There has been a big hype about a recent meta-analysis that arose in Spine entitled, “Do Manual Therapies Help Low Back Pain?: A Comparative Effectiveness Meta-Analysis” by J. Michael Menke.  Abstract can be found here and conclusion is quoted below with emphasis of last sentence bolded and underlined:

Conclusion. Meta-analyses can extract comparative effectiveness information from existing literature. The relatively small portion of outcomes attributable to treatment explains why past research results fail to converge on stable estimates. The probability of treatment superiority between treatment arms was equivalent to that expected by random selection.Treatments serve to motivate, reassure, and calibrate patient expectations – features that might reduce medicalization and augment self-care. Exercise with authoritative support is an effective strategy for acute and chronic low back pain.

So as a clinician who treats low back pain everyday, I couldn’t agree more that exercise is important.  But, as impractical as meta-analysis are; the question remains; what type of exercise?

Is it yoga? Is it pilates? But wait, those aren’t physical therapist’s brand per say: let’s not go down that track or why have 1:1 care when you can just got a group class.

Is it core strengthening? Doubtful….Just doubtful.

Is it directional preference? Possibly, I always heard 50% of chronic LBP patients have it, 70% of acute patients have it.

Is it self-management strategies (as indicated above through statement of features that augment self-care)? Yes of course. Seriously, do recommend self-management strategies. 

Do you prescribe by listening to signs/symptoms of the patient through a patient-response model? Yes, absolutely.

I, just like any responsible clinician, will tell you: we don’t have the magic bullet for LBP! It is challenging, no doubt.  Very quickly, here are my approaches:

-Just like the meta-analsysis stated, minimize fear (re-assure).  This is an absolute must must easier said than done.  Pain science education has really helped me attack the yellow-flags, as in my earlier years, I just let them hang out and knew in the back of my mind that the prognosis was not as good.  99.99% of patients should get better without having other, more invasive, interventions.

-Minimizing fear and providing reassurance takes more than talking to the patient.  This can include de-emphasizing imaging results. It takes them to be able to move without pain.  So, in order for that to occur, you have to prescribe pain-free exercises—–bottom line.  This varies from patient to patient but I typically approach exercise from addressing a directional preference, if one.  I typically prescribed unloaded exercise (such as plinth exercises) first too as these typically are the most pain relieving.

-I perform manual therapy.  Is it needed?  Yes, in most cases. The reason why I do: because it can then get the patient to move better, easier, with less pain, improved motor control patterns, less restrictions, etc.  Do I boggle them down with a lot of structural faults? No.  This is not necessary.  I think most clinicians who are do not perform manual therapy think that all ‘manual’ therapists are structural-based: not all but you will miss the boat if you don’t.   Do I need to perform manual therapy after 8 sessions?  Hopefully not or I’m not doing something right.  Something to keep in mind about manual therapy: MOST patients want it right? Just read the statement in quotations above that recommend you addressing ‘patient expectations’.

-As symptoms are abolishing, prevention is key.  I don’t have all the answers to prevent re-occurences too.  But, I look at ‘Avoiding Repetitious Behavior‘, help to ‘Change Lifestyles‘, and decrease unnecessary forces on your spine.

-As symptoms are abolishing, you should (if not already) be examining the whole body through regional interdependence.  Dissociation of movements is important to me.

So, out of all of that roundabout hype, what is the answer to what type of exercise is best? My best answer: If you provide an exercise program that is non-threatening, self-applicable on a consistent basis that is adhered to as prescribed, you get within and between visit results, and not just looking at satisfaction but outcomes, then you are doing your job.  Pat yourself on your ass, because this is all we got!

Oh yeh, and ‘manual therapies’ will and can get you there.  Don’t flush it down the toilet yet.

What are your thoughts on this meta-analysis? And I would like what your approach to low back pain is too? I know I’m not always right. 



  1. Harrison,
    I so much agree with your blog. You touch on alot of important points like words that harm and words that heal. Not concentrating on the pathoanatomical or the biomechanics so much but instead looking at the patient response model. I also like your thoughts on set up the patient for success through patient expectations. The problem with low back pain is how it is managed. So what happens to us when we have LBP ..we go the doctor he tells us to take this medicine and rest avoiding vigorous activity so now we develop mal adaptive behaviors…we go back because we are not better…so we get an xray now the doctor tells us we have degenerative disc disease or degenerative joint disease…great just what my mind needs now..more labels so now I become fear ful of activity and on stronger pain meds…now I am not better I go for MRI..NOW I am told I have a bulging disc… mudding the waters even more…so now I am on the road to chronicity and I have a nervous system that has become highly sensitized. I am now the black whole of chronic low back pain. This is where we as physical therapist can intervene early to avoid this from happening. We need to educate our pts about normal radiogrgraphic imaging and that we don’t treat MRI or Xrays. We PT’s treat people. We PT’s are looking at changing the behavior of one’s condition by using the patient response model so we know what those aggravating and easing factors are. From there we can use evidence informed medicine to get our pts better faster. Our society is over imaged and over drugged. We need to get people in to see PTs earlier so we dispel myths about LBP and get people moving so that mal adaptive behavoirs, negative emotions and fear avoidance can be addressed early avoiding chronicity.

    1. Hey Ron,
      Good to hear from you man! I hope all is well in Christiansburg! Sorry I haven’t been in VPTA to catch up with ya lately.

      Thanks for reading and making a very informed comment. I am actually going to print it off and give to my intern now as it is written so clearly! (much better than I can do).

      I think us all PTs know these points…we are running into barriers getting this to the public. May take years or decades. I try to change it on a grassroot level if you may say daily with patients, but this type of information needs to be of more public knowledge.



  2. Have you thought of putting an RSS feed on your blog so that others can subscribe to it instead of adding another email to their overflowing inbox? Just food for thought 🙂

    1. Hey J,
      Yeh you know I had that at one point…but then I thought the RSS feed was going ‘out of style’.

      I’ll look to include it again…thanks for the input!

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