By Amy Hay Azevedo PT ScD COMT

As physical therapists, all of us share a common purpose.  We want our patients to achieve their goals.  This is what drives us to learn more about various pathologies and treatment techniques.  This is why we watch videos on YouTube, read blog posts, research articles, and take continuing education courses.  

So what is the answer?  What is the best treatment?  This question, like many we are asked, has a very common answer “It depends…”

Each patient is unique and each therapist is unique.  Patients differ based on pathology, biopsychosocial considerations (anxiety, depression, prior experiences with pain, family experiences with pain, financial stress, emotional stressors, etc), and other health comorbidities.   As therapists, each of us has, in our treatment tool bag, various manual therapy, exercise, education, and posture and body awareness techniques.  

So what treatments do we choose?  Do we choose only one?  Due to the numerous pain generators, dysfunctions, and goals of the patients, utilizing multiple treatment techniques (manual therapy, education/biopsychosocial treatment, exercise and postural training) is a very efficient and effective way to address the patient’s goals. However, the amounts of each treatment technique required can vary based on three important factors.  

These three factors to consider are:  The clinical diagnosis, patient expectations, and stage of the patient’s pain.

Clinical diagnosis is important for numerous reasons.  The primary reason is to provide an explanatory framework for the patient about what is going on with their body and to decrease their overall fear/anxiety. Explanation helps the patient understand how physical therapy can help them achieve their goals and what they need to do to achieve their goals.  Diagnosis also allows a tailored, efficient, and effective treatment approach to be designed for the patient.  For example, with lumbar stenosis flexion exercises and postural activities are beneficial for treatment.  However, flexion exercises would not be helpful with an acute lumbar disc protrusion patient who is unable to tolerate flexion or sitting activities.  Finally, diagnosis provides us information about local dysfunctions ie segmental hypomobilities that may benefit from mobilization to decrease stress on pain generators. For example, with L5-S1 lumbar stenosis mobilizations to improve thoracolumbar extension can be performed to decrease stress on the stenotic segments.  With disc pathology, disc traction techniques and disc hydration/dehydration techniques can be applied to the symptomatic disc level.  


Patient expectations are a key factor in the development of a treatment algorithm.  Based on a study by Kalauokalani D, et al. patients had better outcomes if they were assigned to the intervention which they expected the greatest benefit.  Therefore, with the history determination of patient expectations is vital to ensure that the components patients feel are valuable will be incorporated into their treatment.  This also allows the patient to play an active role in their healing process and establishes trust as the therapist is listening and responding to what the patient feels would be beneficial.


Acute pain, recurrent and chronic pain each have different pathological considerations that need to be considered.  These considerations also affect which treatment techniques are most beneficial.  With acute pain, the tissue is more of an issue with pain generation.  Therefore, more tissue based manual therapy techniques and modalities can be beneficial initially to decrease the pain.  As pain decreases, exercise and postural/balance training are important to incorporate to prevent recurrence.  Also addressing biopsychosocial factors is important to perform initially with acute pain to assist with decreasing pain and prevent pain from becoming chronic.  With recurrent pain, exercise for strengthening as well as posture and balance training is important initially to improve control and prevent symptom recurrence.  Manual therapy is often applied not to the pain generator with recurrent pain but rather to mobilize hypomobile regions above and below the pain generator to indirectly decrease pain as well as to prevent recurrence.  Biopsychosocial considerations are also very valuable with recurrent pain in order to prevent these patients from transitioning to chronic pain.  Finally, with chronic pain, the central nervous system is the primary pain generator.  Therefore, education and passive as well as active movement to the affected area helps to desensitize the central nervous system.  Manual therapy is not as valuable with these patients to address the pain generator.  However, manual therapy can be performed at sympathetic centers to help decrease their sympathetic response in their neck, upper back and arms or their low back and lower extremities.  

The treatment techniques (manual therapy, exercise, posture, and balance) that we choose for our patients’ plan of care can be higher or lower importance based on the patients’ clinical diagnosis, patient’s expectations, and the stage of the patient’s pain.  

IAOM-US provides courses to assist with clinical diagnosis of spinal pathology as well as treatment techniques for soft tissues, segments, and sensorimotor control.  The above information is more thoroughly covered in the course IAOM-US Course Clinical Reasoning for Spinal Pain Management.  


Kalauokalani D, Cherkin DC, Sherman KJ, et al. Lessons from a trial of acupuncture and massage for low back pain: patient expectations and treatment effects. Spine (Phila Pa 1976). 2001;26:1418–1424.