Pain can be exacerbated by ongoing injury, disuse of affected body parts, general deconditioning, and disability. Physical medicine and rehabilitation (PM&R) interventions aim to directly address these issues, complementing and reinforcing pharmacological and psychological treatments.

Despite empiric support for these modalities, however, there is little high-grade experimental evidence demonstrating objective benefits. The oft-cited Philadelphia Panel Physical Therapy study, for instance, found little or no supporting evidence to use the following modalities for the treatment of acute (<6 wks) low back pain: mechanical traction, therapeutic exercise, massage, ultasound, TENS, EMG biofeedback, and postural re-education. Nonetheless, the use of selected PM&R modalities is clearly warranted in cases involving motivated patients, where the emphasis is placed on functional recovery (i.e., of ADLs or return to work) and functional status is closely monitored.

Orthoses – Back brace (back support): a prospective cohort study over 2 years involving thousands of material-handling employees in 30 states revealed that neither frequent back braces use nor policies requiring back brace use were associated with reduced incidence of back injury claims or low back pain (Wassell, 2000). Other studies have also failed to demonstrate the utility of lumbar supports, corsets, braces, or other orthoses in preventing back pain or injury.

Manual therapy – involves a “hands-on” approach and includes modalities such as massage, soft tissue mobilization, and manipulation. Massage is the stroking, friction, and kneading of muscles and soft tissues. Stroking maneuvers can decrease edema and produce muscle relaxation. Friction and kneading massage break down intramuscular adhesions and prepare the muscles and soft tissues for stretching. Myofascial release is a method of soft tissue mobilization that focuses on the fascial component believed to cause pain and dysfunction.

Manipulation is a skilled, passive movement of a spinal segment, usually within and occasionally beyond its active range of motion. Various professionals, including osteopathic physicians, chiropractors, and primary care physicians, use spinal manipulation but differ in the rationale and techniques used.

When combined with exercise, mobilization and manipulation techniques have been shown to be effective for subacute and chronic mechanical neck disorders with or without headache (Gross, 2004). Mobilization or manipulation alone, however, were not effective and there was insufficient literature to support either of these modalities in the presence of radicular pain.

The older evidence-based literature had generally been supportive, if somewhat lukewarmly, of manipulation techniques as primary or adjunctive therapies in nonspecific low back pain. A now classic study published in the New England Journal of Medicine (Cherkin, 1998) compared McKenzie-style physical therapy (PT), chiropractic manipulation, and educational booklet as treatments for patients with nonradiating low back pain. The study found that manipulation was at least as effective as PT. Both therapies were slightly superior to the booklet. A Cochrane Back Review Group review found that manipulative therapy had no clinical advantage over general practitioner care, analgesics, PT, or exercise therapy (Assendelft, 2003). A randomized sham-controlled trial conducted at the Texas Coll. of Osteopathic Med., however, showed benefit from both osteopathic and sham manipulation when used as adjunctive therapies to conventional care, making it unclear if the benefits were due to manipulation or time spent interacting with patients, representing placebo effects (Licciardone, 2003).

Traction involves the manual or mechanical distraction of vertebral bodies and facet joints to reduce pain from nerve irritation. The current literature does not support or refute the effectiveness of traction for neck pain when compared
to placebo traction or other treatment modalities (Graham, 2008). Lumbar traction is not supported by the evidence-based medical literature (Clarke, 2006).

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