Physiotherapy

Exercise Therapy

Exercise therapy is the most widely recommended component of physiotherapy, though evidence quality is generally low. A Cochrane overview of 21 systematic reviews found physical activity and exercise may produce small improvements in pain severity and physical function for chronic pain, but evidence quality was consistently low^{[?:exercise-chronic-pain-cochrane-2017]}.

What the Evidence Shows

• Aerobic exercise (walking or cycling) improved pressure pain thresholds by a median of 10.6% in people with musculoskeletal pain — but clinical trials required 2–12 weeks of repeated exercise to show improvement^{[?:aerobic-exercise-pain-2022]}
• For low back pain, the best exercise type depends on the goal: Pilates ranked highest for pain relief, resistance training and motor control for physical function, and aerobic exercise for mental health^[1]
• Very low-quality evidence suggests exercise is not significantly more effective than placebo interventions for chronic pain^{[?:exercise-vs-placebo-chronic-pain-2021]}

Why Exercise Is Still Recommended

• Despite modest effect sizes, exercise is safe — adverse events are rare and limited to temporary muscle soreness^{[?:exercise-chronic-pain-cochrane-2017]}
• Low cost and accessible
• May address contributing factors like deconditioning and reduced mobility
• Clinical guidelines consistently recommend exercise as a core component of chronic pain management

Massage Therapy

A large umbrella review found moderate-certainty evidence that massage helps with short-term pain relief, but no high-certainty evidence for any condition^{[?:massage-pain-umbrella-2024]}. See the full [massage](/massage) page for details.

• Better than no treatment for pain relief
• A meta-analysis gave a weak recommendation for massage over active comparators for pain (SMD −0.26), but massage was more clearly effective for reducing anxiety (SMD −0.57)^{[?:massage-pain-populations-2016]}
• Effects may not persist — at 6-month follow-up, active treatments like exercise showed better outcomes than massage

Ultrasound Therapy

Ultrasound^ⓘ

What the Evidence Shows

• A 2024 systematic review of 10 trials found ultrasound reduced pain for knee osteoarthritis but was ineffective for shoulder disorders^{[?:ultrasound-msk-pain-2024]}
• A broader review of 35 RCTs found that of 10 methodologically sound trials, 8 showed no greater benefit of ultrasound over placebo — the only conditions showing benefit were carpal tunnel syndrome and calcific tendinitis^{[?:ultrasound-effectiveness-review-2001]}
• For most conditions, ultrasound is not consistently better than sham treatment

Hot and Cold Therapy

Heat Therapy

• A network meta-analysis of 59 RCTs found hot packs were the most effective treatment for muscle soreness within 48 hours after exercise^{[?:hot-cold-doms-2022]}
• Heat increases blood flow and muscle flexibility
• Best for muscle stiffness and chronic aching pain

Cold Therapy (Cryotherapy)

• After 48 hours, cryotherapy ranked first for ongoing pain relief from muscle soreness^{[?:hot-cold-doms-2022]}
• However, evidence for cold therapy reducing swelling is weaker than commonly believed:
• A systematic review found only marginal evidence that ice combined with exercise helps after ankle sprains^{[?:ice-soft-tissue-injury-2004]}
• A 2023 critically appraised topic found consistent evidence that cryotherapy does not substantially reduce swelling during rehabilitation^{[?:cryotherapy-swelling-cat-2023]}

Practical Summary

• First 48 hours of muscle soreness: heat ranked most effective (low-quality evidence)
• Beyond 48 hours: cold therapy ranked most effective (low-quality evidence)
• Acute injury with swelling: traditionally recommended, but clinical trial evidence for reducing swelling is limited^{[?:ice-soft-tissue-injury-2004]}
• Chronic stiffness: heat is commonly used, but high-quality comparative evidence is limited

TENS

TENS^ⓘ

What the Evidence Shows

• A meta-analysis of 381 RCTs (24,532 participants) found moderate-certainty evidence that TENS reduces pain during or immediately after treatment (SMD −0.96 vs placebo, based on 91 placebo-controlled trials)^{[?:tens-meta-analysis-2022]}
• However, a Cochrane overview of 51 RCTs (2,895 participants) from 8 systematic reviews found the underlying evidence was consistently rated very low quality and concluded they were "unable to confidently state whether TENS is effective" for chronic pain^{[?:tens-chronic-pain-cochrane-2019]}
• Adverse events are rare and mild when reported
• TENS is safe, inexpensive, and can be used at home

Limitations

• Effects are measured during or immediately after treatment — evidence for sustained pain relief is lacking
• TENS produces a tingling sensation that makes blinding difficult, potentially inflating placebo effects^{[?:tens-chronic-pain-cochrane-2019]}
• Clinical significance for chronic conditions is uncertain

What Works Best Overall

The evidence does not clearly establish a single "best" physiotherapy treatment. Comparisons across modalities are limited by differences in study populations, outcome measures, and evidence quality.

• Exercise therapy: consistently recommended in clinical guidelines as a core treatment for chronic pain. Effects are small-to-moderate but exercise is safe, accessible, and may improve function beyond pain relief^{[?:exercise-chronic-pain-cochrane-2017]}
• Massage therapy: moderate-certainty evidence for pain relief; may be particularly effective for anxiety^{[?:massage-pain-umbrella-2024]}. Benefits may not persist beyond the short term compared to active treatments
• Hot and cold therapy: low-quality evidence suggests heat for early muscle soreness and cold for later muscle soreness^{[?:hot-cold-doms-2022]}
• TENS: moderate-certainty evidence for immediate pain relief; very low-quality evidence for chronic pain
• Ultrasound: evidence supports use only for knee osteoarthritis; not effective for most other conditions^{[?:ultrasound-effectiveness-review-2001]}

Active treatments (exercise) consistently outperform passive treatments (ultrasound, TENS) for long-term outcomes.

Key Takeaway

Exercise therapy is the most broadly recommended physiotherapy intervention for chronic pain, though its effects are small-to-moderate and evidence quality is generally low. Passive treatments like massage may provide short-term relief (particularly for anxiety), and hot/cold therapy may help with muscle soreness, but their long-term benefits are less established. Ultrasound lacks evidence for most conditions. A good physiotherapist focuses on teaching exercises and self-management strategies, supplemented by other modalities for short-term symptom relief where appropriate.

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