Physical therapy

Physical therapy is care from a physical therapist, a health professional who specializes in how the body moves. For neck and back pain, it centers on exercise and on learning to manage your pain. Every state requires physical therapists to be licensed. New physical therapists in the US now earn a doctoral degree, the Doctor of Physical Therapy (DPT).

Some visits may be with a physical therapist assistant, who works under the physical therapist’s direction.

Physical therapy is used for both neck pain and back pain, including pain that spreads into an arm or a leg. Most of the research is on the low back. There is less research on neck pain.

Physical therapy usually combines several parts, planned around your goals and adjusted as you improve.

• Exercise to build strength, endurance and flexibility, and to practice moving with more control.
• Learning about pain. Understanding why pain happens, and that it often does not mean damage, can make it easier to move with less fear.
• Pacing. Planning activity in steady, manageable amounts, so you can do more over time with fewer flare-ups.
• Hands-on treatment, such as moving a stiff joint or working on tight muscles. It may ease pain and stiffness for a while, and it is usually paired with exercise.
• Some physical therapists use a method called McKenzie. They test movements in different directions and may have you repeat one, such as bending backward, if it eases your pain or draws it back toward your spine.
• A home program of exercises between visits, often with written instructions or videos. Doing them regularly is a big part of the treatment.

Researchers think exercise helps in more than one way: stronger muscles, more confidence moving, and a pain system that becomes less sensitive. No one knows yet which of these matters most.

The goal is to help you move and do more, not to change how your spine looks on a scan. Changes on scans, such as worn discs, are common in people with no pain at all.

Getting started

In every US state, you can see a physical therapist without a referral, though many states set limits. Some insurance plans still require a referral or approval before they pay, so it helps to check your plan.

The first visit

Expect questions about how your pain started, what makes it better or worse, and what you want to get back to doing. Your physical therapist will watch how you move and check your strength, flexibility, reflexes and the feeling in your arms or legs.

They also look for signs of a more serious problem that needs medical care. Such problems are uncommon. Then you set goals and make a plan together.

Treatment visits

Visits often last 30 to 60 minutes, once or twice a week for several weeks. The number of visits depends on your needs, your progress and your insurance.

Most of the time is active. You learn and practice exercises, and your physical therapist adjusts them as you improve.

How it may feel

Some muscle soreness is common when you start new exercises. Pain may flare a little as you get moving again. Hurting does not always mean you are doing harm.

Tell your physical therapist if an exercise leaves you much worse the next day, or if pain spreads further down an arm or a leg. They can change the plan.

Long-lasting back pain

For low back pain lasting more than 3 months, exercise lowers pain on average by a modest but meaningful amount, compared with no treatment or usual care. The effect on day-to-day function is smaller. [6]

Compared with other treatments, exercise does only slightly better on average, and about the same as hands-on treatment. Machine-based treatments, such as electrical stimulation or a traction machine, have less support than exercise. [1] [6]

The American College of Physicians lists exercise, and rehabilitation programs that combine exercise with psychological support, among the first treatments to try for long-lasting low back pain. Physical therapy guidelines agree. [1] [8]

New back pain

For new back pain, the added benefit is less clear, partly because most new back pain improves a lot within about 6 weeks anyway. In one US trial of 220 adults with new low back pain, 4 early physical therapy visits improved function slightly at 3 months compared with usual care. The gain was less than a meaningful amount, and pain was no different. [18] [21]

Neck pain

For long-lasting neck pain, exercises that strengthen the neck, shoulders and upper back reduce pain, at least in the short term. Stretching alone may not help much. Neck pain guidelines also support exercise and hands-on care, though the evidence is weaker than for the low back. [2] [5] [22]

Which exercise

No single type of exercise is clearly best. Studies comparing types disagree, and the best choice may be one you enjoy and will keep doing. Programs designed for the person and checked by a therapist tend to do better than exercises done at home with no follow-up. [9] [10] [11]

Averages hide a wide range. Some people improve a lot, and others notice little change.

Common and short lived

• Muscle soreness after new exercises.
• A short-term increase in pain, especially if you do too much too soon.
• Soreness, stiffness or a headache for a short time after hands-on treatment such as spinal manipulation.

Rare but serious

• Serious harm from exercise-based physical therapy is rare. Trials of exercise for back pain have reported mostly minor problems, such as sore muscles.
• Fast, forceful manipulation of the neck has been linked, very rarely, to a tear in a neck artery that can cause a stroke. Experts are not sure whether manipulation causes these tears, or whether an early tear caused the neck pain that led to treatment. Before any neck manipulation, ask about its risks and other options. Call 911 for sudden signs of a stroke afterward, such as dizziness or loss of balance, double vision or loss of vision, a drooping face, weakness or numbness on one side, trouble speaking or swallowing, or a sudden, severe headache.

Other downsides

• It takes time and effort: travel, visits, and exercises at home.
• Copays can add up over many visits, and some plans limit how many visits they cover.
• Progress can be slow, and back pain often comes back later.

When to get help

See the warning signs.