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Sorting crayons: is manual therapy an effective treatment for low back pain?

Posted on January 7, 2014 by Andrew Young

Evidence Reviews
back pain

My wife loves life. She loves playing tennis, reading good books, drinking coffee in the mornings and cooking delicious food (which works out quite well for me). She eats healthy, exercises several times a week, and has never had any serious health concerns. My wife also has recurring low back pain.

My initial reaction to her complaint of low back pain probably sounded like: “What!?! People like you are not supposed to have back pain at 24!”

As it turns out, frequently recurring low back pain without a specific origin or injury is actually quite common. In medical terminology, this is called chronic non-specific low back pain. Research has shown that as many as 60-80% of active people in developed countries incur low back pain at least once in their lifetime.

Treatments for low back pain are as diverse as the different shades of Crayola crayons (I’m talking about the box of 96 crayons with built-in sharpener). One specific type of treatment that has been used for relief of low back pain is manual therapy. Manual therapy is an umbrella term used to describe any type of “hands-on” treatment administered by a health professional. Examples of manual therapy include joint manipulation (usually associated with a chiropractic adjustment when you hear the joints in your spine “pop”), joint mobilization (gentle oscillating movements administered at a joint), and a variety of stretches facilitated by a health care professional. Active exercise is another type of treatment commonly used in the treatment of low back pain. Active exercise is another umbrella term, and it describes any exercises performed to increase strength or endurance of your muscles. When treating low back pain, active exercises usually target your abdominals and back muscles (also referred to as your “core”).

One particular research study I came across specifically tested the effectiveness of manual therapy in combination with active exercise in the treatment of chronic non-specific low back pain.


The researchers recruited forty-two patients with chronic non-specific low back pain, and split them into two treatment groups.


The first treatment group, we will call them “Group A”, received manual therapy in combination with active exercise for 8 therapy sessions over a four to eight week period. The participants were also instructed to complete specific active exercises assigned to them by a skilled physical therapist.

The second treatment group, we will call them “Group B”, received detuned ultrasound in combination with active exercise. Ultrasound is a type of treatment that is used by physical therapists to treat a variety of different impairments a patient may have. Detuned ultrasound is ultrasound that is not actually turned on, however as far as the patient knows the ultrasound machine is humming right along. The reason this was included as a part of the study is to see if even the idea of receiving a treatment improved the patient’s symptoms. Sometimes this concept is referred to as the placebo effect.

What was measured?

The researcher’s decided to measure a number of things in this study. Outcome measurements included pain intensity, disability caused by low back pain, fear-avoidance beliefs (the participants’ opinions on how physical activity and work affect their low back pain), and the endurance of abdominal and back muscles.


  1. Patients in group A (received manual therapy and active exercise) displayed a greater  decrease in pain immediately following treatment when compared to group B (ultrasound and active exercise).
  2. Patients in group A displayed less physical disability following treatment when compared to group B.

Overall Impressions

When looking at this study as a whole, there is a lot to like. First, the overall number of participants in the study was great at 42. Patients were also randomly selected and divided into treatment groups with a good number of overall participants. As the number of participants in a study increases, the results gain more weight. It is also important that the participants are randomly divided between groups so that they are similar prior to treatment. One area in which the study could have improved was in the recruitment of their participants. Every participant in the study was recruited from the same rheumatology hospital in Switzerland. This could mean that the participants in this study do not accurately represent individuals with chronic non-specific low back pain as a whole. In general, however, this study was very well done and offered very few weaknesses.

…And The Survey Says!

(Kudos to all of you who understand that reference)

This study suggests that the use of manual therapy with active exercise as an intervention for chronic non-specific low back pain is an effective mode of treatment.


Balthazard, P de Goumoens P, Rivier G, Demeulenaere P, Ballabeni P, Deriaz O. Manual therapy followed by specific active exercises versus a placebo followed by specific active exercises on the improvement of functional disability in patients with chronic non specific low back pain: A randomized controlled trial. BMC Musculoskeletal Disorders. 2012;13(162):1-11.


Andrew Young

Andrew Young

My name is Andrew Young and I am currently a third year Doctor of Physical Therapy Student at Elon University. I am interested in orthopedic and neurological physical therapy, and am excited about working with patients and their families. In addition to being a physical therapy student, I am also passionate about health and wellness in our communities. I believe that in order to improve our patients' quality of life, we need to focus on all aspects of their wellness. View more posts from Andrew

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