General Spine Physiotherapy

Physiotherapy for the spine is a broad, active, largely exercise-based treatment aimed at reducing pain and, more importantly, restoring function and confidence in movement. Depending on the problem, a physiotherapist may use graded exercise to build strength and endurance, techniques to improve movement and posture, education about the condition and about staying active, and hands-on manual therapy as an adjunct. What unites good physiotherapy is that it is active and self-directed — the patient does the work, guided by the therapist — rather than something done passively to them. It is delivered by chartered physiotherapists, and the specifics of any programme are their expertise, not mine.

My view, shared by essentially every major guideline, is that most spinal pain does not need surgery and does better with an active, non-operative approach. As a surgeon, that matters to me for two reasons. First, it means I can reassure the majority of people I see that they are likely to improve without an operation, and that physiotherapy is the right first step. Second, for the minority who do need surgery, physiotherapy before and after the operation improves the result. Recognising who genuinely needs an operation and who will do better with physiotherapy is one of the most important judgements I make, and it is only possible because I work within a team that includes excellent physiotherapists.

In practice, this means I refer to and communicate closely with physiotherapy colleagues rather than trying to do their job. When someone comes to me with back or neck pain that does not need surgery, the most useful thing I can do is explain the diagnosis clearly, offer reassurance, and direct them to appropriate physiotherapy. Where surgery is planned, I work with the physiotherapists on preparation beforehand and rehabilitation afterwards. The best outcomes I see come from this kind of joined-up, multidisciplinary care — the surgeon, the physiotherapist and the patient all pulling in the same direction.

The evidence for exercise-based physiotherapy in spinal conditions is extensive and consistent. A large Cochrane review of exercise therapy for chronic low back pain, drawing on hundreds of trials, found that it reduces pain and improves function compared with no treatment or usual care. Major clinical guidelines — including those from the American College of Physicians and the international Lancet Low Back Pain Series — recommend exercise and active, non-pharmacological approaches as first-line care for back pain, and advise against relying on rest, imaging or medication for most people. This is a rare area of strong agreement in spinal medicine, and it is why I place physiotherapy at the centre of the care I recommend.

Because physiotherapy is active, the results depend on engagement over weeks and months rather than a single treatment, and progress is usually gradual. A physiotherapist will assess the individual, set realistic goals, and adjust the programme over time. For most spinal problems this is the mainstay of treatment; where it does not settle the problem, that itself is useful information that helps me and the team decide whether further investigation or, occasionally, surgery is appropriate.

• —Hayden JA, et al. Exercise therapy for chronic low back pain. Cochrane Database Syst Rev 2021. (PMID 34580864)
• —Qaseem A, et al. Noninvasive treatments for low back pain: ACP clinical practice guideline. Ann Intern Med 2017. (PMID 28192789)
• —Chou R, et al. Nonpharmacologic therapies for low back pain: systematic review for ACP guideline. Ann Intern Med 2017. (PMID 28192793)
• —Foster NE, et al. Prevention and treatment of low back pain: evidence, challenges, and promising directions. Lancet 2018. (PMID 29573872)
• —Hartvigsen J, et al. What low back pain is and why we need to pay attention. Lancet 2018. (PMID 29573870)
• —Hayden JA, et al. Meta-analysis: exercise therapy for nonspecific low back pain. Ann Intern Med 2005. (PMID 15867409)