Almost everyone will deal with back pain at some point in their lives. Most recover quickly—but for about 20% of people, acute pain becomes a chronic condition that interferes with daily life and keeps them out of the workforce.
Low back pain is one of the leading causes of disability worldwide, and more money is spent managing it in the United States than any other health condition. Despite that, the most effective way to prevent a short-term episode from becoming a long-term problem has not been clear—especially for people who are most at risk.
“Chronic low back pain prevention is a public health issue,” said Michael Schneider, D.C., Ph.D., professor in the School of Health and Rehabilitation Sciences at the University of Pittsburgh and co-principal investigator of the Pitt arm of the study. “The 20% of patients who turn chronic account for 80% of the costs and the suffering. This paper shows that helping people self-manage their pain through a properly trained physical therapist or chiropractor is a great way to mitigate this public health problem.”
Results from a randomized clinical trial, published in JAMA Internal Medicine, have found that a personalized self-management program—delivered by physical therapists and chiropractors—was more effective at preventing the conversion to high-impact chronic low back pain than standard medical care or hands-on spinal manipulation alone.
The trial, called PACBACK, enrolled 1,000 adults through Pitt and the University of Minnesota. It was one of the largest clinical trials ever to include spinal manipulation as one of its treatment arms.
Importantly, it didn’t recruit just anyone with back pain. Participants had to have acute or subacute low back pain and score at moderate or high risk of developing chronic pain based on a validated screening tool that accounts for physical and psychological risk factors.
A clinical trial comparing four treatment approaches for low back pain
Participants were randomly assigned to one of four groups for up to eight weeks of treatment and then followed for a full year:
Supported self-management (SSM): A personalized program combining pain education, physical exercises, relaxation techniques, strategies for reframing negative thought patterns and guidance for staying active in daily life—all supervised one-on-one by a physical therapist or chiropractor and designed for home use.
Spinal manipulation therapy (SMT): Hands-on manual therapy techniques commonly used by physical therapists and chiropractors, along with supportive methods like soft tissue mobilization and lumbar neural mobilization.
A combination of both (SSM + SMT).
Guideline-based medical care (MC): Individualized treatment from physicians or advanced practice providers, primarily using anti-inflammatory medications and muscle relaxants following current clinical guidelines.
Self-management improves long-term outcomes for chronic low back pain
When researchers measured outcomes at 10 to 12 months, participants in the self-management group reported significantly lower pain-impact scores compared with those receiving medical care alone. They were also more likely to see meaningful improvement: Sixty-four percent of the self-management group had at least a 50% reduction in pain impact, compared with 55% in the medical care group.
Spinal manipulation was equally effective as medical care in its effect on pain impact, though combining spinal manipulation with self-management didn’t seem to add any extra benefit over self-management alone.
Why the self-management approach to treating chronic low back pain worked
Perhaps the most striking finding was why the self-management approach worked. Three psychological factors—improved self-efficacy, reduced fear of movement and shifts away from unhelpful thinking patterns about pain—explained 76% of the treatment effect.
Carol Greco, Ph.D., emeritus associate professor of psychiatry at Pitt, led the development of the training materials that taught physical therapists and chiropractors how to guide patients through these psychological shifts.
“A lot of what we were doing was give-and-take with the patient, as opposed to, ‘Here’s the booklet, here’s what we’re going to teach you today, here’s what you need to do,'” Greco said. “It was very much tailored and patient-centered.”
Even the language clinicians used mattered. When showing patients the various home-based exercises that were part of the SSM approach, Greco trained providers to say “this is safe” rather than “this won’t hurt you”—because the brain tends to latch onto the word “hurt” even when it’s preceded by “won’t.”
“Hurt does not equal harm—that was another mantra we used,” Schneider added.
Why fear of pain can limit back pain recovery—and what works better for high-risk patients
The researchers stress that spinal manipulation still works—just not for everyone.
“The dramatic responders to manipulation are people with acute pain who aren’t afraid of their pain. They tend to get better quickly,” Schneider said. “But people with fear of movement and higher psychological risk—you can’t just manipulate their spine and expect them to get better without addressing their fear of pain and movement. For those patients, supported self-management can be the winning strategy.”
Next, the team plans to map participants’ weekly pain over the full year and identify characteristics that distinguish responders from nonresponders within each treatment group—work that could eventually help clinicians match patients with the approach most likely to help them and inform future guidelines for managing acute and subacute back pain. https://inside.upmc.com/when-back-pain-wont-quit-a-large-clinical-trial-points-to-the-power-of-self-management/
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