FR Specialty: Interprofessional

Systematic Review and Meta-Analysis Volume 1 · Issue 3 Manual Therapy Mental Health

Does Chiropractic Help Your Mind Too? What a 2026 Review of Manual Therapy and Mental Health Really Shows

Lots of people say they feel calmer and lighter after hands-on care. A 2026 review of 72 trials puts numbers to that feeling, and the numbers look big. They are also fragile. Here is the honest read on what manual therapy can and cannot do for anxiety, depression, and stress, and the clear line where you need a different kind of help.

Jason Forward, DC, Vanguard Chiropractic, Tulsa, Oklahoma Published June 2026

✓ Medically reviewed by Dr. Jason Forward, DC, June 2026. Last updated June 2026.

Reviewing

Mo Y, Jiang Y, Li H, Liu J, Wu S, Wang L, Qi F, Zhang X. Effectiveness of manual therapy on physical and mental health promotion in adults: a systematic review and meta-analysis. Frontiers in Psychology. 2026;17:1815296.

DOI: 10.3389/fpsyg.2026.1815296

Key Points

A 2026 systematic review and meta-analysis in Frontiers in Psychology pooled 72 randomized trials and 5,524 adults, and reported lower anxiety scores after manual therapy by a mean difference of 9.68 points on the STAI scale (95% CI -14.17 to -5.19), with near-total statistical heterogeneity (I-squared = 97%) (Mo and colleagues, 2026).
The mood signal is mostly massage and soft-tissue work, not spinal adjustment. Of the 88 trials in the review, 58 tested massage therapy and only 12 tested joint mobilization. This is not a study of the chiropractic adjustment most patients picture (Mo and colleagues, 2026).
The certainty of the evidence is low to very low by the authors' own GRADE rating. Manual therapy cannot be blinded, so a patient's expectation is baked into every self-reported mood score, which inflates the effect (Mo and colleagues, 2026).
The honest line comes from the NIH: only a small amount of high-quality research has looked at spinal manipulation for conditions other than musculoskeletal problems, and a review of six non-musculoskeletal conditions found no clear benefit (NCCIH, NIH).
The defensible chain is indirect: manual therapy may ease pain, muscle tension, and poor sleep, and relief from those physical loads can lift mood. That is adjunctive and associational. It is not a treatment for clinical anxiety or depression, and never a replacement for a mental-health professional.
If your main problem is mood, anxiety, depression, or any thought of self-harm, a chiropractor is the wrong first stop. See a physician or mental-health professional, and for a crisis, call or text the 988 Suicide and Crisis Lifeline.

Plain Language Summary

The feeling is real. Many people do feel calmer after a massage or an adjustment, and a big 2026 review found lower anxiety, depression, and stress scores after manual therapy. Taken at face value, those numbers are large.

The catch is that the numbers are shaky. Most of the studies were massage, not chiropractic adjustment. The results varied wildly from trial to trial, and the quality of the evidence is rated low. You cannot give someone a fake massage, so part of the mood lift is simply expecting to feel better, which is real but hard to measure.

The fair takeaway: hands-on care can ease the pain, tension, and bad sleep that drag your mood down, and that can help you feel better indirectly. It is not a treatment for anxiety or depression, and it does not replace a counselor, doctor, or medication. If your mind is the main problem, start with a mental-health professional. In a crisis, call or text 988.

Why Patients Ask This Question

Anxiety and depression are among the most common health problems in the world, and many patients notice they feel calmer after hands-on care. It is fair to ask whether that feeling is a real treatment effect or just a pleasant byproduct. The answer matters because the wrong answer can keep someone from the care they actually need.

"The feeling of relief is real. The question is what the evidence can honestly attribute it to."

I hear it in the room every week. Patients in Tulsa tell me they always feel lighter after an adjustment, or that their anxiety is worse when their back is locked up, or they ask whether the relaxed feeling is the real thing or just a placebo. Those are honest questions and the sensation behind them is real. People are not making it up.

The internet's answer to those questions is a mess. Search for chiropractic and mental health and the first page fills with clinic marketing pages promising that an adjustment helps anxiety and depression, almost always with a vague "studies show" and no actual study named. That pattern is exactly what my own research rules forbid, and it is what this commentary is built to correct. If you want the wider picture on how good the underlying evidence base really is, I covered that separately in a review of whether chiropractic is evidence based.

The Study: What Mo and Colleagues Actually Did

Mo and colleagues (2026) pooled 88 randomized trials in their systematic review and 72 in the meta-analysis, covering 5,524 adults. They measured how manual therapy affected anxiety, depression, blood pressure, heart rate, sleep, and pain. Most of the trials tested massage, not spinal adjustment, which shapes how the results should be read.

The paper appeared in Frontiers in Psychology on May 26, 2026 (Mo and colleagues, 2026). The team searched PubMed, Web of Science, the Cochrane Library, and Embase through November 2025, then pooled the trials that measured both a physical and a mental-health outcome. That gave them 88 trials in the systematic review and 72 in the statistical pooling, with 5,524 participants in total. By the count of trials, this is a large body of evidence.

Here is the single most important fact for reading it correctly. The interventions were not mostly chiropractic adjustments. Of the 88 trials, 58 tested massage therapy, 12 tested reflexology, and 12 tested joint mobilization. Spinal manipulation, the high-velocity adjustment a patient pictures when they think "chiropractor," was a minority of the studies. So when a headline says manual therapy lowers anxiety, the honest translation is that mostly massage and soft-tissue work lowered self-reported anxiety in these trials. That distinction is not a technicality. It is the whole story.

"Of 88 trials, 58 were massage. This is a study of soft-tissue work, not the spinal adjustment most people imagine."

Manual therapy is a family of hands-on techniques. It includes massage and soft-tissue work, joint mobilization, which is a slow and controlled movement of a joint through its range, and spinal manipulation, which is the faster thrust technique. They share a hands-on logic but they are not interchangeable, and the evidence for one does not automatically carry to another. The two biggest buckets in this review, soft-tissue massage and joint mobilization, map cleanly onto a question I dug into for the jaw, where I compared joint mobilization against soft-tissue manual therapy in my commentary on manual therapy research for TMD in Tulsa.

The Headline Numbers, With Their Caveats Attached

The pooled effects looked large. Anxiety dropped by 9.68 STAI points, depression by 12.51 BDI points, and pain by 16.01 VAS points after manual therapy. But the heterogeneity was near-total, with I-squared as high as 97 percent, meaning the trials disagreed so much that a single pooled number barely describes them. The size and the fragility have to be read together.

I will give you the numbers in full, because cherry-picking the good ones is exactly the failure this article exists to avoid. Every effect below is the mean difference favoring manual therapy, with its 95 percent confidence interval and its heterogeneity, drawn straight from the meta-analysis (Mo and colleagues, 2026).

Pooled Effects From Mo and Colleagues, 2026

Outcome	Mean Difference (95% CI)	Heterogeneity (I-squared)
Anxiety (STAI)	-9.68 (-14.17 to -5.19)	97%
Depression (BDI)	-12.51 (-15.69 to -9.33)	71%
Sleep (PSQI)	-4.06 (-5.34 to -2.78)	93%
Pain (VAS)	-16.01 (-19.35 to -12.68)	97%
Systolic blood pressure	-3.91 mmHg (-4.63 to -3.18)	32%
Heart rate	-4.20 bpm (-6.09 to -2.30)	62%

Now the part the marketing pages leave out. The number in the right-hand column is the catch. I-squared measures how much the trials disagree with each other. Roughly speaking, above 75 percent is considered very high, the level where a single pooled average stops meaning much because the underlying studies are pulling in different directions and at different strengths. The anxiety and pain estimates sit at 97 percent. The sleep estimate is at 93 percent. When heterogeneity is that high, the precise mean difference is far less trustworthy than its size suggests.

The blood pressure and heart rate numbers are more believable, and for a reason worth naming. Their heterogeneity is lower, 32 percent for systolic blood pressure and 62 percent for heart rate, and these are objective measurements a cuff or a monitor records, not a score a patient fills in while knowing they just got a relaxing massage. That objectivity matters, and it ties into the autonomic, fight-or-flight side of the nervous system that I explain on the nervous-system chiropractor page. A small, brief drop in blood pressure and heart rate after hands-on relaxation is plausible. It is also a long way from treating a mood disorder.

Why You Cannot Trust a Mood Score the Way You Trust a Blood Pressure Cuff

There is a deeper problem with the anxiety and depression numbers, and the study authors flag it themselves. You cannot blind a person to whether they received hands-on care. They know a therapist's hands are on them. In this review, 59 percent of trials were at high risk of bias for blinding participants and 52 percent were high risk for blinding the people scoring the outcomes (Mo and colleagues, 2026). When someone knows they are being treated and then rates their own mood, the expectation of feeling better becomes part of the score. That is not fraud. It is human. But it means a self-reported anxiety drop after a massage cannot be cleanly separated from the simple effect of expecting to feel calmer. The role of expectation and the way a clinician communicates is real enough that I gave it its own commentary on how communication shapes pain relief.

What the Spinal-Manipulation-Specific Evidence Says

When you narrow the question to spinal manipulation alone, the psychological signal shrinks. The first systematic review of psychological outcomes from spinal manipulation found only a small benefit, a standardized effect of about 0.13 at one to five months, which faded and lost statistical significance by six to twelve months. Small and short-lived, not a mood cure.

The Mo review is massage-heavy, so to ask the chiropractic-specific question I went to the work that isolated it. The PRISM review (Williams and colleagues, 2007) was the first to systematically gather psychological outcomes from spinal manipulation trials. The authors screened 129 randomized trials and found that only 12 of them adequately reported any psychological outcome at all, which tells you how thin this evidence base is. Among those, they found a small benefit over physical treatments, a standardized mean difference of 0.13 at one to five months, fading to 0.11 and no longer statistically significant by six to twelve months.

"Narrow the lens to spinal manipulation and the mood effect is small and fades within a year. The honest verb is 'may support,' not 'treats.'"

A standardized effect around 0.13 is small by any convention. It is not nothing, and I am not waving it away. But it is a world apart from the implied promise on a clinic page that an adjustment lifts depression. The most defensible reading of the spinal-manipulation evidence is that it may be associated with a small, short-term improvement in mood, most likely riding on the back of pain relief, and that the effect does not durably hold. That is a reasonable thing to tell a patient. "It treats your anxiety" is not.

NCCIH, National Institutes of Health, on spinal manipulation: only a small amount of high-quality research has looked at the effects of spinal manipulation on conditions other than musculoskeletal problems. A review of six studies on non-musculoskeletal conditions, such as high blood pressure and menstrual cramps, found that none of the studies showed a clear benefit of spinal manipulation.

What this means in plain terms: for back pain, neck pain, and similar mechanical problems, hands-on care has real support. For everything else, including mood and other non-musculoskeletal conditions, the evidence does not show a clear benefit. That is the line. Manual therapy belongs in the musculoskeletal lane.

For the full resource: NCCIH (NIH), Spinal Manipulation: What You Need To Know.

The Honest Mechanism: An Indirect Chain, Not a Brain Effect

The defensible explanation is a chain, not a switch. Manual therapy may reduce pain, ease guarded muscle tension, and improve sleep. Chronic pain, tight muscles, and bad sleep all drag on mood. Relieve those physical loads and mood can lift as a downstream result. That is indirect and associational. It is not the adjustment reaching into your brain and treating depression.

Here is the mechanism I am comfortable standing behind as a clinician. Persistent pain is a heavy psychological load. It wears people down, wrecks their sleep, and keeps the nervous system on edge. When a stiff, guarded spine or a knot of tight muscle eases, two things happen. The immediate pain load drops, and sleep often improves, which the Mo data picked up as a better PSQI sleep score. Both of those are genuine physical changes, and both of them can lift mood as a side effect. I unpacked the sleep piece on its own in a commentary on back pain, sleep, and fatigue.

This indirect chain is also why chronic pain and mood get tangled in the first place. A pain signal that has been firing for months can make the nervous system more sensitive, so the body amplifies pain and the brain stays in a state of guard, which feeds stress and low mood. I walk through that loop in detail in my commentary on how the brain ramps up chronic pain sensitivity, and in a related TFR on the way stress, pain, and brain chemistry interact in jaw pain. Easing the physical input can help quiet that loop. What it does not do is act as a direct antidepressant. The honest verbs are "may ease," "may support," and "is associated with." The dishonest verbs are "treats," "cures," and "fixes."

What This Means in My Tulsa Practice

In my practice at Vanguard Chiropractic, I treat the mechanical problem in front of me, and I am honest that any mood benefit is a welcome side effect, not the goal. If someone tells me their main struggle is anxiety or depression, I tell them plainly that I am not the right first stop and I point them toward a counselor or physician.

At Vanguard Chiropractic in Brookside, here is how this plays out. A patient comes in with a locked-up lower back or a neck that seizes at the desk. I evaluate the mechanical problem, and I treat the mechanical problem. Many of those patients do tell me they feel calmer and sleep better once the pain settles. I am glad they do, and the research above gives a plausible reason why. But I frame it for them exactly the way the evidence supports it: easing your pain and helping you sleep can take a weight off your mood. The adjustment is not treating your anxiety. It is taking away one of the things making it heavier.

That honesty is the whole point of how I practice and the reason this page exists. Every competing result on this search is a clinic implying an adjustment cures mood disorders. I would rather be the one result that tells you the truth, because trust is built on honest limits, not hype. If your stress is bound up with physical tension and pain, hands-on care can be a genuine part of feeling better, and you can read more on that on the chiropractic for stress relief in Tulsa page. If your mind is the primary problem, you deserve to be sent to the right person, not sold a standing appointment.

If Your Mental Health Is the Main Concern, Read This

A chiropractor is not a mental-health provider, and manual therapy is not a treatment for clinical anxiety, depression, or any psychiatric condition. If any of the following describe you, please see a physician or a licensed mental-health professional rather than starting with the clinic:

Your primary struggle is anxiety, depression, panic, or another mood or mental-health condition
Persistent low mood, loss of interest, hopelessness, or anxiety that interferes with daily life
Any thoughts of harming yourself or others, or feeling that you cannot keep yourself safe
A mental-health condition that is getting worse, or symptoms that are new and frightening

If you are in crisis or thinking about suicide, you do not have to wait. Call or text 988 to reach the 988 Suicide and Crisis Lifeline, available 24 hours a day, 7 days a week, free and confidential. If you or someone else is in immediate danger, call 911 or go to the nearest emergency room. Manual therapy is a fine companion to real mental-health care. It is never a substitute for it.

Limitations: What This Evidence Cannot Tell Us

The Mo and colleagues (2026) review carries low to very low certainty by the authors' own GRADE assessment. The statistical heterogeneity is enormous, ranging from 32 percent to 97 percent across outcomes, with most mental-health and pain estimates above 70 percent. A pooled mean difference under that much disagreement is a rough average of trials that did not agree, not a precise effect you can promise an individual.

The intervention mix is the central caveat. With 58 of 88 trials testing massage and only 12 testing joint mobilization, this evidence is mostly about soft-tissue work, not the spinal adjustment most patients associate with a chiropractor. The mood findings should not be read as a result for the chiropractic adjustment.

Manual therapy cannot be blinded. With 59 percent of trials at high risk of bias for participant blinding and 52 percent for outcome-assessor blinding, expectation effects are baked into the self-reported anxiety and depression scores. The objective measures, blood pressure and heart rate, are more trustworthy but show small, short-term changes only.

The spinal-manipulation-specific evidence, from the PRISM review (Williams and colleagues, 2007), is small and fades within a year, and rested on only 12 of 129 trials reporting psychological outcomes at all. The NIH (NCCIH) is direct that non-musculoskeletal claims are not supported by clear benefit. The most established, well-supported use of spinal manipulation remains musculoskeletal pain, where the JAMA review by Paige and colleagues (2017) found modest improvements in back pain and function. None of this evidence supports manual therapy as a treatment for any mental-health condition.

This commentary concerns elective, non-emergency musculoskeletal care and general mood and stress in that context. It does not apply to anyone whose primary concern is a mental-health condition, who should seek the care described in the red-flag box above.

The Bottom Line

The big 2026 anxiety and depression numbers are real on paper and fragile in practice: massage-heavy, near-total heterogeneity, low-quality evidence, and no way to blind a person to a hand on their back. The fair, board-safe truth is that manual therapy may ease the pain, tension, and poor sleep that weigh on mood, which can help you feel better indirectly. It is not a treatment for anxiety or depression, and it never replaces a mental-health professional.

Frequently Asked Questions

Can a chiropractor help with anxiety and depression?

Not as a treatment for those conditions. A 2026 review (Mo and colleagues) reported lower anxiety and depression scores after manual therapy, but the evidence is low quality, varies enormously between trials, and is mostly massage rather than spinal adjustment. What hands-on care can honestly do is ease the pain, muscle tension, and poor sleep that often weigh on mood, which may help you feel better indirectly. If anxiety or depression is your main concern, see a physician or mental-health professional. In a crisis, call or text 988.

Does manual therapy reduce stress?

It may, in the short term, and partly for measurable reasons. In the 2026 Mo and colleagues review, manual therapy was associated with small drops in systolic blood pressure (about 3.9 mmHg) and heart rate (about 4.2 bpm), markers tied to the body's stress response. Those objective changes are more believable than the self-reported mood scores. A brief sense of calm after hands-on relaxation is plausible. It is not the same as treating an anxiety disorder, and the effect is small and short-lived.

Can chiropractic adjustments improve your mood?

The spinal-manipulation-specific evidence shows only a small, short-term mood benefit that fades. The PRISM review (Williams and colleagues, 2007) found a standardized effect of about 0.13 at one to five months, which lost statistical significance by six to twelve months. The most likely explanation is indirect: relieving pain can lift mood. There is no good evidence that an adjustment directly treats a mood disorder, and the NIH states that non-musculoskeletal claims for spinal manipulation are not supported by clear benefit.

Does spinal manipulation lower blood pressure?

The 2026 Mo and colleagues review found a small average reduction in systolic blood pressure of about 3.9 mmHg after manual therapy, with relatively low heterogeneity, which makes it one of the more trustworthy findings in the analysis. But this is a brief, modest change measured around the time of treatment, mostly from massage and soft-tissue work, not a treatment for high blood pressure. The NIH notes that a review of non-musculoskeletal conditions, including high blood pressure, found no clear benefit from spinal manipulation. Do not stop any blood pressure medication. Talk to your physician.

Is chiropractic a replacement for therapy or medication?

No. Manual therapy is not a substitute for counseling, psychotherapy, or psychiatric medication, and no honest reading of the evidence supports using it that way. It can be a reasonable companion to real mental-health care by easing physical pain and tension that add to stress. If your main problem is anxiety, depression, or any mental-health condition, the right first stop is a physician or licensed mental-health professional. Never stop a prescribed medication without talking to the doctor who prescribed it.

Can chiropractic care improve sleep quality?

Possibly, when poor sleep is being driven by pain. The 2026 Mo and colleagues review reported better sleep scores after manual therapy (a 4.06-point drop on the PSQI scale), though the heterogeneity was very high at 93 percent, so read the exact number with caution. The plausible mechanism is simple: when pain eases, people sleep better. If pain is keeping you up at night, addressing the mechanical problem may help your sleep as a side effect. If you have a primary sleep disorder, see a physician.

Why is most of this research about massage and not adjustments?

Because of how the studies were built. In the 2026 Mo and colleagues review, 58 of 88 trials tested massage therapy, 12 tested reflexology, and only 12 tested joint mobilization, with spinal manipulation a minority. Manual therapy is a family of hands-on techniques, and massage and soft-tissue work make up most of the mental-health research. That is why the review's mood findings should not be read as a result for the chiropractic adjustment specifically. It is mostly evidence about soft-tissue work.

Cite This Commentary Forward J. Does chiropractic help your mind too? What a 2026 review of manual therapy and mental health really shows. The Forward Review. 2026;1(3). https://vanguardchiro.com/research/tfr-manual-therapy-mental-health-2026/

References

Mo Y, Jiang Y, Li H, Liu J, Wu S, Wang L, Qi F, Zhang X. Effectiveness of manual therapy on physical and mental health promotion in adults: a systematic review and meta-analysis. Frontiers in Psychology. 2026;17:1815296. doi:10.3389/fpsyg.2026.1815296. Tier 1
Williams NH, Hendry M, Lewis R, Russell I, Westmoreland A, Wilkinson C. Psychological response in spinal manipulation (PRISM): a systematic review of psychological outcomes in randomised controlled trials. Complementary Therapies in Medicine. 2007;15(4):271-283. doi:10.1016/j.ctim.2007.01.008. Tier 1
Paige NM, Miake-Lye IM, Booth MS, et al. Association of Spinal Manipulative Therapy With Clinical Benefit and Harm for Acute Low Back Pain: Systematic Review and Meta-analysis. JAMA. 2017;317(14):1451-1460. doi:10.1001/jama.2017.3086. Tier 1
National Center for Complementary and Integrative Health (NIH). Spinal Manipulation: What You Need To Know. nccih.nih.gov. Tier 1
988 Suicide and Crisis Lifeline. 988lifeline.org. Tier 1

Editorial Disclosure

The Forward Review is editorial commentary, not peer reviewed. Written and medically reviewed by Jason Forward, DC, a licensed chiropractor at Vanguard Chiropractic in Tulsa, Oklahoma. Commentary reflects clinical interpretation and does not represent the views of the original study authors, Frontiers in Psychology, the National Institutes of Health, or any institution. Manual therapy is not a treatment for any mental-health condition. Individual results vary.

Conflict of interest: Dr. Forward is a practicing chiropractor whose clinical work includes hands-on care for musculoskeletal problems. No financial relationships with the cited authors or publishers.

Corrections policy: Errors are corrected with a dated correction notice appended to the article. Original text remains accessible via revision history.

Level of evidence: One systematic review and meta-analysis with low to very low GRADE certainty (primary), one systematic review of psychological outcomes from spinal manipulation, one systematic review and meta-analysis of spinal manipulation for low back pain, and one government health resource. Certainty for the mental-health outcomes is low.

June 12, 2026

Home›The Forward Review›Volume 1, Issue 2
The Forward Review Live Commentary Vol. I · Issue 2 · May 2026
Annals SMART RCT, n=749 Volume 1 · Issue 2 Chronic Low Back Pain Conservative Care First
OPTIMIZE in Annals: Physical Therapy First for Chronic Low Back Pain, and What That Actually Means for Conservative Care
Fritz and colleagues randomized 749 adults with chronic low back pain across three health systems using a SMART design that adapted second-stage treatment based on early response. Patients started with either evidence-based medical care or physical therapy. Those who did not respond were re-randomized to add mindfulness or to switch the other arm in. PT first beat medical care first. Among nonresponders, second-stage choices did not separate. The trial reads as a vote for starting conservative, not as a vote for one specific brand of conservative.
Jason Forward, DC, Vanguard Chiropractic, Tulsa, Oklahoma Published May 11, 2026
Reviewing
Fritz JM, Sharpe J, Greene T, et al. Effectiveness of Nonpharmacologic Treatments for Chronic Low Back Pain: A Sequential, Multiple-Assignment, Randomized Trial (OPTIMIZE). Annals of Internal Medicine. Published online April 21, 2026.
DOI: 10.7326/ANNALS-25-04645 · PMID: 42008809
Key Points
OPTIMIZE enrolled 749 adults with chronic low back pain (12 or more weeks of symptoms) across three United States health systems from March 2019 through September 2023. Follow-up ran 52 weeks.
Design was SMART (sequential multiple-assignment randomized trial): patients were randomized at study entry to first-stage treatment, then nonresponders were re-randomized at 10 weeks to a second-stage strategy. This is uncommon in low back pain research and lets the trial answer two questions at once.
First-stage randomization: evidence-based medical care versus physical therapy. PT first produced meaningfully better disability and pain outcomes than medical care first.
Second-stage randomization (for nonresponders): add mindfulness-based stress reduction, or switch to the alternate first-stage arm. Neither strategy outperformed the other at 52 weeks.
Author conclusion in plain language: chronic LBP patients may benefit from physical therapy as a first-line treatment. Among those who do not respond, the specific next move appears to matter less than the fact that the patient is still inside conservative care.
The Vanguard Chiropractic read: this is a vote for "conservative care first," not a vote that PT is the only acceptable on-ramp. Chiropractic care sits in the same conservative-care category alongside PT in every major clinical guideline. The trial validates the broader principle.
Plain Language Summary
If you have had back pain for more than three months, what is the first move that gives you the best shot at less disability a year from now? A multisite team led by researchers at the University of Utah enrolled 749 adults with chronic low back pain and ran one of the more carefully designed trials this question has seen.
Everyone started in one of two paths. Half were sent into physical therapy. The other half got what the trial called evidence-based medical care, which is the package a primary care doctor would assemble: a structured visit, advice on staying active, simple medication options, and standard follow-up. At ten weeks, the patients who had not improved were sent back into the trial for round two. Some had mindfulness-based stress reduction added on top of what they were already doing. Some were switched into the other first-stage arm (so PT patients moved into medical care, and medical care patients moved into PT).
One year out, the patients who started with physical therapy were doing better than the patients who started with medical care. Among the patients who did not respond to either starting point, the second-stage choice did not seem to matter. Mindfulness was not better than switching. Switching was not better than mindfulness.
The headline most outlets are running is "PT first for chronic back pain." That is fair. The deeper headline is that being inside an active, conservative care plan beat sitting in a passive one, and that once you are inside that active plan, the specific next move matters less than the fact that you are still inside it. Chiropractic care lives in the same conservative-care category as physical therapy in every major guideline, and the trial says less about which brand of conservative wins than about how badly the default of "wait and see plus a pill" loses.
Why This Paper Matters
Chronic low back pain is the most expensive musculoskeletal condition in the United States. Standard primary care does poorly with it. The 2017 American College of Physicians guideline (Qaseem et al., Annals of Internal Medicine 2017) ranked nonpharmacologic care, including spinal manipulation, exercise, and mindfulness, ahead of medication for first-line treatment. Insurance pathways have been slow to follow. Most patients still hit a primary care visit, a prescription, and a wait-and-see strategy before any conservative provider sees them.
OPTIMIZE tested a simple counterproposal. Send the patient directly to physical therapy. Skip the wait. See what happens at one year. The trial then layered a second question on top of the first by using a SMART design: when the patient does not respond to the first move, what is the best next move? This is the question every clinician actually has to answer in practice, and it is almost never the question randomized trials are powered for.
The result is one of the cleanest pieces of conservative-care-first evidence published in a top medical journal in the last five years. It pairs naturally with the PACBACK trial in JAMA, which tested the same principle (start with structured conservative care) in a slightly earlier-onset population.
What a SMART Trial Actually Is
A standard randomized trial answers one question. You give half the patients drug A and half the patients drug B, and you measure who does better. The real world is messier than that. Most chronic conditions involve a first treatment, a check-in, and a second treatment if the first one does not work. Almost no trial is designed to test the whole sequence.
SMART (sequential multiple-assignment randomized trial) designs solve that gap. Patients are randomized at the start of treatment AND at a planned re-check point if they have not responded. The output is not just "which first treatment wins," but "which sequence of treatments produces the best outcome." It is a closer mirror of clinical practice than a two-arm trial.
For OPTIMIZE, the structure was:
Stage 1: All 749 patients randomized to evidence-based medical care (EBMC) or physical therapy (PT). Each arm ran for about 10 weeks.
Re-assessment at 10 weeks: Patients with a clinically meaningful improvement in disability (per the Oswestry Disability Index) continued the same care. Patients who had not responded entered the second randomization.
Stage 2 (nonresponders only): Re-randomized to add mindfulness-based stress reduction (MBSR) on top of current care, or to switch into the alternate stage-1 arm.
The 52-week outcome compared disability and pain across the full embedded sequences (PT-then-MBSR, PT-then-switch-to-EBMC, EBMC-then-MBSR, EBMC-then-switch-to-PT, and the responder paths). The headline comparison is the stage-1 winner. The interesting comparison is among the nonresponder sequences.
What They Found
At 52 weeks, patients in the PT-first arm showed clinically meaningful reductions in disability compared to patients in the EBMC-first arm. Pain scores moved in the same direction. The effect size sits in the range where guideline bodies have historically treated a finding as actionable for first-line care.
Among nonresponders to stage 1, the second-stage randomization produced no statistically significant separation. Mindfulness added on did not outperform switching arms. Switching arms did not outperform mindfulness added on. The author conclusion was direct: "Among nonresponders, there were no differences in second-stage treatment with mindfulness or switching."
Read that finding carefully. Two things follow.
First, the stage-1 choice matters. Patients who started with PT did better at one year than patients who started with EBMC. The clinical-policy implication is that the front door of chronic LBP management probably should not be a primary-care visit followed by a pill and a wait. It should be an active, hands-on, structured conservative care contact.
Second, when the first move does not work, the literature does not yet tell us what the best second move is. The trial tested two reasonable candidates and they both performed about the same. That is a useful piece of clinical humility. The patient who is not getting better at 10 weeks is a real clinical population, and the best move for them is probably "keep trying something inside conservative care" rather than "the algorithm says do X."
Where Chiropractic Sits in This Picture
OPTIMIZE did not include a chiropractic arm. The trial tested PT versus EBMC at stage 1, and MBSR versus switching at stage 2. A reader could finish the abstract and walk away thinking the paper says "PT, not chiropractic." That is not what the paper says.
Here is what it actually says, read in the context of the broader guideline literature.
Every major clinical guideline for low back pain groups chiropractic spinal manipulation and physical therapy together inside the same first-line category. The ACP guideline lists spinal manipulation alongside exercise, heat, and acupuncture as appropriate first-line care. The NICE guideline (NG59) in the United Kingdom does the same. The U.S. Department of Veterans Affairs guideline does the same. The distinction the literature consistently draws is between active conservative care (any of the above) and passive medical management (medication, rest, observation). OPTIMIZE is a test of the second of those two categories versus the first. PT was the first-line arm because the trial had to pick one operationalizable provider, not because the literature says PT is the only acceptable on-ramp.
The honest read of OPTIMIZE for chiropractic patients is this: starting with active conservative care produces better outcomes than starting with passive medical care. Active conservative care includes physical therapy, chiropractic, and exercise-based rehab. The trial's design picked one of those to test. The principle applies more broadly.
This is consistent with the dos Santos 2026 review on manual therapy plus exercise, which found that manual therapy and exercise together produced larger effects than either alone. It is consistent with the Liang 2024 Bayesian network meta-analysis, which ranked active modalities at the top of the dose-response hierarchy. It is consistent with the 2026 Cochrane review placing spinal manipulation in the same effectiveness band as other conservative options. The literature has been pointing in this direction for ten years. OPTIMIZE is the latest data point, and it is a high-quality one.
The Mechanism Question
Why does active conservative care outperform passive medical care for chronic low back pain? The mechanisms are not mysterious.
Chronic low back pain is associated with measurable changes in motor control, fear-avoidance behavior, deconditioning, and central pain processing. None of these respond to a prescription. They respond to graded loading, exposure to feared movement, restored joint mobility, and consistent contact with a clinician who treats the patient as someone who is going to get better.
Physical therapy delivers most of these elements. Chiropractic care delivers most of these elements with a different emphasis on the joint-mobility piece and a different visit format. Both arms of the first-line literature share the active ingredients. Wait-and-see medical care delivers almost none of them. The OPTIMIZE result is what you would predict if you started with that mechanism map and asked which arm would win.
The second-stage null result also makes mechanistic sense. A patient who has not responded to one form of active conservative care has not exhausted the active-care category. They have exhausted that specific dose, with that specific provider, at that specific time. Adding a stress-reduction component on top, or switching providers, are both reasonable second moves. Neither is structurally superior. The principle is that the patient stays inside active care, with adjusted inputs, rather than dropping out into passive management.
What I Tell My Patients
Most of my chronic low back pain patients arrive at Vanguard Chiropractic having already cycled through some version of the passive medical management arm of this trial. Primary care visit. Prescription. Maybe an MRI. Wait and see. By the time they walk in, they have usually been at the problem for months or years, and the wait-and-see arm has not delivered.
When I read OPTIMIZE in that context, the clinical message is straightforward. The first move on chronic low back pain should be active, hands-on, conservative care. That is what I deliver. It is what a physical therapist delivers. It is what a movement-focused exercise program delivers. The data say start there.
For chronic radicular and recurrent presentations, I recommend ongoing weekly care for at least twelve weeks after the initial acute phase resolves, then a taper. This is not maintenance for its own sake. Each flare of nerve-root irritation compounds tissue irritation and central sensitization patterns, and the responsible approach is to prevent flares before they happen rather than chase them after. The OPTIMIZE second-stage finding (that the patient who has not responded should stay inside conservative care, with adjusted inputs) is consistent with the same principle: stay in the active-care loop until the system has stabilized.
I do not run a six-session structured psychoeducation protocol the way the PT arm of OPTIMIZE did. My visit format is shorter and the price point is lower. What I can do, and do at every visit, is layer brief active-care elements into a $40 adjustment encounter: a movement to take home, a fear-avoidance reframe when the patient says "I am afraid to bend," a graded-loading suggestion, a return instruction. None of these match a one-hour PT session in isolation. Across multiple visits, they build the same scaffolding.
Limitations and Caveats
Limitations
OPTIMIZE did not include a chiropractic arm. Direct extrapolation to chiropractic care relies on the parallel guideline placement of chiropractic and PT inside the same first-line category, not on a head-to-head test. A future SMART trial that tested PT versus chiropractic at stage 1 would be the cleaner comparison.
The evidence-based medical care arm reflects how primary care actually treats chronic LBP, which is a low bar. Beating EBMC is meaningful, but it is not the same as beating an optimized, integrated primary care pathway that aggressively refers to conservative providers. The trial does not test that comparator.
The second-stage null result on mindfulness versus switching is hypothesis-generating, not definitive. The trial may have been underpowered to detect a small but real difference between these strategies. A bigger trial may yet separate them.
Adherence to the assigned care was monitored but is not perfect in any pragmatic trial. Real-world adherence to either PT or EBMC over 10 weeks varies by patient, and the intention-to-treat analysis carries the structural noise that comes with that.
Three health systems is more external validity than a single-center trial provides, but the United States health-system context still differs from the international guideline environment. Findings extrapolate most cleanly to insurance-pathway populations and less cleanly to cash-pay or uninsured populations where the access pattern is different.
The trial cannot distinguish "PT first works because PT is uniquely effective" from "PT first works because any structured active care delivered at the front door beats wait-and-see." The second interpretation is what the broader guideline literature supports. The trial design cannot adjudicate between the two.
Clinical Context: Conservative Care First, Not Conservative-Brand-A First
The risk in how this paper will be reported is the brand-versus-principle confusion. Outlets will write "PT first for chronic back pain." Policy people will hear "PT, not chiropractic." That is not what the trial says. It says active conservative care, delivered as the first move, beats passive medical management. PT was the specific operational arm tested. The principle is broader.
For a Tulsa patient sitting at their kitchen table trying to decide what to do about back pain that has not gone away in three months, the practical implication is the same whether they read OPTIMIZE, PACBACK, the dos Santos review, or the Cochrane verdict. Start with active conservative care. Pick the provider you can access, afford, and stick with. A physical therapist works. A chiropractor focused on back pain works. A structured exercise program works. The wait-and-see strategy does not.
For my walk-in patients in Brookside, the access piece is the part that matters most. $40 per visit, no appointment required, open six days a week. That is not a research-trial intervention. It is a practical answer to the "pick the provider you can access, afford, and stick with" sentence in the paragraph above.
The Bottom Line
749 adults with chronic low back pain across three health systems, a SMART design that adapted treatment based on early response, and a clean first-stage finding: starting with physical therapy beat starting with usual medical care at one year. Among nonresponders, the specific second move did not separate. The story the trial actually tells is "active conservative care first," not "PT, not chiropractic." Chiropractic, PT, and structured exercise all live in the same first-line guideline category. The trial reinforces what the literature has been pointing at for a decade: wait-and-see is the loser, and any responsible front door of active care is the winner. For a patient with chronic LBP, the best move is to start, not to wait.
Cite This Commentary Forward J. OPTIMIZE in Annals: physical therapy first for chronic low back pain, and what that actually means for conservative care. The Forward Review. 2026;1(2). https://vanguardchiro.com/research/physical-therapy-first-chronic-low-back-pain-fritz-2026/
Read More From The Forward Review
PACBACK in JAMA: 1,000 Patients and the SMT-Only Lesson (Bronfort et al. 2026) Does Adding Manual Therapy to Exercise Help Chronic LBP? Five Trials Say Sometimes (dos Santos et al. 2026) 82 Trials, 5,033 Patients: The Exercise Dose for Chronic LBP (Liang et al. 2024) Dual-Task Training Plus Core Stability Beats General Exercise (Raoufi et al. 2026) Cochrane Verdict on Spinal Manipulation for Chronic LBP (de Zoete et al. 2026) Chiropractic Care and Opioid Reduction in Spine Pain (Emary et al. 2026) Return to The Forward Review Clinical resource: Back pain chiropractor in Tulsa Clinical resource: Chiropractor vs physical therapy Clinical resource: Walk-in chiropractor in Tulsa
Editorial Disclosure
The Forward Review is editorial commentary, not peer reviewed. Written by Jason Forward, DC, a licensed chiropractor at Vanguard Chiropractic in Tulsa, Oklahoma. Commentary reflects clinical interpretation of published research and does not represent the views of the original study authors, the journal Annals of Internal Medicine, or any institution.
Conflict of interest: Dr. Forward is a practicing chiropractor whose clinical work includes spinal manipulation as part of a multimodal approach to musculoskeletal care. No financial relationships with the cited authors, Annals of Internal Medicine, or any party to this work.
Scope of practice note: The OPTIMIZE trial studied physical therapy delivered by licensed PTs and medical care delivered by primary care clinicians. This commentary discusses published research and does not constitute individual treatment prescription. Patients with new or worsening back pain should be evaluated by a qualified clinician; red flags including unexplained weight loss, fever, progressive neurological deficit, bowel or bladder changes, or saddle anesthesia require urgent medical evaluation.
Corrections policy: Errors are corrected with a dated correction notice appended to the article. Original text remains accessible via revision history.
Level of evidence: Sequential multiple-assignment randomized trial, n=749, three United States health systems, 52-week follow-up. Published in Annals of Internal Medicine, April 21, 2026.
Continue here: Why This Paper Matters
May 11, 2026
Home›The Forward Review›Volume 1
The Forward Review Live Commentary Vol. I · May 2026
Cross-Sectional Study Volume 1 Infant Care Referral Patterns
Why Infants Get Referred to Chiropractors: A 1,049-Baby Danish Snapshot
Overgaard and colleagues pulled the curtain back on what actually walks through the door of a Danish chiropractic clinic when the patient is under one year old. The complaint pattern is more mechanical than most parents (and most pediatricians) would guess, and the referral pathway runs through public-health visitors more often than through the family doctor.
Jason Forward, DC, Vanguard Chiropractic, Tulsa, Oklahoma Published May 5, 2026
Reviewing
Overgaard FG, Hedegaard-Johansson C, Hestbaek L. Clinical profiles and referral patterns of infants attending Danish chiropractic clinics: a nationwide cross-sectional study. Chiropractic & Manual Therapies. 2026 Feb 24;34(1):9.
DOI: 10.1186/s12998-026-00629-z · PMID: 41736128
Featured Definition
Infant chiropractic referral patterns describe how babies under one year arrive at a chiropractic clinic, who sends them, and what the parents are asking about. In this Danish study of 1,049 infants, the most common reason was abnormal range of motion in the neck or spine (48 percent). About half of the babies were referred by another healthcare professional, most often a public-health visitor (44 percent of all referrals).
Key Points
Nationwide cross-sectional survey of Danish chiropractic clinics, covering 1,049 infants aged 0 to 12 months seen between November 2018 and October 2019.
The most common primary complaint was abnormal range of motion in the neck or spine, at 48 percent. Crying or infantile colic came second at 17 percent. Feeding problems and disturbed sleep tied at 5 percent each.
Most complaints had been present for somewhere between one week and three months before parents sought care. This is not a same-day visit pattern. Parents tried other things first.
Secondary complaints showed up in 58 percent of cases. Babies rarely came in with one isolated issue. Range of motion, sleep, and feeding clustered together more often than not.
Healthcare-professional referrals accounted for 51 percent of visits. The single largest source was the Danish public-health visitor system at 44 percent of those referrals, not the family physician.
Denmark integrates chiropractors into the standard healthcare pathway in a way the United States does not. The complaint mix probably translates. The referral mix definitely does not.
What the Researchers Did
The team behind this paper sat at the Spine Centre of Southern Denmark, the University of Southern Denmark, the Chiropractic Knowledge Hub, and Macquarie University in Sydney. They invited every chiropractic clinic in the Danish Chiropractors' Association, all 238 of them, to take part in a national electronic survey. Clinicians pulled retrospective data from their own medical records, capturing every infant visit between November 2018 and October 2019.
The questionnaire asked four straightforward things. What is the baby's primary complaint? Is there a secondary complaint, and if so what is it? How long has the symptom been present before this visit? Was the family referred by another healthcare professional, and if so by whom? Demographic data filled out the rest.
By the time the data window closed in early 2020, 1,049 completed infant questionnaires were in. That is a meaningful national sample for a country of roughly 5.9 million people. The Danish Agency for Patient Safety classified the work as quality assurance, which under Health Act paragraph 42d removed the written-consent requirement. The University of Southern Denmark approved the protocol.
What They Found
The headline finding is the complaint mix. Abnormal range of motion in the cervical or upper-thoracic spine accounted for 48 percent of primary complaints. In plain terms, parents were noticing that the baby preferred to look one direction, struggled to turn the head fully, or held the neck in a fixed posture. Crying or infantile colic followed at 17 percent. Feeding problems and disturbed sleep each came in at 5 percent. The remaining 25 percent split across a long tail of less common reasons.
The duration data is just as telling. Most of these complaints had been present somewhere between one week and three months before the family showed up at the chiropractic clinic. Parents were not bringing newborns in on day three. They were bringing in babies whose problems had persisted long enough to outlast the early reassurance of "this will probably resolve on its own."
Secondary complaints showed up in 58 percent of cases. The most common secondary patterns were abnormal range of motion (41 percent), disturbed sleep (22 percent), and feeding problems (21 percent). The clinical takeaway here is that infant presentations cluster. A baby who is hard to console at night is often also a baby who turns the head one way more easily than the other. Parents may report only the loudest symptom. The clinician has to look for the rest.
The referral pathway data is where the Danish context becomes impossible to ignore. Fifty-one percent of infants were referred by another healthcare professional. Of those referrals, 44 percent came from the Danish healthcare-visitor system, a publicly funded program in which trained nurses visit every newborn at home in the early months of life. General practitioners and other providers made up the rest of the referral pool. In other words, the system is built so that the people who already see the baby at home in the first weeks of life have a clear pathway to a chiropractor when something looks off.
Clinical Perspective: What I See in My Practice
The complaint mix in this Danish dataset matches what I see in my Tulsa practice when parents bring in an infant. I do treat infants. I am not a board-certified pediatric chiropractor and I do not hold the Webster certification. I want that on the record up front because parents deserve to know what credentials a clinician carries before any hands go on a baby. With that boundary stated, the work I do with infants is gentle, low-force, and focused on restoring symmetric movement of the cervical spine and pelvis using sustained light pressure rather than the higher-velocity adjustments used on adults.
The most common reason I see infants is the same thing this study found. A parent notices that the baby always turns the head one direction, has a flat spot starting on one side of the skull, fights tummy time, or refuses to nurse from one breast. Pediatricians often call this a positional preference or, when it is more pronounced, congenital muscular torticollis. Whatever the label, the underlying issue is asymmetric movement of the upper neck. The baby is not choosing the favorite side. The favorite side is the only side that moves freely.
I also see the cluster pattern this study documented. The baby who cannot turn the head left often also struggles to nurse on one side, sleeps poorly, and arches the back when laid down. Parents typically present the loudest symptom first. My job is to ask the next three questions and look for the rest.
What I do not see in my practice, because the U.S. system is not built this way, is referrals from a public-health visitor. There is no equivalent program in Tulsa. Most of my infant referrals come from word of mouth, from lactation consultants, from a small number of pediatricians who know my work, and from postpartum doulas. The Danish 44 percent figure is not a number I will replicate. The complaint pattern is.
What This Means for Parents
If you are a Tulsa parent reading this, here is the practical translation.
First, an infant who consistently turns the head one direction more easily than the other is showing you something mechanical. It is worth getting checked. The fix may be repositioning, tummy time strategy, lactation guidance, gentle physical therapy, gentle chiropractic care, or some combination depending on what is going on. The right starting point is an honest assessment of which side moves and which does not.
Second, the cluster pattern matters. If your baby has feeding trouble on one side, sleep difficulty, and a head-position preference, those are likely connected, not three separate problems. A clinician who treats them as one mechanical picture will get you further than one who treats each in isolation.
Third, ask about credentials. Chiropractors in the United States are licensed to treat patients of all ages, including infants. That said, training in pediatric care varies clinician to clinician. Ask any provider you are considering, including me, what their specific experience with infants looks like, what techniques they use, and what red flags would prompt a referral out. A good answer is specific. A vague answer is a flag.
Fourth, infant chiropractic care, when delivered appropriately, uses light sustained pressure, not the higher-force adjustments adults receive. The amount of force applied is roughly what you would use to test the ripeness of a tomato. If anyone describes anything more aggressive than that for a baby under one year, walk out.
Vanguard Chiropractic Connection
At Vanguard Chiropractic in Tulsa, the infants I see most often arrive with the same head-position story this Danish study describes. Parent noticed the baby always looks right, or always nurses better on the left, or has a flattening on one side of the skull. The visit usually starts with watching the baby move, palpating the cervical spine and pelvis with the parent holding, and walking through what positional changes at home might do over a one to two week trial before any hands-on work begins.
I work with each family on the specific picture in front of me. Some infants benefit from a few gentle visits combined with home positioning changes. Others need a referral to lactation, to physical therapy, or back to the pediatrician for imaging if anything in the history or exam suggests something beyond a positional pattern. The decision tree is built around the baby in front of me, not a protocol applied to every infant who walks in.
Parents in the Brookside and midtown Tulsa area who want to talk through whether a chiropractic visit makes sense for their baby are welcome to call or walk in. Individual results vary, and if I do not think chiropractic care is the right answer for your specific situation I will tell you so and point you toward what is.
Limitations and What Is Not Yet Known
Limitations
This is a descriptive cross-sectional study. It captures who walked in the door and why. It does not measure outcomes, does not compare against any control, and cannot tell us whether any of these infants got better with chiropractic care, with anything else, or on their own with time.
Recall and documentation depended on chiropractors pulling data from their own records. Coding of complaints was not standardized across the 238 clinics that were invited. The 1,049 cases came from a subset of clinics that returned the survey, which introduces participation bias. Practices that did not respond may serve a different patient mix.
The Danish healthcare context limits external translation of the referral findings. The 44 percent healthcare-visitor referral rate reflects a public-health structure that does not exist in the United States. The complaint mix may translate. The referral pathway probably does not.
Parental report drives the symptom data. What a parent calls colic, what a clinician calls colic, and what the underlying mechanism actually is may be three different things. The category is broad on purpose, but breadth limits how precisely the findings map to specific clinical pictures.
The data window closed in October 2019. Healthcare delivery patterns since the pandemic period have shifted in ways the dataset cannot reflect.
What this paper does not establish is whether chiropractic care helps these infants. That is a separate research question requiring a different design. Several small randomized trials and prospective cohort studies have looked at infant chiropractic care for specific complaints, with mixed and generally low-certainty results. The Danish authors are clear that their goal here was to describe the population of infants showing up at chiropractic clinics, not to evaluate the care delivered. Any reader who walks away from this paper claiming it shows chiropractic care works for babies has read more into it than the data supports.
The Bottom Line
Forty-eight percent of infants showing up at Danish chiropractic clinics come in for asymmetric neck and spine movement. Crying and colic are a distant second. Most have had the issue for weeks or months before the visit. Half are referred by another healthcare professional, with the public-health visitor system carrying most of that load. The complaint pattern probably describes infant presentations in any country. The referral pathway describes Denmark. Both pieces are useful.
Cite This Commentary Forward J. Why infants get referred to chiropractors: a 1,049-baby Danish snapshot. The Forward Review. 2026. https://vanguardchiro.com/research/infant-chiropractic-referral-patterns-denmark-2026/
Read More From The Forward Review
Cochrane Verdict on Spinal Manipulation for Chronic LBP (de Zoete et al. 2026) PACBACK in JAMA: 1,000 Patients, Four Treatment Arms (Bronfort et al. 2026) Forty-Seven Trials of TMD Patient Education (Ferland et al. 2026) Return to The Forward Review Clinical resource: Walk-in chiropractor in Tulsa
Editorial Disclosure
The Forward Review is editorial commentary, not peer reviewed. Written by Jason Forward, DC, a licensed chiropractor at Vanguard Chiropractic in Tulsa, Oklahoma. Commentary reflects clinical interpretation and does not represent the views of the original study authors, the journal Chiropractic & Manual Therapies, or any institution.
Scope of practice note: Dr. Forward treats infants and pregnant patients. He is not a board-certified pediatric chiropractor and does not hold Webster certification. Parents should always verify a provider's specific experience and training before infant care.
Conflict of interest: Dr. Forward is a practicing chiropractor who provides infant care in his Tulsa clinic. No financial relationships with the cited authors, the publisher, or any party to this work.
Corrections policy: Errors are corrected with a dated correction notice appended to the article. Original text remains accessible via revision history.
Level of evidence: Cross-sectional descriptive study (n=1,049 infants, nationwide Danish sample).
May 5, 2026

Secondary Analysis of RCT Volume 1 · Issue 2 Spinal Manipulation Clinical Communication

Sixty-Six Patients, Three Verbal Framings, and the Mediator That Was Not Belief

A new secondary analysis of a randomized trial in chronic low back pain finds that the words delivered before lumbar manipulation, not patient expectations or attitude, predict 24-hour pain. The result reframes which lever in the chair-side encounter actually moves outcomes.

Jason Forward, DC, Vanguard Chiropractic, Tulsa, Oklahoma Published May 4, 2026

Reviewing

Zaworski K, Baj-Korpak J, Tokarska-Rodak M, Plażuk E, Nazarewicz A, Rossettini G. Verbal framing, rather than measured cognitive-affective variables, is associated with short-term outcomes after spinal manipulation: a secondary analysis of a randomized controlled trial. Pain Management. 2026 Mar 4:1-10.

DOI: 10.1080/17581869.2026.2638403 · PMID: 41778600 · Trial Reg: NCT06537739

Key Points

Zaworski and colleagues randomized 66 young adults with chronic non-specific low back pain to one of three short verbal scripts (positive, neutral, negative) delivered immediately before a single lumbar spinal manipulation.
The same operator delivered the same lumbar HVLA technique in every group. The only manipulated variable was the framing sentence.
In a multiple regression predicting 24-hour pain (NPRS-11), framing group was the only retained predictor (adjusted R² = 0.26, p < 0.001). Negative framing predicted higher pain (β = 0.35). Positive framing predicted lower pain (β = -0.26).
Pre-treatment expectations, attitude toward manual therapy, and post-treatment expectation fulfillment showed sparse and inconsistent associations with both pain and lumbar pressure pain threshold across all groups.
For the practicing clinician, the implication is direct. The opening sentence of an adjustment encounter is not preamble. It is part of the intervention.

Plain Language Summary

A research group looked again at data from a study of young adults with long-lasting low back pain. Everyone in the study received the same hands-on lumbar adjustment. The only difference between groups was a short message the patient heard right before the adjustment.

One group heard a positive message. One group heard a neutral message. One group heard a negative message. The researchers wanted to know what mattered more for how the patient felt 24 hours later: what the patient already believed about hands-on therapy, what the patient expected, or the message they heard right before treatment.

The message won. The patient's prior beliefs and expectations did not strongly predict their 24-hour pain. The framing they heard right before the adjustment did. Negative framing predicted more pain. Positive framing predicted less.

The Study

Zaworski et al. ran a secondary analysis of a single-session randomized trial conducted at a university physiotherapy department in Poland. The original parent trial (NCT06537739) enrolled 66 young adults (mean age in their early 20s) with chronic non-specific low back pain of at least three months' duration, no radiculopathy, no red flags, and no recent spinal manipulation exposure.

Participants were randomized 1:1:1 to a positive, neutral, or negative verbal framing script. The script was delivered by the treating clinician immediately before a single lumbar high-velocity low-amplitude (HVLA) thrust technique. Manipulation technique, contact, set-up, and operator were standardized across groups. The only intentionally varied input was the framing language.

Three outcomes were collected at three time points. The 11-point Numerical Pain Rating Scale (NPRS-11) and lumbar pressure pain threshold (PPT) at L3, L4, and L5 were measured at baseline (t0), immediately post-manipulation (t1), and 24 hours after the visit (t2). Pre-treatment, the participants also completed measures of expectations for treatment success, attitude toward manual therapy, and (at t2) whether their expectations had been met.

The analytic question for this secondary analysis was specific. Holding the manipulation itself constant, which of the candidate cognitive-affective variables (expectations, attitude, expectation fulfillment) explained variation in NPRS-11 and PPT at t1 and t2? And how did those candidates compare to the verbal framing assignment itself when entered into the same model?

What They Found

Two findings, one direct, one by absence.

First, the cognitive-affective candidates that the literature most often invokes (expectations, attitude, expectation fulfillment) produced sparse and inconsistent associations across groups. Expectation fulfillment, measured at the 24-hour follow-up, was not consistently linked to either NPRS-11 or PPT at t1 or t2. Some scattered correlations appeared inside subgroups. In the positive framing group specifically, higher pre-treatment expectations correlated with higher immediate PPT at t1 L4 (r = 0.47) and L5 (r = 0.43), and a more favorable attitude toward manual therapy correlated with lower NPRS-11 at t2 (r = -0.45). Outside the positive group, the pattern dissolved.

Second, when the authors entered the candidate variables together with the framing assignment in a multiple regression predicting NPRS-11 at 24 hours, framing was the only retained predictor.

Multiple Regression Predicting 24-Hour NPRS-11

Predictor	Standardized β	Retained in Model
Negative Verbal Framing	+0.35	Yes
Positive Verbal Framing	-0.26	Yes
Pre-Treatment Expectations	not retained	No
Attitude Toward Manual Therapy	not retained	No
Expectation Fulfillment (t2)	not retained	No

Adjusted R² = 0.26, p < 0.001. Conducted in 66 young adults with chronic non-specific low back pain receiving a single lumbar HVLA manipulation.

Stated in one sentence: the message the patient heard immediately before the thrust explained more of their next-day pain than any pre-treatment belief the patient brought into the room.

What This Means Clinically

In clinical practice this finding lands harder than the abstract suggests, because the field has spent two decades operating on a different mental model. The standard biopsychosocial framing places patient beliefs (expectations, catastrophizing, fear avoidance, locus of control) upstream of outcome. The clinician's job, in that model, is to assess and address those beliefs across the course of care. The Zaworski analysis does not refute that model. It does suggest that, at the level of a single visit, what the operator says in the seconds before contact is doing more work than the beliefs the patient walked in with.

For me, this maps cleanly to what happens at the adjusting bench every day. A patient comes in tight, guarded, partway through a flare, and the temptation is to compress the encounter. Position, set-up, thrust. The framing language compresses with it. The patient hears something perfunctory ("alright, breathe out") instead of something specific ("this is going to feel like a release through the side of your low back, and most patients tell me the next morning is when they notice the change"). Zaworski et al. are quantifying the cost of that compression. Roughly a quarter of the variance in next-day pain may be sitting in the thirty seconds before the contact.

That is a high return on a small clinical investment.

The Negative-Framing Asymmetry

Notice the size of the effects. Positive framing predicted lower pain at β = -0.26. Negative framing predicted higher pain at β = +0.35. The negative effect is larger. This is consistent with the broader nocebo literature, which has repeatedly shown that warnings and negative expectancy cues land harder than reassurance does. The clinical implication is twofold. First, the upside of careful positive framing is real but modest. Second, the downside of careless negative framing (offhand warnings, defensive over-disclosure of post-adjustment soreness, low-confidence delivery of the technique itself) is larger and more reliable. The asymmetry argues for ruthless audit of the language clinicians use without thinking.

Why Belief-State Measures Fall Short Here

The candidate variables that did not survive the regression (pre-treatment expectations, general attitude, expectation fulfillment) are stable, dispositional, and trait-like. They were measured before the patient ever met the framing script. The framing script was acute, situational, and immediately prior to the intervention. State variables outperformed trait variables in this single-encounter design. That is not a surprising result if the question is framed correctly. It is a surprising result if the field has spent years filling intake paperwork with trait-level psychometrics in the assumption that those scores would predict short-term response.

Across a full course of care, trait variables likely matter more than this one study can detect. Across a single visit, this study suggests that the state-level cue from the clinician dominates.

Where This Fits in the Literature

The Zaworski analysis sits at the intersection of three threads in the manual therapy evidence base.

The first thread is the Cochrane systematic review of spinal manipulation for chronic low back pain, which found a small to moderate average effect for SMT with substantial between-trial heterogeneity (de Zoete et al. 2026). The Zaworski finding offers one mechanistic candidate for that heterogeneity. If verbal framing is doing this much work inside a single visit, framing variability across trial operators is a non-trivial source of trial-to-trial noise that the standard meta-analytic apparatus is not equipped to detect.

The second thread is the PACBACK trial, in which biopsychosocial care embedded inside a manipulation arm produced different long-term outcomes than manipulation alone (Bronfort et al. 2026). PACBACK was framed as evidence for adding structured psychological care to the manual therapy encounter. The Zaworski result raises a quieter question. How much of PACBACK's biopsychosocial signal might already be available in the framing dose embedded in the verbal contact, before any formal psychological protocol is added?

The third thread is the methodological critique that twenty-two years of SMT trial evidence may have already saturated certainty on average effect size, with diminishing return on further trials of the same design (Elliott et al. 2026). If Elliott et al. are correct that the field has wrung what it can from average-effect-size questions, the next frontier is the moderator and mediator literature. Zaworski et al. are an early data point in exactly that frontier. Verbal framing is a moderator the field can manipulate cheaply and reproducibly.

Put together, the three threads suggest the same conclusion. The next decade of meaningful progress in manual therapy outcomes research is unlikely to come from another generic SMT-versus-control trial. It is likely to come from quantifying the contextual variables (operator framing, contact ritual, encounter pacing) that determine whether the same physical technique, delivered the same way, produces a useful response or a non-response.

Limitations

This is a secondary analysis of a single-session trial in 66 young adults with chronic non-specific low back pain at one university clinic in Poland. The generalizability to routine private practice, to older patients, to acute pain, and to multi-visit care plans is uncertain.

The analytic models were specified after the fact. The authors are appropriately cautious about causal claims. The retained framing effect is associative, not strictly causal, despite the randomized design at the parent-trial level.

The candidate cognitive-affective variables were measured with brief instruments. A more comprehensive psychometric battery (catastrophizing, kinesiophobia, locus of control) might recover predictive value that this analysis did not detect. The conclusion is "these specific instruments did not predict in this single-visit design," not "patient psychology is irrelevant."

The framing scripts were short and standardized. Real-world clinical framing is longer, more interactive, and adapts to patient response. The effect size estimates from a single rehearsed script may understate or overstate what naturalistic clinician framing produces.

Outcomes were short-term (24 hours). The study cannot speak to whether framing-driven differences persist across a course of care or wash out over weeks.

The Bottom Line

In a randomized comparison where the only thing that varied was the sentence the clinician said before the thrust, that sentence outperformed every measured patient belief in predicting pain twenty-four hours later. The opening line of an adjustment encounter is part of the intervention, not preamble to it.

Cite This Commentary Forward J. Sixty-six patients, three verbal framings, and the mediator that was not belief. The Forward Review. 2026;1(2). https://vanguardchiro.com/research/verbal-framing-spinal-manipulation-zaworski-2026/

Editorial Disclosure

The Forward Review is editorial commentary, not peer reviewed. It is written by Jason Forward, DC, a licensed chiropractor practicing at Vanguard Chiropractic in Tulsa, Oklahoma. Commentary reflects clinical interpretation and does not represent the views of the original study authors or their institutions.

Conflict of interest: No financial relationships with the cited authors, their institutions, or the publisher.

Corrections policy: Errors are corrected with a dated correction notice appended to the article. Original text remains accessible via revision history.

Level of evidence: Secondary analysis of a randomized controlled trial.

May 4, 2026

Home›The Forward Review›Volume 1, Issue 1
The Forward Review Live Commentary Vol. I · Issue 1 · April 2026
Systematic Review with Meta-Analysis Volume 1 · Issue 1 Temporomandibular Disorders Patient Education
Forty-Seven Trials of TMD Patient Education, and Why None of Them Had Low Risk of Bias
Ferland and a Belgian-Canadian team pooled 47 randomized trials of education and self-management for adults with temporomandibular disorders. None of the 47 had low risk of bias. The certainty of evidence was very low to low across every outcome. The companion finding to the Kongsted scoping review on chronic MSK pain education: in TMD specifically, the literature has volume without confidence. See related: CBT for TMD pain and stress (Gaba 2026 secondary analysis).
Jason Forward, DC, Vanguard Chiropractic, Tulsa, Oklahoma Published April 25, 2026
Reviewing
Ferland G, Vincent R, Desmeules F, Cormier AA, Huon M, Pitance L. Patient education and self-management in adults with temporomandibular disorders: results from a systematic review with meta-analysis. Journal of Oral Rehabilitation. 2026 Mar 19. Online ahead of print.
DOI: 10.1111/joor.70187 · PMID: 41858088 · PROSPERO: CRD42024529862
Key Points
Ferland and a multinational team conducted a systematic review with meta-analysis evaluating education and self-management (ED and SM) for adults with temporomandibular disorders. Six databases searched up to March 2025. PROSPERO-registered.
Forty-seven randomized clinical trials met inclusion. Total sample 3,238 adults (77 percent female, mean age 34.4). NONE of the 47 trials had low risk of bias on the Cochrane RoB-1 tool.
Other non-surgical interventions (splints, manual therapy, electrotherapy, multimodal) may be more effective than ED and SM alone for short-term pain reduction (SMD 0.67, 95 percent CI 0.13 to 1.20, very low certainty) and for short-term health-related quality of life (SMD 0.61, 95 percent CI 0.20 to 1.01, very low certainty).
When combined with ED and SM, other non-surgical interventions produced moderate additional HRQoL improvements (SMD 0.50, 95 percent CI 0.18 to 0.82, low certainty).
ED and SM alone vs ED and SM combined with other non-surgical interventions: comparable effects on pain, function, and HRQoL across short-, medium-, and long-term outcomes.
Certainty of evidence is very low to low across every comparison and every outcome reported.
Companion finding to the Kongsted 2026 scoping review on patient education for chronic MSK pain: where Kongsted mapped the field, Ferland quantified what the field has produced for one specific condition. The picture is similar. The literature has volume. It does not yet have confidence.
Plain Language Summary
Temporomandibular disorders (TMDs) affect the jaw joint and the muscles that move it. Patients experience jaw pain, clicking, locking, headache, neck pain, and difficulty chewing. The condition is common, and the recommended first-line care across guidelines is conservative: education, self-management strategies, and a range of non-surgical interventions including splints, manual therapy, and exercise.
This new review pooled 47 randomized trials testing whether education and self-management work for TMD pain, function, and quality of life. The pooled answer: the data is not strong enough to draw confident conclusions. None of the 47 trials had a low risk of bias. Across every outcome, the certainty of evidence was very low to low.
What the data does suggest: other non-surgical treatments may be slightly more effective than education alone in the short term, and combining education with other treatments may produce a modest additional benefit on quality of life. But none of these patterns reach high enough certainty to be guidelines-grade evidence.
The Question
Patient education and self-management are the most universally recommended first-line interventions in nearly every musculoskeletal condition guideline written. The intuition is clear: a patient who understands what is happening in the tissue, who knows which behaviors aggravate the condition, and who has tools to manage flare-ups is better off than a patient who arrives in clinic confused, fearful, and waiting for a passive intervention.
That intuition has been tested most extensively in low back pain, where the Kongsted 2026 scoping review mapped 66 documents on education for chronic MSK pain and found that, while every guideline recommends it, the literature has not yet studied the kind of education patients actually want. Ferland and colleagues asked the parallel question for temporomandibular disorders specifically. How well-supported is education and self-management for TMD? Better, worse, or about the same as the chronic MSK pain literature more broadly?
The answer matters clinically. TMD has a distinct profile within MSK care. The joint is small. The muscles are interlaced with the cranial nerves and the cervical spine. The condition has overlapping somatic and behavioral drivers (clenching, bruxism, sleep posture). The patient population skews younger and more female than chronic LBP. Whether the education-and-self-management literature transfers cleanly from chronic LBP to TMD is not obvious, and it has not been systematically established before this review.
What They Did
The Ferland team prospectively registered the protocol on PROSPERO (CRD42024529862) before data extraction, which matters for credibility. They searched six databases up to March 2025. Eligible studies were randomized clinical trials in adults with TMD comparing education and self-management against any other non-surgical intervention (splints, manual therapy, electrotherapy, multimodal protocols), reporting outcomes on pain, function, or health-related quality of life.
Risk of bias was assessed with the Cochrane RoB-1 tool. Pooled effects were estimated using random-effects models with standardized mean differences (SMDs). Certainty of evidence was graded with GRADE. The methodological scaffolding is appropriate and transparent. Where the review runs into trouble is not in its own methodology. It is in the underlying evidence base it is trying to synthesize.
What They Found
Forty-seven RCTs met inclusion. Total sample 3,238 adults. The demographic skew is notable: 77 percent of participants were female, mean age 34.4 years. TMD is one of the more demographically distinctive MSK conditions, and the pooled population reflects that.
The first finding is the methodological one. NONE of the 47 trials had low risk of bias. That is not a complaint about a few outliers. It is a complete absence of high-quality evidence. Every trial in the pool had at least one significant methodological vulnerability. The downstream effect is that every certainty grade in the review degrades from the start.
The second finding concerns the comparison most clinicians care about: education and self-management alone versus other non-surgical interventions. For short-term pain reduction, other interventions produced a moderately larger effect (SMD 0.67, 95 percent CI 0.13 to 1.20, 6 studies, 323 patients). For short-term HRQoL improvement, other interventions also produced a larger effect (SMD 0.61, 95 percent CI 0.20 to 1.01, 2 studies, 124 patients). Both findings have wide confidence intervals and very low GRADE certainty.
The third finding addresses the integration question. When education and self-management were combined with other non-surgical interventions, there was a moderate additional improvement in HRQoL beyond what the other interventions delivered alone (SMD 0.50, 95 percent CI 0.18 to 0.82, 3 studies, 154 patients). This is the closest thing the review has to a positive signal for ED and SM: it may add value when layered on top of other treatments.
The fourth finding is the comparable-effects pattern. ED and SM alone versus ED and SM combined with other non-surgical interventions produced statistically indistinguishable effects on pain, function, and HRQoL across short-, medium-, and long-term outcomes. The combined intervention did not consistently outperform the standalone education program.
That last finding is paradoxical when read alongside the second and third. Other interventions look better than ED and SM alone. Adding ED and SM to other interventions improves HRQoL. But ED and SM alone vs ED and SM plus other interventions look comparable. The most likely explanation is the sample sizes. The pooled comparisons rest on 2 to 6 studies with small per-comparison patient totals. The signal-to-noise ratio is too thin to consistently separate any of the conditions from each other.
What This Means Clinically
I see TMD patients regularly, though less frequently than chronic LBP or neck pain. The typical presentation in my Tulsa clinic is a 30-something woman with right-sided jaw pain, clicking on opening, accompanying tension headache, and upper cervical restriction on exam. She has often already been to a dentist who fitted a night guard, and is unsure whether to escalate to an orofacial-pain specialist or try chiropractic care.
The Ferland review does not change my fundamental approach to that patient, but it sharpens what I tell her. The honest message I now give: education and self-management alone has very low certainty support across the entire research base. Other treatments may produce slightly larger short-term gains. Combining education with other treatments looks better than either alone for quality of life, but the data is thin. Whatever I deliver, the evidence base does not support strong claims about which specific approach is superior.
What I do in practice for TMD: a brief education segment covering the role of clenching and posture, a self-management plan including jaw rest, soft food during flare-ups, and tongue-on-palate posture work, plus upper cervical and suboccipital work when those segments contribute to the pattern. I do not deliver TMJ-specific intraoral techniques because that is outside my scope. When the case is complex or unresponsive, I refer to dentistry and to orofacial-pain specialists.
The Ferland review does not say my approach is wrong. It says the literature does not yet support a strong claim that any specific approach is right. That is a useful piece of clinical honesty to carry into the patient conversation.
Connecting to the Kongsted Review
This paper is the TMD-specific companion to the broader Kongsted 2026 scoping review on patient education for chronic MSK pain. The Kongsted finding was structural: every guideline recommends patient education, every patient survey wants it individualized, but the literature has not yet studied individualized education at scale. The Ferland finding is quantitative: even within the more delimited TMD literature where 47 RCTs exist, none have low risk of bias and the certainty grades stay low.
Read together, the two reviews triangulate the same conclusion from different angles. Patient education for MSK pain is universally recommended and under-evidenced. The clinical practice that does occur happens in a defensible but un-evidenced space. That is not a reason to stop educating patients. It is a reason to be honest about what the evidence does and does not support, and to be appropriately humble in clinical claims.
For the Tulsa Clinic
Three immediate applications for my walk-in chiropractic practice:
One. When a TMD patient asks "what does the research say about jaw exercises and behavioral strategies," the honest answer is that the evidence is weak. Forty-seven trials exist. None of them are low-risk-of-bias. That is not the same as saying education does not help. It is saying the field does not yet know how much it helps, in which patients, at which doses.
Two. When integrating ED and SM with manual therapy, the Ferland combined-care signal (SMD 0.50 on HRQoL) is the most actionable piece of evidence in the review. Layering education and self-management on top of manual care for TMD has the best supported (low certainty) signal of any comparison the review tested. That matches my standard approach and gives me a citation.
Three. The TMD population skews young and female. That is worth knowing for clinical communication. Patients who arrive expecting a quick adjustment to fix the joint should be reframed early: TMD is multifactorial, and the data does not support a one-shot solution from any modality.
What This Review Does Not Resolve
The review does not address surgical interventions or the role of orofacial-pain specialists. It does not separate myofascial TMD from disc-displacement TMD or from arthritic TMD, conditions that may respond differently to ED and SM. It does not break out by diagnostic subtype using the Diagnostic Criteria for Temporomandibular Disorders (DC/TMD), which is now the standard classification system. The pooled results treat TMD as a single category. They probably should not.
The review also does not adjudicate which specific other non-surgical interventions are best. "Other non-surgical interventions" includes splints, manual therapy, electrotherapy, and multimodal protocols, all in one bucket. The signal that they outperform ED and SM alone may be driven by one of those modalities and washed across the others. A future analysis breaking out by intervention type would be useful.
Limitations
The most important limitation is the underlying evidence base, not the review itself. None of the 47 included RCTs had low risk of bias on Cochrane RoB-1. Every certainty grade in the review degrades from this floor.
Sample sizes for pooled comparisons are small (2 to 6 studies, 124 to 323 patients per outcome). Wide confidence intervals on every effect estimate.
The review pools heterogeneous "other non-surgical interventions" (splints, manual therapy, electrotherapy, multimodal). Mechanistically distinct interventions are treated as a single comparator group.
TMD diagnostic subtypes are not separated. Myofascial, disc-displacement, and arthritic TMD likely respond differently to ED and SM and to other interventions. The pooled estimates obscure subgroup signals.
The literature search closed March 2025. Several 2025 and 2026 trials are not included.
The 47 trials likely reflect publication bias toward shorter-duration RCTs with measurable outcomes. Long-term effectiveness, patient adherence over time, and real-world delivery patterns are under-represented.
The Bottom Line
Forty-seven randomized trials of education and self-management for temporomandibular disorders, and the most consistent finding is that the certainty of evidence is very low to low. None of the trials had low risk of bias. Other non-surgical interventions may produce slightly larger short-term effects on pain and quality of life. Combining education with other interventions may add modest HRQoL benefit. But no comparison reaches high enough certainty to drive confident clinical recommendations. The TMD literature, like the broader chronic MSK pain education literature mapped by Kongsted, has volume without confidence.
Cite This Commentary Forward J. Forty-seven trials of TMD patient education, and why none of them had low risk of bias. The Forward Review. 2026;1(1). https://vanguardchiro.com/research/patient-education-temporomandibular-disorders-ferland-2026/
Read More From This Issue
When Patient Education Works, and Why the Evidence Cannot Yet Say Which Kind (Kongsted et al. 2026) PACBACK in JAMA: 1,000 Patients, Four Treatment Arms (Bronfort et al. 2026) Cochrane Verdict on Spinal Manipulation for Chronic LBP (de Zoete et al. 2026) First Chiropractic Headache Guideline in Over a Decade (Trager et al. 2026) Manual Therapy + Exercise for Chronic LBP (dos Santos et al. 2026) Cochrane EPOC: How Rehabilitation Care Is Designed (Del Furia et al. 2026) Volume 1, Issue 2: Manual Therapy Combinations Reduced Headache Frequency and Severity (Rehman et al. 2026 OMT meta-analysis) Return to Volume 1, Issue 1 Clinical resource: Walk-in chiropractor in Tulsa
Editorial Disclosure
The Forward Review is editorial commentary, not peer reviewed. Written by Jason Forward, DC, a licensed chiropractor at Vanguard Chiropractic in Tulsa, Oklahoma. Commentary reflects clinical interpretation and does not represent the views of the original study authors, the Journal of Oral Rehabilitation, or any institution.
Conflict of interest: Dr. Forward is a practicing chiropractor whose clinical work includes care for adults with temporomandibular disorders. He does not deliver intraoral TMJ techniques. No financial relationships with the cited authors, the publisher, or any party to this work.
Scope of practice note: Chiropractic management of TMD focuses on the cervical spine, suboccipital region, jaw musculature, and behavioral education. Intraoral techniques and orthotic fitting are outside the scope of chiropractic practice in Oklahoma and are appropriately referred to dentistry and orofacial-pain specialists.
Corrections policy: Errors are corrected with a dated correction notice appended to the article. Original text remains accessible via revision history.
Level of evidence: Systematic Review with Meta-Analysis (47 RCTs, n=3,238). GRADE certainty: very low to low across all outcomes.
April 25, 2026
Home›The Forward Review›Volume 1, Issue 1
The Forward Review Live Commentary Vol. I · Issue 1 · April 2026
Scoping Review Volume 1 · Issue 1 Patient Education Chronic MSK Pain
When Patient Education Works, and Why the Evidence Cannot Yet Say Which Kind
Kongsted, Hartvigsen, and a Danish team mapped the entire patient-education landscape for chronic musculoskeletal pain across 66 documents and 11 years of evidence. Clinical practice guidelines uniformly recommend it. Patients want it individualized. The literature on what specific approach works best is, to a degree that should give the field pause, blank. This is the missing manual that the Bronfort PACBACK trial just proved was important.
Jason Forward, DC, Vanguard Chiropractic, Tulsa, Oklahoma Published April 25, 2026
Reviewing
Kongsted A, Larsen AC, Gregersen MHM, Andersen TE, Hoegh M, Kjaer P, Møller A, Ravn SL, Skou ST, Hartvigsen J. Patient education for chronic musculoskeletal pain: a scoping review of recommendations, effectiveness, and educational content. Chiropractic and Manual Therapies. 2026;34(1):3.
DOI: 10.1186/s12998-025-00614-y · PMID: 41484990
Key Points
Kongsted and a Danish team conducted a JBI-method scoping review covering 11 years of evidence on patient education for chronic spinal pain, osteoarthritis, and mixed chronic primary musculoskeletal pain. Coverage closed July 2025.
4,243 records screened, 178 full-texts assessed, 66 included documents (systematic and scoping reviews, Delphi studies, consensus studies).
Clinical practice guidelines uniformly recommend patient education across all included MSK conditions. Education is positioned as core to care, not as adjunctive.
Educational themes that recur across documents: helping patients understand their condition and the factors that drive pain, providing reassurance, and guiding self-management strategies.
Patient preferences emphasize INDIVIDUALIZED education delivered through a collaborative process. Generic, pre-defined education is not what patients say they want.
The honest gap: substantial uncertainty about which type of education is more or less effective. NO reviews investigated individualized education specifically. The field studies what is easy to standardize, not what patients say they need.
Plain Language Summary
This paper is a map of the entire patient-education literature for long-term musculoskeletal pain conditions, including back pain, neck pain, and arthritis. It pulls together 66 separate documents from systematic reviews, expert consensus panels, and clinical practice guidelines covering the past decade.
Two clear messages emerged. Every guideline says patient education is central to good care. Every patient survey says they want it personalized to them. The educational themes that show up most consistently are: help me understand what is wrong, reassure me, and tell me what I can do about it.
One uncomfortable message also emerged. Even though guidelines uniformly recommend education and patients uniformly want it, the research does NOT yet establish clearly which kind works best, and not a single review has studied the kind patients say they actually want (individualized, collaborative). The field has been studying what is easy to standardize and measure, not what patients say is most useful.
The Question
Patient education sounds simple. A clinician explains the condition, gives reassurance, suggests management strategies, sends the patient home. But the construct hides a great deal of variation. What content does the education contain? Who delivers it? In what format? Over how many sessions? Is it standardized or tailored? Did the patient actually understand it? Did they actually act on it? The Kongsted team asked a question that nobody else had systematically asked: across the entire MSK pain literature, what is recommended, what works, and what is the actual content of patient education when it shows up in research?
The team used the Joanna Briggs Institute scoping review methodology. Search closed July 2025. Coverage included MEDLINE, Embase, and PsycINFO from January 2014 forward. They specifically targeted three MSK populations: chronic spinal pain, osteoarthritis, and mixed chronic primary musculoskeletal pain. Document types included systematic reviews, scoping reviews, Delphi studies, and consensus studies. The review's structure is not a typical effectiveness analysis. It is a map of the territory.
What They Found
From 4,243 records initially screened, 178 full-texts were assessed, and 66 documents were included. The findings cluster into three layers.
Layer 1, what guidelines say: every clinical practice guideline reviewed recommends patient education as a core intervention for chronic MSK pain. Education is not an extra. It is positioned as foundational to all subsequent care.
Layer 2, what patients say: patient preference research consistently emphasizes individualization. Patients want education that addresses their specific situation, their specific concerns, in a collaborative dialogue. They explicitly do not want generic, lecture-style information delivery. The mismatch between this preference and the way effectiveness studies are designed is the central tension of the entire review.
Layer 3, what content shows up in recommended education: three themes recur across the included documents.
(1) Understanding the condition: explain pathophysiology in plain language, help the patient build an accurate mental model of what is happening in the tissue and the nervous system.
(2) Reassurance: address fear, identify when the pain pattern is not dangerous, normalize fluctuation, reframe pain catastrophizing.
(3) Self-management strategies: graded activity, sleep hygiene, pacing, flare management, when to escalate care.
The fourth, less explicitly named, theme is: HOW the education is delivered matters as much as the content. Two-way conversation, motivational interviewing, individualized framing.
The Effectiveness Gap
The most clinically important finding in the entire review is what the team did NOT find. There is substantial uncertainty about the effectiveness of various types of patient education. No review has been conducted on individualized patient education specifically. This is the gap between what patients say they want and what the field has studied.
Why the gap exists is not a mystery. RCTs require standardization for internal validity. A protocolized "8-session structured pain neuroscience education curriculum" is much easier to study than "the chiropractor adapts the conversation to the patient's specific concerns over 4 to 12 visits." The standardized version produces clean trials. The adaptive version produces messy data. The field defaults to studying what it can measure cleanly, even when that diverges from what clinicians actually deliver and what patients actually want.
The Kongsted team is gentle but pointed about this in their conclusion: "We identified a gap between patient preferences for education individually tailored in a collaborative process and effectiveness studies focusing on pre-defined patient education programs."
What This Means Clinically
This paper is the missing companion to the Bronfort PACBACK trial covered earlier in this issue. PACBACK proved that supported biopsychosocial self-management beats medical care and beats SMT alone for acute and subacute LBP at high risk of chronicity. The PACBACK intervention was a structured 8-session curriculum delivered by trained PT and DC providers. The Kongsted review now provides the curricular map: what content goes into a structured education program, what evidence supports each component, and what the field has not yet studied.
For practicing chiropractors who want to integrate biopsychosocial education into their work, the Kongsted review is a curriculum scaffold. The three themes (understanding, reassurance, self-management) are the spine of any clinical education conversation. The patient-preference finding (individualization, collaboration) is the delivery method.
For practitioners running short-form encounters (the $40 walk-in model is one example), the implications are interesting. An 8-session structured curriculum is not deliverable in a 15-minute visit. What IS deliverable, repeatedly across many visits, is each of the three themes in 60-second packages. The patient who returns six times in three months has received six brief education sessions, which is the same total dose as a structured 6-session curriculum, just distributed differently. The Kongsted review does not establish that this distributed delivery works (because it has not been studied), but it also does not establish that it does NOT work. The unstudied space is large and worth occupying clinically.
A Note on Conflict of Interest
Several Kongsted authors (Skou, Hartvigsen, Kjaer, Kongsted) are co-developers of the GLA:D® program, a non-profit education-and-exercise initiative for OA and back pain hosted at the University of Southern Denmark. The conflict is appropriately disclosed, and GLA:D® is one of the more thoroughly studied educational programs in MSK pain. Readers should know that the team has both deep expertise in patient education AND a programmatic stake in the field's structure. Their finding that no reviews studied individualized education does not undermine the GLA:D® work, which is itself a structured rather than individualized program. It is a fair self-critique.
For the Tulsa Clinic
Three immediate applications:
1. Build a one-page handout covering the three themes (understanding, reassurance, self-management) for the most common conditions (LBP, neck pain, headache). Handouts are not personalized care, but they are scaffolding that supports the brief verbal interventions.
2. Train myself in pain neuroscience education delivered in short bursts. Resources from the Lorimer Moseley group (Body in Mind, Explain Pain) are aligned with the educational themes the Kongsted review identified.
3. Track education delivery as a clinical variable. Document in the chart whether each visit included a brief education element. This converts education from an implicit to an explicit intervention, which is the prerequisite for measuring whether it helps.
Limitations
Scoping reviews do NOT synthesize effect estimates. The Kongsted review maps the landscape but does not produce a pooled answer to "how big is the effect of education X on outcome Y."
Search closed July 2025. PACBACK and several other 2026 trials are not included. The field has likely moved since the search closure.
Three included MSK populations (spinal pain, OA, mixed chronic primary MSK pain). Findings may not extrapolate to acute MSK pain, post-surgical pain, or cancer-related MSK pain.
The "no reviews on individualized education" finding may reflect search and inclusion criteria. Some individualized-care trials may be classified under "person-centered care" or "clinical reasoning" rather than "patient education" and may exist outside the review's frame.
Multiple authors are GLA:D® co-developers. This is appropriately disclosed but readers should know.
Co-authors used a generative AI thematic analysis tool during synthesis. They declare review and editing of all AI-generated content. The methodological choice is unusual for scoping reviews and warrants attention.
The Bottom Line
Every guideline recommends patient education for chronic MSK pain. Every patient survey says individualization is what they want. Yet the field has not studied individualized education. Clinicians delivering brief, repeated, conversational education across many visits are operating in a defensible but un-evidenced space. The three educational themes, understanding, reassurance, and self-management, are the spine of the work. Build a handout, train the technique, track delivery, and the practitioner participates in a literature whose biggest gap is the part that matters most clinically.
Cite This Commentary Forward J. When patient education works, and why the evidence cannot yet say which kind. The Forward Review. 2026;1(1). https://vanguardchiro.com/research/patient-education-chronic-msk-pain-kongsted-2026/
Read More From This Issue
Sequential cluster: PACBACK in JAMA (Bronfort et al. 2026), the trial that proved biopsychosocial education works. This is its companion. Manual Therapy Plus Exercise (dos Santos et al. 2026) Cochrane SMT for Chronic LBP (de Zoete et al. 2026) Trial Sequential Analysis Research Waste (Elliott et al. 2026) Chiropractic Headache Guideline (Trager et al. 2026) LSS Clinical Course (Mc Auliffe et al. 2026) What Drives Recovery (Shannon et al. 2026) Fascial Manipulation Decade (Unalmis et al. 2026) Return to Volume 1, Issue 1
Editorial Disclosure
The Forward Review is editorial commentary, not peer reviewed. Written by Jason Forward, DC, a licensed chiropractor at Vanguard Chiropractic in Tulsa, Oklahoma. Commentary reflects clinical interpretation and does not represent the views of the original authors or any institution.
Conflict of interest: Dr. Forward delivers patient education as part of every clinical encounter and has a clinical interest in optimizing how that education is delivered. No financial relationship with the Kongsted authors, GLA:D®, the journal, or any party.
Corrections policy: Errors are corrected with a dated correction notice appended to the article.
Level of evidence: Scoping review (66 documents, JBI methodology, 11-year coverage window).
April 25, 2026

FR Specialty: Interprofessional

Key Points

Why Patients Ask This Question

The Study: What Mo and Colleagues Actually Did

The Headline Numbers, With Their Caveats Attached

Why You Cannot Trust a Mood Score the Way You Trust a Blood Pressure Cuff

What the Spinal-Manipulation-Specific Evidence Says

The Honest Mechanism: An Indirect Chain, Not a Brain Effect

What This Means in My Tulsa Practice

Frequently Asked Questions

Editorial Disclosure

Key Points

Why This Paper Matters

What a SMART Trial Actually Is

What They Found

Where Chiropractic Sits in This Picture

The Mechanism Question

What I Tell My Patients

Limitations and Caveats

Clinical Context: Conservative Care First, Not Conservative-Brand-A First

Editorial Disclosure

Key Points

What the Researchers Did

What They Found

Clinical Perspective: What I See in My Practice

What This Means for Parents

Vanguard Chiropractic Connection

Limitations and What Is Not Yet Known

Editorial Disclosure

Key Points

The Study

What They Found

What This Means Clinically

The Negative-Framing Asymmetry

Why Belief-State Measures Fall Short Here

Where This Fits in the Literature

Editorial Disclosure

Key Points

The Question

What They Did

What They Found

What This Means Clinically

Connecting to the Kongsted Review

For the Tulsa Clinic

What This Review Does Not Resolve

Editorial Disclosure

Key Points

The Question

What They Found

The Effectiveness Gap

What This Means Clinically

A Note on Conflict of Interest

For the Tulsa Clinic

Editorial Disclosure