Why So Much Physiotherapy Does Not Resolve Chronic Structural Pain

Physiotherapy is an evidenced discipline with a legitimate and important role in acute injury rehabilitation, post-surgical recovery, and the management of neurological conditions. The critique offered here is specific and narrow: conventional physiotherapy protocols for chronic musculoskeletal pain tend to focus on the tissue reporting pain, rather than systematically assessing the mechanical forces acting on that tissue and addressing their structural origin. The clinical outcome of this focus is well documented: short-term improvement in a large proportion of patients, followed by high recurrence rates.

The Recurrence Problem

A systematic review of physiotherapy outcomes for chronic lower back pain found that the majority of patients treated achieve meaningful short-term improvement, defined as significant reduction in pain and disability scores. The same review found that at 12 months, approximately 60 to 70 percent of patients have recurred to their pre-treatment pain level or above. This is not a measurement artefact. It reflects the reality that the factors that created the pain have not been resolved by the treatment, and they continue to act on the tissue after the treatment course has ended.

What a Structural Assessment Changes

A systematic postural assessment looks at the entire load-bearing chain: foot position, ankle and knee alignment, pelvic tilt and rotation, hip symmetry, thoracic kyphosis, shoulder height and rotation, and head position. It asks which structural compensations are creating the abnormal forces at the pain site. This analysis frequently reveals that the painful tissue is not the source of the problem but the destination of forces originating elsewhere in the system. Treatment directed at correcting these upstream sources, rather than managing the downstream symptom, produces structural change that addresses the root cause.

Sources

• Henschke, N., et al. (2010). Prognosis in patients with recent onset low back pain in Australian primary care. BMJ, 340, c1425.
• Chou, R., et al. (2007). Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians. Annals of Internal Medicine, 147(7), 478-491.
• Fersum, K.V., et al. (2010). Patients with chronic low back pain show altered patterns of movement. Spine, 35(26), 1412-1418.