Can a Chiropractor Help Keep Back Pain From Becoming Chronic?
Most recent low back pain improves over time, as the American College of Physicians notes. For people at higher risk, though, it often turns into a long-term problem that keeps getting in the way. PACBACK, a 1,000-person trial reported in JAMA and JAMA Internal Medicine, tested four ways of caring for people at that higher risk, to see which did most to stop that happening. Physical therapists and chiropractors provided the care in three of the four groups.
The short answer
- Coached self-management helped. People coached one-on-one by a physical therapist or chiropractor to manage their own back (exercise, learning how pain works, ways to cope with it) had slightly less impact from back pain 10 to 12 months later than people given medication-based medical care. On a secondary measure, 12% fewer of them reported chronic pain that often got in the way of their usual activities. The researchers call the difference small, but judge it clinically relevant given their other results.
- Spinal manipulation on its own didn't differ significantly from medical care, and adding it to self-management didn't add benefit.
- Over the year, the self-management groups also had slightly less disability than the medical care group. Averaged over the year, pain scores didn't differ significantly between groups.
- In secondary analyses, all three groups that weren't given medication-based care used medication for their back in fewer months.
If your back has been bothering you, you can book a first visit, or read on for how the trial worked.
Dr. Jeff's walk-through of the trial
Jeffrey T. Morrey, D.C., recorded this walk-through of the trial's first report, on disability and pain over the year. It's his take as a chiropractor, and the details further down follow the published papers. Two of those details differ from the video: the trial's self-management program covered pain education, exercise, coping skills and activity planning, not diet or supplements, and the trial measured each approach against medical care rather than ranking self-management against spinal manipulation.
Video: the PACBACK trial (6 min 22 s)
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Watch on YouTube (new tab) ↗Who was in the trial?
The trial enrolled 1,000 adults at research clinics affiliated with the University of Minnesota and the University of Pittsburgh between 2018 and 2023. People qualified if their low back pain episode, whether new or a flare-up of a back problem they already had, was 2 to 12 weeks old, and their pain averaged at least 3 out of 10 over the previous week. Most (70%) were having a flare-up.
They also had to score at medium or high risk on the STarT Back tool, a short questionnaire clinicians use to spot who is more likely to have back pain that persists and gets in the way of daily life. People whose back pain had a specific cause, such as a spinal fracture or an inflammatory arthritis, weren't included. Ninety-three percent of the people who started finished the trial.
What were the four groups?
Everyone got the same booklet on what to expect from back pain and how to manage it. Then each person was assigned at random to one of these, with treatment running for up to 8 weeks:
- Spinal manipulation. Two or more visits of 15 to 20 minutes with a physical therapist or chiropractor, using the kinds of spinal manipulation those professions commonly use, plus soft tissue work, nerve mobilization and moist heat.
- Supported self-management. Four to eight one-hour, one-on-one sessions with a physical therapist or chiropractor, built around a personal plan. People learned how pain works, did exercises for posture, strength, stability and mobility, and practiced stretches. They also learned relaxed breathing, muscle relaxation, guided imagery and ways of rethinking unhelpful thoughts about pain, and planned activities they enjoyed.
- Both. At least four visits of 75 to 80 minutes combining the two.
- Medical care. Two or more visits with a physician or advanced practice clinician for guideline-based medical care, with anti-inflammatories and muscle relaxants as the first medicines tried. Heat, massage or acupuncture could also be recommended.
For the next year, people filled in a disability questionnaire every month and rated their pain every week. At 10 to 12 months they also scored how much back pain was affecting their lives.
Spinal manipulation vs medical care vs self-management: what the trial found
Back pain's impact at 10 to 12 months. This was the trial's measure of whether back pain had become a chronic, life-disrupting problem, scored from 8 to 50 where lower is better. Compared with medical care, scores were 1.7 points lower in the self-management group and 1.3 points lower in the combined group, both statistically significant. Spinal manipulation alone was 0.3 points lower, which wasn't a significant difference. In the self-management group, 64% cut their impact score by half or more, against 55% with medical care. A statistical analysis attributed 76% of the self-management effect to changes in psychosocial factors at 6 months, such as how confident people felt managing their pain and how afraid they were of moving, which the trial measured.
Disability over the year. The Roland-Morris questionnaire asks how back pain is affecting everyday things like getting dressed, walking and sleeping, and scores from 0 to 24, where lower is better. Averaged over the year:
| Group | Average disability score (0 to 24) | Share who cut their disability score by half or more |
|---|---|---|
| Supported self-management | 4.7 | 67% |
| Self-management plus spinal manipulation | 4.8 | 65% |
| Spinal manipulation | 5.5 | 54% |
| Medical care | 5.9 | 54% |
Both self-management groups scored lower than medical care, by about a point, a difference the researchers call statistically significant but small. Spinal manipulation alone didn't differ significantly from medical care.
Pain. Average pain over the year was 2.8 out of 10 in both self-management groups and 3.0 in the other two, not a statistically significant difference.
Medication and satisfaction. In the trial's secondary, exploratory analyses, people in the medical care group used medication for their back in an average of 54% of months from the fourth month on, against 37 to 40% in the other three groups. All three groups that weren't given medication-based care also rated their overall improvement and their satisfaction with care higher.
Safety. About 11% of people reported a back-related adverse event over the year, with small differences between groups. During the treatment period there were three serious events possibly linked to treatment: two people were hospitalized because their back got worse, one in the spinal manipulation group and one in the combined group, and one person in the medical care group had a life-threatening rise in blood pressure.
What it couldn't show. Neither patients nor clinicians could be blinded to which care they got, and the main results were people's own ratings. The self-management groups also spent much more time with a clinician, and the trial didn't separate that out. These are group averages from research clinics, where the care was designed to test specific approaches rather than match everyday practice.
So, can a chiropractor help keep back pain from becoming chronic?
In this trial, the care that lowered back pain's impact a year later was coached self-management: exercise, learning how pain works and ways to cope, taught one-on-one by physical therapists and chiropractors. Spinal manipulation on its own didn't lower it significantly, and adding manipulation to self-management didn't provide additional benefit. The researchers conclude that, while small, the self-management difference appears to be clinically relevant.
Dr. Jeff's take: thoughts, toxins and traumas
In the video, Dr. Jeff connects self-management to an idea he traces back to chiropractic's founders: the "three T's" of thoughts, toxins and traumas. For him, that means stress, what you eat, and the strain that bad posture, inactivity and injuries put on your body. Those are the things he talks with patients about.
He describes it in chiropractic's traditional terms. The trial's program lines up most with his "thoughts" and with the posture and inactivity side of "traumas". His summary of the study is short: "Take care of yourself." He takes the first of the three, thoughts, in a second video, on what a study of adults over 50 found about stress and new pain, and traumas in a third, on what sitting at a desk all day does to your health.
What a first visit looks like here
We start with an exam and tell you what we find before we recommend anything. Depending on what we find, care can include adjustments and rehab exercises to keep up between visits, and we'll talk about the things outside the office that affect your back, like stress, how much you move and your posture.
Some back pain needs emergency care first, including back pain with difficulty passing urine or any other new change in bladder or bowel control, numbness in the area that would touch a saddle, or a leg that's getting weaker. See all the warning signs.
Book a visit
Whether your back started hurting in the last few weeks or has bothered you for longer, a first visit in Clarksville is where we start working out what's behind it. We'll tell you what we find, including when what we find isn't something we treat. If we are not able to help you with your problem or are unable to reduce your pain levels, we will make sure to give you a recommendation to another experienced provider.
Book your first visit or see what's included in the new patient visit.
Research, with context.
Selected published sources behind what we've written, each with what it found and what it can't tell us. We give you both halves because no paper can diagnose you or predict how your own care will go.
Spinal Manipulation and Clinician-Supported Self-Management for Preventing Chronic Low Back Pain Impact: The PACBACK Randomized Clinical Trial
The same 1,000 PACBACK participants: adults with low back pain of 2 to 12 weeks at moderate to high risk of chronic pain, followed for a year.
What it foundAt 10 to 12 months, back pain impact (8 to 50 scale) was 1.7 points lower with physical therapist- or chiropractor-supported self-management and 1.3 points lower with self-management plus spinal manipulation than with medical care. Spinal manipulation alone did not differ from medical care, and adding it to self-management gave no additional benefit.
What it can't tell usThe researchers call the impact difference small, and judge it clinically relevant from the responder analyses and secondary outcomes. Per the trial's first report, patients and clinicians were not blinded and the main outcomes were self-reported.
Publication details & citation
Bronfort et al. Spinal Manipulation and Clinician-Supported Self-Management for Preventing Chronic Low Back Pain Impact: The PACBACK Randomized Clinical Trial. JAMA Internal Medicine. 2026. DOI: 10.1001/jamainternmed.2026.1893.
Read the publication recordSpinal Manipulation and Clinician-Supported Biopsychosocial Self-Management for Acute Back Pain: The PACBACK Randomized Clinical Trial
1,000 adults with low back pain of 2 to 12 weeks, at medium or high risk of persistent disabling pain on the STarT Back tool, treated for up to 8 weeks and followed for a year.
What it foundSelf-management coached by a physical therapist or chiropractor, with or without spinal manipulation, lowered average disability over the year by about 1 point on a 24-point scale compared with medication-based medical care. Spinal manipulation alone did not differ significantly from medical care on disability, and pain did not differ significantly between groups. All three groups not given medication-based care used medication in fewer months.
What it can't tell usThe researchers call the disability difference small, and the secondary outcomes, medication use among them, were exploratory. Neither patients nor clinicians were blinded, the main outcomes were self-reported, and the self-management groups got much more clinician time.
Publication details & citation
Bronfort et al. Spinal Manipulation and Clinician-Supported Biopsychosocial Self-Management for Acute Back Pain: The PACBACK Randomized Clinical Trial. JAMA. 2026. DOI: 10.1001/jama.2025.21990.
Read the publication recordAssociation of Spinal Manipulative Therapy With Clinical Benefit and Harm for Acute Low Back Pain: Systematic Review and Meta-analysis
26 randomized trials of adults with low back pain of six weeks or less, treated with spinal manipulation in outpatient settings, plus observational studies for harms.
What it foundSpinal manipulation was associated with modest improvements in pain and function at up to six weeks (moderate-quality evidence). Minor, temporary effects such as increased pain, muscle stiffness and headache were reported in more than half of patients in large case series, and no trial reported a serious adverse event.
What it can't tell usResults varied a lot between trials, and the review covers only the first six weeks.
Publication details & citation
Paige et al. Association of Spinal Manipulative Therapy With Clinical Benefit and Harm for Acute Low Back Pain: Systematic Review and Meta-analysis. JAMA. 2017. DOI: 10.1001/jama.2017.3086.
Read the publication recordNoninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians
Adults with acute, subacute or chronic low-back pain considering noninvasive management.
What it foundThe guideline prioritizes non-drug options for chronic low-back pain, including exercise. Spinal manipulation is one of several options, supported by lower-quality evidence.
What it can't tell usA guideline pulls together existing evidence; it doesn't report a new experiment. It doesn't establish disc realignment, a cure for everyone, or superiority over all other care.
Publication details & citation
Qaseem et al. Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians. Annals of Internal Medicine. 2017. DOI: 10.7326/M16-2367.
Read the publication record
Our editorial policy explains how to read these sources and what our clinical-review labels mean.