Spinal Manipulation and Clinician-Supported Self-Management for Preventing Chronic Low Back Pain Impact: The PACBACK Randomized Clinical Trial
Clinician-supported self-management modestly reduced later low back pain impact versus medical care.
*Factorial randomized clinical trial; Level 2.
Citation
Bronfort G, Meier EN, Leininger B, et al. Spinal Manipulation and Clinician-Supported Self-Management for Preventing Chronic Low Back Pain Impact. JAMA Intern Med. 2026;186(8):952-963. doi:10.1001/jamainternmed.2026.1893
Background
Acute and subacute low back pain can become chronic and disabling, especially in higher-risk patients. This trial tested whether non-drug approaches could prevent that progression better than guideline-based medical care.
Patients
1000 adults with 2 to 12 weeks of nonspecific low back pain, pain at least 3 of 10, and moderate to high risk for chronic pain. Exclusions included specific spinal causes, contraindications, pregnancy, serious illness, current outside treatment, and non-English fluency.
Intervention
Eight weeks of clinician-supported self-management, spinal manipulation, or both.
Control
Guideline-based medical care, mainly anti-inflammatory drugs and muscle relaxants.
Outcome
Low back pain impact score (8 best to 50 worst), averaged over months 10 to 12.
Follow-up Period
12 months.
Results
| Outcome | Significant finding versus medical care |
|---|---|
| Pain impact score (primary) | Self-management: mean difference −1.7 (95% CI −2.7 to −0.6) |
| At least 50% pain-impact improvement | Self-management: 64% vs 55%; difference 10% (95% CI 2 to 17); NNT 10 |
| Chronic low back pain at 12 months | Self-management: 34% vs 54%; difference −20% (95% CI −28 to −12); NNT 5 |
| Chronic pain interfering with activities | Self-management: 15% vs 27%; difference −12% (95% CI −18 to −5); NNT 9 |
Analyses were intention-to-treat. A 30% within-patient improvement was considered clinically important. Spinal manipulation alone did not improve the primary outcome; adding it to self-management added no benefit.
Limitations
Participants and clinicians were not blinded. The mean score difference was small and below the within-patient clinically important threshold, though responder and secondary outcomes supported clinical relevance. Hispanic, lower-income, and less-educated patients were underrepresented.
Funding
U.S. National Institutes of Health; no funder role.
Clinical Application
For higher-risk acute low back pain, consider early clinician-supported self-management; do not add spinal manipulation solely to prevent chronic impact.
Discussion
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In this 2×2 factorial randomized clinical trial, clinician-supported biopsychosocial self-management lowered 10–12 month low back pain impact vs medical care by −1.7 points and increased ≥50% responders from 55% to 64%; is this effect valid, clinically meaningful, and practice-changing for your patients? In the trial, supported self-management produced about a 10 percentage-point higher rate of ≥50% improvement in low back pain impact than medical care. Which interpretation is most appropriate?