Low back pain affects more than 80 percent of people at some point in their lives, and it can be disruptive and debilitating. Fortunately, most back pain is short-term, or acute, resolving within four weeks or so.
Physical therapy (PT) has been promoted as a treatment for low back pain, although there has been some debate regarding its benefits and when it is most effective. Often, doctors don’t recommend PT for people with low back pain unless they don’t improve with time and self-care, or they’re at risk for developing long-term or chronic back pain. Those at risk for chronic back pain typically have severe pain that doesn’t let up, or pain that radiates down into their legs (radicular pain).
Here’s what you should know if you’re prescribed PT for your low back pain.
What to expect in physical therapy
Before treatment begins, your physical therapist will perform a thorough evaluation that includes questions about your health history and your specific symptoms. Be prepared to describe your symptoms in as much detail as possible. Before creating a treatment program, the therapist will also assess your movements and ask about how you use your body at home.
Physical therapists use a variety of techniques to relieve back pain. Following are a few interventions the American Physical Therapy Association recommends based on sound evidence about their effectiveness:
- Spinal manipulation. This technique, also referred to as thrust manipulation, is similar to the method chiropractors use when they perform a spinal adjustment. The therapist applies a quick force to the joints of the back, which produces a popping or cracking sound. Thrust manipulation can relieve pain and improve spinal mobility.
- Core strengthening exercises. The muscles in your abdomen and pelvic floor area (collectively known as your “core”) support and stabilize your lower back. Strengthening these muscles can help relieve both back pain and disability.
- Flexion exercises. These exercises strengthen abdominal, gluteal, and quadriceps muscles to ease strain on the back. Examples include pelvic tilts, pulling your knees into your chest, and rotating your bent knees from side to side.
- Progressive endurance and fitness exercises. Physical therapists also recommend moderate to high-intensity exercise like riding a stationary bike or walking on a treadmill.
Your physical therapist will teach you how to do some of these exercises at home. Continuing to do them on your own will help you further strengthen the muscles that support your back. The therapist can also show you the proper techniques for sitting, standing, and lifting without straining your back. By continuing to strengthen your back and maintaining proper posture, you can help to prevent future back pain episodes.
What the research says
Research suggests that PT may offer modest relief for acute back pain that doesn’t improve with self-care. It can also help patients avoid a recurrence of pain.
Recently, in its efforts to curb opioid use, the CDC has endorsed PT as a nonpharmacological alternative for pain relief. Also, the American College of Physicians (ACP), in its 2017 guidelines for lower back pain, recommends starting treatment with therapies such as spinal manipulation, exercise, massage, and superficial heat—techniques employed by physical therapists—rather than turning to pain-relieving drugs. The ACP, a professional organization, bases its guidelines on extensive reviews of available evidence.
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Other research has explored the benefits of starting PT as soon as possible after experiencing acute low back pain, and has found the practice both saves money and cuts down on the need for medications and surgery. In a study of approximately 150,000 insurance health claims, published in December 2018 in Health Services Research, the majority of participants (about 80 percent) did not see a physical therapist, just under 9 percent saw a physical therapist first, and the remaining 11 percent saw a physical therapist later (the average time elapsed was 38 days).
Compared to people who saw a physical therapist later or never, those who visited a physical therapist first were 89 percent less likely to receive an opioid prescription, 28 percent less likely to need imaging tests like a computed tomography (CT) scan or magnetic resonance imaging (MRI), and 15 percent less likely to visit an emergency room. They also had significantly lower out-of-pocket, pharmacy, and outpatient (including imaging) health care costs, although they paid more in provider costs to see a physical therapist. (The study did not take into consideration the potential differences in benefits offered by the various health insurance plans.)
Participants who saw a physical therapist first were also 19 percent more likely to be hospitalized for low back pain—but the authors said this finding may have been because physical therapists appropriately referred patients for more specialized care when their pain didn’t improve.
One concern about immediately starting PT is its cost, which can vary depending on your insurance coverage. With private health insurance, you may be responsible for a copay as high as $75 per session—and your provider may limit the number of sessions or months of physical therapy you receive.
Medicare Part B covers 80 percent of the approved cost, once you’ve met your deductible (which was $183 in 2018). But it puts yearly caps on outpatient rehabilitation services, which in 2018 was $2,010.
Back pain guidelines are gradually changing to favor the use of exercise therapy, talk therapy, spinal manipulation, education, and other nondrug, nonsurgical interventions. Yet some doctors still rely too heavily on costlier and less proven interventions like opioids, surgery, and injections, according to an article published in The Lancet in April 2018.
That’s why it’s important to ask your primary care doctor whether PT might be an option for managing your pain. Find out how many PT sessions you’ll need before you should expect to see an improvement, and what home remedies you can try before or along with PT.
Provided your pain isn’t severe or radiating down your leg, you might consider going directly to a physical therapist for your initial consultation. Many states have direct access, meaning that patients can visit a physical therapist without getting a referral from their doctor. Just check with your insurance company first, to make sure PT visits are included, and to find out how many sessions it will cover.
This article first appeared in the 2019 UC Berkeley Back Pain and Osteoporosis White Paper, medically reviewed by Lee H. Riley III, MD.
Also see What Causes Back Pain?
Published August 26, 2019