In short, the approaches for which there is best evidence for long term benefits for musculoskeletal pain are:

  • Physiotherapy: for physical causes of pain, including both manual therapy and exercise therapy.
  • Psychology: for those patients who also have a significant contributing factors such as depression or anxiety.

These professions provide the cornerstone of effective long term care for people with persistent pain. 

What treatments have been proven to be ineffective?

  • Bed rest >2days: people who stay more active on average do better;
  • Medication: does NOT address the causes (but can help your physio & psychologist to more easily address the underlying causes by reducing the severity of your pain in the short term);
  • Electrotherapy modalities: electrical gadgets (like TENS) do not address the underlying causes either!
  • Massage: there is no LONG TERM evidence that it makes a lasting difference (there is evidence of short term benefit);
  • High velocity, low amplitude manipulation (ie cracking your spine): there is no LONG TERM evidence that it makes any difference (there is evidence of short term benefit but the risk-reward profile needs to be considered here in comparison to other manual therapy treatment options).


There is a current trend for practitioners to adopt a “hands-off” approach to managing chronic pain.  In my view this is a mistake, as highly skilled manual therapy or “hands-on” treatment can offer a great deal to patients who present with clear signs of dysfunction that are treatable with manual therapy.   “Hands-on” physical examination is how you identify most of the types of dysfunction responsible for over 90% of persistent pain.  So make sure your practitioner has a comprehensive hands-on approach if you want to uncover the subtle or hidden causes of your problem.  It is skill dependent – you need a practitioner who has the skill sets!

There is another trend towards providing education for patients to help them understand their pain and how to better deal with it, which is fantastic and has been to shown to really help manage persistent pain – providing that it is accompanied by some actual treatment to address any physical and/or psychological causes that are present.  Simply talking about pain but doing nothing to address the underlying causes won’t make the pain go away if there are physical dysfunctions that require treatment.  In many cases that I see, symptomatic or adjunctive treatments have been offered in large part because the previous practitioner lacked the training to identify and manage the underlying causes.


What your GP may help with: at times you may require medical intervention from your doctor, perhaps an injection into a chronically inflamed bursa.  Alternatively a script for one of the medications shown to be helpful in managing severe chronic pain that is difficult to treat might be of benefit.  These medications don’t actually treat the cause of pain, but they tend to reduce the sensitivity of the nervous system, making it easier for your Physio or Psychologist to help eliminate underlying causes. 

Nutritional and environmental medicine:  some patients have systemic (body-wide) issues which can create a pro-inflammatory state in the body.  For example, some people with auto-immune conditions experience a greater degree of inflammation than others and this may be reflected in a stronger degree of pain that a medical doctor may be able to help with.  Some people have food intolerances that can have a similar effect in creating a pro-inflammatory state and a practitioner of nutritional and environmental medicine can be helpful in this situation.  Eliminating these systemic factors can make it much easier to manage your pain as the body tends to react with a lesser degree of inflammation and pain to any dysfunction that may occur.

In our next post we complete this series of 10 blogs exploring the complexity of persistent pain and its EFFECTIVE management.