Spine Conversations · Episode 1 · About 8 minutes

In Spine Conversations, Mr Ahmed-Ramadan Sadek talks through common treatments for back and neck pain with the people who deliver them. In this first episode he talks with Sam, a fictional physiotherapist, about what physiotherapy involves, what NICE recommends, what the evidence shows and how to get it.

📄 Download the slides (PDF) · Read the full physiotherapy guide

Transcript

Ahmed: Hello, I’m Ahmed Sadek, a neurosurgeon, and welcome to Spine Conversations from Spinemathema. In this series I talk through common treatments with the people who deliver them. Today it’s physiotherapy for back and neck pain. Before we start, I should say that my guest, Sam, is a fictional physiotherapist voiced using AI. The conversation is scripted, and everything in it comes from our written guide and the national guidance. Sam, welcome.

Sam: Thanks, Ahmed. Happy to be here, even if I am made up.

Ahmed: Let’s start simply. Someone with back pain has been told to see a physio. What do you actually do?

Sam: Physiotherapists are trained to assess and treat problems with movement and function. For back and neck pain, our work has three main parts. Exercises to improve movement and strength. Manual therapy, where we use our hands to massage and move the area. And advice on managing symptoms. But the heart of it is exercise, advice and helping you stay active. The hands-on part sits alongside that, not instead of it.

Ahmed: I think that surprises people. Many expect to lie on a couch and have something done to them.

Sam: It does surprise them. And I understand why. But the treatment that makes the difference is mostly what you do between appointments, not what I do during them.

Ahmed: So what happens at the first appointment?

Sam: I’ll ask about your symptoms, your general health and your daily life. Work, sleep, what you’re finding hard. Then I’ll examine you. I’ll watch how you move, and check your strength and balance. I’ll also ask some screening questions. They’re there to pick up the rare but serious causes of back pain, and if anything worries me, I’ll refer you on.

Ahmed: And what do people leave with?

Sam: Usually a short list of exercises, a plan for staying active, and an idea of how many sessions they might need.

Ahmed: Let’s talk about the guidance. In England, the National Institute for Health and Care Excellence, or NICE, has a guideline on low back pain and sciatica. What does it ask you to do?

Sam: First, give people tailored advice and information so they can manage their own pain, including encouragement to carry on with normal activities. Then consider a group exercise programme. That might be biomechanical, aerobic, mind-body, or a mix, chosen to suit the person.

Ahmed: And manual therapy?

Sam: NICE says it can be considered, but only as part of a package that includes exercise. Spinal manipulation, mobilisation, massage. Never on its own.

Ahmed: There’s also a risk tool, isn’t there?

Sam: Yes. NICE suggests considering one, such as STarT Back, at first contact. It helps us match the level of support to the person. People at low risk get simpler support. People at higher risk get more intensive help. And throughout, the aim is getting back to work and normal daily life.

Ahmed: What I find useful for patients is knowing what NICE says not to offer.

Sam: Agreed. For low back pain, it advises against traction, acupuncture, belts or corsets, foot orthotics, rocker sole shoes, ultrasound, and several electrical treatments. Those include TENS, which stands for transcutaneous electrical nerve stimulation, as well as PENS and interferential therapy.

Ahmed: Those used to be very common.

Sam: They did. So if a clinic builds a whole course of treatment around them, it’s fair to ask why.

Ahmed: Now the question patients really want answered. Does it work?

Sam: For long-standing low back pain, the largest Cochrane review of exercise included two hundred and forty nine trials. It found moderate-certainty evidence that exercise reduces pain compared with no treatment, usual care or placebo. The reduction was around fifteen points on a scale of nought to a hundred. The authors judged that to be clinically important.

Ahmed: And function?

Sam: The improvement in day-to-day function was smaller. Exercise was probably more effective than advice alone or electrical treatments, and about as effective as manual therapy. Side effects were mostly minor, like muscle soreness.

Ahmed: So exercise has the strongest evidence of any physical treatment for long-standing low back pain. But I always want to be honest with people. The benefit is usually moderate, not dramatic.

Sam: I’d say exactly the same. The World Health Organization reached a similar view in its twenty twenty three guideline on chronic low back pain. It supports structured exercise programmes, though it rates the evidence as low certainty.

Ahmed: What about the neck?

Sam: The research is thinner. A Cochrane review of twenty seven trials found no high-quality evidence. But there was moderate-quality evidence that strengthening and endurance exercises for the neck, shoulders and upper back can reduce pain in long-standing neck pain. Stretching on its own didn’t seem to help.

Ahmed: And manual therapy for the neck?

Sam: A twenty twenty five Cochrane review looked at manual therapy combined with exercise, mostly for long-standing neck pain. Compared with no treatment, the combination may produce a large reduction in pain. Compared with a placebo treatment, it may improve function, but it made little or no difference to pain. All of that evidence was low certainty. Only minor side effects were reported, such as short-lived soreness, headache or dizziness.

Ahmed: So if I had to sum it up, physiotherapy doesn’t usually make pain vanish. What it does well is help you move more, worry less, and get back to the things you need to do.

Sam: That’s a good summary.

Ahmed: Let’s be practical. How does someone get physiotherapy?

Sam: On the NHS, in many parts of England, you can refer yourself to a community musculoskeletal service, often called MSK, without seeing your GP first. Search your local NHS trust or integrated care board website for MSK self-referral, or ask at your GP surgery reception. Some practices also have a first contact physiotherapist you can book directly. Waiting times vary a great deal between areas.

Ahmed: And privately?

Sam: Check that your physiotherapist is registered with the Health and Care Professions Council. Physiotherapist is a protected title, so anyone using it must be on that register. The NHS also suggests looking for chartered status, which shows as the letters M C S P after their name. And a good private physio will be clear about how many sessions they expect you to need, and what you should be doing at home.

Ahmed: Last question. How do people get the most out of it?

Sam: Do the exercises. That really is the main thing. Most of the benefit in trials came from regular practice, not from what happened in the treatment room.

Ahmed: And when it hurts?

Sam: Expect some discomfort as you start moving more. Mild, short-lived soreness is normal and isn’t a sign of damage. Ask what the plan is if you’re not improving after several weeks. Be wary of open-ended courses of passive treatment with no exercise in them. And tell your physio if your symptoms change, especially new numbness, weakness, or pain spreading down an arm or leg.

Ahmed: Thank you, Sam. Before we finish, the warning signs. Seek urgent medical help, at A and E or by calling nine nine nine, if you have numbness around the genitals, bottom or inner thighs, new problems passing urine, or loss of bladder or bowel control. These can be signs of cauda equina syndrome. Also seek urgent help for new or worsening weakness in the legs or arms, for clumsy hands, unsteady walking or electric shock sensations with neck pain, and for back or neck pain with a fever, unexplained weight loss, or a history of cancer.

Sam: Physios will always want to know about those straight away too.

Ahmed: This is general information and not a substitute for advice about your own situation, so please speak to your GP or specialist. The full written guide on physiotherapy, with references, is on spinemathema dot com. Thanks for listening.

References

1. NHS. Physiotherapy. Page last reviewed 3 April 2025. Link
2. National Institute for Health and Care Excellence. Low back pain and sciatica in over 16s: assessment and management (NG59). 2016, last updated 2026. Link
3. Hayden JA, Ellis J, Ogilvie R, Malmivaara A, van Tulder MW. Exercise therapy for chronic low back pain. Cochrane Database Syst Rev. 2021;9(9):CD009790. Link
4. World Health Organization. WHO guideline for non-surgical management of chronic primary low back pain in adults in primary and community care settings. Geneva: WHO; 2023. Link
5. Gross A, Kay TM, Paquin JP, et al. Exercises for mechanical neck disorders. Cochrane Database Syst Rev. 2015;1(1):CD004250. Link
6. Chacko N, Gross AR, Miller J, et al. Manual therapy with exercise for neck pain. Cochrane Database Syst Rev. 2025;12(12):CD011225. Link
7. Health and Care Professions Council. Professions and protected titles. Link
8. Hill JC, Whitehurst DG, Lewis M, et al. Comparison of stratified primary care management for low back pain with current best practice (STarT Back): a randomised controlled trial. Lancet. 2011;378(9802):1560-1571. Link
9. Liddle SD, Pennick V. Interventions for preventing and treating low-back and pelvic pain during pregnancy. Cochrane Database Syst Rev. 2015;(9):CD001139. Link
10. NHS. Back pain. Page last reviewed 5 March 2026. Link
11. Davies BM, Mowforth OD, Smith EK, Kotter MR. Degenerative cervical myelopathy. BMJ. 2018;360:k186. Link
12. National Institute for Health and Care Excellence. Chronic pain (primary and secondary) in over 16s: assessment of all chronic pain and management of chronic primary pain (NG193). Published 7 April 2021. Link

This conversation is general information and is not a substitute for advice about your own situation. Please speak to your GP or specialist.

Last checked: October 2026