Best Practice & Research Clinical Rheumatology
Volume 17, Issue 1 , Pages 151-166, February 2003

Efficacy of rehabilitative therapy in regional musculoskeletal conditions

  • Edwin Yoshiyuki Hanada, md, frcpc (Staff Physiatrist)

      Affiliations

    • Corresponding Author InformationTel.: +1-416-586-4800x6449; Fax: +1-416-586-5364. E-mail address: ehanada@yahoo.com(E. Y. Hanada)

Department of Rehabilitation Medicine, Mount Sinai Hospital, 600 University Avenue, Room 1171, Toronto, Ontario, Canada M5G 1X5

Article Outline

Abstract 

This chapter reviews the best evidence for the rehabilitation of regional musculoskeletal conditions. Evidence-based efficacy of different modalities for treatment of musculoskeletal pain is presented, and the value of the patient's active participation in the rehabilitation programme is emphasized. The following modalities are commonly included in the holistic approach to patient-centred care and are reviewed: exercise therapy, thermotherapy, transcutaneous electrical nerve stimulation (TENS), and alternative therapies such as acupuncture, massage and yoga. A review of cognitive–behavioural strategies in pain management to prevent or treat fear-avoidance behaviour is also presented. Furthermore, the application of biomechanics in treating and preventing musculoskeletal disorders is illustrated. Moreover, the evidence for pain self-management to improve symptoms, health status and decrease the utilization of health care resources and cost is outlined. Finally, an overview will be presented, concerning the application of the evidence for treatment modalities to patient care, with focus on patient-centred, holistic treatment in a supportive setting.

The following key questions/issues are addressed. What are the relevant therapeutic modalities for musculoskeletal pain disorders? What is the evidence of efficacy of these modalities in regional musculoskeletal conditions? What is the importance of understanding biomechanics? What is the importance of understanding fear-avoidance beliefs? What is the evidence for ‘alternative’ therapies such as acupuncture, massage or yoga? What is the evidence for ‘pain self-management?’ How does one apply the evidence for rehabilitation in regional musculoskeletal conditions into clinical practice?

Keywords:  rehabilitation, physical therapy, musculoskeletal disorders, exercise therapy, physical modalities, cognitive therapy, alternative therapy, biomechanics, rheumatological

 

Rehabilitation of regional musculoskeletal conditions is a time-limited, goal-oriented, interdisciplinary process with the primary goals being to decrease symptoms, to optimize daily function and to minimize disability. The approach to patients with musculoskeletal disorders is a holistic, patient-centred one, through a more linear rather than hierarchical, supportive physician–patient relationship. The emphasis of treatment should include active participation, both in the physical and psychological therapies.

Many of the conventional therapeutic modalities have a tenuous foundation of scientific data supporting their efficacy as treatment options. Furthermore, there are alternative therapies such as acupuncture, massage therapy and yoga, which generally have not undergone the rigours of high-quality clinical trials. As clinicians, it is important to be familiar with the evidence pertaining to both conventional and alternative medicine in order to be able to offer to the patient the full spectrum of evidence-based treatment choices.

Moreover, an understanding of the role of biomechanics in the manifestation of regional musculoskeletal conditions is essential in the assessment and management of the patient. Their rehabilitation may implement stretching and strengthening of the muscles around the joints to correct for biomechanical deficits, and utilize orthoses or assistive devices to protect and decrease load on the joints.

With knowledge of the best evidence in the literature for various treatment strategies for musculoskeletal disorders, the challenge for the clinician is to synthesize this knowledge into clinical practice, still preserving the patient's individuality while avoiding ‘cookbook treatment’ and yet maintaining the art of medicine.

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2. Overview of relevant therapeutic modalities 

2.1. Exercise 

Exercise is the cornerstone of rehabilitation of regional musculoskeletal disorders and may include activities to boost aerobic conditioning, increase strength, enhance flexibility and improve proprioception. Exercises are often prescribed as an adjunct to medications or physical modalities. Evidence for the role of exercise as an intervention for regional musculoskeletal disorders may be further categorized into those studies either pertaining to spinal pain or to the appendicular region.

2.2. Physical modalities 

The most common physical modalities employed for musculoskeletal disorders are heat, either superficial or deep, and cold, or cryotherapy.1 Moist hot packs are the most common means of treating musculoskeletal disorders and are usually applied for only 15–20-minute intervals to avoid scalding, to heat the superficial tissues. Heat has been shown to increase blood flow to the skin and to the joint, while decreasing joint stiffness.2., 3. Also, increasing the joint temperature, especially above 41°C, may decrease the activity of the cartilage-degrading enzymes. Furthermore, increased muscle temperature may reduce muscle spasm4, and decrease inflammatory compounds known to sensitize and activate primary afferent fibres by increasing blood flow.4

For deep tissue heating, ultrasound therapy may be utilized. Ultrasound waves consist of alternating compressions and rarefactions, require a medium for transmission, and emit energy with the ability to penetrate tissue, allowing them to be utilized for deep heating at tissue interfaces. The delivery of ultrasound therapy may be by continuous-wave beam with limited intensities, to deliver thermal energy, or by brief pulses of high-intensity ultrasound waves separated by no power, which have no direct thermal effects and which may aid in the reduction of inflammation during acute phases of inflammation.5

Local application of cold therapy, in the form of ice packs, ice massage, cold baths or vapocoolant sprays to the skin, have been commonly utilized to decrease musculoskeletal pain and swelling. Topical use of cold has been shown to reduce skin, subcutaneous tissue, muscle and joint temperatures6, decrease blood flow, slow metabolic activity, reduce muscle tone, inhibit spasticity, and increase joint stiffness.4 Furthermore, cooling may produce analgesia7 through slowing of nociceptive nerve fibres so that the transmission of noxious stimulus to the spinal cord is delayed, or by serving as a counterirritant by bombarding central pain pathways with painful cold stimulus, activating the descending inhibitory pathways in the spinal cord.8

Electrotherapy is commonly used for pain modulation in musculoskeletal disorders, most commonly in the form of transcutaneous electrical nerve stimulation (TENS), which is a pulse generator that can be administered at high (>50Hz), low (<10Hz), or burst frequencies, for stimulation of peripheral nerves via skin surface electrodes. TENS may act according to the gate control theory of pain, and may activate peripheral A-beta fibres, thereby modulating pain-carrying A-delta and C-fibres at the level of the dorsal horn.9 In addition, counterirritation may activate neurons in the rostral ventral medulla which, in turn, inhibits the activity of dorsal horn nociceptive neurons.10 More recent studies have demonstrated the release of endorphins, both at low-frequency11 and at high-frequency.12

Although it is desirable to keep patients as active as possible throughout their rehabilitation, these passive modalities are still often used as an adjunct to allow the patient to participate in their exercise therapy.

2.3. Alternative therapies 

Acupuncture has its roots in traditional Asian medicine and is gaining greater favour in Western medicine, particularly for musculoskeletal pain disorders. Fine-calibre sterile needles are inserted at predetermined acupuncture points, and it is thought that this stimulates endogenous opioid pathways.13 More recently, treatment has also included the flow of electrical current through the needles, called electroacupuncture, for reducing pain.

Massage requires trained individuals to mobilize soft tissues manually, especially the skin and the underlying muscle. It has been reported to contribute to pain modulation through activating descending pain inhibitory pathways, relaxation, tissue repair and improved mood.14

Yoga arises from Indian culture and has been adapted in Western civilization as a therapy to increase flexibility, strength and stamina, while also fostering self-awareness, emotional stability and peace of mind.15 Yoga implements controlled postures, breathing and meditation to achieve these goals.

2.4. Cognitive–behavioural therapy 

Along with more physical therapy, cognitive–behavioural therapy is important in the interdisciplinary rehabilitation setting for patients with regional musculoskeletal conditions. This may involve operant, cognitive or respondent treatments. Operant treatments include positive reinforcement of healthy behaviours and removal of attention towards pain behaviours, emphasizing time-contingent versus pain-contingent pain management, and encouraging the involvement of the spouse. Cognitive treatment emphasizes imagery and diverting attention to modify maladaptive thoughts, feelings and beliefs. Finally, respondent treatment aims to alter directly the physiological response to pain, such as through relaxation techniques and biofeedback to reduce muscular tension.

The rehabilitation of regional musculoskeletal conditions should be based on the biopsychosocial model, implementing exercise, physical modalities, and cognitive–behavioural therapy, with special emphasis on patient-centred care in a supportive environment.

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3. Evidence for the efficacy of modalities in regional musculoskeletal conditions 

3.1. Exercise 

3.1.1. Spinal pain 

A myriad of exercise therapies have been implemented in the treatment of individuals with low back pain, ranging from low-intensity aerobic exercises to more vigorous strengthening exercises. A recent systematic review by van Tulder et al16 involving 39 randomized control trials (RCTs) of exercise therapy for acute (≤12 weeks) or chronic (≥12 weeks) low back pain examined the efficacy of these exercise programmes. Their review of high-quality RCTs showed strong evidence that more extension-based back exercises17 and stretching, in combination with isometric abdominal exercises18, are not more effective in reducing pain or improving functional status than chiropractic manipulations or usual care by a general practitioner.16 In addition, there is strong evidence that exercise therapy in acute low back pain is not effective compared to placebo in improving pain or functional status.16 Furthermore, there is a moderate level of evidence that exercises involving either strengthening or flexion or extension with lateral bending are not effective compared to ordinary activity with regard to functional status and return to work16., 19. in the treatment of acute low back pain.

For chronic low back pain, the high-quality RCTs showed strong evidence that intensive trunk lifting or leg-lifting20, sit-ups, arching or trunk rotation21, or progressively graded exercise therapy, including mobilizing hypomobile areas of the spine and stabilizing exercises22, are equally effective in reducing pain compared to conventional physiotherapy, which consisted of physical modalities such as cold, traction and electrotherapy as well as massage and stretching. However, there is strong evidence that exercise therapy is more effective than usual care by a general practitioner, with conflicting evidence on the effectiveness of exercise therapy compared to placebo16, and whether flexion or extension exercises are more effective.16 Furthermore, there is strong evidence that strengthening exercises are not more effective than other types of exercise, with conflicting evidence that strengthening exercises are more effective than more passive treatment for chronic low back pain.16

The fundamental limitation to the RCTs reviewed included the heterogeneity of the aetiology of the acute or chronic low back pain in the subjects participating in the majority of trials. The prescribed therapy in each trial was similar despite different aetiologies for the low back pain, although the frequency and duration of therapy in some cases were individualized. Generalized exercise therapy for non-specific back pain may not be as effective as specific exercises for specific spinal disorders.23 The importance of determining the directional preference for each patient with back pain prior to initiating exercise treatment in that preferential plane has been well documented.24., 25., 26. Furthermore, targeting specific muscles in the low back may be more useful than a global strengthening regimen.

In a randomized controlled trial by O'Sullivan et al23, 44 patients with a radiological diagnosis of spondylolysis or spondylolisthesis were randomized into two treatment groups. The first treatment group underwent a 10-week exercise treatment programme involving the strengthening of the deep abdominal muscles and the co-activation of the lumbar multifidus muscles, which were incorporated into functional tasks and static postures, while the control group engaged in conditioning exercises with physical modalities. The results indicated a significant improvement in pain intensity and functional disability levels at 30-month follow-up in the strengthening exercise group that was not experienced by the control group.23

Hides et al further delineated the importance of specific exercises for acute, first-episode low back pain in their RCT that targeted the con-contraction of the multifidi and transversus abdominis, two spinal stabilization muscles.27., 28. Both the treatment and control groups showed significantly decreased pain after 4 weeks. More importantly, the recurrence rate at 1- and 3-year follow-up was reduced by more than 50% in the exercise group compared to the control group.28

Future research should focus on determining the efficacy of specific exercise programmes for specific causes of low back pain in the acute and chronic stages, and to determine whether prospectively implementing this therapy can help prevent low back pain. Future research may also target the effect on spinal pain of strengthening the ‘core muscles’, the muscles that contribute to spine stabilization, including the multifidus posteriorly, the transversus abdominis anteriorly, pelvic floor muscles inferiorly, and the diaphragm superiorly in a cylindrical manner.

3.1.2. Appendicular pain 

A recent systematic review by van den Ende et al29 assessed 6 weeks of aerobic conditioning exercises in patients with non-active to moderately active rheumatoid arthritis (RA). In the six selected RCTs, aerobic capacity, muscle strength30., 31., and flexibility31 improved in the dynamic exercise groups compared to the control group. Furthermore, functional ability, shown as the time required to walk 50 feet, was statistically significant in only one32 of the two studies.31., 32. These results suggest that dynamic exercise therapy is effective in improving aerobic capacity, muscle strength and joint mobility, but less effective in improving functional ability.29 Importantly, there were no deleterious effects of dynamic exercise therapy on joint inflammation and disease activity shown in the studies.

Similarly, there has been some benefit demonstrated with exercise therapy and osteoarthritis (OA). An 8-week RCT by Kovar et al33 demonstrated that patients with primary knee osteoarthritis who were assigned to 24 90-minute supervised fitness walking sessions increased their walking distance, showed an improvement in physical activity, a decrease in pain, and less frequent use of medication compared to the control group.33 Another RCT by Ettinger et al34 demonstrated decreased physical disability and knee pain and better performance in the 6-minute walk and weight-carrying tests in the groups either assigned to 18 months of walking or a general strengthening programme compared to the control group. Another RCT with a blinded observer35 studied patients with hip or knee OA, and the group assigned to 12 weeks of exercise therapy had decreased pain and observed disability, decreased use of acetaminophen, improvement in global well-being and muscle strength around the hips.35 Similar improvements were seen in individuals with knee OA with a 4-month home-based exercise programme36, and ADL disability was reduced in older patients with knee OA who were assigned to an aerobic or strength exercise group, compared to the control group.37

3.2. Physical modalities 

3.2.1. Temperature 

Superficial heat. RCTs utilizing superficial heat as an intervention for musculoskeletal disorders are scarce. However, one recent randomized single-blinded trial study compared the efficacy of continuous low-level heat wrap therapy for 8 hours per day with that of ibuprofen and acetaminophen in subjects with acute non-specific low back pain.38 The extent and duration of pain relief, lateral trunk flexibility, muscle stiffness and disability were all improved in the heat wrap group compared to the control groups.38 However, there was an unequal distribution of patients in the treatment and control groups.

A recent systematic review by Robinson et al39 evaluated the efficacy of thermotherapy, both moist heat and cold, and its effect in patients with rheumatoid arthritis (RA). The result of the systematic review, which included seven randomized controlled trials, was that there were no significant beneficial or detrimental effects of heat or ice pack applications on measurements of RA disease activity, such as joint swelling, pain, medication intake, range of motion, grip strength or hand function, when compared with a control or alternative treatment.39

In a study of 52 patients with chronic RA, the intervention group with paraffin wax in addition to exercise therapy for 4 weeks showed significantly greater improvement compared to the control group in range of motion of finger flexion, pain on non-resisted motion, and grip and pinch functions of the hand40, with no improvement demonstrated in stiffness or grip strength.40 Overall, the study supported the utilization of superficial heat before an exercise session to optimize benefit.

There is conflicting evidence supporting the use of superficial heat in patients with RA. Variables such as type, temperature, duration and frequency of the intervention have not been consistent in order to compare fairly the effect of treatment among different studies. Furthermore, important population characteristics, including age, gender and duration of disease, have not been uniform.39 Finally, the difficulty in blinding the patients to thermotherapy, and the lack of consistently valid and reliable outcome measures in these studies are shortcomings that need to be addressed in future investigations.

Deep tissue heating. In a systematic review of ultrasound therapy for knee OA5, only one high-quality randomized controlled trial was found, utilizing ultrasound three times per week for 6 weeks in a total of 74 patients41, along with lower extremity stretching and strengthening exercises. There was no statistically significant difference between the intervention group versus control for pain, range of motion or gait velocity both at the end of treatment and 3 months later.41 In another systematic review, there was only weak evidence for this modality's effectiveness in lateral epicondylitis.42 Overall, in 11 out of 13 placebo-controlled trials, there were no statistically or clinically significant effects of ultrasound therapy on shoulder pain, degenerative rheumatic disorders, ankle distortions, temporomandibular joint pain or myofascial pain.42 In two of the randomized, double-blinded clinical trials in patients with shoulder pain, there were no differences shown in pain relief, functional activities, or pain relief between sham ultrasound and ultrasound.42., 43., 44. In combination with exercise therapy, there was little evidence that ultrasound therapy was effective compared to a control group42, and there was no difference between groups in pain relief with ultrasound compared to other physical modalities such as superficial heat45, ice46, transcutaneous electrical nerve stimulation (TENS)45, or massage.47 The lack of high-quality studies resulted from inadequate reporting of trial methods, selection criteria, treatment parameters and outcome measures.

Cryotherapy. In the systematic review of thermotherapy in patients with rheumatoid arthritis by Robinson et al39 two RCTs showed no difference between application of ice on either an inflamed knee48 or hand49 compared to control groups. However, there was a trend that favoured cryotherapy in decreasing hand swelling after 2 days and 3 days post hand surgery49.

3.2.2. Transcutaneous electrical nerve stimulation 

Milne et al evaluated the effect of TENS on chronic low back pain in a recent systematic review.50 Five RCTs were included, with the schedule of treatments ranging from once per day for 2 consecutive days to three treatments per day for 4 weeks. There were no statistically significant differences between the intervention groups compared to the placebo group for any of the outcome measures, which included pain, function, well-being, range of motion, activity level and satisfaction with care.50

A systematic review by Reeve et al51 reported four high-quality studies that found TENS to be associated with significantly decreased pain, increased exercise capability, ability to perform straight-leg raising, compared to massage, sham TENS and no TENS in patients with either low back pain, OA of the hip or knee>7 months, or chronic pain.51 In one of these studies, Thorsteinsson et al52 showed short- and long-term relief of pain after treatment using TENS when compared with sham TENS in subjects with chronic low back pain. However, four other high-quality studies did not find TENS to be more effective than placebo in subjects with low back pain, rheumatoid arthritis with hand involvement, or OA of the knee.53 Deyo et al54 compared the effect of TENS to placebo with and without exercise therapy in patients with low back pain >3 months and showed no difference. In contrast, Osiri et al conducted a systematic review of TENS in patients with knee OA, and in their seven qualified studies the overall result was pain relief from active TENS and acupuncture-like TENS, as well as improved knee stiffness compared to placebo.55

There are conflicting results regarding the effect of TENS on musculoskeletal pain disorders. Comparison between studies has been difficult because of the lack of standardization of the stimulation parameters and the type of TENS stimulation, the control for other simultaneous modalities, the use of outcome measures, and the homogeneity of the patient population.

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4. Evidence for efficacy of alternative therapies 

4.1. Acupuncture 

In a systematic review of acupuncture in patients with RA56, only two studies met the author's strict design criteria. One randomized, cross-over study by David et al57, involving 64 subjects with RA assigned to 5 weeks of manual acupuncture or placebo, with follow-up at 6 weeks post-treatment, showed no difference in the pain score, the number of swollen or tender joints, the erythrocyte sedimentation rate (ESR), values of C-reactive protein (CRP), scores on the general health questionnaire or modified disease activity scale, or the amount of analgesic intake.57 In the second study, using electroacupuncture, a significant decrease in knee pain was reported in the experimental group, 24 hours after treatment, but no difference was found at 1, 2 or 3 months after initiation of therapy compared to the placebo group.58 However, the poor experimental design, with small numbers of subjects in the above studies, makes it difficult to make recommendations regarding acupuncture treatment and RA.

Ezzo et al59 conducted a systematic review of acupuncture for knee OA that included seven trials. Overall, these clinical trials suggest that acupuncture may be effective in reducing pain in the knee in patients with OA compared to sham acupuncture, but not necessarily function or medical costs/utilization.59 The authors also hypothesized that, based on the study, an average of 10 treatments with at least eight points per session per knee were required to obtain a positive result.59 In a systematic review of acupuncture utilized in the treatment of lateral epicondylitis60, two RCTs demonstrated that acupuncture leads to significantly longer pain relief than placebo.61 Also, the group assigned to the acupuncture therapy was more likely to experience a 50% or greater reduction in pain after one treatment61, and more likely to result in overall improvement after 10 treatments.62 No significant differences were found in the longer term after 3 or 12 months.

A recent RCT looked at 50 subjects with chronic low back pain who were randomized to receive manual acupuncture, electroacupuncture or placebo.63 Treatments were administered once weekly for 8 weeks, with assessments at 1, 3 and 6 months after treatment for pain, analgesic intake, quality of sleep and activity level. There were significant improvements at all time points between the acupuncture groups compared to placebo.63

Important future research questions include determining optimal treatment dose, frequency, duration, and the effect of acupuncture as an adjunct to other therapies, and the role of maintenance treatments.

4.2. Massage 

One systematic review of massage therapy for low back pain by Furlan et al64 found that massage therapy might be beneficial for patients with subacute and chronic non-specific low-back pain with regard to improving symptoms and function, especially if administered in addition to exercise and education, and delivered by a licensed therapist. Furthermore, they found that massage has long-lasting effects (at least 1 year after end of treatment), and may be cost-effective, with decreased use by the patient of pain medication and lower costs of spine care services.64 Another meta-analysis by Ernst65 in subjects with low back pain demonstrated that massage therapy is superior to control and might be as effective as TENS and spinal manipulation, although the studies reviewed were of poor quality. Deep transverse friction massage combined with physiotherapy modalities did not demonstrate clinical benefit compared to control in the treatment of iliotibial band syndrome.66 Future research is required to determine the optimal dose and duration of massage therapy, its duration of clinical effects, and its effects in relation to other modalities for various musculoskeletal disorders, with larger sample sizes in RCTs.

4.3. Yoga 

Although there have been published clinical trials showing some positive effects of yoga on asthma67, diabetes68, and mood69, there is a paucity of clinical trials, especially RCTs, that involve yoga as a therapeutic modality for musculoskeletal disorders.

In an RCT by Garfinkel et al70, patients with OA of the hands who underwent yoga exercise for 60 minutes per week for 8 weeks – focusing on stretching and strengthening exercises for the upper body – showed significantly greater decreases in pain during activity, joint tenderness, and improved finger range of motion compared to the control group, with no significant differences in grip strength or joint circumference. Individuals with carpal tunnel syndrome who were randomly assigned to yoga postures for strengthening, stretching and balancing each joint in the upper body, along with relaxation given twice weekly for 8 weeks, had significant improvement in grip strength and pain reduction, and the manifestation of Phalen's sign, with no significant differences in sleep disturbance, Tinel's sign, and median motor and sensory nerve conduction studies71compared to a control group who wore wrist-hand orthoses.71

Clearly, more studies are required with larger sample sizes, and longer follow-up, to determine the long-term effects of yoga. Furthermore, control groups should involve a group setting, to control for the benefit that may be derived from the supportive group format that was seen in the yoga intervention group.

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5. Biomechanics 

A knowledge of biomechanics is important in treating regional musculoskeletal conditions. For example, educating the patient with low back pain in proper lifting techniques is essential to decrease the stress on painful structures, such as the paraspinal muscles or intervertebral ligaments, or employing strategies for safe transitional movements. Furthermore, a comprehensive stretching programme with emphasis on the hip flexors for those patients with lumbar facet joint pain may also aid in decreasing the hyperlordosis and the mechanical load on the posterior elements of the spine.

For those individuals with a painful hip from OA, a knowledge of biomechanics allows one to rationalize the utilization of a cane in the contralateral hand in order to decrease the compressive load on the affected hip joint. More distally, patients with patellofemoral pain syndrome, with abnormal patellar tracking in the trochlear groove, may benefit from foot orthoses if they exhibit excessive pronation to decrease the valgus orientation at the knee and subsequently decrease patellofemoral pressures, or to strengthen the gluteal muscles, to decrease internal rotation of the femur and, again, reduce the valgus orientation at the knee. Finally, distally, in the lower extremities, excessive pronation may require correction with a foot orthosis with a medial, longitudinal arch support, and shoes with a firm heel counter to keep the calcaneous in a neutral position. If not corrected, excessive pronation may be associated with Achilles tendinitis, plantar fasciitis or early fatigue of pretibial muscles, or more proximal joint disorders. Kerrigan et al showed that lateral-wedge insoles reduced the varus torque during walking in patients with medial compartment knee OA.72 Also, leg-length discrepancies may be associated with low back pain and hip and knee OA, and may require treatment with a heel lift.73

The concept of the ‘kinetic chain’ is also important: the joints are viewed from the lower extremities up to the pelvis, to the spine and to the upper extremities as joined to one another in a ‘linkage system.’74 This becomes key in the evaluation and treatment of the patient with a regional musculoskeletal condition. For example, a baseball pitcher with a diagnosed rotator cuff injury may recover better with rehabilitation directed at improving the range of motion at the hips and spine, where most of the torque for throwing is generated, in addition to shoulder.74 Unfortunately there are few clinical trials to support these practical clinical points about the utilization of biomechanics in the treatment of musculoskeletal disorders.

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6. Fear of avoidance beliefs 

Fear of avoidance beliefs may be instrumental in the transformation of acute pain into chronic pain disorders. In a recent review by Vlaeyen and Linton75, the authors describe ‘fear-avoidance’ as the act of evading movements or activities based on being afraid of anticipated pain. This may arise from negative appraisals about pain and its consequences, and catastrophic thinking, which may, in turn, precipitate fear. This fear is characterized by avoidance behaviours, such that daily activities are no longer performed, leading to functional disability, and subsequent deconditioning, both on the cardiovascular and musculoskeletal systems, which may further contribute to pain.75 Pain-related fear is one of the most powerful predictors of observable physical performance and self-reported disability levels.75 Therefore, one of the treatment goals should be to reduce these anticipatory fears in a clinical setting, and to positively reinforce favourable actions such as confrontation of these fears. That is, a programme emphasizing active rather than passive means of treating chronic pain conditions, and discouraging avoidance behaviour is desirable. This is supported by a study by Brox and Brevik76 which demonstrated that the prognosis for recovery from rotator tendinosis was improved by active treatment, a more restricted prescription of medication, and fewer sick days off work, decreasing the avoidance behaviour.

This goal of minimizing fear-avoidance behaviour may be difficult in reality because of often-conflicting information given to the patient from both family members and clinicians, such as the extent of possible injury or the prognosis of the injury with continued activity; the reinforcement of fear-avoidance behaviour may stem from encouraging the patient to continue therapy despite pain during treatment sessions, which may cause increased pain and avoidance. In view of the importance of fear-avoidance in chronic musculoskeletal pain, treatment of these disorders should involve cognitive–behavioural therapy.

In a systematic review by van Tulder et al77 on behavioural treatment for chronic low back pain, the studies demonstrated strong evidence that behavioural treatment had a moderately positive effect on pain and a small positive effect on functional status and behavioural outcomes when compared to controls in patients with chronic low back pain.77 There was no strong evidence favouring one type of behavioural treatment over another, and there was conflicting evidence of behavioural treatment versus other conservative treatment.77 Furthermore, there was moderate evidence that behavioural treatment added to exercises and education, to a multidisciplinary treatment programme, to an inpatient pain management programme, or to various forms of medical treatment, had no difference in positive effects—although the studies in general were of poor quality.77

Karjalainen et al78 reviewed the effect of multidisciplinary biopsychosocial rehabilitation for neck and shoulder pain among workers. Two studies were included, one by Ekberg et al79 with 107 participants with neck and shoulder disorders who saw the physician for treatment. The trial demonstrated a similar effectiveness of an active multidisciplinary rehabilitation programme compared to traditional care with regard to sick leave, pain, health-related behaviour and working conditions after 12 and 24 months of follow-up.79 In the study of Jensen et al80, 70 patients with chronic neck and shoulder pain were randomized to multimodal inpatient cognitive–behavioural treatment along with traditional multidisciplinary treatment, compared to traditional multidisciplinary treatment alone for 5 weeks. There were no differences in pain and other clinical outcomes, but there was a significantly higher cost to the consumer of the intervention group.80 A study by Rose et al looked at the different effects that cognitive–behavioural therapy had on psychological distress, cognition and function in 84 patients with chronic low back pain randomly assigned to either group or individual therapy sessions, of either 15, 30 or 60 hours duration.81 The results indicated a significant improvement in the outcome measures, independent of whether the subjects received group or individual therapy, and the duration of treatment.81 Therefore, the studies pointed to limited evidence that cognitive–behavioural rehabilitation was effective in treatment of neck and shoulder pain. In future studies, the quality must improve, particularly with emphasis on RCTs, and utilizing an improved means of blinding the patient and observer, with an intention-to-treat analysis. The dose of cognitive–behavioural intervention, the duration of treatment, the appropriate outcome measures and endpoints need to be determined in the future.

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7. Evidence for ‘pain self-management’ 

In the last decade there has been more research performed on the effect of patient self-management in chronic disorders on behaviours, health status and utilization of health services. Self-management programmes have been shown to have long-term positive effects on these outcome measures.82., 83., 84. The focus of these programmes is to give the patient the skills and knowledge to manage their illnesses daily, through disease-related problem-solving, and short-term goal-setting, in a supportive environment, in which the patient is confident in their self-efficacy.85 In a study by Lorig et al86 613 patients with various chronic disorders, including arthritis, were randomly assigned to 7 weeks of small-group self-management instruction emphasizing problem-solving, decision-making and confidence-building, or to a control group. After 1 year, participants in the self-management programme experienced improvements in health behaviours, self-efficacy and health status, and had fewer visits to the emergency department compared to controls.86 Various studies have demonstrated improvements in health-related outcome measures up to 2 years after implementation of the self-management programmes in patients with various chronic disorders87, and up to 4 years in an arthritis self-management group.83

The quality of future studies must improve in their design, with emphasis placed on blinded randomized-controlled trials, with an intention-to-treat analysis. Moreover, the appropriate dose of cognitive-behavioural intervention, duration of treatment, outcome measures and end points need to be determined in the future.

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8. Consequences for clinical practice 

There is substantial evidence for the benefits of exercise therapy, mostly for appendicular pain, and this should be the mainstay of treatment, emphasizing active patient participation. However, the evidence behind the use of physical modalities has been mixed. There is mixed evidence for the benefits of superficial heat and cryotherapy in rheumatological disorders, and poor evidence for ultrasound and TENS. For alternative therapies, acupuncture has more evidence supporting its beneficial effect. Furthermore, future clinical trials implementing correction of abnormal biomechanics need to be performed, although there are some biomechanical studies that support the use of orthoses and assistive devices. A comprehensive treatment programme should include cognitive–behavioural intervention to prevent musculoskeletal pain conditions becoming chronic, as through the fear-avoidance model. There is also strong evidence that demonstrates the benefits of improved health outcomes, with decreased health care utilization and subsequent costs, in patients who undergo training to become self-managing ‘expert patients’. This may be encouraged by instilling confidence in the patient by providing support, encouraging collaboration with other patients who practise self-management, assisting in setting short-term goals, and by being available for consultation should the patient require further positive reinforcement.

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9. Summary 

This chapter reviewed the best evidence for the rehabilitation of regional musculoskeletal conditions. The efficacy of various modalities for the treatment of musculoskeletal pain according to the most recent scientific evidence was presented. Included in the holistic approach to patient-centred management were thermotherapy, transcutaneous electrical nerve stimulation, and alternative therapies such as acupuncture, massage and yoga, with a review of cognitive–behavioural strategies in pain management. Furthermore, knowledge of biomechanics is important, to correct for abnormal forces at the particular musculoskeletal region of concern for successful outcome, and the concept and importance of the ‘kinetic chain’ were presented. Emphasis on patient participation in active treatment was emphasized, with patients enrolling in self-management programmes to improve health outcome and to decrease utilization of health care services with subsequently reduced costs.Box 1Box 2

Box 1. Practice points

•rehabilitation of regional musculoskeletal conditions should be patient-centred, and active participation should be emphasized

•exercise therapy should be the mainstay therapy when possible, with physical modalities utilized as an adjunct

•evaluate and correct for abnormal biomechanics, using assistive devices and orthoses as necessary

•cognitive–behavioural strategies should be employed in a multidisciplinary team setting to prevent and treat fear-avoidance behaviour

•self-management programmes should be encouraged to optimize health status and reduce utilization of health care resources, and to decrease overall health care costs

Box 2. Research agenda

•high-quality randomized, blinded controlled trials are required to assess the efficacy of physical modalities, alternative therapies, and cognitive behavioural interventions

•trials with larger numbers of subjects are required that have well-explained therapeutic parameters with standardized outcome measures

•optimum dose, frequency and duration of the various modalities need to be further delineated through high-quality clinical trials

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PII: S1521-6942(02)00096-7

doi:10.1016/S1521-6942(02)00096-7

Best Practice & Research Clinical Rheumatology
Volume 17, Issue 1 , Pages 151-166, February 2003

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