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

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


Transcutaneous electrical nerve stimulation (TENS) and percutaneous 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 hormones. TENS involves placing electrodes on the skin to send electrical impulses through the skin (transcutaneously). In PENS, the electrical impulses are transmitted through acupuncture 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 infection.

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 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 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.