Physiotherapy.
The foundation of back pain treatment.
Movement & therapy
WHO · NICE · KNGF · Zorginstituut
How do we rate this?
We look at whether the pain decreases and whether people can move and function better again, not at how satisfied patients were with the treatment, because that says little about whether it really works. Strong comparative research is scarce for back pain, so some ratings are based on limited evidence.
For back pain that keeps going, physiotherapy is what the guidelines suggest first: the KNGF guideline (2021), NICE (2016) and the WHO (2023) all do. Worth knowing who is saying it, though: the KNGF is the professional body for physiotherapists. The Zorginstituut, which decides on reimbursement and represents no physiotherapists, reached a different conclusion. Further down this page you will find where that difference comes from.
Modern physiotherapy for back pain goes far beyond traditional "exercises". It includes pain education, graded activity, manual therapy and behavioural coaching.
The counter-argument you deserve to know about
Zorginstituut 2024In June 2024 the National Health Care Institute, the body that decides what Dutch basic insurance covers, assessed 42 studies and concluded that first-line physiotherapy and exercise therapy for back pain without a specific physical cause does not belong in the basic package, because there is not enough evidence that it leads to less pain, better functioning and better quality of life than treatment without first-line physiotherapy (standpunt, 25 June 2024). That is a serious verdict from a serious body, and this site is not going to leave it out because it is inconvenient.
What it does not say is “exercise therapy does not work”. The question the Zorginstituut asked is narrower: does the supervision add anything on top of what you would achieve without it? Guidelines ask a broader question and keep recommending supervised exercise, and a 2025 review of 301 placebo-controlled trials does find exercise effective for chronic back pain (Cashin et al., 2025), with a small effect.
Practically: a physiotherapist is worth it if you need guidance to get moving again, if fear of movement is holding you back, or if you cannot judge how fast to build up. If you are already moving well on your own, the honest answer is that a course of physiotherapy may add less than you would hope.
Why guidelines disagreeWhat to expect
Intake and examination (session 1)
The physiotherapist takes a comprehensive history: your complaints, activity level, work, stress, sleep and expectations. A physical examination follows. Red flags are ruled out. You receive an explanation of your condition and a treatment plan.
Pain education
You learn about pain mechanisms, the biopsychosocial model, and why pain does not equal damage. This is one of the most powerful components: understanding reduces fear and promotes recovery.
Exercise therapy
A personalized exercise program you can continue at home. Focus on gradual build-up, not specific muscle-strengthening exercises. The goal is normalizing movement.
Manual therapy (if needed)
Joint mobilization or manipulation can provide temporary pain relief. Used as adjunct to exercise therapy, never as sole treatment.
Self-management
The physiotherapist teaches you to manage your own condition. The goal is independence, not dependence on the therapist.
How long does a course take?
Session 1
Intake & examination
History, physical examination and a plan you make together.
Week 1–6
Guided exercise
Usually 1–2 sessions per week, plus exercises at home.
Week 6–12
Tapering off
Increasingly independent; sessions become less frequent.
After that
On your own
You manage it yourself. Return only if needed.
Direct access
Since 2006, you can go directly to a physiotherapist without a GP referral (Directe Toegang Fysiotherapie). The physiotherapist performs a screening and determines if physiotherapy is suitable. After 3 sessions without improvement, you will be referred back to your GP. Some supplementary insurances may still require a referral for coverage, so always check with your insurer.
When recommended?
- Back pain lasting longer than 6 weeks
- Recurring episodes of back pain
- Back pain limiting daily activities
- Fear of movement or loading
- Need for guidance in building up activities
Sources
Next step