Low Back Pain? Why Hands-On Care and Exercise Beat Pills and Procedures
By Dr. John Mishock, PT, DPT, DC
If you live long enough, your back will complain. Low back pain is now the most expensive health problem in the United States. In 2016, Americans spent an estimated $134.5 billion on low back and neck pain alone—more than on heart disease, cancer, or diabetes. JAMA Network+1 It’s also a leading cause of work disability, accounting for roughly hundreds of millions of lost workdays each year. aprilaba.com
That’s the bad news. The good news? A large body of research now shows that manual therapy plus targeted exercise—what physical therapists and chiropractors do every day—can reliably reduce pain, restore function, and do it in a way that is cost-effective for both patients and the health-care system.
What do we mean by “manual therapy” and “exercise”?
When I talk about manual therapy, I’m referring to hands-on techniques such as:
• Spinal manipulation (“adjustments”)
• Joint mobilization
• Soft-tissue and myofascial techniques
• Gentle traction and movement of stiff segments
We pair that with an individualized exercise program:
• Mobility and stretching for the hips and spine
• Core and hip strengthening
• Directional-preference exercises (moving in the direction that reduces symptoms)
• Gradual return-to-work and sport-specific training
In other words, we don’t just chase pain—we rebuild the system that supports your spine.
How much can exercise really help?
A major Cochrane review in 2021 pooled 249 trials of exercise for chronic low back pain. Here’s what they found: PubMed+2Cochrane+2 Compared with no treatment/usual care, people who did structured exercise rated their pain about 15 points better on a 0–100 scale at about 3 months. Their disability scores (how much back pain limited daily activities) were about 7 points better on that same 0–100 scale. Put simply, if someone started at a pain level of 6/10, exercise often brought them down closer to a 4/10—and with meaningful gains in function (walking, lifting, working).
When exercise was compared to other conservative treatments (like generic advice or minimal care), it still came out ahead: About 9 points less pain and 4 points less disability than other non-exercise approaches. PMC
Those aren’t miracle-cure numbers, but they are real, reproducible improvements from something that’s safe, low-risk, and under your control.
Does manual therapy (spinal manipulation/mobilization) add value?
Short answer: yes—especially when combined with exercise. A large best-evidence review found moderate-quality evidence that manipulation and mobilization reduce pain and improve function in chronic low back pain, with effects similar to recommended medications and exercise. thespinejournalonline.com+1 For acute low back pain (less than 6 weeks), a 2017 JAMA systematic review of 26 randomized trials showed that spinal manipulative therapy produced statistically significant improvements in pain and function over the first six weeks—modest in size but clinically meaningful, with mostly minor, short-lived side effects like temporary soreness. APTA Orthopedics A systematic review specific to physical therapists concluded there is support for
PT-delivered spinal manipulation as part of routine care. PMC Think of manual therapy as the “accelerator” that can quickly reduce pain and stiffness so that you can fully participate in the exercise program that makes lasting change. A 2024 mega-review of over 300 randomized trials found that only a small group of non-surgical treatments clearly help back pain—among them, exercise and spinal manipulative therapy. The Guardian That’s a strong vote in favor of a hands-on, movement-based plan.
Why this approach is cost-effective (for you and the system)
We’re spending a fortune on the wrong things. Analyses of U.S. health spending show that low back and neck pain lead the pack at $134.5 billion per year, with costs growing faster than many other conditions. JAMA Network+2PMC+2 Crucially, only about 10% of back-pain cases are severely disabling, yet they account for around 85% of total costs—often because these patients end up in cycles of imaging, injections, long-term medications, and sometimes surgery. Medical Journals Sweden
That’s where early, conservative care can change the trajectory.
Seeing a physical therapist first changes the whole cascade.
A large Health Services Research study analyzed 150,000 insurance claims for people with new episodes of low back pain. Patients who saw a physical therapist as their first point of care had: UW Medicine | Newsroom
• 89% lower probability of receiving an opioid prescription
• 28% lower probability of getting advanced imaging (like MRI)
• 15% lower probability of visiting the emergency department
• Significantly lower out-of-pocket costs
That’s huge. Every MRI avoided can save over a thousand dollars. Every prevented ER visit or opioid prescription saves not just money, but future complications.
Early PT is a “good buy” in cost-effectiveness studies.
In one economic analysis, patients who had early physical therapy for low back pain cost the system about $580 more per person than usual care over one year, but they gained an extra 0.02 quality-adjusted life-years (QALYs)—about one extra week of “perfect-health-equivalent” life. That translates to ~$32,000 per QALY, which is well below the commonly accepted U.S. thresholds ($50,000–$100,000 per QALY). PubMed
In plain English: spending a few hundred extra dollars up front on high-quality PT buys better health at a price that health economists consider a bargain.
Exercise therapy consistently proves to be cost-effective.
A 2019 systematic review and meta-analysis of cost-effectiveness studies concluded that exercise therapy is generally cost-effective compared with usual care for subacute and chronic low back pain. PubMed+1
International pain experts (IASP) reached a similar conclusion: among all the treatments studied for chronic low back pain, exercise, spinal manipulation, interdisciplinary rehab, and cognitive-behavioral approaches are the ones with the strongest cost-effectiveness data. IASP
Fewer sick days and doctor visits.
In a 12-week structured exercise program for people with hip, knee, and back pain in the UK (over 40,000 participants), researchers found: The Guardian
• 35% reduction in pain
• 29% fewer visits to the GP
• 50% fewer sick days
• 21% reduction in the need for family caregiving
Scaling that kind of program nationally was estimated to generate tens of billions of dollars in economic and social value.
When your back hurts less, you’re not just saving on copays—you’re back at work sooner, moving more, and needing fewer visits overall.
The bottom line
Low back pain is common, costly, and frustrating—but it’s not hopeless.
A program built around manual therapy plus exercise is one of the few approaches that:
• Has solid evidence for real (if not magical) pain relief
• Improves function and quality of life
• Reduces reliance on opioids, imaging, and emergency care
• Is cost-effective for both individuals and the health-care system
If your back is talking to you, consider making your first stop a physical therapist or chiropractor who emphasizes hands-on care, movement, and education—not a prescription pad.
We can help!
If pain is limiting you from doing the activities you enjoy, give Mishock Physical Therapy a call: locations in Gilbertsville (610-327-2600), Skippack (610-584-1400), Phoenixville (610-933-3371), Boyertown (610- 845-5000), Limerick (484-948-2800) at www.mishockpt.com or request your appointment by clicking here.
Dr. Mishock is one of only a few clinicians with doctorate-level degrees in both physical therapy and chiropractic in the state of Pennsylvania. He has also authored two books; “Fundamental Training Principles: Essential Knowledge for Building the Elite Athlete”, “The Rubber Arm; Using Science to Increase Pitch Control, Improve Velocity, and Prevent Elbow and Shoulder Injury” both can be bought on Amazon or train2playsports.com.
