New, Large Meta-Analysis Says “Yes”
In the broadest terms, one of the main reasons patients present themselves to healthcare practitioners is pain. Pharmacological treatments rank as the most common approach to pain,1 but recent decades have seen an increasing interest in non-pharmacological approaches. Physiotherapy methods in particular have grown in popularity due to increasingly effective protocols, general safety, the benefits of addressing root causes, and patient empowerment. Given these facts, should doctors prescribe physiotherapy for pain?
To answer this question in an overarching way, Elisabeth Ginnerup-Nielsen and colleagues published an ambitious meta-analysis of randomised trials last August.2 Scores of studies present seemingly conflicting conclusions on specific issues. Part of the difficulty in interpreting these studies stems from thinking of physiotherapy as a treatment. In fact, physiotherapy is a profession and scope of practice specialising in physiologic therapeutics - as opposed to pharmacologic or surgical. Even within the treatment umbrella of “exercise therapy,” published protocols show vast diversity. There is growing consensus in the scientific community that studies involving physiologic therapeutics (especially exercise therapies) need to demonstrate key points of specificity to be of any use in future research, physio practice, or policy decisions.3,4 The authors of the present meta-analysis recognized the value of this specificity, but also point out that inasmuch as physiotherapy practices are presently employing relatively different approaches to similar problems, and overarching answers can be of use to referring doctors, that asking the question of whether physiotherapy alleviates pain can be useful.
The researchers sought controlled, randomised trials since 2004, measuring pain before and after physiotherapy treatments. They combined 174 trials covering 224 comparisons and 14,687 patients. Above and beyond patients in placebo or waiting list groups, researchers found an overall treatment effect of physiotherapy on pain of 0.65 standard mean deviation - an effect they qualitatively describe as moderate and clinically significant. The included studies cover pain from external causes, musculoskeletal disorders, neoplasms, nervous system, pregnancy/childbirth, and “other.” Across all categories, the meta-analysis finds a moderate to large effect on pain from physiotherapy approaches including therapeutic exercise, mechanical modalities, electrotherapeutic modalities, and education.
Similar, but more narrowly focused meta-analyses have also found physiotherapy effective against pain in knee osteoarthritis,5,6 fibromyalgia,7 and back pain.8 Ginnerup-Nielsen and colleagues point out that practice approaches vary widely between countries and even between physiotherapy practices down the street from one another. Instead of answering which protocol is better, this study answers the broader question of “Are there solutions for pain in physiotherapy?” Across a variety of pain categories, the modern evidence answers, “Yes.”
- Kumar N. WHO normative guidelines on pain management. Geneva: World Health Organization. 2007.
- Ginnerup-Nielsen E, Christensen R, Thorborg K, et al. Physiotherapy for pain: a meta-epidemiological study of randomised trials. BJSM. 2016; 50 (16): 965-971.
- Boutron I, Moher D, Altman D, et al. Methods and processes of the CONSORT Group: example of an extension for trials assessing nonpharmacologic treatments. Ann Intern Med. 2008; 148: W60-6.
- Helmhout P, Staal J, Maher C, et al. Exercise therapy and low back pain: insights and proposals to improve the design, conduct, and reporting of clinical trials. Spine. 2008; 33: 1782-8.
- Corbett M, Rice S, Madurasinghe V, et al. Acupuncture and other physical treatments for the relief of pain due to osteoarthritis of the knee: network meta-analysis. Osteoarthritis Cartilage 2013; 21: 1290-8.
- Juhl C. Christensen R, Rose E, et al. Impact of exercise type and dose on pain and disability in knee osteoarthritis: a systematic review and meta-regression analysis of randomized controlled trials. Arthritis Rheumatol. 2014; 66: 622-36.
- Busch A, Barber K, Overend T, et al. Exercise for treating fibromyalgia syndrome. Cochrane Database Syst Rev. 2007; (4): CD003786.
- Pennick V, Liddle S. Interventions for preventing and treating pelvic and back pain in pregnancy. Cochrane Database Syst Rev. 2013; 8: CD001139.