Many Paths to Recovery: The Case for Treatment Pluralism

Decades of research has not identified a consistently superior treatment for musculoskeletal (MSK) pain conditions. Across trials, interventions such as exercise therapy and manual techniques demonstrate modest, broadly equivalent average treatment effects, likely mediated by overlapping, non-specific and contextual mechanisms. Treatment pluralism provides a practical way to interpret this evidence. It acknowledges that, while treatments may appear comparable at the group level, substantial heterogeneity in treatment effects means that individual patients can respond quite differently. Frameworks such as the Person-Centred Hypothesis (PCH) aim to integrate pain phenotype, context, and pattern recognition to refine treatment selection. For now, predictive precision remains aspirational. Pluralism encourages a bounded range of safe, plausible, evidence-informed treatment options; it allows clinicians to practise with different orientations provided these are communicated transparently and aligned with patient values, goals and preferences. Rather than enforcing uniformity, embracing pluralism offers an honest and patient-centred way to navigate uncertainty in MSK care.