Passive treatments: Massages, heat and manual therapy

Photo of a massage
PantherMedia / Wavebreakmedia ltd

Passive treatments such as massages or applying heat may help relieve back pain for a short time, if at all. Some of these treatments can improve your wellbeing. But active treatments are more important when trying to improve low back pain. These include exercise and strength training, relaxation techniques and psychological treatments.

Research has shown that active treatments provide the most effective relief for non-specific low back pain. By "active" we mean treatments that you actively participate in, that you carry out yourself and also continue doing yourself over the long term. Examples of active treatments include exercises to strengthen and stretch your muscles, pilates, yoga and relaxation techniques. Psychological treatments such as or cognitive behavioral therapy are also considered to be active treatments.

Passive treatments, on the other hand, are carried out by other people – because you can't do them yourself or because they don't involve being active yourself. These treatments include the following:

  • Acupuncture
  • Electrotherapy
  • Kinesiology taping
  • Short-wave diathermy
  • Laser therapy
  • Magnetic field therapy
  • Manual therapy techniques such as manipulation and mobilization of the spine
  • Massages
  • Osteopathic treatments
  • Applying heat or cold
  • Therapeutic ultrasound
  • Traction

According to previous research, passive treatments only help for a short time or do not help at all. Many of them haven't been properly tested in good studies. When it comes to most of the complementary or alternative medicine approaches, such as magnetic field therapy, there is no scientifically plausible explanation for how they might work either. The claimed mechanisms of action often contradict the basic principles of science. Most of the passive treatments are classed as individual health care services in Germany (individuelle Gesundheitsleistungen, or IGeL for short), which means they aren't covered by German statutory health insurers.

Although things like massages, applying heat or can improve your wellbeing, they don't help in the long term so they aren't a solution for chronic back pain. In the German national guidelines (Versorgungsleitlinie), these passive treatments are therefore only seen as an option when used in addition to active treatments.

The national guidelines consist of a collection of recommendations to improve the care of people with back pain. They were developed by several medical societies in Germany, based on current research.

Acupuncture

Acupuncture is a traditional Chinese treatment in which thin needles are inserted into specific points on the skin. According to traditional beliefs, the needles influence the flow of energy through the body when they are placed at points along the energy pathways (meridians). This is thought to activate the body’s own healing powers. But these energy pathways haven't been proven to exist. Research has shown that it doesn't matter where exactly you insert the needles and whether they actually enter the skin or not.

There aren't many good-quality studies on for the treatment of chronic back pain. The best study concluded that wasn't more effective than "fake" . Other studies found that was slightly better at relieving the pain. But the effect was only small and didn't last long.

Inserting the needles sometimes causes minor bleeding or bruising. To avoid , it is important to use sterile disposable needles. The risk of serious side effects is low.

Electrotherapy

Transcutaneous electrical nerve stimulation (TENS) and electrical nerve stimulation (PENS) are types of electrotherapy. These treatments use specialist equipment to trigger electrical impulses in the nervous system. This is done to stop pain signals being sent to the brain and to stimulate the production of endorphins, the body's own pain-relieving . TENS involves placing electrodes on the skin to send electrical impulses through the skin (transcutaneously). In PENS, the electrical impulses are transmitted through needles inserted into the skin (percutaneously). Inferential current therapy is another technique that works in a similar way to TENS.

Electrotherapy hasn't been proven to relieve chronic back pain. In PENS, the small punctures in the skin may lead to minor bleeding or an .

Mobilization and manipulation of the spine

Mobilization and manipulation are both types of manual therapy ("manual" comes from the Latin word for “hand”: manus). In mobilization, the therapist slowly moves the joint within its natural range of movement. Manipulation therapy, on the other hand, involves using short, sharp movements to push a joint beyond its normal range of movement.

This type of sudden manipulation is also known as chiropractic adjustment. Popping or cracking sounds may be heard during the procedure. These sounds occur when small bubbles of gas in the joints burst, just like when people crack their knuckles. It's not exactly clear how these approaches are meant to work. Some of the current theories involve the release of muscle tension, the "unsticking" of tissue that is stuck together, and the realignment of certain joint structures.

There are only a few good-quality studies on the manipulation and mobilization of the spine for the treatment of chronic back pain. Further research is needed in order to properly assess the effectiveness of these treatments.

Manual therapy can sometimes have side effects such as sore muscles, cramping and temporary stiff joints or pain. More serious complications of joint manipulation, such as broken bones or partial paralysis, are very rare. They could occur if, for instance, someone has osteoporosis or if the manipulation leads to a slipped disk or makes an existing slipped disk worse.

Massages

Massages are a traditional way of treating back pain. They are meant to relax your muscles, reduce painful muscle tension, and increase your general sense of wellbeing.

There are different types of massage. Common techniques include traditional (Swedish) massage, Thai massage, and acupressure. The methods differ in terms of the type of hand movements that are used and which parts of the body are massaged. They also vary in the amount of pressure applied, and whether the massage therapist uses their hands, fingertips or special tools.

Massages can relieve chronic back pain a little, for a short time, but they don't have a lasting effect. Depending on how much pressure is applied to the affected area, the massage might be painful or you might feel sore afterwards. Some people are allergic to massage oil, which can cause things like rashes.

Osteopathy

Osteopathy is a type of alternative treatment. It is based on the idea that all of the body's structures and functions influence each other. This means that problems and diseases in one joint or organ are thought to have an effect on other parts of the body. Connective tissue is considered to be particularly important in osteopathy because it connects the body's different physical structures and organs. There is no scientific proof that this theory is true, though.

In osteopathy, therapists use nothing but their hands when performing physical examinations and treatments. The therapist first feels for areas of limited mobility and areas of tension in the body, as well as other kinds of tissue changes. Then they apply various stretching techniques, massage approaches and hand movements to help with these problems. One type of osteopathic treatments is known as "muscle energy techniques." The aim of these approaches is to release areas of physical tension by tensing the muscles and stretching. Research on osteopathic treatments for back pain have produced contradictory results. There is no proof that muscle energy techniques work.

In Germany, the job title "osteopath" isn't protected and doesn't require specific training.

Other treatments

Other treatments that haven't been proven to help reduce back pain include kinesiology taping, short-wave diathermy, laser therapy, magnetic field therapy and therapeutic ultrasound. The German national guidelines (Versorgungsleitlinie) do not recommend using these treatments for back pain.

Bundesärztekammer (BÄK), Kassenärztliche Bundesvereinigung (KBV), Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften (AWMF). Nationale Versorgungsleitlinie Nicht-spezifischer Kreuzschmerz. AWMF-Registernr.: nvl-007. March 2017.

Chenot JF, Greitemann B, Kladny B, Petzke F, Pfingsten M, Schorr SG. Nichtspezifischer Kreuzschmerz. Dtsch Arztebl Int 2017; 114(51-52): 883-890.

Chou R, Deyo R, Friedly J, Skelly A, Hashimoto R, Weimer M et al. Noninvasive Treatments for Low Back Pain. February 2016. (AHRQ Comparative Effectiveness Reviews; Volume 169).

Chou R, Deyo R, Friedly J, Skelly A, Hashimoto R, Weimer M et al. Nonpharmacologic Therapies for Low Back Pain: A Systematic Review for an American College of Physicians Clinical Practice Guideline. Ann Intern Med 2017; 166(7): 493-505.

Franke H, Franke JD, Fryer G. Osteopathic manipulative treatment for nonspecific low back pain: a systematic review and meta-analysis. BMC Musculoskelet Disord 2014; 15: 286.

Franke H, Fryer G, Ostelo RW, Kamper SJ. Muscle energy technique for non-specific low-back pain. Cochrane Database Syst Rev 2015; (2): CD009852.

Nielsen SM, Tarp S, Christensen R, Bliddal H, Klokker L, Henriksen M. The risk associated with spinal manipulation: an overview of reviews. Syst Rev 2017; 6(1): 64.

Skelly AC, Chou R, Dettori JR, Turner JA, Friedly JL, Rundell SD et al. Noninvasive Nonpharmacological Treatment for Chronic Pain: A Systematic Review. June 2018. (AHRQ Comparative Effectiveness Reviews; Volume 209).

Wu LC, Weng PW, Chen CH, Huang YY, Tsuang YH, Chiang CJ. Literature Review and Meta-Analysis of Transcutaneous Electrical Nerve Stimulation in Treating Chronic Back Pain. Reg Anesth Pain Med 2018; 43(4): 425-433.

IQWiG health information is written with the aim of helping people understand the advantages and disadvantages of the main treatment options and health care services.

Because IQWiG is a German institute, some of the information provided here is specific to the German health care system. The suitability of any of the described options in an individual case can be determined by talking to a doctor. informedhealth.org can provide support for talks with doctors and other medical professionals, but cannot replace them. We do not offer individual consultations.

Our information is based on the results of good-quality studies. It is written by a team of health care professionals, scientists and editors, and reviewed by external experts. You can find a detailed description of how our health information is produced and updated in our methods.

Comment on this page

What would you like to share with us?

We welcome any feedback and ideas. We will review, but not publish, your ratings and comments. Your information will of course be treated confidentially. Fields marked with an asterisk (*) are required fields.

Please note that we do not provide individual advice on matters of health. You can read about where to find help and support in Germany in our information “How can I find self-help groups and information centers?

Created on February 14, 2019
Next planned update: 2022

Authors/Publishers:

Institute for Quality and Efficiency in Health Care (IQWiG, Germany)

How we keep you informed

Follow us on Twitter or subscribe to our newsletter or newsfeed. You can find all of our films online on YouTube.