Which portion of physiotherapy treatments’ effect is attributable to contextual effects in people with musculoskeletal pain?: A meta-analysis of randomised placebo-controlled trials

Review written by Jared Powell info

Key Points

  1. Many physiotherapy treatments have been shown to reduce pain and improve disability.
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There is a myriad of treatment options to help individuals with musculoskeletal (MSK) pain, including manual therapy, exercise-based rehabilitation, education, and dry needling. While these treatments may help reduce pain in an individual with MSK pain, it is often unclear how a reduction in pain is caused. Put simply, what causal process underpins an improvement in pain with various physiotherapeutic treatments?

It has been proposed that an overall treatment effect can be partitioned into specific, non-specific, and contextual effects (1). Specific effects are the intended target of a particular intervention (such as increasing strength or improving intervertebral mobility), non-specific effects refer to changes that occur without treatment, such as the natural history of the condition and regression to the mean.

Contextual effects refer to changes that occur because of the clinical interaction, such as the therapeutic relationship and health care setting. Contextual effects are sown into the fabric of the clinical encounter and can be either positive or negative. There is growing evidence that non-specific and contextual effects make up a large proportion of a treatments effect, however the exact percentage across various physiotherapy treatments is unknown.

The aim of this study was to quantify what proportion of common physiotherapy treatments effects are due to non-specific/contextual effects.

Contextual effects are sown into the fabric of the clinical encounter and can be either positive or negative.
Whenever you see a patient there will be a response that is influenced by you and the setting in which you see them, so it makes sense to try and make this response as positive as you can.


This was a systematic review and meta-analysis using the proportion of contextual effects (PCE) metric.

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