Physical therapies
Physiotherapy in chronic pain
Definition of physiotherapy
Physiotherapy is a form of treatment which employs physical approaches to promote, maintain, and restore physical, psychological, and social well-being, applicable to a wide range of variations in health status.
Core skills include manual therapy, the application of electrophysical modalities, and therapeutic exercise. Through problem-solving and clinical reasoning the physiotherapist works in partnership with the individual to optimize their functional ability and potential. Physiotherapists work with patients who have neuromuscular and musculoskeletal problems, including pain.
Indications for physiotherapy in the management of chronic pain
Physiotherapy may be indicated in various types of chronic pain, whether of malignant or benign origin. It may be helpful in cancer pain, but this chapter focuses on chronic pain of benign origin, such as mechanical musculoskeletal pain or neuropathic pain. Whatever the origin of pain, physiotherapy may be indicated in the following circumstances when there is:
• Deconditioning.
• Loss of confidence in movement and activity.
• Fear avoidance beliefs and behaviours.
• Activity cycling interfering with effective pain management.
Aims of treatment
• To improve self-management of pain-associated incapacity.
• To reduce the risk of development of pain-associated incapacity.
• To relieve pain.
If pain relief is the main aim, the related incapacity may also be tackled, e.g. stretching within an active exercise programme to avoid/reduce soft tissue contractures. Pain management approaches occasionally result in pain relief but this is not a stated aim.
Principles of treatment
• Assessment including diagnostic triage—to exclude serious pathology and to make clinical diagnosis as a basis for the treatment programme.
• Use of methods to manage or reduce the risk of pain-associated incapacity and improve self-management.
• Use of methods to reduce or relieve pain.
Pain-relieving approaches in physiotherapy
Model of care
Treatment approaches aimed at relieving or reducing pain are underpinned by a tissue-based model of disease, with treatment intended to rectify or reduce the perceived dysfunction in order to relieve the pain. The treatment philosophy is neuromusculoskeletal or biomechanical (i.e. biomedical) and the approach may be manual, electrophysical, or by therapeutic exercise (with or without education). Treatment is on a one-to-one basis except in the latter approach which may also be delivered in a group.
Aims of treatment
At the end of treatment the patient should:
• Report reduced or relieved pain.
• Show practical awareness of the relevance of posture, biomechanics, and movement in the management of pain.
• Implement an exercise programme in order to maintain desirable changes that have been achieved and to increase fitness.
Manual therapy
Traction (no evidence for use in chronic pain)
• This is passive movement applied to spinal joints and is a mobilization technique.
Massage
• Massage is manipulation of soft tissue using various techniques depending on the tissue interface being targeted.
• Therapeutic massage is claimed to have effects on the circulation, muscle, connective tissue, the autonomic nervous system, and on pain and sensation.
• Techniques are effleurage, petrissage, kneading, wringing, rolling, picking-up, shaking, clapping, pounding, vibration, and deep transverse frictions. Techniques are chosen depending on the target tissues. Effleurage, for example, targets superficial tissue whereas deep transverse frictions may target specific, deeper tissues such as ligaments.
• Massage is known to reduce oedema and muscle spasm and may have an effect on pain by breaking into the ‘pain–muscle spasm’ cycle.
Contraindications
Include: open wounds, inadequate circulation, thrombophlebitis or delicate vessels, haemophilia, psoriasis, haemorrhage, early stages of healing, active bacterial or fungal infection, febrile conditions, acute inflammation, and active bone growth such as at a healing fracture site.
Caution
Malignant disease, fragile skin, collagen weakening such as in long-term steroid use, advanced RA or diabetes, heart problems, the early stages of pregnancy, and over the anterior neck or chest and mid scapular regions where reflex responses may be stimulated.
Evidence for its use in chronic pain supports short-term effects only and it may best be viewed as an active strategy within an overall package of self-management.
Manipulative therapy
There are various theories as to how manipulative therapy acts to reduce pain (although supportive evidence is lacking). These include changing the viscosity of intra-articular synovial fluid, increasing joint accessory range of motion, enhancing endorphin release, and stimulating joint mechanoreceptors so that the inputs from small diameter C-fibres are blocked by closing the pain gate. Physiotherapists may use techniques from different schools of manipulation such as Maitland, Cyriax, or Kaltenborn.
2 types of therapy are applied by physiotherapists:
• Manipulative techniques: small-amplitude, high-velocity thrust applied to spinal or peripheral joints beyond restricted range of motion.
• Mobilization techniques: high-amplitude, low-velocity physiological or accessory passive movement applied to spinal or peripheral joints within or at the limit of range of motion.
Caution should be exercised in the choice between manipulative or mobilizing techniques. Care should be taken but gentle mobilizing techniques may be selected in the following (where manipulative techniques present a risk):
• Some medical conditions such as Paget's disease, RA, osteomyelitis, or ankylosing spondylitis where bone and/or joint structures may be compromised.
• Vertebro-basilar insufficiency.
• Vertigo.
• Generalized joint hypermobility.
• Instability such as spondylolisthesis.
There is evidence for modest effectiveness for manipulative therapy in chronic LBP but no evidence that it is more effective than other treatments such as analgesia or exercise.
Electrophysical modalities
This includes thermal agents such as local superficial heat, deep heat (e.g. electromagnetic energy and US), hydrotherapy and cryotherapy.
Thermal agents
Thermal agents are claimed to produce local metabolic, neuromuscular, haemodynamic, and collagen extensibility changes in tissue. Although it is known that heat elevates the pain threshold, alters nerve conduction velocity, and changes muscle spindle firing rates, the underlying mechanism for pain relief is unclear.
Thermal agents are applied therapeutically to reduce pain and muscle spasm and to increase soft tissue extensibility and may be part of a treatment or self-management package.
Local superficial heat
Can be applied by hot packs or pads (71–82°C), hot baths, paraffin wax (49–54°C), hydrotherapy, or radiant heat.
• Heats tissue up to 3cm from the skin surface.
• Contraindicated by local or systemic inflammatory processes, reduced circulation, decreased skin sensation or integrity, over areas of infection or malignancy and in areas where liniments have recently been applied.
Deep heat
• Delivered with various electrotherapies, mainly electromagnetic energy, US, and laser.
• Heats tissue 3–5cm from the skin surface.
• Contraindicated by local or systemic inflammatory processes, reduced circulation or skin sensation, malignancies, pregnancy, metal implants, or cardiac pacemakers. Should not be applied to areas of high water content such as the eyes or gonads.
Electromagnetic energy
Clinical effects are claimed to be pain relief and improved wound healing as well as other general effects of heat where this is applied. Evidence for pain relief is weak.
• Non-ionizing RF radiation: applies electromagnetic energy to the tissues at a frequency of 27.12MHz.
• Shortwave diathermy: continuous electromagnetic energy is absorbed to produce heat in the tissues.
• Pulsed electromagnetic energy: the waves may be pulsed at regular intervals and may be set to produce heat or not to produce heat.
The intensity, duration, and frequency of the treatment determines how much heat is produced. It is vital that the patient can appreciate and report the sensation of heating in the tissues in order that appropriate adjustments are made.
• Contraindications as listed earlier.
Ultrasound
Acoustic energy converted to mechanical energy which produces heat in tissues. Is non-ionizing.
• Frequency: 1MHz optimum dose for compromise between deep penetration and adequate heating. 3MHz available for superficial tissue effects.
• Continuous waves provide constant intensity whereas pulsed waves provide interrupted intensity (duty cycle of 0.05–0.5).
• Intensity determines the strength of the US beam and gives the rate at which energy is delivered to a unit area. Ranges from 0.5–2 watts per cm2.
• The greater the intensity, the greater the temperature elevation.
• US is known to reduce the nerve conduction velocity of C-fibres but evidence for pain relief is weak.
• Contraindicated over areas of high fluid content, such as the eyes, malignancies, areas of suspected fracture or reduced bone density.
Hydrotherapy
Movement or exercise in water that uses heat, buoyancy, and turbulence as well as the sedative effects of being in warm water. Therapeutic effects are said to be:
• Reduction in pain and muscle spasm.
• Improved joint motion.
• Re-education and increase of muscle strength.
• Improved circulation and balance.
• Improved confidence and function.
There is a lack of supportive evidence for these effects in chronic pain.
Cryotherapy
• Cold may be applied to reduce pain, muscle spasm, swelling, and as a counterirritant. Can be applied with cold packs (ice or gel at 5–12°C), cold baths, vapocoolant sprays, or local application with ice cubes. Often part of the patient's set of self-management strategies.
• Action is to cool tissue by conduction or evaporation. Has haemodynamic and neuromuscular effects. The greater the temperature gradient between the skin and the cooling source, the greater the tissue temperature change.
• Dose depends on method of application; from 1 min for ice massage to 30min for cold packs.
Therapeutic exercise
The aim of exercise therapy (individual or group), may be to extend joint and soft tissue range of motion, increase muscle strength, improve general, CV, or respiratory function, develop overall mobility and balance, or foster a sense of well-being. Exercise programmes may, therefore, include stretch, muscle strengthening and endurance, and aerobic exercise, as well as exercise aimed at improving balance and coordination. In chronic pain management, the aims are frequently to improve general fitness and function and all these elements may be incorporated into the exercise programme. Some specific exercise approaches claim to relieve pain and this may be reported as a result of general exercise.
Evidence for exercise therapy alone shows it to be slightly effective at reducing pain and improving function in chronic LBP. Evidence for specific (e.g. directional) back exercises rather than general exercises in LBP is unclear. Combined with education (i.e. Back School), exercise does not decrease LBP or work absence, but when delivered in an occupational setting, there is some evidence that it reduces work absence.
Exercise as part of an active rehabilitation programme is effective in improving function, either in a unidisciplinary setting or as part of a multidisciplinary Functional Restoration Programme or an inter-disciplinary Pain Management Programme.
Pain management approaches in physiotherapy
Model of care
Pain management approaches to physiotherapy treatment focus on managing or reducing the development of pain-associated incapacity rather than on the pain itself. They are based on a biopsychosocial rather than a disease model of human behaviour. The biopsychosocial model is the underlying treatment philosophy and a cognitive behavioural approach to physical therapy is used to achieve the aims of treatment. The use of cognitive behavioural approaches is not a physiotherapy core skill and therefore is typically delivered by a specialist pain physiotherapist. Treatment may be individual or in groups.
Aims of treatment
At the end of treatment the patient should be able to:
• Demonstrate and develop principles of pacing with exercise and physical activity.
• Show practical awareness of the relevance of posture, biomechanics, and movement in the management of pain.
• Plan and implement achievable goals using principles learned.
• Reflect on prior physical activity level with a view to developing independence.
• Justify requirement for exercise and explain the effects of disuse and deconditioning.
• Plan continuous development of exercise in order to maintain and improve fitness.
• Show confidence in physical activity and abilities.
• Acknowledge risks and implement plans for setbacks as these occur.
• Employ relaxation and exercise skills as part of an overall stress management strategy.
Methods
Improve fitness, mobility, and posture by exercise; taught using cognitive and behavioural principles. Help the patient return to a range of usual and more satisfying activities by applying improved fitness with goal-setting and a graded increase in chosen activities. Assist the patient in counteracting unhelpful beliefs and improve mood and confidence by:
• Teaching cognitive principles.
• Building steadily on successes.
• Educating about pain and healthy use of the body.
• Identifying and addressing fears relating to movement and activity.
Improve stress management and sleep by:
• Assisting with the identification of stress.
• Teaching strategies to deal with stress including relaxation and exercise.
Choice of whether treatment is with the individual or in a group will be influenced by:
• The existence of comorbidity where specific rather than general messages may be more helpful.
• Ability to communicate in the language used in a group.
• The patient's choice.
Contraindications and cautions
Presence of serious pathology (potentially worsened by physiotherapy) requiring investigation and further medical management.
Evidence
The evidence supporting a cognitive behavioural pain management approach to physiotherapy intervention is growing. Reduced fear-avoidance beliefs and behaviours, negative coping strategies, and disability, and improvements in exercise behaviour have been demonstrated.
Multidisciplinary pain management intervention is more likely to be successful where psychological factors influence adjustment and where these would not be expected to improve with physiotherapy alone.
Conclusion
Physiotherapy in chronic pain may aim for pain management or pain relief. Treatment begins with assessment and diagnostic triage. This leads to clinical diagnosis and an appropriate treatment programme is planned which may be unidisciplinary or multidisciplinary. The aims of treatment are always agreed with the patient. A range of physiotherapy techniques is available and the physiotherapist is best placed to select the most appropriate modality. Many patients with chronic pain develop associated disability and these two factors are only moderately correlated. Treatment emphasis is shifting towards a pain management rather than purely pain-relieving approach, aiming for more effective self-management and improved quality of life. Although the physiotherapist should consider whether patients with complex disability and distress are likely to benefit more from interdisciplinary treatment, many patients benefit from a programme of physiotherapy alone.
Acupuncture
Acupuncture: from the Latin acus, ‘needle’ (noun) and pungere, ‘to prick’ (verb). The treatment modality of piercing the skin with fine needles to elicit a therapeutic effect is one of the best known and most accepted of the complementary therapies. It is practised in primary care and pain centres by a wide variety of health-care practitioners.
Brief history
The development of therapeutic needling has uncertain historical origins. Recent discoveries date the use to 3200BC in Europe with evidence of use in ancient Egyptian, Greek, and Hindu scripts. However, acupuncture is, to the majority, associated with Traditional Chinese Medicine (TCM), the components of which may have originated ~1600BC, and were influenced by the philosophical and cultural framework of Taosim, ~400BC.
In the UK the 2 main schools of acupuncture are:
• Traditional Chinese medical acupuncture
• Western medical acupuncture.
Traditional Chinese acupuncture
This is the use of acupuncture, moxibustion, and Chinese herbal medicine following a detailed assessment (incorporating examination of the tongue and radial pulses) in order to maintain the smooth and balanced flow of Qi (vital energy) through a series of channels (meridians) that exist beneath the skin. The presence of Qi in all living matter is a core belief in Chinese philosophy and Qi moves in equal and opposite qualities (yin/yang). Disease exists when this flow is interrupted. The insertion of fine needles into these channels is believed to stimulate an innate healing response resulting in the restoration of an individual's physical emotional and spiritual equilibrium. The British Acupuncture Council (BAcC 
http://www.acupuncture.org.uk) is the main non-statutory registering body for professional acupuncturists in the UK.
Western medical acupuncture
This is a modern scientific approach to acupuncture used in conjunction with orthodox clinical diagnosis, predominantly for the treatment of somatic pain. Specific points are chosen based on neurophysiological principles. The effects of treatment are mediated through stimulation of the peripheral nerves and neuromodulation within the CNS, to provide analgesic and some non-analgesic effects. Points are chosen in order to stimulate localized painful areas (usually myofascial trigger points) or areas which have a spinal segmental innervation corresponding with the painful and dysfunctional area. The British Medical Acupuncture Society (BMAS http://www.medical-acupuncture.co.uk) represents regulated health-care professionals who use this approach.
Regulation
Presently in the UK, acupuncture is not regulated, although there are moves to address this as appropriate and adequate training can reduce the potential for adverse events.
Acupuncture treatment
Mechanism of action for treatment of pain
Traditional Chinese medicine
• By attempting to resolve local or systemic accumulation or deficiencies of Qi. Pain is considered to indicate blockage or stagnation of Qi flow
• TCM treatment attempts to influence interruptions of flow of Qi at specific channels/meridians or in the corresponding yin yang organ (termed zang fu) at tender points termed ah shi points.
(refer to 
Further reading, [link]).
Western medical theory
Stimulation of the peripheral nervous system via Aδ or type II and III afferent nerve fibres induces neuromodulation of the CNS resulting in analgesia and some non-analgesic effects.
There are 4 categories of therapeutic effects:
• Local (immediate vicinity of the needle) release of trophic and vasoactive neuropeptides from the terminals of small-diameter sensory nerves.
• Segmental (within segment of spinal cord where the nerves from needle site enter CNS) at the DH. Sensory modulation occurs by inhibition of C-fibre pain transmission to substantia gelantinosa by enkephalinergic interneurons as a result of Aδ afferent stimulation. Most powerful effect.
• Heterosegmentally (all segmental levels of CNS). Projections to sensory cortex via thalamus have brain stem collateral connections to the PAG, where release of B-endorphin results in potentiation of serotoninergic and noradrenergic descending inhibitory pathways. Effect on afferent drive in DH of all spinal segments. Diffuse noxious inhibitory controls contribute in a minor way to the acupuncture effect.
• Generally (on whole body via central and possible humeral release of neuropeptides and hormones into the blood and CSF).
Point selection
The principle of point selection for pain treatment is to stimulate the body as close to the primary site of pain as possible or to a point within the same spinal innervation (segmental acupuncture). Needling occurs at localized tender points, trigger points, or traditional acupuncture points. Distant points are used to stimulate the required spinal segment, because they are conveniently located and thought to generate strong analgesic effects (heterosegmental and general effects).
Clinical aspects
Technique
• Clinically clean hands (of practitioner).
• Clinically clean needle site (on patient).
• Needles: deposable stainless steel of varying length and diameter with or without attached guide tube.
• Needle is gently inserted to desired depth.
• Duration: 5s to 30min (depending on technique).
• Electroacupuncture (EA): electrical stimulus applied to needles to increase therapeutic effect (especially analgesic).
Strength of stimulus
(Can vary loosely as follows:)
• Depth of needle insertion: from superficial to muscle or fascial level (sensations of de qi obtained at this level), or ‘pecking’ the periosteum.
• Duration of needling: �1–30min in chronic cases. Trigger points can be deactivated with very brief needling. No longer than 45min—EA of this duration may result in the release of CCK-8, an endogenous opioid antagonist.
• Amount of needle manipulation: via lift and thrust, and rotation techniques.
• Number of needles: average 4–6 per treatment, initially 1–5, following sessions can be up to 20.
• Frequency of treatments: normally weekly for 6–12 sessions, can be longer and more frequent.
Patient variables
• 10% strong responders—very sensitive and require gentle treatment.
• 10% non-responders.
Needle sensation and treatment responses
Termed de qi, describes sensation occurring from needling muscle or some other deep tissue, usually desired effect of acupuncture and occurs with strong responders. Individual variables exist.
• Symptoms: transient sharpness through skin, ache, pressure, swelling, numbness, and pain (caused by type II and III fibre stimulation in muscle).
• Signs: wheal and flare response, localized muscle twitch, and recognition of pain complaint (when needling a trigger point in muscle).
Safety aspects
As with any needling therapy there are serious risks associated with transmission of blood-borne infection and direct trauma of vital structures. It is often regarded by the public as being completely safe but clearly piercing the body with sharp metal instruments is not entirely so.
Adverse effects
Pain
• Persistent pain is rare, but commonly a temporary exacerbation of presenting condition may occur for 24–48h.
Syncope and sedation
• Syncope can be reduced by treating patients when they are lying down; however, very rarely profound sinus bradycardia will result in loss of consciousness even when supine.
• Sedation relatively common especially during initial treatments.
Infections
• Very uncommon but nearly always serious. Hepatitis B and C most commonly reported. Others include HIV (unproven claims), bacterial endocarditis (from use of indwelling needles in patients with valvular heart disease), septicaemia, and isolated reports of joint infections.
• Auricular chondritis or perichondritis result exclusively from use of indwelling needles left in the pinna.
It should be noted that the incidence of infections is significantly reduced by the use of sterile disposable needles and the avoidance of indwelling needles or reusable needles requiring sterilization.
Trauma
• Pneumothorax is the most frequently reported serious injury caused by acupuncture with nearly 200 incidents being reported in scientific publications.
• Cardiac tamponade as a result of deep needling through a congenital sternal foramina (10% ♂; 4% ♀) or through precordial rib interspaces.
• Trauma to abdominal viscera, peripheral nervous system, CNS, and blood vessels has also been described.
Contraindications
• Patient refusal.
• Indwelling needles in patients with a prosthetic heart valve or valvular heart disease.
• EA in patients with implanted defibrillators.
Cautions
• Anticoagulant medication
• EA in patients with demand pacemakers
• Hyperaesthetic or anaesthetic areas
• Oedematous tissue
• Tumours or swellings
• Immunosuppression
• Lack of orthodox diagnosis
• Pregnancy (a patient's beliefs are the key concern here rather than any physiological risk).
It should be concluded that acupuncture is a very safe form of therapy in competent hands.
Further reading
British Medical Acupuncture Society (BMAS) website: http://www.medical-acupuncture.co.uk
Ernst E and White A (eds) (1999). Acupuncture-A Scientific Appraisal. Butterworth Heinemann, Oxford.
Find This Resource
Filshie J and White A (eds) (1999). Medical Acupuncture-A Western Scientific Approach. Churchill Livingstone, Edinburgh.
Find This Resource
Kaptchuk TJ (1983). Understanding Chinese Medicine: The Web that has no Weaver. Congdon & Weed, New York.
Find This Resource
Maciocia G (1989). The Foundations of Chinese Medicine: a comprehensive text for acupuncturists and herbalists. Churchill Livingstone, Edinburgh.
Find This Resource
White A, Cummings M, Filshie J (2008). An Introduction to Western Medical Acupuncture. Churchill Livingstone, London.
Find This Resource
Osteopathy and chiropractic
Osteopathy and chiropractic developed in the late 1800s as alternatives to a conventional medical approach, in which it was believed that if the structural and mechanical integrity of the body could be restored, then function would improve, and health would be restored in a wide variety of conditions. This improvement in integrity was achieved primarily using manual techniques. Since then osteopathy and chiropractic have become primarily recognized in the management of musculoskeletal pain syndromes, and are particularly known for their manipulative approaches. Whilst they developed independently, they have been included together here because of the considerable overlap in approaches used.
What pain syndromes are treated?
A large part of the caseload of most practitioners comprises patients with mechanical spinal and neck pain, headaches, and regional musculoskeletal pain syndromes (e.g. shoulder pain, knee pain, pelvic pain, thoracic spinal/chest/rib pain), often related to work, road traffic collisions, and sports injuries. Both acute and chronic pain syndromes are seen. These services are usually provided on a fee basis within the UK.
Assessment
History and examination
• All practitioners carry out a conventional medical history and examination, with the aim of identifying non-musculoskeletal causes of pain, which will be referred on when necessary. Many chiropractors take X-rays in their own clinics, whereas osteopaths will refer on for imaging (usually to the GP), as well as for any other tests deemed appropriate.
• A detailed pain history is taken, including a psychosocial assessment. Practitioners identify psychosocial yellow flags, such as catastrophizing and fear avoidance, and any other obstacles to recovery.
• Physical examination usually involves a postural and biomechanical assessment, as well as orthopaedic and neurological examination.
Management
Approaches to treatment and management depend on the diagnosis made, on the needs of the patient, and on the training of the practitioner. Relief/reduction of pain and/or restoration of function are the primary aims, using a biopsychosocial model of care. An emphasis is placed on giving patients a positive explanation and encouraging return to work or normal activities as soon as possible.
• Self-management: patients may be given advice on maintaining mobility, work station assessment, posture, and lifting techniques.
• Manual techniques:
• Mobilization: techniques used include various soft tissue release methods (including massage techniques, stretches, muscle energy technique, trigger point release), joint articulation and mobilization, and harmonic technique.
• Manipulative thrust techniques: this is often the technique for which chiropractors and osteopaths are best known. It involves a high-velocity thrust to a joint taking it beyond its restricted range of motion, but within its normal physiological range of motion. It is frequently accompanied by an audible ‘click’. Theories vary as to how it works; however one effect seems to be an increase in joint accessory range of motion, which is essential to normal function.
• Rehabilitation: traditionally regarded more the preserve of physiotherapists, all undergraduate courses now include some training in rehabilitation, including basic exercise prescription. A graded return to activity is encouraged. Many practitioners go on postgraduate courses such as advanced rehabilitation, exercise prescription, or CBT.
• Acupuncture: whilst not taught at an undergraduate level, many practitioners undergo postgraduate training in acupuncture. For most, this is based on a series of weekend courses, learning the fundamentals of ‘trigger point’ dry needling (though it is acknowledged the evidence in this field is still controversial). Some undergo longer training in traditional Chinese acupuncture.
• Electrotherapy: rarely taught in the undergraduate curriculum, though some practitioners undergo postgraduate training.
• Pharmacology: currently osteopaths and chiropractors are not licensed to prescribe or inject in the majority of countries, with the exception of some states in the USA where osteopaths have full medical practice rights.
• More ‘alternative’ approaches: both professions have their advocates for more alternative approaches, including release of ‘visceral and fascial restrictions’, or ‘cranial’ approaches, which are believed to work on a so-called ‘craniorhythmic impulse’. Evidence is currently lacking for any of these approaches.
Evidence
It can be difficult to provide evidence ‘for chiropractic’ or ‘for osteopathy’ since most practitioners deliver a package of care using a variety of the aforementioned approaches. Reassuring patients and advice on management are integral parts of a consultation. It is therefore possible to look at whether there is evidence for particular approaches used in particular conditions (e.g. manipulation and acute back pain), or whether there is evidence for an overall package of care (e.g. chiropractic care and neck pain).
With respect to manipulation, for example, most research has been carried out on manipulation and low back pain, with >40 RCTs and numerous systematic reviews. Most trials have not differentiated between manipulative thrust techniques and mobilization, and many trials are of a more pragmatic nature involving a package of care, making it difficult to determine the exact contribution which each manipulation had made. Most national guidelines include recommendations on the use of manipulation/mobilization in the management of acute and chronic low back pain. Because of the overlap between the professions, no national guidelines distinguish between approaches used by physiotherapists, osteopaths, or chiropractors in the management of LBP. A recent Medical Research Council1-funded trial on back pain looked at an overall package of care agreed by chiropractors, physiotherapists, and osteopaths.1
Less research has been carried out on osteopathic and chiropractic approaches to limb musculoskeletal pain, pelvic pain, or musculoskeletal chest pain, though many practitioners claim efficacy.
It is hoped that with the increase in research, practitioners will be prepared to adopt approaches for which there is evidence, and reject approaches where there is clear evidence of lack of efficacy or harm.
Differences
With the increase in research and evidence-based medicine, the traditional boundaries between the 3 professions have become more blurred. Traditionally physiotherapy has had a greater emphasis on exercise rehabilitation and electrotherapy, and chiropractic and osteopathy have had a greater emphasis on manipulative approaches. Most osteopaths and chiropractors graduate with extensive skills in musculoskeletal assessment and manipulative approaches. Physiotherapists work in a range of areas including CV, respiratory, and surgical rehabilitation, and musculoskeletal/pain medicine is seen as a postgraduate specialization (see
Physiotherapy in chronic pain [link]). The difference in emphasis is gradually changing, and these days many practitioners will go on postgraduate courses provided by one of the other professions; a chiropractor might have an MSc in core stability, an osteopath in pain management, or a physiotherapist an MSc in manipulation. However, the historical differences are still reflected in current practice. Physiotherapists, for example, may work in pain clinics with a completely hands-off approach, whereas chiropractors and osteopaths will invariably use ‘hands-on’ approaches.
Training and status in the UK
Both professions have achieved statutory regulation, with the General Osteopathic Council and the General Chiropractic Council performing similar regulatory functions to the General Medical Council. All chiropractors and osteopaths must complete a minimum 4-year full-time degree in chiropractic or osteopathy to achieve registration, with compulsory continuing professional development in order to maintain registration. All courses include training in the basic medical sciences, together with advanced training in musculoskeletal examination and treatment approaches. Many will achieve postgraduate qualifications, including training in acupuncture, ergonomics, or pain management. All undergraduate courses will include training in evidence-based medicine.
The vast majority of practitioners work in private practice. A limited number provide services funded by the NHS, such as Primary Care Trust-funded joint physiotherapy and osteopathy back pain services. Most patients will contact their practitioner directly, though increasingly more are referred by their GP.
Further reading
1 UK BEAM Trial (2004). United Kingdom back pain exercise and manipulation (UK BEAM) randomised trial: effectiveness of physical treatments for back pain in primary care. BMJ 329:1377–81.