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Exercise and physiotherapy for chronic low back pain

Created: ; Last Update: December 2, 2015; Next update: 2018.

Studies show that multidisciplinary treatment programs and manual therapy can relieve chronic low back pain, at least in the short term – especially if you start doing more physical activity at the same time. Similar claims can be made for acupuncture.

Only a few treatments for chronic low back pain have been proven to help. Many treatments have not been tested well enough to be able to say whether they can effectively relieve pain or improve quality of life in the long term. The same is true of many conservative (non-surgical) treatments for low back pain, such as exercise programs and physiotherapy techniques.

Exercise programs

In the past, people with low back pain were often advised to rest. But lack of exercise can weaken your back muscles and make low back pain worse. It can also lead to other health problems. So nowadays people with low back pain are most likely to hear that they need to get "more exercise."

Regular exercise has also been shown to be very effective at preventing low back pain from returning. Studies show that it can prevent a recurrence in 1 out of 3 people who have recurring acute low back pain. Exercise programs may include things like strength training, stretching, and endurance training. Other kinds of exercise like yoga and pilates may also be suitable for low back pain.

But it is not as clear whether exercise programs also help reduce chronic low back pain. While some studies have found beneficial effects, other studies have not. But exercise programs do seem to improve overall mobility somewhat. The main thing is to be patient: It might take several weeks for the program to have an effect. Your body also has to get used to the extra exercise, and you may have sore muscles at first, but that is nothing to worry about.

If you have low back pain, it is generally important to stay as active and mobile as possible in daily life  so you don't let the pain take over and your body doesn't become weak due to a lack of exercise. Letting your life be dominated by the pain, isolating yourself or stopping doing things you enjoy will make it even more difficult to cope with low back pain.

Staying active despite the pain is often hard, though. Many people are not sure what types of activities are suitable for them. Others are afraid that exercise will make their symptoms worse, or that they might hurt themselves. But there is no reason to be too afraid or to completely avoid exercise in the long run.

Patient education classes

Patient education classes provide you with facts and techniques to help prevent or relieve low back pain. There is usually both a theoretical and practical part. The classes typically include modules on the anatomy of the spine and the back, advice on postures and movements that do not strain the back, and back-strengthening exercises. These courses are often offered at gyms and physiotherapy practices.

Patient education classes have not been proven to help people with chronic low back pain. Some studies found that the programs had a positive effect, while others did not. There are a great number of different patient education classes, sometimes differing greatly in terms of what they cover and the approaches they use. This might explain the differing results of the studies. It is therefore not possible to draw any reliable conclusions about the effectiveness of patient education classes.

Occupational therapy and multidisciplinary treatment programs

Occupational therapy aims to support people who are restricted or might become restricted in their work or everyday life by a disease. Occupational therapy can include professional training in doing everyday tasks and movements properly. Occupational therapists also give advice on things that might help you in your daily activities and check whether it might be a good idea to make some adjustments in your home or workplace. Occupational therapy is designed to relieve pain and restrictions and help you return to work quicker.

In a multidisciplinary treatment program you are supported by specialists from various areas of expertise, such as doctors, physiotherapists and psychologists. The program may involve a combination of drug treatment for pain, exercise programs, occupational and behavioral therapy. These types of programs are often done in groups. They are mostly an option for people who have not benefited from less involved approaches.

Multidisciplinary treatment programs seem to be able to relieve low back pain for a period of at least three months. But there have not been any conclusive studies to give answers to the issue of long-term benefits and possible disadvantages for these programs. It also remains unclear as to how multidisciplinary programs should best be structured in order to be successful. Because cognitive behavioral therapy in particular has been shown in studies to be helpful in the long term as well, multidisciplinary programs that contain this therapy as an element might be worth doing.

Manual therapy

Mobilization and manipulation are both manual therapy techniques (manual comes from the Latin word for hand: "manus"). The goal of manual therapy is to relieve pain and improve joint mobility using certain hand movements.

Mobilization aims to help people improve their range of movement by slowly and repeatedly moving the joints. Sometimes the therapist carries out the movements slowly at first, and then gradually starts doing them faster. In manipulation, on the other hand, small, rapid movements are used in order to try to make the joints more flexible again. This is also known as chiropractic adjustment.

Studies have suggested that manual therapy might relieve chronic low back pain in the short term – especially if physical activity is also increased at the same time. But it is not clear how long this effect lasts.

Manual therapy can sometimes have side effects such as sore muscles and temporary stiff joints or pain.


Massages are a traditional way of treating low back pain. They are meant to relax your muscles, reduce painful muscle tension, and increase your general sense of wellbeing. The aim is also to make your muscles, ligaments and joints more flexible again.

There are different types of massage. Common techniques include traditional (Swedish) massage, Thai massage, and acupressure. The methods differ in terms of the type of hand movements that are used and which parts of the body are massaged. They also vary in the amount of pressure applied, and whether the massage therapist uses their hands, fingertips or special tools.

There is not enough research on whether massage  can relieve chronic low back pain and reduce the limitations caused by the pain. There is also a lack of research on how long massages should last or how often they should be done in order to be effective. And it is not clear whether certain types of massage are more suitable than others.

Depending on how much pressure is applied to the affected area, the massage might be painful or you might feel sore afterwards. Also, some people are allergic to massage oil, which can cause things like rashes.


Osteopathy is a type of alternative medicine. It is based on the idea that all of the body's structures and functions influence each other. This means that problems and diseases in one joint or organ are thought to have an effect on other parts of the body. Connective tissue is considered to be particularly important in osteopathy because it connects the body's different physical structures and organs. There is no scientific proof of this theory, though. 

In osteopathy, therapists use nothing but their hands when performing physical examinations and treatments. The therapist first feels for areas of limited mobility and areas of tension in the body, as well as other kinds of tissue changes. Then they apply various stretching techniques, massage approaches and hand movements to help with these problems. This is also believed to activate the body's self-healing powers and to normalize blood pressure and the flow of lymph fluid.

There are no good-quality studies on the benefits and harms of osteopathy when used for chronic low back pain. In Germany the occupation of "osteopath" is not protected and does not require specific training.


Transcutaneous electrical nerve stimulation (TENS) and percutaneous electrical nerve stimulation (PENS) are types of electrotherapy. These treatments use specialist equipment to trigger electrical impulses in the nervous system. This is done to stop pain signals being sent to the brain and to stimulate the production of endorphins, the body's own pain-relieving hormones. TENS involves placing electrodes on the skin to send electrical impulses through the skin (transcutaneously). In PENS, the electrical impulses are transmitted through acupuncture needles inserted into the skin (percutaneously). Inferential current therapy is another technique that works in a similar way to TENS.

Electrotherapy has not been proven to relieve chronic low back pain. Also, PENS may lead to minor bleeding or an infection where the needles are inserted into the skin.


Acupuncture is a traditional Chinese treatment where thin needles are inserted into very specific points on the skin. According to traditional beliefs, the needles influence the flow of energy through the body when they are placed at points along the energy pathways (meridians). This is thought to activate the body’s own healing powers. But these energy pathways have not been proven to exist. There is also some disagreement about where exactly the needles should be inserted and whether it even makes a difference where they are put.

It is thought that acupuncture may relieve pain through other mechanisms. One theory is that inserting acupuncture needles might cause pain-relieving substances to be released in the nervous system. Studies on acupuncture in chronic low back pain suggest that the treatment may relieve pain somewhat, at least for a short time. But the effect is not especially strong and probably does not last long. Acupuncture seems to be most effective in combination with other treatments like physiotherapy or exercise programs.

The acupuncture needles can sometimes cause minor bleeding or bruising when they are inserted. To avoid infection, it is important to use sterile disposable needles. The risk of serious side effects is low, though.


© IQWiG (Institute for Quality and Efficiency in Health Care)
Bookshelf ID: NBK284944


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