Nonpharmacological Treatments For Musculoskeletal.6

The Clinical Journal of Pain
17:33–46 © 2001 Lippincott Williams & Wilkins, Inc., Philadelphia
Nonpharmacological Treatments for Musculoskeletal Pain

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*Anthony Wright, Ph.D., and †Kathleen A. Sluka, Ph.D.

CywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdgGj2MwlZLeI= on 05/25/2023
*School of Medical Rehabilitation, University of Manitoba, Winnipeg, Manitoba; current position: School of Physiotherapy,
Curtin University of Technology, Perth, Western Australia; †Graduate Program in Physical Therapy and Rehabilitation Science,
Neuroscience Graduate Program, College of Medicine, University of Iowa, Iowa City, Iowa
Abstract:
Background: Several types of physical therapy are used in the management of
painful musculoskeletal disorders. These treatment modalities can be broadly catego-
rized as electrotherapy modalities (e.g., transcutaneous electrical nerve stimulation),
acupuncture, thermal modalities (e.g., moist heat, ultrasound), manual therapies (e.g.,
manipulation or massage), or exercise. Within each of these broad categories signifi-
cant variations in treatment parameters are possible.
Objective: To consider the evidence base for each of these main categories of
physical therapy in the management of musculoskeletal pain.
Method: To consider the available evidence related to clinical effectiveness and
then to review evidence from basic science studies evaluating potentially therapeutic
effects of the various therapies.
Results: There seems to be evidence from basic science research to suggest that
many of the therapies could have potentially therapeutic effects. However, there ap-
pears to be limited high-quality evidence from randomized clinical trials to support the
therapeutic effectiveness of several of the therapies.
Conclusions: There is some preliminary evidence to support the use of manual
therapies, exercise, and acupuncture in the management of some categories of mus-
culoskeletal pain. Limitations of the existing research base are discussed and recom-
mendations for areas of future research are provided.
Key Words: Physical therapy—Electrotherapy—Acupuncture—Manual therapy—
Exercise
A number of physical therapies are used to manage different groups of therapists. Increasingly, however,
pain of musculoskeletal origin and to address sensorimo- physical therapists are adopting an evidence-based ap-
tor dysfunction in patients with musculoskeletal disor- proach to patient management and are therefore selecting
ders. These can be broadly categorized as electrotherapy those therapeutic modalities for which there is scientific
modalities (e.g., transcutaneous electrical nerve stimula- evidence indicating effectiveness. Each of the aforemen-
tion [TENS]), acupuncture, thermal modalities (e.g., tioned broadly outlined therapeutic categories has been
moist heat, ultrasound), manual therapies (e.g., manipu- subject to scientific investigation in recent decades.
lation or massage), or exercise. In practice, physical However, there are still many specific therapies or spe-
therapists use a combination of modalities to address the cific dosage regimes that have not been subjected to
treatment needs of each patient based on the findings of scientific investigation. Given the variety of physical
clinical examination. In the past, some therapies have therapies that exist, the variety of ways in which they can
been particularly espoused in different countries or by be applied, and the lack of a major funding source such
as the pharmaceutical industry, it may be several decades
before all physical therapies have been thoroughly inves-
Address correspondence and reprint requests to Prof. Anthony
Wright, School of Physiotherapy, Curtin University of Technology, tigated. The aim of this review is to provide a current
Selby Street, Shenton Park, WA 6008, Australia. perspective on research related to the mechanism of ac-
33
34 WRIGHT AND SLUKA
tion and therapeutic effectiveness of each of the broad postoperative pain, acute and chronic pain, musculoskel-
therapeutic categories listed above, specifically related to etal pain, and neuropathic pain conditions.3–6 With re-
the management of musculoskeletal pain. gard to treatment of musculoskeletal pain, clinical stud-
ies show mixed results, and few studies compare the
OVERVIEW OF MODALITIES effects to a placebo treatment. Many studies do not stan-
dardize the stimulus parameters of TENS, which makes

Electrotherapy modalities
interpretation difficult between groups and studies;
Electrical stimulation can be used in a variety of ways
therefore, this review will highlight a few of the better-

to achieve therapeutic outcomes. In general, it can be
quality studies. Deyo et al.7 compared the effects of
used to produce sensory effects or to facilitate motor
TENS with those of placebo TENS with and without
function. By varying parameters such as frequency,
exercise in patients with chronic low back pain. The
waveform, pulse duration, electrode configuration, and
effects of TENS were the same as those of placebo
duration of stimulation, it is possible to produce a range
TENS. However, the stimulation parameters were not
of therapeutic effects. Transcutaneous electrical nerve
standardized for TENS, and other modalities, such as hot
stimulation and interferential therapy are two forms of
packs, were used. In contrast, Marchand et al.8 showed
electrical stimulation most commonly used for pain
that high-frequency TENS treatment significantly re-
modulation. Transcutaneous electrical nerve stimulation
duced the affective component of pain. The effects of
is usually used as a self-administered therapy in which
TENS were cumulative across treatments.8 However,
the patient is given initial instruction on safe and appro-
when treatments were terminated, no long-term effects
priate use of the TENS device and then self-administers
were observed (1 month or 6 months) when compared
the treatment according to a predefined schedule. Con-
with placebo TENS. The patients in this study did not
versely, interferential therapy usually is used in a physi-
receive other therapies. Thoresteinsson et al.9 showed
cal therapy clinic setting.
short- and long-term relief of pain after treatment using
Transcutaneous electrical nerve stimulation TENS when compared with placebo TENS for patients
Transcutaneous electrical nerve stimulation is nonin- with chronic low back pain. However, several studies
vasive, inexpensive, safe, and easy to use. Clinically, showed no significant difference between placebo TENS
TENS is administered at varying frequencies of stimula- and TENS for pain relief in patients with acute low back
tion. These frequencies can be broadly classified as high- pain,10 chronic low back pain,11 temporomandibular
frequency (>50 Hz), low-frequency (<10 Hz), or burst joint disorders,12 or osteoarthritis.13 Therefore, the cur-
TENS (bursts of high-frequency stimulation adminis- rent data are conflicting. However, it is difficult to draw
tered at a much lower frequency). Intensity is determined conclusions regarding effectiveness because different
by the response of the patient as being sensory level or pain syndromes, different stimulation parameters, and
motor level TENS. For sensory level TENS, the voltage different outcome measures were used in each study.
(i.e., amplitude) is increased until the patient feels a com- Transcutaneous electrical nerve stimulation alone may
fortable tingling (perceived with high frequency) or tap- not provide complete inhibition of hyperalgesia and pain
ping (perceived with low frequency) sensation without and thus will probably not be the only method used clini-
motor contraction. This amplitude is referred to as low cally for pain relief. However, as an adjunct to other
intensity. For motor level TENS, the intensity is in- pain-relief methods, TENS may have several benefits.
creased to produce a motor contraction. Usually the in- Knowledge of the mechanism of TENS enables clini-
tensity is increased to the maximal tolerable level but is cians to determine better which patients will benefit from
not noxious. This is referred to as high-intensity TENS. TENS treatment based on the type of medication the
High-frequency TENS is administered at low intensities patient is using for pain control. Effective pain relief
and is referred to as conventional TENS. In contrast, using TENS in combination with other therapies will
low-frequency TENS usually is administered at high in- allow the patient to increase activity level and return to
tensities so that a motor contraction is produced. This work more quickly. Treatment with TENS increases joint
mode of stimulation is referred to as strong, low-rate, or function in patients with arthritis4–6,14 and improves the
acupuncturelike TENS. Stimulus strength duration physical and mental component summary on the Short
curves for administration of TENS to the skin show that Form–36 quality of life survey in patients with chronic
sensory level TENS occurs with the lowest amplitude, low back pain.15 Improving physical function allows the
followed by motor contraction and then noxious sensa- patient to tolerate other therapies and activities, which
tion (see review1,2). results in an improved quality of life.
Transcutaneous electrical nerve stimulation is used for Animal models of inflammation show that TENS par-
pain relief in a variety of patient populations, including tially reduces hyperalgesia at the site of injury16 and
The Clinical Journal of Pain, Vol. 17, No. 1, 2001

NONPHARMACOLOGICAL TREATMENTS FOR MUSCULOSKELETAL PAIN 35
completely reduces hyperalgesia outside the site of in- or intensity. The interference frequency will usually
jury.17,18 This reduction in primary hyperalgesia (at the range from 2 to 200 Hz (similar to TENS), and treat-
site of injury) is dependent on frequency of stimulation, ments may involve low-frequency or high-frequency
such that high-frequency but not low-frequency stimula- stimulation. Many treatments also involve a sweep fre-
tion reduces the hyperalgesia.16 However, high- and low- quency in which the frequency is systematically changed
frequency TENS are equally effective in reducing sec- over a predetermined range (e.g., 50–100 Hz). Intensity
ondary hyperalgesia.17,18 will normally be adjusted to produce either a strong but
Two different theories have been proposed for the comfortable sensation or a motor response. Similarly to
mechanism of pain relief using TENS. The most popular TENS, high-frequency stimulation is normally adjusted
theory for the mechanism of action of TENS is the gate to produce a sensory response and low-frequency stimu-
control theory of pain.6,19–21 This theory suggests that lation will often be adjusted to produce a motor response.
stimulation of large-diameter afferent fibers inhibits sec- Interferential therapy is thought to have similar
ond-order neurons in the dorsal horn and prevents pain mechanisms of action to TENS and is considered to act
impulses carried by small-diameter fibers from reaching through segmental inhibition or through activation of de-
higher brain centers. It is most commonly used to explain scending pain-inhibitory systems. It is also thought to
the relief of pain using high-frequency TENS. Alterna- have a positive influence on blood flow, which may con-
tively, release of endogenous opioids is thought to un- tribute to improved tissue healing.32
derlie the actions of low-frequency TENS.22–25 Increas- The evidence base to determine the clinical effective-
ing evidence also supports a role of opioid receptors in ness of interferential therapy is less adequate than that
pain relief using high-frequency TENS. Selective block- for TENS. One study did not show additional benefit for
ade of ␮-opioid receptors in the spinal cord prevents the interferential therapy and exercise beyond that produced
antihyperalgesia produced by low-frequency TENS,
by exercise therapy alone in the management of patients
whereas blockade of ␦-opioid receptors prevents the an-
with musculoskeletal pain in the shoulder region at 12-
tihyperalgesia produced by high-frequency TENS.26
month follow-up.33 A study comparing interferential
This opioid-mediated inhibition could be segmental or
therapy with traction in the management of patients with
supraspinal. High- and low-frequency TENS both reduce
low back pain did not show any difference between the
dorsal horn neuron responses to noxious stimuli in nor-
outcomes for the two treatments.34 Unfortunately, no
mal27,28 and arthritic animals,29 which supports a role for
control group was included in the study and so it is
spinally mediated inhibition. However, low- or high-
frequency TENS antihyperalgesia is prevented using impossible to determine whether the treatments were
blockade of ␮-opioid or ␦-opioid receptors in the rostral equally effective or equally ineffective.
ventral medulla, a component of the opioid-mediated de- Although it is likely that interferential therapy may
scending inhibitory pathways. trigger physiologic mechanisms similar to those of
TENS, and it has the advantage of potentially providing
Interferential therapy more effective stimulation of deep musculoskeletal
Interferential therapy involves a different form of elec- structures, the evidence base to allow us to properly de-
trical stimulation than TENS, although the physiologic termine the effectiveness of this treatment modality is
and therapeutic effects of interferential therapy poten- inadequate. Those studies that have been reported do not
tially are similar to those of TENS. It is based on the suggest significant therapeutic benefit. There is a clear
principle that when two medium-frequency (KHz) cur- need for more high-quality trials investigating this form
rents are applied to the skin, a low-frequency current will of treatment.
be induced in the deep tissues that is equivalent to the There are many other forms of electrical stimulation
difference in frequency between the two medium- (e.g., diadynamic current, H-wave therapy) but there is
frequency currents. Therefore, interferential therapy al- little evidence to suggest that any of these treatments are
lows effective stimulation of deep tissues, whereas effective, or that there is likely to be any difference in
TENS is predominantly a cutaneous or superficial stimu- therapeutic outcome between different forms of electri-
lus. In the British Isles, interferential therapy is used cal stimulation.
more frequently than TENS for the management of low In summary, there is compelling evidence from basic
back pain,30 and it is also a popular treatment modality in science studies to suggest that electrical stimulation has
Canada.31 important physiologic effects on pain modulatory sys-
Treatment usually is administered using two pairs of tems and modulation of blood flow. Although these
electrodes, and most treatment units allow variation in findings suggest potential therapeutic benefit for electri-
waveform, stimulus frequency and stimulus amplitude, cal stimulation, this has yet to translate into data from

36 WRIGHT AND SLUKA
randomized, controlled clinical trials that provide con- physical therapy in reducing pain. In fact, physical
vincing evidence of either short-term or long-term thera- therapy also reduced opioid intake.37
peutic effectiveness. In part, this is because of the lack of Acupuncture is thought to activate endogenous opioid
research studies and because of the inadequacies and pathways in human subjects and animals.49–54 Ulett et al.
limitations of many of the studies that have been com- have systematically examined the effects of electroacu-
pleted. In addition, there is no evidence to suggest that puncture and found similar mechanisms to TENS (see
any one form of electrical stimulation is superior to any review49). Specifically, blockade of opioid receptors
other form of electrical stimulation, although differences with naloxone in the habenula, nucleus accumbens,
in frequency appear to underlie differences in the physi- amygdala, or periaqueductal gray matter prevents the an-
ologic effects of different treatment regimes. Much more algesia produced using electroacupuncture (4–15 Hz).55
research is required to provide evidence for or against the Further, microinjection of antisera against ␤-endorphin
therapeutic effects of electrotherapy modalities. There is into the PAG reduced the analgesia produced using low-
insufficient evidence to allow us to make an evidence- frequency electroacupuncture (4–15 Hz).56 Increased
based determination of therapeutic effectiveness or concentrations of methionine enkephalin and dynorphin
lack of effectiveness in the management of musculoskel- A were observed in the lumbar cerebrospinal fluid after
etal pain. treatment of patients using low- or high-frequency elec-
troacupuncture, respectively.57 Further, rats made toler-
ant to a ␮-opioid agonist were also tolerant to 2 Hz but
Acupuncture not to 100 Hz electroacupuncture, which suggests that
Acupuncture is administered via insertion of needles
low-frequency stimulation activates ␮-opioid recep-
into designated acupuncture points, and subsequently the
tors.58 However, rats tolerant to a ␦-opioid receptor ago-
needles are manually manipulated or electrical current is
nist were also tolerant to 2 Hz but not to 100 Hz elec-
administered via the needles. When electrical current is
troacupuncture,58 whereas rats tolerant to a ␬-opioid ago-
administered via the needles, it is similar to TENS in
nist were tolerant to 100 Hz electroacupuncture.58
regard to parameters and mechanisms, and it is more
Supraspinal (intracerebroventricular administration)
effective than manual acupuncture (see review35). A
blockade of ␮- or ␦-, but not ␬-opioid, receptors signifi-
number of clinical trials have been performed over the
cantly prevented the analgesia produced using low-
years that show the effectiveness of acupuncture in the
treatment of musculoskeletal conditions.36–47 frequency (2 and 30 Hz) but not high-frequency (100 Hz)
Manual acupuncture produces a short-term improve- electroacupuncture.59 Conversely, supraspinal blockade
ment in pain and function in patients with osteoarthritis of ␬-opioid receptors prevented the analgesia produced
of the knee when compared with a no-treatment control using high-frequency but not low-frequency electroacu-
group39 but not with a placebo acupuncture group.48 puncture.59 These data suggest that analgesia from high-
Similar results were observed for osteoarthritis of the frequency electroacupuncture is not mediated through ␮-
cervical spine47 and temporomandibular joint disor- or ␦-opioid receptors but through ␬-opioid receptors, and
ders.38 However, in a group of patients with myofacial that analgesia from low-frequency electroacupuncture is
neck pain, acupuncture administered to sites relevant to mediated by ␮- or ␦-opioid receptors. Further, descend-
the cervical spine produced significantly increased pain ing inhibitory pathways involving the amygdala and
relief when compared with irrelevant sites outside the PAG, opioid peptides and opioid receptors are involved
cervical spine or with no treatment.44 Kleinhenz et al.42 in electroacupuncture analgesia.
showed in a single-blind clinical trial that manual acu- In summary, manual acupuncture, low-frequency elec-
puncture significantly improved function scores in pa- troacupuncture, and high-frequency electroacupuncture
tients with rotator cuff tendonitis. Electroacupuncture may produce analgesia via different mechanisms. In par-
shows similar results, with improvements in pain and ticular, low-frequency electroacupuncture seems to in-
function compared with placebo acupuncture in patients volve descending systems and activation of ␮- or ␦-opi-
with fibromyalgia40 or no treatment in patients with tem- oid receptors. Conversely, high-frequency electroacu-
poromandibular disorders.41 Long-term effects were ob- puncture is more dependent on ␬-opioid receptor
served in patients with chronic low back pain when activation. There is some encouraging evidence from
treated using low-frequency electroacupuncture but not clinical trials to support the use of acupuncture in the
when using manual or high-frequency electroacupunc- management of musculoskeletal pain; however, it is dif-
ture.46 However, when compared with physical therapy ficult to provide a satisfactory placebo control for acu-
that consisted of massage, cryotherapy, TENS, and re- puncture and, therefore, the quality of some research
laxation exercises, electroacupuncture was similar to studies is less than satisfactory. Although there is good

evidence to support the analgesic effect of acupuncture creased range of motion and decreased pain. No differ-
in basic science studies, further research is required to ence between groups was observed when superficial heat
investigate the clinical outcomes of acupuncture therapy was compared to cold treatment.67,74 Thus, there is little
in the management of musculoskeletal pain. evidence to support the use of superficial heat in the
treatment of pain. However, few types of painful condi-
tions have been studied, the outcome measures have been

Thermal modalities limited, and the quality of trials could be improved.
A variety of methods produce heating and cooling of
We can only speculate on potential mechanisms of

the tissues to manage musculoskeletal pain in acute mus- relief of pain by heating modalities. Muscle spasms or
culoskeletal injuries and in chronic musculoskeletal dis- guarding can result in a pain response or contribute to the
orders. The effects and effectiveness of superficial heat- pain experienced. Muscle spasms can cause local isch-
ing, deep tissue heating, ultrasound therapy, and cryo- emia activating nociceptive afferent fibers. Reducing
therapy are discussed. muscle spasms and guarding would then be expected to
reduce pain by reducing ischemia and preventing activa-
Superficial heat tion of nociceptors. Elevating muscle temperature to
The use of heat to relieve pain of musculoskeletal about 42 °C decreases the firing frequency of Type II
origin is common. Heat can be applied superficially by muscle spindle afferent fibers and increases the firing
application of moist hot packs, immersion in hot water frequency of Type Ib Golgi tendon organ afferent fi-
baths, use of infrared light, or paraffin wax application. bers.75 However, Type Ia muscle spindle afferent fiber
The most common method utilized for treating muscu- firing frequencies are also increased in response to el-
loskeletal conditions is moist hot packs. Moist hot packs evation of muscle temperature.75 Type II muscle spindle
are applied over the area of pain for 20–30 minutes and afferent fibers are tonically active and respond to muscle
only heat the superficial tissues. length. Type Ia muscle spindle afferent fibers respond
Many of the local physiologic effects of heat have dynamically and respond to velocity of change in muscle
been studied thoroughly. For instance, heat increases length. When activated, the Type Ia and Type II muscle
skin and joint temperature and blood flow, and decreases spinal afferent fibers cause an excitation of the agonist
joint stiffness.60,61 Activity of local cartilage-degrading muscle and inhibition of the antagonist muscle.
enzymes is influenced by joint temperature. As found in Golgi tendon organs respond to muscle stretch and
patients with rheumatoid arthritis, when temperature in- when activated inhibit the agonist muscle and excite the
creases from the normal of 33 °C to 36 °C these enzymes antagonist muscle.76 Thus, increasing muscle tissue tem-
are considerably more active.62,63 Temperatures above perature could reduce muscle spasm by decreasing ac-
41 °C decrease the activity of these enzymes.62,63 How- tivity of Type II muscle spindle afferents and increasing
ever, the data on superficial heat treatment are not con- activity of Type Ib Golgi tendon organ afferents. This
sistent with respect to decreasing pain or increasing func- may be a viable explanation for the use of deep heating
tion (see review61,64). Some studies show decreases, some modalities. Alternatively, heat could decrease pain indi-
show increases, and some show no change in arthritic pain rectly. Increasing skin temperature or deep tissue tem-
or associated symptoms65-68 (see review64,69). perature would cause vasodilation of the tissue, increased
The use of superficial heat is common and has been metabolism, and increased blood flow, all of which assist
studied by several different groups with little support for with healing and repair. Improving healing and repair
its use in the treatment of painful conditions. Superficial would result in increased removal of inflammatory com-
heat increased the pressure pain threshold over approxi- pounds, known to activate and sensitize primary afferent
mately 50% of trigger points immediately after treatment fibers. This would result in less input being transmitted
in patients with myofascial pain who had at least one to the spinal cord and higher brain centers, and thus
trigger point. However, the patient population was not decreased perception of pain.
specified.70 Increases in pressure pain thresholds were
also noted in patients with temporomandibular joint dys- Deep tissue heating
function.71 Hoyrup and Kjorvel72 compared either whirl- Several methods exist to produce heat in the deeper
pool or paraffin wax baths alone or with exercise, and tissues and these treatments are often used in the man-
showed significant pain relief in all groups with no dif- agement of painful musculoskeletal disorders (e.g., os-
ferences between groups. Toomey et al.73 studied pa- teoarthritis of the hip). One commonly used method is
tients with Colles’ fractures and compared warm whirl- short-wave diathermy, which involves the application of
pool baths with exercise to exercise alone and found no high-frequency oscillating current (27 MHz). The rapidly
difference between groups, although both groups had in- alternating electromagnetic field induces a rapid to and

38 WRIGHT AND SLUKA
fro motion of ions, generating heat within the tissues. heat, there is more evidence to support the use of ultra-
Short-wave diathermy may be administered in either a sound for pain relief. However, all heating modalities
continuous or a pulsed mode and a variety of different show similar improvements in reducing pain.
electrodes can be used to heat specific regions of the
body. Cryotherapy
Such deep heating methods are likely to induce similar The use of cold for the treatment of inflammatory pain
physiologic effects to more superficial heating but they has been recognized for hundreds of years. Cold is ap-
have the advantage of specifically heating deep muscu- plied in a variety of ways to reduce pain and swelling,
loskeletal tissues that may be the source of musculoskel- including ice bags, ice baths, cold packs, cold baths, and
etal pain. They may influence muscle spindle sensitivity ethyl chloride spray to the skin.
in line with the mechanism outlined above. Cold treatment decreases skin and joint temperature,
A few studies have investigated the therapeutic effec- decreases blood flow, and increases joint stiffness.60,61 In
tiveness of short-wave diathermy in the management of addition, it is quite clear that cold is analgesic.66,69,89–95
painful musculoskeletal disorders. Foley-Nolan et al. Topical application of cold decreases skin, muscle, and in-
showed short-term beneficial effects of pulsed short- traarticular temperature.60,90,96
wave diathermy in the management of patients with Measuring local pain thresholds after treatment with
acute whiplash injury77 and individuals with chronic ice gives varying results, with the effectiveness lasting
neck pain.78 These effects were not sustained with long- from 30 minutes to 12 hours.67,89,90,92,93 Cold also slows
term (12-week) follow-up. the conduction velocity of peripheral nerves.97,98 This
being the case, decreased nociceptive information trans-
Ultrasound mitted through primary afferents centrally to the spinal
Therapeutic ultrasound consists of inaudible acoustic cord would result in a decrease in behavioral signs, and
vibrations delivered at a frequency between 0.75 and 3.0 a decrease in neuronal activity of dorsal horn neurons.
MHz and intensity between 0.5 and 3 W/cm2. The lower Because an ice bath decreases secondary hyperalgesia,99
the ultrasound frequency, the deeper the penetration of it is inferred that there would be a decrease in activity of
sound waves. Ultrasound as a therapeutic modality for central neurons and a reduction of the expanded recep-
pain relief is applied through the skin overlying the pain- tive fields. Alternatively, Williams et al.67 suggest that
ful area (see review79). Ultrasound preferentially heats application of cold to an arthritic joint serves as a coun-
deeper tissues and the effects are not normally perceived terirritant by bombarding central pain pathways with
by the patient, making placebo controlled studies rela- painful cold impulses and activating descending inhibi-
tively easy. Heating occurs predominantly at tissue tory pathways. Support for this is based on the observa-
interfaces. tion that cooling the skin alone, as with ethyl chloride
Several studies have examined the effects of ultra- spray, increases pain threshold.100
sound versus either no ultrasound or sham ultrasound for Several studies demonstrate immediate or short-term
a variety of musculoskeletal conditions (see review80). effects of ice on pain in patients with rheumatoid arthri-
Downing and Weinstein,81 in a double-blind randomized tis74,92 and low back pain.93 Williams et al.67 compared
controlled trial in patients with shoulder pain, showed no heat packs in combination with exercise to ice packs in
difference in pain relief, range of motion, or functional combination with exercise in patients with rheumatoid
activities between sham ultrasound and ultrasound. In arthritis of the shoulder. Significant reductions in pain
contrast, two nonrandomized studies with blind evalua- occurred for both groups but there was no difference
tors showed differences between ultrasound and either between groups. Melzack et al.93 compared the effects of
no ultrasound82,83 or sham ultrasound83 for patients with ice massage for low back pain to TENS and found a
shoulder pain or low back pain, respectively. When com- significant reduction in pain with both techniques, with
pared to other noninvasive physical modalities such as TENS showing longer lasting relief (23 hours) compared
ice,84 TENS,85,86 superficial heat,85 or massage,87 there to ice (12 hours). Curkovic et al.101 demonstrated an
was no difference between groups, although significant analgesic effect from both heat and cold treatment in
pain relief occurred with any of these treatments. For the patients with rheumatoid arthritis, without differences
treatment of trigger points, a program of exercise and between groups. Thus, short-term effects of ice are
massage with ultrasound or sham ultrasound showed sig- clearly analgesic and there may be some long-term ben-
nificant differences between groups in pain relief or an- efits. However, cold treatment does not appear superior
algesic intake, although both groups demonstrated a sig- in effect to other noninvasive treatments. It may be that
nificant improvement over controls who did not receive application of cold, like heat, is useful as an adjunct
treatment.88 Thus, in contrast to the use of superficial therapy to allow a patient to exercise with reduced pain.

Manual therapy cious in the management of acute low back pain (less
Manual therapy techniques include a vast array of than 3 weeks) but that there is insufficient evidence to
treatment procedures intended to promote motion and support or refute its effectiveness in the management of
relieve pain in musculoskeletal structures. The most chronic low back pain.110 Anderson et al.112 concluded
common forms of treatment are joint manipulation, joint that spinal manipulative therapy is consistently more ef-
mobilization, and various forms of massage, although fective than any comparison treatment used in the studies
techniques specifically intended to mobilize nerve tis- analyzed. The findings of different groups are therefore
sue102 and muscle103 are also commonly used. There are not consistent, even though the groups of randomized
also a large number of approaches that have been devel- clinical trials evaluated were similar. One reason for this
oped by particular practitioners or groups of practitio- is the low quality of some of the published studies and
ners. Research to date has focused on joint mobilization, the variability in both the quality and outcomes of the
joint manipulation, and massage. Many other manual studies.
therapy approaches have yet to be subjected to scientific A major government-appointed group in the United
scrutiny. States reviewed the literature and concluded that ma-
nipulation produces short-term beneficial effects in the
Joint manipulation and mobilization management of acute low back pain.113 The report states
Joint manipulation is one specific form of joint mobi- that “manipulation can be helpful for patients with acute
lization. Mobilization techniques are procedures de- low back problems without radiculopathy when used
signed to increase the range of movement in a joint. They within the first month of symptoms.”113 The authors also
involve specific positioning of a joint and then oscilla-
suggest that manipulation can be used safely with pa-
tory movement of that joint, either in the mid range or at
tients who have had pain for more that 1 month but that
the limit of the available range of movement. The move-
there is insufficient evidence to determine whether such
ment may involve either an accessory glide of the joint or
treatment is efficacious. Their conclusions were based on
a physiologic movement of the joint. Determination of
studies that included both mobilization and manipulation
dosage involves either changing the position in the range
techniques. In general, it appears that there is evidence to
of movement or modifying the duration of the mobiliza-
support the use of manipulation to promote pain relief in
tion. Typically the duration of treatment will vary from
the management of low back pain. It is clear, however,
30 seconds to several minutes. Joint manipulation in-
volves similar positioning of the joint but the movement that the duration of effect is limited.
performed is a low amplitude thrust beyond the normal The use of manipulation and mobilization in the man-
range of movement. agement of neck pain has also been investigated using
Manipulation of spinal joints has been the subject of a structured reviews and meta-analysis.104,105,111 Follow-
substantial number of randomized clinical trials. To date, ing a structured review of randomized clinical trials
there have been fewer randomized trials specifically in- evaluating manipulation and mobilization in the manage-
vestigating joint mobilization. There is also a noticeable ment of neck pain and headache, Hurwitz et al.111 con-
lack of studies addressing the use of manipulation or cluded that both mobilization and manipulation were
mobilization techniques to treat peripheral joints. probably of short-term benefit in the management of
A sufficient number of randomized clinical trials for acute and subacute neck pain. They also concluded that
spinal manipulation and mobilization have been reported manipulation and mobilization are beneficial in the man-
to allow researchers to conduct structured reviews or agement of muscle tension headache.111 The authors sug-
meta-analyses to summarize the findings.104–111 An early gested that there was a clear need for further better-
meta-analysis suggested beneficial effects of spinal ma- quality studies and those future studies should address
nipulation and mobilization on measures of pain, flex- different doses of manual therapy and comparisons be-
ibility, and physical activity, although the effects were tween manipulation and mobilization. They also indi-
considered to be short term.108 Subsequent structured cated the need for studies to clearly report any compli-
reviews evaluating the effect of manipulation on back cations that arise in the course of treatment. Other re-
pain have failed to find convincing evidence of the ef- searchers, however, have been more cautious in their
fectiveness of manipulation,106,107 although it was con- support of manual therapies for the management of neck
cluded that spinal manipulation might be beneficial for pain. Aker et al.104 concluded that although there is
subgroups of patients with chronic back pain.107 Other “early evidence of support [for] manual treatments in
researchers have used meta-analytical techniques to combination with other treatments, conclusions must be
evaluate the outcomes of multiple randomized controlled made cautiously because of the small numbers of trials
trials and concluded that spinal manipulation is effica- on which they are based.” However, when presenting the

40 WRIGHT AND SLUKA
same analysis in a different context, Gross et al.105 con- Several randomized clinical trials have been published
cluded that “manual therapies have been demonstrated to evaluating the therapeutic effectiveness of massage. Re-
be effective for mechanical neck pain in the short term cently, these studies have been the subject of two meta-
when used in combination with other treatments.” Part of analyses.119,120 In 1999, Ernst reviewed four studies that
the reason for the difference in conclusions between used massage in the treatment of low back pain.119 The
studies may be that although there is clearly a positive quality of studies reviewed was poor and it was not pos-
effect of manual therapies, the average effect size is rela- sible to make any reliable evaluation of effectiveness.
tively small (12–16 mm on a 100-mm scale) and there One study suggested that massage is superior to no treat-
are not sufficient studies to determine whether the effect ment; two suggested that it might be as effective as
is different for patients with acute, subacute, or chronic TENS and spinal manipulation; the other clearly demon-
neck pain. strated that spinal manipulation was superior to massage.
In summary, it appears that both manipulation and A further meta-analysis120 reviewed studies that had spe-
mobilization are beneficial in the management of neck cifically investigated the effect of massage on delayed
pain, low back pain, and muscle tension headache, but onset muscular soreness (DOMS). The studies reviewed
much more research is needed to determine the magni- exhibited significant methodological flaws and produced
tude of that effect and the relative effectiveness for pa- conflicting results. However, it was concluded that “mas-
tients with pain of different durations. There is a paucity sage may be a promising intervention for the reduction
of research investigating the effects of manual therapy of DOMS.”
treatments on peripheral joint problems. There is also a It appears that massage may be of limited benefit,
lack of studies evaluating manual therapy treatments that although much more research is required to determine
are directed toward structures other than joints and there the magnitude and duration of any therapeutic effect. At
is a clear need for studies directly comparing joint mo- this stage there is no evidence to suggest that massage
bilization and joint manipulation. produces effects that are superior to those of other physi-
Multifactorial models have been presented to explain cal treatments.
the effect of manual therapy treatments on pain.105,114,115 Massage is considered to have a number of beneficial
It is believed that these procedures may have beneficial physiologic effects that may contribute to tissue repair,
effects on local tissues and that they can suppress pain by pain modulation, relaxation, and improved mood state
activating neurophysiologic mechanisms at either spinal (see review121). Goats121 suggested that massage has
or supraspinal levels. Emerging evidence suggests that beneficial effects on arterial and venous blood flow and
manual therapy techniques applied to the cervical spine edema. For example, vigorous massage increases local
blood flow and cardiac stroke volume122; it has also been
elicit concurrent changes in pain perception, autonomic
shown to improve lymph drainage123 and it appears to
function, and motor function in patterns that are similar
have an anticoagulant effect.124 Massage is also thought
to the patterns of change elicited by direct stimulation of
to activate segmental inhibitory mechanisms to suppress
the periaqueductal gray region of the midbrain.116–118
pain and it is considered that some techniques such as
Interestingly, manual therapy treatments appear to exert
connective tissue massage may activate descending pain
a predominant influence on mechanical nociception
inhibitory systems.121 It is clear that massage may have
rather than thermal nociception.118 See Wright116 for a
a number of beneficial physiologic effects that vary de-
review of research detailing the neurophysiologic effects
pending on the massage technique used. In common with
of mobilization treatments. This emerging evidence
a number of other physical therapies, the available re-
therefore supports the concept that manual therapy tech-
search does not clearly demonstrate that these effects
niques exert important neurophysiologic effects that may
translate into beneficial clinical outcomes.
contribute to the ability of these treatments to reduce
pain. Further research is required to provide a detailed
understanding of these mechanisms. To date, no studies Therapeutic exercise
have attempted to determine if there are distinctions Exercise is used very extensively in the physical
among the neurophysiologic effects produced by electri- therapy management of musculoskeletal disorders. Al-
cal stimulation, acupuncture, and manual therapy. though there may be different rationales for using exer-
cise, it is increasingly recognized that exercise can have
Massage a relatively direct influence on pain perception. There are
Massage techniques include a range of procedures to a variety of different forms of exercise that can be used
move and mobilize soft tissues, particularly skin and un- in the treatment of painful musculoskeletal disorders.
derlying muscle tissue. These can include moderate aerobic exercise, intense

aerobic exercise, strengthening exercises, isometric ex- 1-year and 3-year follow-up.128,129 This very specific
ercises, mobility exercises, and exercises to promote spe- form of exercise therefore seems to offer a protective
cific activation and re-education of key muscle groups. effect against subsequent recurrence when used in the
The effects of exercise interventions have been most period after an acute back injury.
extensively investigated for three main groups of mus- A similar approach to specific re-education of the
culoskeletal disorders: painful spinal disorders, arthritic transversus abdominis muscle has been shown to have a
diseases, and fibromyalgia. beneficial effect on patients with chronic low back pain
A variety of exercise approaches have been used in the due to spondylolysis or spondylolisthesis.127 In this case,
management of patients with back pain. These range the exercise group showed significant reduction in pain
from low intensity aerobic exercise programs to high and functional disability relative to a control group that
intensity strengthening programs. Findings from a recent received normal care under the direction of their family
meta-analysis of randomized controlled trials125 suggest physician. These differences were maintained at 30-
that exercise is not more effective than other treatments month follow-up. A more general exercise program, in
such as manual therapy, back school and usual care by a the form of Norwegian medical exercise therapy, has
family physician, or inactive treatments of acute back been shown to be more effective and more cost effective
pain (less than 12 weeks’ duration). There appears to be than a self-exercise, walking program in the management
little evidence to support the use of either flexion or of chronic back pain.131 An interesting study by Taimela
extension exercises in the management of acute back et al.132 points to the importance of patients maintaining
pain, although the evidence suggests that extension ex- their exercise program even after the end of any formal
ercises (such as the McKenzie approach) seem to be exercise intervention. Subjects in this study completed a
more effective than flexion exercises in patients with 12-week supervised exercise program. Those who main-
discogenic back pain. tained a significant level of exercise after the program
The situation is rather different for chronic back pain ended had significantly fewer recurrences of pain and
(greater than 12 weeks’ duration). In that situation exer- less absence from work in the 2-year period after
cise interventions appear to be superior to usual care by treatment.
a family physician, although exercise alone is not su- Exercise has also been shown to be beneficial in the
perior to a general physical therapy intervention. It is not management of patients with neck and shoulder pain
possible to differentiate between different forms of affecting the trapezius muscle. In this case the particular
exercise. exercise approach seemed to be of limited importance
Many studies have adopted a general exercise ap- because improvements occurred in three treatment
proach in the management of acute low back pain. Stud- groups whose exercise programs focused on improving
ies such as that by Faas et al.126 suggest that this ap- strength, endurance, and coordination, and there were no
proach has no beneficial effect on pain or pain recur- differences among the groups.
rence. Some physical therapists have adopted a much Although it appears that general exercise may be of
more specific approach to exercise in the treatment of limited value in the treatment of acute back pain, there is
low back pain.127–129 This approach is based on specific preliminary evidence to support the use of a highly spe-
re-education of motor control and muscle function for cific exercise intervention in the management of acute
those muscles that contribute to stabilization of the lum- back pain. General active exercise and more specific ac-
bar spine (e.g., multifidus and transverses abdominis).130 tivation of muscles contributing to spinal stability appear
An interesting study that was not included in the meta- to be useful in the management of chronic back pain.
analysis conducted by Tulder et al.125 suggests that al- Potential benefits may include reduced pain, reduced re-
though specific exercise may have a minimal impact on currence, and reduced costs. More research is required to
pain in patients with acute low back pain, they may determine the optimum approach to exercise therapy for
significantly reduce subsequent recurrence of back both acute and chronic back pain.
pain.128,129 Hides and colleagues adopted a highly spe- Exercise programs have also been recommended for
cific approach to exercise that involved using ultrasound patients with arthritis. Whereas in the past the emphasis
imaging as a biofeedback technique to encourage spe- has been on range of movement exercises and exercises
cific activation and improved endurance of the segmental to strengthen specific muscle groups, more recently there
lumbar multifidus at the level of injury. Although both has been an increased emphasis on moderate aerobic
the treatment group and the control group showed a sig- exercise as a means to improve function and self-efficacy
nificant reduction in pain after 4 weeks, recurrence rates in patients with arthritis. A recent structured review133
for the treatment group were significantly lower at both concluded that moderate aerobic exercise, sufficient to

42 WRIGHT AND SLUKA
improve aerobic capacity, resulted in improved strength, a reduction in pain report.141,142 One problem with ex-
improved joint mobility, and small improvements in ercise programs seems to be poor compliance in this
functional ability (e.g., time required to walk 50 feet). patient population with consequent loss of any improve-
The studies evaluated did not suggest any specific im- ment in the period after completion of a formal exercise
provement in pain or joint inflammation as a result of the program.141 It seems that exercise is beneficial for pa-
interventions. Importantly, however, they did not suggest tients with fibromyalgia but there are difficulties in terms
any increase in pain or inflammation as a result of rela- of determining the optimum intensity of exercise and
tively vigorous exercise. Other studies have suggested ensuring patient compliance in the long term.
that pain may be improved with aerobic exercise pro- A beneficial effect of moderately intense exercise on
grams, however.134,135 A study by O’Reilly et al.135 in- pain in clinical populations is not entirely unexpected
vestigated the effect of a moderate intensity home exer- because there is good evidence from basic science re-
cise program in patients with osteoarthritis of the knees. search to suggest that exercise is capable of activating
This program resulted in improvements in pain scores endogenous pain control systems (see review143). In hu-
and physical function scores after a 6-month exercise mans, the analgesic effects of walking and cycling have
program. The control groups received no intervention. been extensively tested. A variety of models have been
Significant improvements in quadriceps strength were used to evaluate the effect of exercise on pain perception.
also noted. Similar results have been reported for both an One approach has been to evaluate the effect of cycling
aerobic exercise program and a strengthening pro- on dental pain thresholds, determined using electrical
gram.136 These programs resulted in improved function stimulation.144,145 It seems to require moderately intense
and decreased pain relative to a group that received exercise with workloads in excess of 200 Watts for pe-
health education information only. There were no sig- riods of at least 15 minutes before demonstrable analge-
nificant differences between the two forms of exercise. sia is apparent in this model. Running (10 km) has been
Interestingly, this study also evaluated patient X-rays as shown to have an analgesic influence on thermal pain
a means of determining any deterioration in joint status. and ischemic pain but no influence on cold pressor
No significant differences were noted for joint X-ray pain.146 Running has also been shown to increase pres-
scores, suggesting that the exercise interventions did not sure pain thresholds and this effect was reversed by the
hasten deterioration in arthritic joints. administration of naloxone (10 mg). Similar increases in
A similar study by Stenstrom134 evaluated a home pressure pain threshold have been demonstrated follow-
exercise program in the management of patients with ing moderately intense cycling for 30 minutes.147 Pres-
rheumatoid arthritis. In this case the program lasted for sure pain thresholds are also elevated following resis-
12 weeks and was followed up after an additional 12 tance exercise training, although the duration of the ef-
weeks. Significant improvements in pain, function, fect is less than 15 minutes.148
Ritchie articular index scores, and joint mobility oc- There is still considerable debate as to the mechanism
curred as a result of the intervention. Relatively short of action of exercise-induced analgesia because studies
durations of exercise (15 minutes per week) appear to evaluating naloxone reversal of this effect have produced
result in significant improvements in pain and function very variable results.143 It appears that exercise may be
and Ritchie articular index in patients with rheumatoid an adequate stimulus to activate the endogenous opioid
arthritis.137 system although many analgesic effects appear to in-
It would appear that moderately intensive exercise volve a mix of opioid and nonopioid mechanisms.
programs are beneficial for patients with rheumatoid ar- There is a substantial body of literature demonstrating
thritis and osteoarthritis. Improvements in physical func- analgesia following swimming in water of various tem-
tion are apparent and at a minimum pain ratings are not peratures in rats and mice. Analgesia has been demon-
increased by the exercise. There are data from some stud- strated after 3.5-minute swims at 2 °C,149 3-minute
ies suggesting that exercise interventions may reduce swims at 20 °C,150 and 3-minute swims at 32 °C.151 On
pain in these patient populations. this basis, it would appear that swimming is the main
Exercise has also been recommended as a component stimulus producing analgesia; however, when cold
of the multidisciplinary management of patients with fi- water and warm water swimming are compared there are
bromyalgia.138 A number of studies have shown positive distinct differences in the mechanism of the induced an-
effects on physical fitness and well being.139,140 It has algesia. O’Connor and Chipkin152 showed that cold wa-
proven more difficult to demonstrate reductions in pain ter swim analgesia was not reversed by the administra-
report as a result of exercise programs. However, there is tion of naloxone, whereas the effect produced by swim-
evidence that well-controlled programs may bring about ming in warm water was significantly reduced by the

administration of naloxone. Spontaneous running has in relation to physical therapies is whether these treat-
also been shown to produce an analgesic effect in rats ments represent multiple ways of accessing the same
that is correlated with the amount of running and is par- endogenous pain control mechanism or whether there are
tially reversed by the administration of naloxone.153 Ex- real differences in the mechanism of action of different
ercise in humans can cause elevation of ␤-endorphin therapies that would allow for judicious combinations of
levels in the peripheral circulation, predominantly related therapies to maximize the endogenous analgesic effect
to increased lactate concentration.154 Both incremental produced. There is clearly a need for more research in
graded exercise and acute anaerobic exercise will pro- this area, which should be a priority for national and
duce a substantial increase in circulating ␤-endorphin international funding agencies.
concentration.154 Changes induced by aerobic exercise
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The Clinical Journal of Pain

17:33–46 © 2001 Lippincott Williams & Wilkins, Inc., Philadelphia

Nonpharmacological Treatments for Musculoskeletal Pain

*Anthony Wright, Ph.D., and †Kathleen A. Sluka, Ph.D.

dardize the stimulus parameters of TENS, which makes

therefore, this review will highlight a few of the better-

The Clinical Journal of Pain, Vol. 17, No. 1, 2001

The Clinical Journal of Pain, Vol. 17, No. 1, 2001

The Clinical Journal of Pain, Vol. 17, No. 1, 2001

tions have been studied, the outcome measures have been

We can only speculate on potential mechanisms of

The Clinical Journal of Pain, Vol. 17, No. 1, 2001

The Clinical Journal of Pain, Vol. 17, No. 1, 2001

The Clinical Journal of Pain, Vol. 17, No. 1, 2001

The Clinical Journal of Pain, Vol. 17, No. 1, 2001

The Clinical Journal of Pain, Vol. 17, No. 1, 2001

The Clinical Journal of Pain, Vol. 17, No. 1, 2001

The Clinical Journal of Pain, Vol. 17, No. 1, 2001

21. Hollman JE, Morgan BJ. Effect of transcutaneous electrical nerve

The Clinical Journal of Pain, Vol. 17, No. 1, 2001

The Clinical Journal of Pain, Vol. 17, No. 1, 2001

Seniors Trial (FAST). JAMA 1997;277:25–31.

The Clinical Journal of Pain, Vol. 17, No. 1, 2001

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