First-Line Treatment for Spine and Joint Pain: What the Research Says About Non-Surgical Care
- Robert J. Zapf, M.S., D.C.
- Feb 15
- 9 min read
Updated: 1 day ago
Author: Dr. Robert J. Zapf, M.S., D.C.
Virginia Back Doctor | Fairfax, Virginia
Date: February 2026
Table of Contents
Pillar 1: Spinal Manipulative Therapy
Pillar 2: Physical Therapy Modalities
Pillar 3: Targeted Rehabilitation Exercise
What Is “First-Line Treatment”?
When medical guidelines designate something as “first-line treatment,” they make a clear statement: this is the approach that should be tried first—before drugs, injections, or surgery.
For back pain, neck pain, and joint pain, first-line treatment now means starting with the safest, most effective conservative approaches that work with the body’s natural healing processes. It means avoiding unnecessary medications with serious side effects and delaying or preventing surgery when hands-on care can achieve comparable results.
This isn't just my personal opinion. This is the position of some of the most respected medical organizations in the world.
The Old Approach: Drugs and Surgery First
For decades, the standard approach to spine and joint pain followed a predictable path:
Step 1: Prescription pain medications—often NSAIDs, muscle relaxants, or opioids
Step 2: Diagnostic imaging (MRI, CT scans)—frequently ordered too early
Step 3: Injections—epidural steroid injections, nerve blocks
Step 4: Surgery—spinal fusion, discectomy, laminectomy
Conservative care—including chiropractic, physical therapy, and exercise—was often treated as a last resort, something to try only after medications failed or as post-surgical rehabilitation.
In my view, and in light of current research, this sequence had it backwards.
The Risks and Shortcomings of Drugs and Surgery
Medications
NSAIDs (ibuprofen, naproxen): Associated with gastrointestinal bleeding and ulcers, increased cardiovascular risk with long-term use, and potential kidney and liver toxicity.
Opioids: High addiction potential, risk of respiratory depression and overdose, and limited evidence for long-term effectiveness in chronic musculoskeletal pain. Among Medicare beneficiaries, adverse drug events are substantially more frequent when opioid analgesics are used as first-line treatment compared with nonpharmacologic approaches.
Muscle relaxants: Can cause marked sedation, dependency risk, and cognitive impairment, with sparse evidence for benefit beyond short-term use.
Surgery
Surgery can be life-changing and absolutely the right choice for some people. However, for many common spine conditions:
Long-term outcomes beyond 24 months often show no significant difference between surgical and conservative approaches for lumbar disc prolapse.
Reoperation rates for spinal surgery commonly range from 8–12%.
The bottom line: when we rush into surgery without a solid trial of conservative care, some patients go through major procedures-and associated risks-when they might have achieved similar or better outcomes with safer options.
The Paradigm Shift: Why Guidelines Changed
Two major forces drove the shift toward conservative first-line care.
The Opioid Crisis
The opioid epidemic forced the medical community to confront the risks of relying on prescription opioids for pain management. The CDC now states that nonopioid therapies are preferred for subacute and chronic pain.
In Virginia, this shift is written into regulation. The Virginia Board of Medicine requires that nonpharmacologic and non-opioid treatments must be given consideration before treating chronic pain with opioids.
The Weight of Evidence
Decades of peer-reviewed research in journals such as Annals of Internal Medicine, JAMA, and the Cochrane Database of Systematic Reviews consistently show that conservative, hands-on care is effective, safe, and often comparable to surgery for many spine-related conditions.
The result is a fundamental reordering of treatment priorities.
The New Medical Guidelines
American College of Physicians (2017)
The American College of Physicians (ACP), representing about 159,000 internal medicine physicians, recommends nonpharmacologic treatment first for acute, subacute, and chronic low back pain. Recommended options include spinal manipulation, exercise, manual therapy, and heat therapy.
Medication is reserved for cases where conservative approaches prove inadequate, and even then, nonopioid medications are preferred over opioids.
JAMA Systematic Review (2025)
A systematic review in JAMA reported that spinal manipulative therapy is associated with significant improvements in pain and function for up to six weeks in patients with acute low back pain, with no serious adverse events reported across the included studies.
The evidence was strong enough to support spinal manipulation as a first-line treatment.
Cochrane Review (2026)
A recent Cochrane review examined 76 studies with 11,866 participants and found that spinal manipulation produced medium to large improvements in functional status compared with no treatment, with only minor, transient side effects and no serious adverse events observed.
CDC Guidance
The CDC’s clinical guidance emphasizes that for most subacute and chronic pain conditions, including common spine and joint problems, nonopioid therapies such as spinal manipulation and physical therapy should be prioritized.
Our Three-Pillar Treatment Program
Research supports a multimodal approach as the most effective form of conservative care. The three pillars of treatment in this clinic reflect that evidence.
Pillar 1: Spinal Manipulative Therapy (SMT)
Spinal manipulative therapy uses controlled, specific forces applied to spinal and extremity joints to restore motion, reduce pain, and improve function.
Key effects:
Restores more normal joint mechanics and reduces muscle spasm
Stimulates sensory receptors that can inhibit pain signals and promote release of the body’s own pain-relieving chemicals
Produces joint “gapping” that can increase space in and around the intervertebral foramen, helping relieve pressure on compressed or “pinched” nerve roots—a common cause of radiating arm or leg pain, numbness, and weakness
May reduce local inflammation and improve tissue healing dynamics
What recent studies show:
A randomized controlled trial in The American Journal of Medicine found that adding spinal manipulation to physiotherapy for patients with subacute and chronic lumbar radiculopathy led to significantly greater reductions in pain and disability than physiotherapy alone, with benefits still present at three months.
A 2023 randomized clinical trial in the Journal of Manual and Manipulative Therapy showed that both spinal manipulation and mobilization, when combined with neurodynamic mobilization, improved back and leg pain, neurological findings, and quality of life in patients with MRI-confirmed disc herniation and radiculopathy, with 95–100% of patients improved at one-year follow-up.
Future spoke posts will cover SMT in more detail for low back pain, neck pain, sciatica, cervicogenic headache, and joint pain.
Pillar 2: Physical Therapy Modalities
Physical therapy modalities reduce pain, improve tissue health, and prepare the body for active rehabilitation.
Modalities used:
Massage and soft tissue mobilization: Decreases muscle tension, improves circulation, and addresses myofascial restrictions.
Trigger point therapy: Targets irritability within taut bands of muscle; imaging and clinical studies support its role in relieving referred pain and improving function.
Muscle stimulation (electrical stimulation): Helps with muscle re-education, pain modulation, and edema reduction through controlled electrical impulses.
Therapeutic ultrasound: Uses sound waves to promote soft tissue healing and decrease pain; systematic reviews report benefit for myofascial pain syndrome.
Shortwave diathermy: Delivers deep heating to muscles and joints, reducing pain and stiffness; recent work combining shortwave diathermy with exercise showed statistically significant reductions in pain and disability in musculoskeletal conditions.
Non-surgical spinal decompression: A form of motorized traction that gently lowers intradiscal pressure, encouraging retraction of herniated disc material and improved nutrient flow. Clinical reports describe substantial pain reduction, reduced disability, and MRI evidence of increased disc height in patients with lumbar disc herniation treated with non-surgical decompression.
Why multimodal care matters:
Studies of patients with chronic low back pain show that adding spinal manipulation to a multimodal treatment program leads to better pain and functional outcomes than single interventions alone.
Upcoming spoke posts will explain when and why each modality is used for specific diagnoses.
Pillar 3: Targeted Rehabilitation Exercise
Passive treatments can calm pain, but exercise drives long-term change.
Core elements:
Flexibility training to restore range of motion
Strengthening exercises to support vulnerable spinal and joint structures
Endurance training to improve tolerance for daily activities
Neuromuscular control exercises to retrain movement patterns and proprioception
Functional training focused on real-world activities such as work, housework, and recreation
Evidence highlights:
The ACP guidelines give exercise therapy a top recommendation for chronic low back pain.
Research compiled in musculoskeletal journals shows that at least six weeks of structured exercise therapy reduces pain and disability in low back pain, and ongoing exercise helps prevent recurrence.
Early physical therapy within three months of diagnosis in large claims datasets was associated with 7–16% lower risk of long-term opioid use and, among those who used opioids, a 5–10% reduction in total opioid consumption.
Receiving physical therapy within two weeks of onset of back, neck, or knee pain has been linked to up to 60% lower odds of later opioid use.
Exercise is not optional. It is the engine that sustains improvement and reduces the chance that pain returns.
What Patients Say: Satisfaction With Conservative Care
Medicare Patient Satisfaction
Among a sample of 380 Medicare beneficiaries in an American Specialty Health analysis:
96.9% reported that their chiropractor was successful in treating their main condition.
91% rated their chiropractic provider a 9 or 10 out of 10, compared with a benchmark of 79% of providers receiving such high ratings.
Regional CAHPS (Consumer Assessment of Healthcare Providers and Systems) surveys consistently place chiropractic services in very high percentiles for overall satisfaction.
Systematic Review of Patient Experience
A 2024 systematic review of patient experience and satisfaction with chiropractic care across 43 studies found that satisfaction with chiropractic was consistently high and often higher than for other healthcare professions. Patients highlighted pain relief, clear communication, time spent with them, and involvement in decision-making as key drivers.
Gallup–Palmer National Data
A Gallup–Palmer report on adults with back or neck pain in the United States found that:
79% of adults with these conditions would prefer to try options other than prescription medication first.
Many respondents chose chiropractic because they believed it offered the most effective and safest treatment with fewer side effects compared with other options.
For Medicare patients, analyses also suggest that those who use chiropractic care as part of their management of low back pain have lower total costs and shorter episodes of care compared with those treated with medical care alone.
Why This Matters for You
The evidence, guidelines, and patient experience all point in the same direction:
Conservative treatment combining spinal manipulation, physical therapy modalities, and therapeutic exercise should be the first choice, not a last resort, for most patients with back, neck, and joint pain.
This approach is evidence-based and guideline-recommended, not experimental.
It offers lower risk than chronic medication use and many surgical procedures.
It empowers patients through education and active participation rather than dependence on passive care.
This clinic’s three-pillar approach is built on those principles and aligned with current medical guidelines and Virginia regulations.
If you are experiencing spine or joint pain, effective treatment exists that does not require a prescription or a surgical procedure as the first step. The choice of where to begin your care can change the entire trajectory of your health.
Coming Next in This Series
This hub post introduces the overall framework. The following spoke posts will go deeper into specific conditions and treatments related to the paradigm shift in pain management:
SMT for Low Back Pain: The 2025–2026 Evidence Update
Neck Pain and Cervicogenic Headaches: Conservative Care Guidelines
Sciatica and Radiating Pain: When Nerves Are the Problem
Why Exercise Therapy Is Essential—Not Optional
Manual Therapy vs. Medication: What the Research Shows
Non-Surgical Spinal Decompression: How It Works and Who It Helps
Avoiding Surgery: Long-Term Outcomes of Conservative Care
The Opioid Crisis and Conservative Care: Changing the Trajectory
Multimodal Treatment: Why Combining Therapies Works Better
Joint Pain and Arthritis: Non-Surgical Options for Hip, Knee, and Shoulder
Patient Safety in Conservative Care: Understanding the Risks
Cost-Effectiveness: Conservative Care vs. Surgery and Medication
Each spoke post will link back to this hub and to other related posts, so readers can easily find articles most relevant to their condition.
References
Centers for Disease Control and Prevention. Nonopioid therapies for pain management.
American Chiropractic Association / American Specialty Health. Increase access to chiropractic services to decrease costs in Medicare.
Journal of Musculoskeletal Surgery and Research. Surgical versus conservative management of lumbar disc prolapse.
Progressive PT and Rehab. Long-term outcomes the same for physical therapy vs surgery for spinal stenosis.
Virginia Board of Medicine. Treatment of chronic pain with opioids, 18VAC85-21-70.
American College of Physicians. Noninvasive treatments for acute, subacute, and chronic low back pain: ACP guideline.
JAMA/Palmer summary: Further support for spinal manipulation for acute low back pain.
Cochrane Library. Spinal manipulative therapy for adults with chronic low back pain.
StatPearls. Cervical Radiculopathy.
Journal of Orthopaedic & Sports Physical Therapy. Spinal manipulative therapy for spinal pain.
Ghasabmahaleh SH et al. Spinal manipulation for subacute and chronic lumbar radiculopathy: randomized controlled trial.
Evaluating Manual Therapy in Musculoskeletal Pain.
Effectiveness of ultrasound therapy on myofascial pain syndrome.
Efficacy and safety of low-intensity ultrasound therapy for myofascial pain.
Shortwave diathermy clinical studies for musculoskeletal pain.
Clinical and imaging outcomes of non-surgical spinal decompression for lumbar disc herniation.
Content on exercise therapy and chronic low back pain.
Stanford early physical therapy and long-term opioid use.
Early physical therapy and reduced odds of opioid use.
Allina Health, Chiropractic spine care and CAHPS findings.
Patient experience and satisfaction with chiropractic care: systematic review.
Gallup–Palmer report on preferences for chiropractic care.
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