Analgesia following exercise: a review

Acute heavy-resistance exercise–induced pain and neuromuscular fatigue in elderly women with fibromyalgia and in healthy controls: Effects of strength training

OBJECTIVE

To examine heavy-resistance exercise-induced acute neuromuscular fatigue, blood lactate concentration, and muscle pain in elderly women with fibromyalgia (FM) and in healthy controls before and after a period of strength training.

METHODS

Thirteen elderly women with FM (mean+/-SD age 60+/-2 years) and 10 healthy women (mean+/-SD age 64+/-3 years) performed a heavy-resistance fatiguing protocol (5 sets of leg presses with 10 repetitions maximum) before and after a 21-week strength training period. Maximal isometric force and electromyography (EMG) activity of leg extensors and blood lactate concentration were measured during the loading. Pain was assessed by visual analog scale.

RESULTS

The strength training led to large increases in maximal force and EMG activity of the muscles and contributed to the improvement in loading performance (average load/set) at week 21. The fatiguing loading sessions typically applied in strength training before and after the experimental period caused remarkable and comparable acute decreases in maximal force and increases in blood lactate concentration in both groups. Acute exercise-induced muscle pain increased similarly in both groups, and the pain level in women with FM was lowered after the 21-week training period.

CONCLUSION

The increased strength in women with FM improved high-load performance and also seemed to attenuate perceived pain. Acute exercise-induced neuromuscular changes and the time course of muscle pain in women with FM were comparable with findings in healthy controls, which suggests a typical fatiguing process and a similar trainability of the muscles in elderly women with FM.

Low-intensity exercise reverses chronic muscle pain in the rat in a naloxone-dependent manner

OBJECTIVE

To determine the effects of low-intensity exercise on chronic muscle pain and potential activation of the endogenous opioid system.

DESIGN

Randomized placebo-controlled trial.

SETTING

Animal laboratory.

ANIMALS

Sixty-three male Sprague-Dawley rats.

INTERVENTIONS

Rats performed a low-intensity exercise protocol for 5 consecutive days after the induction of chronic muscle pain. In a separate experiment, naloxone or saline was administered systemically before 5 low-intensity exercise sessions.

MAIN OUTCOME MEASURE

Mechanical hyperalgesia was measured using von Frey filaments to determine the mechanical withdrawal threshold.

RESULTS

Low-intensity exercise increased mechanical withdrawal threshold in the chronic muscle pain model. Naloxone attenuated the antihyperalgesic effects of low-intensity exercise.

CONCLUSIONS

Low-intensity exercise reversed mechanical hyperalgesia in the chronic muscle pain model through activation of the endogenous opioid system.

Prolonged rhythmic gum chewing suppresses nociceptive response via serotonergic descending inhibitory pathway in humans

Serotonergic (5-HT) neurons are implicated in modulating nociceptive transmission. It is established that 5-HT neuronal activity is enhanced by rhythmic behaviors such as chewing and locomotion in animals. We thus hypothesized that 5-HT descending inhibitory pathways may be enhanced by rhythmic behavior of gum chewing in humans. To evaluate this idea, we examined nociceptive flexion reflex (NFR), while a subject chewed gum rhythmically for 20 min. NFR was elicited by electrical stimulation of the sural nerve, and the evoked potential was recorded from the biceps femoris muscle. Visual analogue scale (VAS) was also obtained. To assess 5-HT activity, we determined 5-HT levels quantitatively in platelet poor plasma (PPP) and whole blood (WB) using HPLC system. Both NFR area and VAS were significantly decreased at 5 min after the onset of chewing and these reductions persisted until cessation of chewing. There were no significant changes in NFR and VAS while resting without chewing. The PPP 5-HT level increased significantly just after cessation of chewing and had returned to the pre-chewing level by 30 min after cessation of chewing. The WB 5-HT level obtained 30 min after cessation of chewing was significantly greater than the pre-chewing level. Serotonin transporters have recently been discovered at the blood-brain barrier, suggesting that the rise in blood 5-HT may possibly reflect an increase in 5-HT level within the brain. The present results support our hypothesis that the rhythmic behavior of chewing suppresses nociceptive responses via the 5-HT descending inhibitory pathway.

Differential regulation of hippocampal progenitor proliferation by opioid receptor antagonists in running and non-running spontaneously hypertensive rats

Voluntary running in mice and forced treadmill running in rats have been shown to increase the amount of proliferating cells in the hippocampus. Little is known as yet about the mechanisms involved in these processes. It is well known that the endogenous opioid system is affected during running and other forms of physical exercise. In this study, we evaluated the involvement of the endogenous opioids in the regulation of hippocampal proliferation in non-running and voluntary running rats. Nine days of wheel running was compared with non-running in spontaneously hypertensive rats (SHR), a rat strain known to run voluntarily. On the last 2 days of the experimental period all rats received two daily injections of the opioid receptor antagonists naltrexone or naltrindole together with injections of bromodeoxyuridine to label dividing cells. Brain sections from the running rats showed approximately a five-fold increase in newly generated cells in the hippocampus, and this increase was partly reduced by naltrexone but not by naltrindole. By contrast, both naltrexone and naltrindole increased hippocampal proliferation in non-running rats. In non-running rats the administration of naltrexone decreased corticosterone levels and adrenal gland weights, whereas no significant effects on these parameters could be detected for naltrindole. However, adrenal gland weights were increased in naltrexone- but not in naltrindole-administered running rats. In addition, in voluntary running rats there was a three-fold increase in the hippocampal levels of Met-enkephalin-Arg-Phe compared with non-runners, indicating an increase in opioid activity in the hippocampus during running. These data suggest an involvement of endogenous opioids in the regulation of hippocampal proliferation in non-running rats, probably through hypothalamic-pituitary-adrenal axis modulation. During voluntary running in SHR naltrexone altered hippocampal proliferation via as yet unknown mechanisms.

Naloxone Fails to Antagonize Initial Hypoalgesic Effect of a Manual Therapy Treatment for Lateral Epicondylalgia

BACKGROUND

Recent research has shown that Mulligan's Mobilization With Movement treatment technique for the elbow (MWM), a peripheral joint mobilization technique, produces a substantial and immediate pain relief in chronic lateral epicondylalgia (48% increase in pain-free grip strength).([1]) This hypoalgesic effect is far greater than that previously reported with spinal manual therapy treatments, prompting speculation that peripheral manual therapy treatments may differ in mechanism of action to spinal manual therapy techniques. Naloxone antagonism and tolerance studies, which employ widely accepted tests for the identification of endogenous opioid-mediated pain control mechanisms, have shown that spinal manual therapy-induced hypoalgesia does not involve an opioid mechanism.

OBJECTIVE

The aim of this study was to evaluate the effect of naloxone administration on the hypoalgesic effect of MWM.

METHODS

A randomized, controlled trial evaluated the effect of administering naloxone, saline, or no-substance control injection on the MWM-induced hypoalgesia in 18 participants with lateral epicondylalgia. Pain-free grip strength, pressure pain threshold, thermal pain threshold, and upper limb neural tissue provocation test 2b were the outcome measures.

RESULTS

The results demonstrated that the initial hypoalgesic effect of the MWM was not antagonized by naloxone, suggesting a nonopioid mechanism of action.

CONCLUSIONS

The studied peripheral mobilization treatment technique appears to have a similar effect profile to previously studied spinal manual therapy techniques, suggesting a nonopioid-mediated hypoalgesia following manual therapy.

Sensitivity to the effects of a kappa opioid in rats with free access to exercise wheels: differential effects across behavioral measures

It is well established that chronic exercise decreases sensitivity to mu opioid agonists; however, it is less clear what effects it has on kappa opioids. The purpose of the present study was to examine sensitivity to the effects of the selective, kappa opioid spiradoline in rats with free access to exercise wheels. Rats were obtained at weaning and randomly assigned to either standard polycarbonate cages (sedentary) or modified cages equipped with exercise wheels (exercise). After approximately 7 weeks under these conditions, sensitivity to the effects of spiradoline on tests of antinociception, locomotor activity, conditioned place preference, and diuresis were examined in both groups of rats. Sedentary rats were more sensitive than exercising rats to the antinociceptive effects of spiradoline, and this effect was observed at both low and high nociceptive intensities. In contrast, exercising rats were more sensitive than sedentary rats to the diuretic effects of spiradoline, and slightly more sensitive to spiradoline's effects in the conditioned place preference procedure. No differences in sensitivity were observed to the effects of spiradoline on locomotor activity. Sensitivity to the antinociceptive effects of spiradoline nonsignificantly increased in exercising rats that were reassigned to sedentary housing conditions, and changes in spiradoline sensitivity were correlated with exercise output in individual subjects. Collectively, these data suggest that exercise alters sensitivity to the behavioral effects of kappa opioids, but that the direction and magnitude of this effect depends on the behavioral measure examined.

Hypoalgesia induced by elbow manipulation in lateral epicondylalgia does not exhibit tolerance

Previous studies have demonstrated that the initial hypoalgesic effect of spinal manipulative therapy was not antagonized by naloxone and did not exhibit tolerance with repeated applications. The implication is that endogenous opioid mechanisms of pain relief are probably not at play in spinal manipulative therapy. The role of endogenous opioid peptides in manipulation of the peripheral joints has not been investigated. The aim of this study was to evaluate whether the initial hypoalgesic effect of a peripheral manipulative technique (mobilization-with-movement treatment for the elbow) demonstrated a tolerance to repeated applications (ie, reduction in magnitude of effect over repeated applications). Twenty-four participants with unilateral chronic lateral epicondylalgia participated in the study. A repeated measures study was conducted to examine the effect of repeated applications of the mobilization-with-movement treatment for the elbow on 6 separate treatment occasions at least 2 days apart. Pain-free grip strength and pressure pain threshold were chosen as the pain-related outcome measures. Changes in the percent maximum possible effect scores of measures of hypoalgesia were evaluated across the 6 treatment sessions by using linear trend analysis. The results showed no significant difference for the hypoalgesic effect of the treatment technique between sessions (P >.05). This peripheral manipulative therapy treatment technique appeared to have a similar effect profile to previously studied spinal manipulative therapy techniques, thereby contributing to the body of knowledge that indicates that manipulative therapy most likely induces a predominant non-opioid form of analgesia.

Investigation of the effects of pool-based exercise on fibromyalgia syndrome

OBJECTIVE

The aim of this study was to compare pool-based exercise and balneotherapy in fibromyalgia syndrome (FMS) patients.

METHODS

Fifty female patients diagnosed with FMS according to the American College of Rheumatism (ACR) criteria were randomly assigned to two groups: group 1 (n=25) with pool-based exercise, and in group 2 (n=25) balneotherapy was applied in the same pool without any exercise for 35 min three times a week for 12 weeks. In both groups, pre- (week 0) and post-treatment (weeks 12 and 24) evaluation was performed by one of the authors, who was blind to the patient group. Evaluation parameters included pain, morning stiffness, sleep, tender points, global evaluation by the patient and the physician, fibromyalgia impact questionnaire, chair test, and Beck depression inventory. Statistical analysis was done on data collected from three evaluation stages.

RESULTS

Twenty-four exercise and 22 balneotherapy patients completed the study. Pretreatment (week 0) measurements did not show any difference between the groups. In group 1, statistically significant improvement was observed in all parameters ( P<0.01) except for the chair test at both weeks 12 and 24. In group 2, week 12 measurements showed significant improvement in all parameters ( P<0.01) except for the chair test and Beck depression inventory. Week 24 evaluation results in group 2 showed significant improvements in pain and fatigue according to visual analogue scale (VAS), 5-point scale, number of tender points, algometric and myalgic scores, and patient and physician global evaluation (P<0.01 and P<0.05, respectively), while improvements were nonsignificant in morning stiffness, sleep, fibromyalgia impact questionnaire (FIQ), chair test, and Beck depression inventory parameters in this group. Comparison of the two groups based on the post-treatment (weeks 12 and 24) percent changes and difference scores relative to pretreatment (week 0) values failed to show a significant difference between the groups for any parameter except Beck depression inventory (P<0.01).

CONCLUSION

The results of our study showed that pool-based exercise had a longer-lasting effect on some of the FMS symptoms, but statistical analysis failed to show a significant superiority of pool-based exercise over balneotherapy without exercise. While we believe that exercise is a gold standard in FMS treatment, we also suggest in light of our results that balneotherapy is among the valid treatment options in FMS, and further research regarding the type and duration of the exercise programs is necessary.

Segmental and plurisegmental modulation of pressure pain thresholds during static muscle contractions in healthy individuals

The purpose of this study was to assess possible segmental (uni- and/or bilateral) and plurisegmental changes in pressure pain thresholds (PPTs) during static muscle contractions. Twenty-four healthy subjects (12 female, 12 male) performed a standardised isometric contraction with the dominant m. quadriceps femoris (MQF) and m. infraspinatus (MI), respectively. PPTs were assessed using pressure algometry at the contracting muscle, at the contralateral (resting) muscle and at a distant resting muscle (MI during contraction of MQF and vice versa). The PPT assessments were performed before, during and 30min. following each contraction. The contractions were held until exhaustion or for a maximum of 10 PPT assessments/muscle. During contraction of MQF PPTs increased compared to baseline at the middle ( p<0.001) and the end (p<0.001) of the contraction period at all assessed sites alike. During contraction of MI PPTs increased compared to baseline at the middle (p<0.001) and the end (p<0.007) of the contraction period at all sites. The increase was more pronounced at the contracting muscle compared to the contralateral (p<0.002; p<0.01) and the distant (p<0.002; p<0.002) site. No statistically significant difference was seen in PPTs between the latter two. Following the contractions PPTs returned to baseline. Submaximal isometric contraction of MQF and MI gave rise to a statistically significant increase in PPTs at the contracting muscle, the resting homologous contralateral muscle and at the distant resting muscle indicating that generalised pain inhibitory mechanisms were activated. Contraction of MI, but not of MQF, gave rise to an additional activation of unilateral segmental antinociceptive effects.

Sensitivity to the effects of opioids in rats with free access to exercise wheels: mu-opioid tolerance and physical dependence

RATIONALE

Exercise stimulates the release of endogenous opioid peptides and increases nociceptive (i.e. pain) thresholds in both human and animal subjects. During chronic, long-term exercise, sensitivity to the effects of morphine and other mu opioids decreases, leading some investigators to propose that exercise may lead to the development of cross tolerance to exogenously administered opioid agonists.

OBJECTIVE

The purpose of the present investigation was to examine the effects of chronic exercise on sensitivity to mu opioids, and to determine whether these effects can be attributed to the development of opioid tolerance and dependence.

METHODS

Rats were obtained at weaning and housed singly in standard polycarbonate cages (sedentary) or modified cages equipped with exercise wheels (exercise). After 6 weeks under these conditions, opioids possessing a range of relative efficacy at the mu receptor (morphine, levorphanol, buprenorphine, butorphanol, nalbuphine) were examined in a warm-water tail-withdrawal procedure.

RESULTS

Morphine, levorphanol and buprenorphine produced maximal levels of antinociception in both groups of rats, but all were more potent in sedentary rats than in exercising rats. Butorphanol and nalbuphine produced maximal levels of antinociception in sedentary rats under some conditions in which they failed to produce antinociception in exercising rats. Sensitivity to the effects of buprenorphine was decreased in sedentary rats that were transferred to cages equipped with exercise wheels, and increased in exercising rats that were transferred to sedentary housing conditions. In the latter group, exercise output prior to housing reassignment was positively correlated with increases in sensitivity to buprenorphine following housing reassignment. Naloxone administration precipitated a mild withdrawal syndrome in exercising rats that was not readily apparent in sedentary rats.

CONCLUSIONS

These data suggest that chronic exercise leads to the development of mu-opioid tolerance and physical dependence, and that these effects are similar to those produced by chronic opioid administration.

Treadmill running and swimming increase cell proliferation in the hippocampal dentate gyrus of rats

The effects of treadmill exercise and swimming on cell proliferation in the dentate gyrus and the involvement of opioid receptors were investigated via 5-bromo-2'-deoxyuridine (BrdU) immunohistochemistry. Sprague-Dawley rats of the running groups were made to run on treadmill for 30 min each day, while those of the swimming groups were made to swim for 5 min each day over 3 consecutive days. In addition, intensity-dependency of the effects of running and swimming on cell proliferation was investigated. The present results demonstrate that both treadmill running and swimming increase the number of BrdU-labeled cells in the dentate gyrus and these increasing effects are more potent in light intensity and 5 min swimming groups. Treatment with naloxone increases cell proliferation in the dentate gyrus in all groups, although this increase is statistically insignificant.

Contribution of individual spa therapies in the treatment of chronic pain

OBJECTIVES

The aim of the present study was to evaluate the contribution of individual spa therapies administered during a period of 3 weeks on measures of well being and pain in a sample of patients with chronic back pain.

DESIGN

One hundred fifty-three patients with chronic back pain undergoing inpatient spa therapy in Bad Tatzmannsdorf, Austria, participated in the study. According to the prescription of their spa physician, patients underwent two or more of the following treatments: mud packs, carbon dioxide baths, massages, exercise therapies, spinal traction, and electrotherapy. The outcome measures were general pain, back pain, negative mood, and health satisfaction. Regression analyses were conducted to predict the 4 outcome measures at the end of spa therapy and at 6 weeks' follow-up for all therapies applied. The pretreatment outcome measure, age, and sex were controlled for by entering them into the analysis.

RESULTS

Patients showed significant improvements in all 4 outcome measures. The prediction of improvement was generally small: only 1% to 11% of the change of the outcome measures could be explained by the type and number of therapies received. On a short-term basis, mud packs and exercise were found to be associated with a greater improvement in mood, whereas a greater frequency of massage therapy and carbon dioxide baths was associated with a smaller improvement in health satisfaction. On a long-term basis, exercise therapy and spinal traction were associated with a greater reduction in back pain.

CONCLUSIONS

The results indicate that, in addition to the individual therapies, other factors relating to spa therapy as a whole must contribute to overall treatment outcome. In addition, the results support the efficacy of exercise therapy for chronic back pain.

Exercise-induced hypoalgesia and intensity of exercise

Pain sensitivity has been found to be altered following exercise. A number of investigators have found diminished sensitivity to pain (hypoalgesia) during and following exercise. However, currently it is unknown whether there is a specific intensity of exercise that is required to produce this hypoalgesia response. Aerobic exercise, such as cycling and running, have been studied most often, and a number of different exercise protocols have been used in this research including: (i) increasing exercise intensity by progressively increasing the workloads; (ii) prescribing a particular exercise intensity based on a percentage of maximum; and (iii) having participants self-select the exercise intensity. Results indicate that hypoalgesia occurred consistently following high-intensity exercise. In the studies in which exercise intensity was increased by increasing workloads, hypoalgesia was found most consistently with a workload of 200 W and above. Hypoalgesia was also found following exercise prescribed at a percentage of maximal oxygen uptake (e.g. 60 to 75%). Results are less consistent for studies that prescribed exercise based on percentage of heart rate maximum, as well as for studies that let participants self-select the exercise intensity. However, there has not been a systematic manipulation of exercise intensity in most of the studies conducted in this area. In addition, the interaction between exercise intensity and exercise duration, more than likely influences whether hypoalgesia occurs following exercise. There is a need for research to be conducted in which both intensity and duration of exercise are manipulated in a systematic manner to determine the 'optimal dose' of exercise that is required to produce hypoalgesia. In addition, there is a need for more research with other modes of exercise (e.g. resistance exercise, isometric exercise) to determine the optimal dose of exercise required to produce hypoalgesia.

The rational management of fibromyalgia patients

The exponential increase in pain research over the last 10 years has established fibromyalgia (FM) as a common chronic pain syndrome with similar neurophysiologic aberrations to other chronic pain states. As such, the pathogenesis is considered to involve an interaction of augmented sensory processing (central sensitization) and peripheral pain generators. The notion, that FM symptomatology results from an amplification of incoming sensory impulses, has revolutionized the contemporary understanding of this enigmatic problem and provided a more rational approach to treatment. To date, the management of FM has been mainly palliative, with the aims of reducing pain, improving sleep, maintaining function, treating psychologic distress and diminishing the impact of associated syndromes. The rapidly evolving neurophysiologic, psychophysiologic and molecular biologic basis for chronic pain states has already opened up new avenues for management which should be applicable to this difficult group of patients. Indeed, it is now possible to think about a "rational" approach to managing FM patients that was unthinkable just a few years ago.

Changes in pain perception during treatment with angiotensin converting enzyme-inhibitors and angiotensin II type 1 receptor blockade

OBJECTIVES

Besides the well-known role of the angiotensin system in blood pressure control, an interaction of angiotensin and pain perception has been suggested. This study sought to investigate whether an angiotensin converting enzyme inhibitor, which facilitates bradykinins, algesic peptides, and/or an AT1 receptor antagonist may modify hypertension-related hypoalgesia in humans. The study was approved by the ethical committee of our Department.

METHODS

A total of 22 hypertensive patients were submitted to dental pulp stimulation to obtain the dental pain threshold and tolerance, and to 24 h blood pressure monitoring together with a control group of 55 normotensives. Then the hypertensives were randomized to enalapril or losartan treatment and were re-evaluated (dental pain perception and ambulatory monitoring) after 8 weeks of the first treatment and after an additional 8 weeks of the second treatment.

RESULTS

Untreated hypertensives showed a reduced perception to painful stimuli when compared with normotensives. A significant reduction of both pain threshold and tolerance was observed during the anti-hypertensive treatments (Friedman test: P = 0.007 and P = 0.006, respectively). Pain sensitivity was similar during the two treatments and it did not differ from pain sensitivity values of normotensive controls. ANCOVAs were computed to evaluate the relationship between anti-hypertensive agents and pain sensitivity, after controlling for blood pressure. A 24 h mean pressure served as covariate, removing any effect of blood pressure; a significant difference was observed entering both pain threshold and tolerance as dependent variables (F = 5.28, P = 0.0076; F = 8.16, P = 0.0007, respectively).

CONCLUSIONS

Both the angiotensin converting enzyme inhibitor enalapril and the AT1 receptor blocking agent losartan acted similarly on pain threshold and tolerance, pain sensitivity being increased during the two anti-hypertensive treatments. The blood pressure reduction during drug assumption could not account for the pain sensitivity changes observed. The latter may be due to a specific pharmacodynamic mechanism mediated through angiotensin II AT1 receptors.

Specific manipulative therapy treatment for chronic lateral epicondylalgia produces uniquely characteristic hypoalgesia

The treatment of lateral epicondylalgia, a widely-used model of musculoskeletal pain in the evaluation of many physical therapy treatments, remains somewhat of an enigma. The protagonists of a new treatment technique for lateral epicondylalgia report that it produces substantial and rapid pain relief, despite a lack of experimental evidence. A randomized, double blind, placebo-controlled repeated-measures study evaluated the initial effect of this new treatment in 24 patients with unilateral, chronic lateral epicondylalgia. Pain-free grip strength was assessed as an outcome measure before, during and after the application of the treatment, placebo and control conditions. Pressure-pain thresholds were also measured before and after the application of treatment, placebo and control conditions. The results demonstrated a significant and substantial increase in pain-free grip strength of 58% (of the order of 60 N) during treatment but not during placebo and control. In contrast, the 10% change in pressure-pain threshold after treatment, although significantly greater than placebo and control, was substantially smaller than the change demonstrated for pain-free grip strength. This effect was only present in the affected limb. The selective and specific effect of this treatment technique provides a valuable insight into the physical modulation of musculoskeletal pain and requires further investigation.

Exercise for patients with fibromyalgia: risks versus benefits

Although exercise in the form of stretching, strength maintenance, and aerobic conditioning is generally considered beneficial to patients with fibromyalgia (FM), there is no reliable evidence to explain why exercise should help alleviate the primary symptom of FM, namely pain. Study results are varied and do not provide a uniform consensus that exercise is beneficial or what type, intensity, or duration of exercise is best. Patients who suffer from exercise-induced pain often do not follow through with recommendations. Evidence-based prescriptions are usually inadequate because most are based on methods designed for persons without FM and, therefore, lack individualization. A mismatch between exercise intensity and level of conditioning may trigger a classic neuroendocrine stress reaction. This review considers the adverse and beneficial effects of exercise. It also provides a patient guide to exercise that takes into account the risks and benefits of exercise for persons with FM.

Nonpharmacological treatments for musculoskeletal pain

BACKGROUND

Several types of physical therapy are used in the management of painful musculoskeletal disorders. These treatment modalities can be broadly categorized 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 significant 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 appears 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 musculoskeletal pain. Limitations of the existing research base are discussed and recommendations for areas of future research are provided.