-
tion and who observe simple guidelines, but thermotherapy may not be appropriate
for people with poor cutaneous thermal sensation. These forms of therapy have
been self-administered for millennia because they are safe, effective, and well liked.4,5
Heating deeper tissues is more difficult, but may be achieved using electrotherapy
interventions – infrared radiation, short-wave diathermy (described later) – which
require expensive specialist equipment and supervision.
For knee osteoarthritis (OA), ice massage is reported to improve joint movement,
pain and function6, while ice packs can reduce swelling7 and improve movement8 but
may not relieve pain.9 In RA, heat or cold packs are reported to have no effect on
oedema, pain, movement, strength or function.10–13
Despite sparse and conflicting evidence, thermotherapy is widely recommended for
many musculoskeletal conditions because it is a safe, easy-to-apply, effective palliative
therapy based on anecdotal reports, expert opinion and patient preferences, and it
does not require complex, expensive equipment.14 If people find short-term benefits
from simple thermotherapy, then it’s ease of self-administration make it potentially
useful for long-term self-application and increase the likelihood of cost-effectiveness
(Table 1). Complex thermotherapeutic modalities that require special equipment
and supervision make them less accessible and more costly, and associated dangers
make them less acceptable.

MANUAL THERAPY

Manual therapy is the skilled application of high-velocity thrust manipulations,

sustained stretch, oscillatory mobilizations, or massage applied to joints, muscles or

Figure 1. Heat/cold packs are commercially available (a), but can easily be made at home by wrapping ice
cubes or a hot-water bottle in a towel (b).
422 M. V. Hurley and L. M. Bearne

Table 1. Short- and long-term effectiveness, cost-effectiveness and clinical practicability of commonly
used physical therapy modalities utilized in the management of musculoskeletal conditions.
Modality Short-term Cost- Practicability Long-term
effectiveness effectiveness effectiveness
Thermotherapy U ?U ?U ?U
Manipulations/mobilizations ?   
Massage ? ?U U ?
Acupuncture ? ? ? ?
Electrotherapies: TENS U ?U ?U ?U
Interferential therapy ?   
Ultrasound ?   
Low-level laser therapy ?   
Short-wave diathermya ?   
U, Good evidence from good-quality randomized controlled trials and systematic reviews; ?, unclear
due to lack of quality trials; ?U, no evidence, but plausible; ?3, no evidence, but unlikely; TENS, trans-
cutaneous electrical nerve stimulation.
a
Also called pulsed short-wave diathermy and pulsed electromagnetic energy.

nerves to reduce pain and increase the range and quality of movement and nerve and
soft tissue mobility.
There are three paradigms for the effects of manual therapy: physiological effects
include the reduction of pain via the pain gate theory2; biomechanical effects may be
mediated by repetitive joint movements improving tissue extensibility and fluid dynam-
ics15–17, reducing intra-articular pressure18–20 and/or increasing the rate of synovial
blood flow and synovial fluid clearance21; psychological effects – any therapy which
has direct physical contact often produces a placebo response to the ‘laying on of
hands’, which has no direct remedial effect but results in a positive effect on treatment
enhanced by the patient–therapist interaction and relationship.22
Manipulation consists of forceful, high-velocity thrusts by a therapist. Mobilization is
less ‘aggressive’ joint movement used more often than manipulations in peripheral
joints.
There are many trials investigating spinal manipulation for patients with back pain,
but most are poorly designed. There is evidence for the effectiveness of manual ther-
apy in the treatment of acute and subacute spinal pain.23–27 Conversely, evidence for
the clinical effectiveness of manual therapy is limited in patients with peripheral degen-
erative or inflammatory joint disease. Mobilization has received much less evaluation
of its efficacy for relieving pain and improving range of joint motion (ROM) or function;
those studies that have been performed suggest it has little efficacy.26
Joint mobilization and manipulations are very popular interventions. Mobilization is
very safe, but vigorous forceful manipulations can have very serious side-effects and
consequences26,28 and should never be performed by unskilled practitioners. The
numerous contraindications mean that only a relatively small number of people are
suitable for manipulation. The dangers, the need for highly skilled practitioners,
the short-lasting effects and associated costs mean that mobilization and manipulation
are not practical long-term interventions (Table 1).
Massage of a painful body area is intuitive. Cutaneous stimulation is thought to
excite large afferents closing the ‘pain gate’ and/or releasing endogenous pain-killers,
 Non-exercise physical therapies 423

but massage also reduces oedema, increases circulation, improves muscle tone and
joint flexibility, and has a placebo response. In some instances people use topical
creams, counter-irritants (‘Deep Heat’, Tiger Baum, etc) and non-steroidal anti-
inflammatory drugs (NAIDs).
Evidence for the efficacy of massage is sparse. A systematic review for low-back
pain suggests that massage is beneficial in patients with subacute and chronic non-
specific low-back pain, especially when combined with exercise and education, but it
was no better than manipulation, and inferior to transcutaneous neuromuscular stim-
ulation for back pain relief29, and was not effective in patients with neck pain.30 How-
ever, 8 weeks’ massage for patients with OA knee improved function and pain relief
with lasting benefits.31 Short-term pain relief and improved quality of life has also
been noted in patients with fibromyalgia following a course of massage.32
Whilst massage is not recommended in clinical guidelines, it is safe, popular, and can
often be self-administered, which make it an attractive intervention. If effective in the
short-term, it is likely to be a practical, effective and cost-effective long-term manage-
ment option for musculoskeletal conditions (Table 1).

ACUPUNCTURE

Acupuncture is one of the most popular complementary medicines for people with
musculoskeletal conditions.33 Until recently, conventional medicine was sceptical
about the efficacy of acupuncture because of prejudices against complementary med-
icine, the contentious mechanisms proposed for pain relief, and concerns about the
wider claims of acupuncture. However, faced with its growing popularity, and anec-
dotal and empirical evidence of efficacy, acupuncture is becoming more widely
accepted.34
Acupuncture normally involves piercing the skin with very fine needles at specific
anatomic sites called acupuncture points or acupoints (Figure 2), but these can also

Figure 2. Acupuncture needling in situ.

424 M. V. Hurley and L. M. Bearne

be stimulated by heat, pressure, friction, suction, or electromagnetic impulses.

Acupuncture is safe, although there is the obvious danger of infection from poor asep-
tic needling techniques, and it won’t be tolerated by people with needle phobia. Its
safety, perception as a natural remedy, and esoteric nature make acupuncture popular
and acceptable to most people.
A review of the mechanism of acupuncture suggests that neural, humeral and bio-
magnetic mechanisms may contribute to the production of acupuncture analgesia.35
Western medicine is willing to accept that acupuncture needling of trigger points
may release muscle tension, ‘close the pain gate’, or stimulate the release of endoge-
nous opioids36, and that it has a place in the management of benign musculoskeletal
conditions. It is less convinced by the explanations of traditional Chinese medicine
that acupuncture points located at specific points on the body release blockages in
the ‘bioelectro-magnetic flow (Qi)’ in invisible energy channels called ‘meridians’,
restoring health and promoting healing, but accepts it as fanciful but harmless non-
sense. What Western medicine will not accept are claims that acupuncture can
improve medical conditions – such as asthma, schizophrenia, depression, etc – which
is implausible with Western medicine conventions. The fear is that seeking acupunc-
ture for these conditions prevents or delays seeking medical attention, which can
have serious consequences.
A recent systematic review of acupuncture for low-back pain could not reach firm
conclusions about its efficacy due to the poor quality of the research.37 Individual
trials report benefits of acupuncture in knee OA, but systematic reviews of
acupuncture for OA report conflicting results.38 This review also emphasizes that
better-designed studies are less likely to support the efficacy of acupuncture. A sys-
tematic review of 18 trials evaluating acupuncture and electro-acupuncture, with
a meta-analysis from three of these studies comparing acupuncture with sham acu-
puncture, concluded that acupuncture can relieve pain in peripheral joint OA.39 In
RA, no change of disease activity, pain, clinical markers or patients’ global assessment
of disease activity and analgesia was reported following acupuncture.40 Few good-
quality studies have evaluated acupuncture as a treatment for fibromyalgia41; overall,
the evidence for the use of acupuncture in the management of fibromyalgia is mixed,
with some studies reporting short-lived, small beneficial effects42–44, and others
reporting no positive effects.45,46
If acupuncture does work, its benefits are short-term, and so maintaining these
benefits requires multiple courses of acupuncture. In addition, acupuncture must be
delivered by a qualified acupuncturist. Given the size of the population. Long-term
reliance on a trained acupuncturist makes it impracticable and expensive, and thus
unlikely to be cost-effective (Table 1).

ELECTROTHERAPY

Electrotherapy modalities are often used by physical therapists treating people with all
kinds of musculoskeletal conditions. The underlying premise of electrotherapy modal-
ities is that application of external energy alters physiological processes which can
relieve pain, reduce inflammation, and improve muscle function. Commonly used elec-
trotherapy modalities involve sensory stimulation that increases afferent input, altering
the perception of pain and operating via the pain gate concept (such as transcutaneous
electrical neuromuscular stimulation and interferential therapy), and motor stimula-
tion (such as low-level laser therapy, ultrasound and short-wave diathermy).
 Non-exercise physical therapies 425

Figure 3. Transcutaneous electrical nerve stimulation (TENS) machine in situ.

Transcutaneous electrical nerve stimulation (TENS) is an easily applied, non-invasive

modality with relatively few contraindications.47,48 Small battery-operated TENS
machines deliver a low-frequency electrical impulse via surface skin electrodes
(Figure 3).
Therapeutic methods of applying TENS are categorized as conventional, ‘acupunc-
ture-like’, burst, brief intense and modulation; the selection used is based upon the
underlying condition and which pain relief mechanism we want to stimulate (Table 2).14
In addition, five parameters can be adjusted to achieve optimal pain relief: (1) wave-
form – balanced, monophasic or biphasic, symmetrical or asymmetrical; (2) pulse
duration - the time between the beginning and end of each pulse (usually 10–
1000 ms); (3) pulse frequency - the number of pulses per second, usually set between
1 and 200 Hz; (4) intensity – usually set between 0.1 and 120 mA, determined by a per-
son’s subjective assessment of pain relief; and (5) electrode position – over an
acupuncture point, trigger point, or painful area (Table 2).
Systematic reviews of TENS in patients with lower-limb OA suggest that all modes
of TENS relieve pain, regardless of the treatment protocol, but not movement, function
or strength.14,49 Closer analysis of treatment parameters suggests that high-frequency,
‘strong-burst’ TENS for more than 4 weeks was most beneficial.49 For inflammatory
musculoskeletal conditions, acupuncture-like TENS relieved pain and improved power,
whilst conventional TENS improved patient assessment of disease but not pain. Clinical
guidelines recommend acupuncture-like TENS for improving pain, joint swelling
and power in patients with RA14 as a relatively safe adjunct therapy for the relief of pain
in patients with OA1,50 and as a modality for osteoporotic (OP) patients with intracta-
ble chronic low-back pain and recent vertebral factures.51
Although the clinical effectiveness of TENS is equivocal, a small, inexpensive, bat-
tery-operated TENS machine offers a relatively safe, easily administered and accept-
able method of pain control which is likely to be cost-effective; and if people find it
effective in the short term they may obtain long-term benefits (Table 1).
426 M. V. Hurley and L. M. Bearne

Table 2. Possible therapeutic methods and indications for applying transcutaneous electrical nerve
stimulation (TENS).
Protocol Definition Possible rationale and suggested
treatment parameters and indication
Conventional High frequency 90e130 Hz Rationale: pain relief via pain gate mechanism
Pulse width <100 ms Time: 30-min periods applied regularly as needed
Intensity: feel comfortable buzz
Indication: less severe pain
Acupuncture Low frequency 2e5 Hz Rationale: pain relief via opioid mechanism
Pulse width >200 ms Time: 30 min
Intensity: strong but comfortable buzz
Indication: chronic conditions
Burst Low frequency 10 Hz Rationale: pain relief via all pain mechanisms
Burst impulses, 2e3/sec Intensity: strong but comfortable buzz
Indication: long-term use
Brief intense High frequency >80 Hz Rationale: pain relief via pain gate theory
Pulse width >150 ms Time: 154e30 min
Intensity: close to maximum tolerance
Indication: short-term use for severe pain
Modulation All characteristics are Rationale: all pain relief mechanisms
varied throughout application Intensity: strong but comfortable buzz
Indication: long-term use

In interferential therapy (IFT) two electrical currents of slightly different frequencies

are applied at right angles to each other. Theoretically, appropriate frequencies effect
pain relief via the pain gate mechanism (80–130 Hz) and opioid release (<10 Hz). The
rationale proposed is that perpendicular currents are reinforced where they intersect,
producing maximum stimulation. However, in deep tissues as the current spreads out
its intensity declines, and the superimposed current is weaker and may not achieve
a therapeutic response.48
An uncontrolled study of nine patients with psoriatic arthritis suggested that IFT may
have a role in pain relief52, and possibly also for people with fibromyalgia53, but overall
there is little evidence to support the effectiveness of IFT in musculoskeletal conditions.
For IFT the size of the apparatus, its expense, and the need for a therapist to set up and
supervise the intervention limits its use to the hospital/clinic, preventing self-
management and making it an expensive and impractical treatment option (Table 1).
Motor stimulation of innervated muscle produces muscle contractions by percutane-
ous electrical stimulation of the motor nerves. Therapeutically it can be used to
increase muscle strength and endurance, re-educate motor control, reduce oedema,
increase joint and soft-tissue range of motion, and alter muscle structure and function
(trophic changes). Stimulators have adjustable parameters, including amplitude (which
is usually set near the maximum that can be tolerated), gradual-onset short-duration
pulses at frequencies between 30 and 100 Hz, on–off stimulation times, and rate of
ramping. For example, a 2-second-on/4-second-off stimulation with a 1-second ramp
mimics voluntary muscle contraction. However, stimulators cannot simulate the com-
plexity of normal muscle-group activity.
 Non-exercise physical therapies 427

There are few studies demonstrating efficacy of motor stimulation. It might be con-
sidered as an adjunct to active exercise in the early rehabilitation for people with very
gross muscle weakness. In patients with RA with secondary disuse atrophy of the first
dorsal interosseous of the hand, muscle stimulation improved general hand function,
strength, and fatigue resistance.54 Similarly, people with OA knee motor stimulation
increased quadriceps strength with concurrent improvements in functioning.55 How-
ever, often the intense stimulation required to effect changes is unacceptably uncom-
fortable. Lack of evidence of efficacy, clinical impracticalities, and poor patient
tolerance mean that motor stimulation is not included in clinical guidelines for manage-
ment of musculoskeletal conditions.
Low-level laser therapy (LLLT) produces a thin beam of concentrated electromagnetic
energy of a single frequency and defined wavelength. This is purported to alter pho-
tochemical reactions in cell membranes, resulting in changes in cell permeability and
calcium ion movement to promote tissue healing and pain relief.48 A systematic review
could not establish the effectiveness of LLLT for pain in OA56, but another for RA sug-
gested LLLT may be effective in the short term for reducing pain and morning stiffness,
although function, ROM, and joint tenderness and swelling are unchanged.14 Conse-
quently, clinical practice guidelines recommend the use of LLLT for patients with
RA14 but not other musculoskeletal conditions. If the rationale is correct it is unclear
why LLLT is useful in some pathologies (e.g. RA) but not others (OA, OP), even those
with very similar inflammatory pathological processes (AS).
Ultrasound therapy is used to reduce inflammation and pain. High-frequency sound
waves (0.5–5 MHz) produce mechanical vibration within the tissues that can produce
thermal and non-thermal effects. High doses of ultrasound cause tissue heating, which
decreases pain and fluid viscosity and increases metabolic rate and blood flow.57
Lower doses have non-thermal, mechanical effects such as ‘stable cavitation’ (forma-
tion of gas bubbles in tissues); ‘standing waves’ (reflected waves superimposed on in-
cident waves) and ‘acoustic streaming’ (fluid movement which exerts pressure changes
on a cell) are said to cause membrane distortion, increased permeability, increased
nutrient transfer, and facilitation of tissue repair.58,59 When applied to inflamed tissues
it is claimed that ultrasound encourages the inflammatory process to progress to the
proliferation stage.60
Although physiological changes following the application of ultrasound have been de-
scribed in laboratory or animal studies, the only evidence of the clinical effectiveness of
ultrasound is in people with carpel tunnel syndrome and calcific tendonitis of the shoul-
der61–63, although it is recommended for OA and RA patients with hand disease.14,64
Short-wave diathermy (SWD), also called pulsed short-wave diathermy (PSWD) and
pulse electromagnetic energy (PEME), uses rapidly alternating electrical and magnetic
currents at short wave frequencies to heat superficial and deep tissues. Large machines
delivering SWD for 20–30 minutes can increase temperatures in cutaneous (3–7  C),
muscle (2–6  C), and intra-articular tissues.3 While it is suggested that the brief, high-
intensity bursts of electromagnetic energy agitate ions, molecules, membranes, and
perhaps cells, which accelerates membrane transport, phagocytic and enzymatic activ-
ity, increasing absorption oedema, rate of fibrin and collagen deposition, and nerve
growth and repair48,65,66, evidence for the clinical efficacy of SWD is limited. In
lower-limb OA, non-thermal PSWD produced no relief of pain or disability67,68,
although a recent review suggested that lengthy PSWD treatment may benefit OA
knee.69 There is no evidence of benefit of SWD in RA. The equivocal evidence for
SWD means it is not included in guidelines for the management musculoskeletal
conditions.
428 M. V. Hurley and L. M. Bearne

Overall, with the exception of TENS, while laboratory-based studies suggest that
electrotherapy modalities may have a physiological rationale for therapeutic effects,
systematic reviews49,70,71 suggest little, if any, clinical benefit (Table 1).

CLINICAL PRACTICABILITY AND COSTS

There is no information about the costs of any of the above physiotherapeutic modal-
ities. However, even if irrefutable evidence of efficacy were forthcoming, given the
enormous numbers of people suffering chronic musculoskeletal conditions, the wide-
spread implementation of any modality that relies on long-term treatment by a thera-
pist (i.e. electrotherapy, acupuncture, manipulation and mobilization) has cost
implications that make them all but impossible to deliver. Interventions that can be
self-administered (i.e. thermotherapy, TENS, massage) are more likely to be cost-
effective and less burdensome, and hence much more attractive long-term manage-
ment options (Table 1).

IN DEFENCE OF THE INDEFENSIBLE

Zealots of evidence-based health care will not be impressed at the widespread use of
modalities that have such poor evidence of efficacy. Indeed it is difficult to advocate the
use of many physiotherapeutic modalities given the weak evidence. However, other
aspects of physiotherapeutic management need to be considered before these modal-
ities are dismissed.
Although it sounds like the refuge of the scoundrel, it should be remembered that
absence of evidence of efficacy/effectiveness is not evidence of absence. Non-exercise
physiotherapy interventions do not have a high research priority, so the paucity of
research forces us to rely on old, small, methodologically flawed studies. We are right
to be sceptical about their efficacy until rigorously designed studies show them to be
effective/ineffective, but wrong to condemn them until then.
A more potent argument for the utility of non-exercise physiotherapeutic modali-
ties is their contribution to the aims of physiotherapeutic management of musculoskel-
etal conditions: to reduce pain, improve functioning, and improve quality of life. Nearly
all non-exercise interventions aim to relieve pain by altering the perception of pain.
We assume that relieving pain will improve quality of life, and it’s difficult to see
how it would not. We also assume pain relief will effect spontaneous improvement
in function; however, this assumption may not be correct, because function is not
only determined by how comfortably an activity can be performed, but also by
what people believe they can and should be doing. If someone believes they cannot
do an activity, or that doing it will cause them harm, they will not do it. People
with musculoskeletal conditions associate activity with increased pain and rest with
pain relief. They assume pain signals damage and rest prevents damage and heals,
and refrain from activity to limit pain and damage and prolong the life of their joints.
Unless these erroneous ‘fear-avoidance’ health beliefs and behaviours are challenged
pain relief will not lead to improved functioning, because people will continue to
refrain from activities they believe will cause pain and damage. Non-exercise physio-
therapeutic modalities do not challenge inappropriate health beliefs, so spontaneous
improvement in functioning is unlikely.
Exercise can improve muscle sensorimotor function, abnormal biomechanics, pain
and functioning72, and when combined with self-managements73 they can challenge
 Non-exercise physical therapies 429

inappropriate health beliefs and can promote the adoption of burdensome lifestyles,
such as participation in regular exercise and maintaining optimal body weight. Unfortu-
nately, advising (nagging) people to exercise and lose weight is not terribly popular, or
successful. This less digestible ‘pill’ can be ‘sugared’ by delivering advice about unpopular,
burdensome lifestyle changes within a package of health care that convinces people of
their benefits. Hi-tech electrotherapies with their attendant flashing lights, whistles,
bells, timers and baffling biophysical rationales, the physical perception of an interven-
tion (heat, cold, manipulation), the direct physical contact and ‘laying on of hands’ of
manual therapy, and the mystical connotations associated with acupuncture, are popular
modalities that have very powerful placebo responses. Giving people what they want
increases their satisfaction with their care, making them more receptive and accepting
of less popular interventions: burdensome lifestyle advice. As in commerce, packaging
attracts the customer and sells a product, but rarely affects a product’s utility directly.
And of course, while people are attached to these machines and undergoing these
interventions, therapists have the undivided attention of a captive audience!
Is this evidence-based health care? No, not as defined within the medical model of
ill health which demands that each intervention must have an identifiable benefit. But
the medical model, which focuses narrowly on the physical effects of pathology and
health care, is inappropriate for chronic musculoskeletal conditions where people
have to learn to live and cope with incurable long-term heath problems. The biopsy-
chosocial model of ill health considers the wider physical, psychological, social, and
economic consequences of ill health and health care. It delivers a package of health
care that aims to improve nebulous, subjective aspects of people’s lives, and may be
a more effective and appropriate way to manage chronic musculoskeletal conditions.
In this context, utilizing non-exercise physical therapy may be extremely useful in win-
ning a patient’s attention, cooperation, understanding and goodwill, and in convincing
them to try things they may be reluctant to try. At present we don’t know, because the
wider effects of physiotherapeutic management of musculoskeletal conditions haven’t
been considered in this way. As well as the efficacy of individual modalities, we need to
establish how important the delivery of physiotherapy is in achieving its aims: pain relief,
better functioning and quality of life.

SUMMARY

Any health-care intervention must be safe, effective, acceptable to patients, deliverable

by clinicians, and affordable by health-care providers. In the management of musculo-
skeletal conditions, physiotherapy is used to relieve pain and improve function.
Overall physiotherapeutic interventions are safe, well tolerated and well liked.
There is some evidence that thermotherapy, TENS and massage can relieve pain,
and these interventions are relatively inexpensive and easy to self-administer, making
them attractive treatment options. There is insufficient evidence for the efficacy of
many electrotherapy interventions, acupuncture, manipulations, and mobilizations,
which all rely on therapists to apply them, making them expensive and unsustainable
given the size of the chronic problem and finite resources.
The lack of evidence partially reflects the paucity and poor quality of research in
this area, but it also suggests that many of these interventions may not have specific
effects. However, in the management for musculoskeletal conditions, physiotherapy
utilizes a holistic, biopsychosocial approach, delivering a complex package of health
care to improve pain and function and to enable people to cope better. The popularity
430 M. V. Hurley and L. M. Bearne

and powerful placebo effects of physiotherapeutic interventions can be utilized when

delivering and advising patients about less popular, burdensome interventions that
require considerable time and effort (weight loss and regular exercise).

Practice points

 physiotherapy is safe, well tolerated, very popular, and has powerful placebo
effects
 there is some evidence that TENS, thermotherapy, and massage relieve pain,
and as they are relatively inexpensive and can be self-administered they are
attractive treatment options
 there is little evidence supporting the use of electrotherapy, acupuncture, ma-
nipulation or mobilization, and as they require a therapist they are expensive,
discourage self-management, and are not viable long-term treatment options
 physiotherapeutic management of musculoskeletal conditions utilizes a holistic,
biopsychosocial approach delivering a complex package of health care involving
important but unpopular burdensome lifestyle advice (regular exercise, weight
control)
 despite lack of evidence of efficacy,the popularity and potent placebo effects of
some physiotherapeutic modalities make them useful in the overall manage-
ment of musculoskeletal conditions

Research agenda

 gather evidence for the effectiveness or ineffectiveness of non-exercise

physiotherapeutic modalities
 evaluate the importance of the overall delivery of physiotherapeutic manage-
ment in incurable chronic musculoskeletal conditions

REFERENCES

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