Treatment Pluralism in Musculoskeletal Care

Introduction

Musculoskeletal pain conditions have been extensively studied; however, no specific treatment has consistently demonstrated superior effectiveness over others. In addition, treatment outcomes appear to be largely influenced by contextual and non-specific factors. As highlighted in an earlier Physiotutors research review, improvements in neck pain are predominantly mediated by such non-specific effects.

While research is conducted at a population level and provides valuable statistical strength, it may not fully capture the variability of individual patient responses to specific interventions. This editorial therefore explores the clinical application of a Person-Centred Hypothesis (PCH) approach, in which pain phenotype, contextual factors, and pattern recognition are used to inform treatment selection.

The authors advocate for a pluralistic framework that promotes a shift toward more patient-centred clinical care.

Methods

This article is an editorial published in the Journal of Orthopaedic & Sports Physical Therapy. As an editorial, it primarily reflects expert perspective and should therefore be interpreted within the context of expert opinion rather than as high-level empirical evidence.

Results

Current clinical strategies for musculoskeletal conditions, such as manual therapy, exercise therapy, surgery, or psychological approaches, generally have moderate and similar effects. While debates are ongoing in the physiotherapy field regarding the best treatment options, none of which have been demonstrated, this editorial fosters a new philosophical approach to care: treatment pluralism.

Treatment pluralism

As mentioned by the editorial’s authors, “treatment pluralism recognises that there are many valid paths to recovery”. In other words, as long as they are grounded in plausible biological mechanisms, are evidence-based and safe, several reasonable treatment options can lead to recovery. Intervention should be individualized according to the patients’ goals, values and preferences, clinical context and clinician’s expertise and judgment.

Pluralism also applies to clinicians themselves. Some may develop expertise within a specific area of practice (e.g., manual therapy or exercise therapy), whereas others may adopt a broader and more integrative approach. Both approaches can be considered valid when they remain evidence-informed, patient-centred, and transparent in their rationale and limitations

Equal Effectiveness, Similar Mechanisms

At the group level, when clinical trials demonstrate comparable outcomes across different treatment approaches, this suggests that these interventions may share common underlying mechanisms. In the case of manual therapy and exercise therapy, outcomes are likely influenced by a combination of biological, psychological, and social processes, with a substantial proportion of treatment effects mediated through non-specific mechanisms.

However, evaluating treatment effectiveness at the group level may obscure meaningful differences in individual responses. While some patients may experience substantial improvements with exercise therapy, others may derive greater benefit from alternative approaches. This variability in treatment response may partly explain why research often demonstrates limited differences between interventions when comparing average outcomes across groups.

From this observation, patient comprehensive appreciation is a crucial stake when designing a treatment plan. Authors advocate for moderator analyses in a research frame where a moderator is a characteristic that changes how well a treatment works. This will help to identify for whom a treatment is best suited. Furthermore, research should also consider patient heterogeneity. For the same diagnosis, patients may present with very different pain mechanisms, psychological profiles, expectations…The Person-Centered Hypothesis, which integrates pain phenotyping, contextual factors, and pattern recognition, may help clinicians organize all the relevant information about a patient into a coherent clinical hypothesis. This could be of great value when designing an intervention plan.

Clinician-Dominant Versus Multi-Framework Clinical Reasoning

The authors compare two approaches to delivering musculoskeletal care in clinical practice. A framework-dominant clinician primarily operates within a specific rehabilitation approach, such as exercise therapy, manual therapy, or psychologically informed care. This model can be highly valuable when supported by strong clinical expertise, transparent communication, and appropriate patient selection.

On the other hand, a multi-framework clinical approach recognizes that complex patient presentations cannot be fully understood through a single perspective. These frameworks integrate patient characteristics, preferences, and contextual factors to guide the selection of different treatment strategies. The authors propose Cognitive Functional Therapy as an example, where education, movement exposure, and therapeutic touch are combined as complementary approaches tailored to the individual patient.

The authors are not favouring one approach over the other. They are advocating for non-rigid clinical care, avoiding dogmatic adherence to a single framework. This editorial argues that treatment pluralism fits with both approaches but requires therapist transparency regarding their clinical orientation, patient goals, and preference-driven intervention.

Pluralism in practice

In practice, treatment pluralism rests on three principles. First, clinicians naturally adopt different clinical orientations, whether specializing in a specific framework or using a broader, integrative approach. Neither is inherently superior, provided they remain evidence-informed. Second, clinicians should be transparent about their approach, allowing patients to make informed decisions while reducing pressure to deliver a single “correct” treatment. Finally, when several evidence-informed options exist, patient goals, values, and preferences should guide treatment selection.

Treatment pluralism does not mean that all treatments are equally acceptable. It allows choice among multiple safe, plausible, and evidence-informed interventions, while excluding ineffective, harmful, or disproven practices. Within these evidence-based boundaries, clinician expertise and patient preferences can guide the final treatment decision. The authors advocate for a “diverse ecosystem of intervention”. Such a paradigm renders the longstanding debate between manual therapy and exercise therapy largely irrelevant, as both are considered valid evidence-informed options.

Questions and thoughts

A fundamental challenge in research is that it often seeks to identify generalizable truths by unifying and simplifying the subjects under investigation. While this approach provides methodological rigor, it may also reduce the complexity and individuality of patients.

Research is mostly conducted on a structural diagnosis paradigm. However, pathoanatomical diagnoses alone may not provide sufficiently precise classifications to guide individualized physiotherapy interventions. As current evidence suggests, clinicians should integrate multiple biological, psychological, and social factors to develop a more comprehensive understanding of each patient. This raises an important question: can current research frameworks adequately capture such individual complexity?

By design, research often requires homogeneous participant groups to identify average treatment effects. Yet, within a specific diagnostic category, patients may present distinct biological and psychosocial profiles and may therefore respond differently to the same intervention. If research frequently demonstrates comparable outcomes between treatments, could this partly reflect limitations in patient classification and treatment matching? As highlighted by the authors, and considering the role of non-specific effects in therapeutic outcomes, some patients may respond particularly well to manual therapy, whereas others may benefit more from exercise-based approaches. We could hypothesize that outcomes may emerge from the interaction between the right patient, the right clinician, and the appropriate clinical context at a given moment. Capturing such complex and dynamic interactions remains a major challenge for current research methodologies.

In the meantime, clinical practice should remain guided by a scientific approach. One of the fundamental contributions of research to healthcare is providing a rigorous foundation for clinical decision-making. In practice, this involves using valid assessments, establishing meaningful baselines, and developing multidimensional clinical hypotheses that extend beyond isolated structural impairments. Treatment plans should be collaboratively developed based on clinical expertise, patient preferences, and individual goals, with outcomes continuously reassessed. Importantly, this framework should acknowledge the contribution of non-specific effects as legitimate mechanisms influencing therapeutic outcomes rather than viewing them as secondary or irrelevant.

Talk nerdy to me

In this context, an important question remains: how can research better capture patient variability and improve the matching between individual patients and interventions?

One promising approach is the greater use of moderator analyses and individual participant data meta-analyses. Rather than asking whether a treatment works, these methods explore for whom and under which circumstances a treatment is most effective. Identifying moderators such as symptom characteristics, psychological factors, or clinical presentation patterns could improve patient stratification and treatment selection.

Another important research direction is phenotyping. Instead of classifying patients solely according to diagnostic labels or anatomical findings, phenotyping aims to describe individuals based on relevant biological, psychological, and contextual characteristics. This multidimensional approach may allow researchers to identify clinically meaningful subgroups that share similar mechanisms or treatment responses.

Finally, emerging methodologies such as adaptive trial designs and precision medicine approaches may help bridge the gap between research and individualized care. Adaptive trials allow researchers to modify aspects of the study based on accumulating data, while precision medicine aims to tailor interventions according to individual patient characteristics. Although these approaches remain challenging to implement in complex conditions such as musculoskeletal pain, they represent promising avenues for moving beyond a one-size-fits-all model.

Take-home messages

This article is an editorial reflecting expert opinion rather than a clinical guideline or systematic review. It provides an important perspective for challenging current assumptions and opening new ways of thinking about physiotherapy practice.
Treatment pluralism recognizes that multiple evidence-informed interventions can lead to recovery, rather than assuming that one treatment approach is universally superior.
The goal is not to choose between competing treatment philosophies, but to identify the most appropriate approach based on patient characteristics, clinical context, clinician expertise, and patient preferences.
Current research often focuses on average treatment effects, which may overlook meaningful differences in individual treatment responses. Future research should improve patient stratification and treatment matching.
Evidence-informed practice does not mean applying research findings rigidly; it requires combining scientific evidence, clinical reasoning, and patient values in shared decision-making.
Non-specific effects and contextual factors are not secondary mechanisms but important contributors to therapeutic outcomes that should be acknowledged in clinical practice.
The future of physiotherapy research may rely on improved phenotyping, moderator analyses, and personalized approaches to better understand which treatments work best for which patients.