Chronic Low Back Pain

Nociplastic Pain: An Introduction

By Frank M. Painter|October 21, 2025|Chronic Low Back Pain, Chronic Neck Pain, Chronic Pain, Nociplastic Pain|

Nociplastic Pain: An Introduction

SOURCE: J Can Chiropr Assoc 2025 (Aug); 69 (2): 131–144

Christopher B. Roecker, DC, MS • Samuel M. Schut, DC

VA Puget Sound Health Care System,
Care Rehabilitation Care Services,
Everett, Washington.

Chronic pain is common in chiropractic practice and often presents without clear evidence of tissue injury. Nociplastic pain is a recently defined concept that highlights altered nociceptive processing within the nervous system. This newer understanding of pain provides insight into chronic conditions such as chronic back or neck pain, chronic headaches, and fibromyalgia. These conditions are commonly encountered in chiropractic practice but may be challenging to address using traditional models. This commentary introduces nociplastic pain, outlining potential mechanisms and relevance to chiropractic care. We advocate a collaborative, multimodal management approach that includes patient education, exercise promotion, and functional goal-setting within a biopsychosocial framework. Understanding nociplastic pain equips chiropractors to support patients with complex chronic pain through compassionate, evidence-based care that addresses the whole person.

Keywords: back; biopsychosocial; central sensitization; chiropractic; chronic; fibromyalgia; headache; interdisciplinary health teams; management; neck; neuropathic; nociception; nociplastic; pain; widespread chronic pain.

From the FULL TEXT Article:

Introduction

Advances in pain science continue to transform our understanding of pain mechanisms. Traditionally, pain has been mechanistically classified as either nociceptive or neuropathic in nature, and cases that did not fall easily into one of these categories were often labeled as idiopathic or pejoratively suggestive of malingering. [1] This framework, however, was incomplete and left many patients without a clear explanation for their symptoms. By 2017, sufficient evidence had accumulated to describe a third pain mechanistic descriptor (i.e., type of pain), characterized by alterations in nociceptive processing. [2–4] This new understanding of pain is now recognized as nociplastic pain. [5–8]

Table 1

Nociplastic pain is defined as “pain that arises from altered nociception despite no clear evidence of actual or threatened tissue damage causing the activation of peripheral nociceptors or evidence for disease or lesion of the somatosensory system causing the pain” (Table 1). [5, 8] The purpose of this commentary is to introduce nociplastic pain, its purported pathophysiologic mechanisms, management strategies, and its implications for clinical decision-making within the chiropractic profession.

Nociplastic pain

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Brain Mechanisms of Anticipated Painful Movements and Their Modulation by Manual Therapy in Chronic Low Back Pain

By Frank M. Painter|September 3, 2025|Chronic Low Back Pain, Fear Avoidance, Neurology|

Brain Mechanisms of Anticipated Painful Movements and Their Modulation by Manual Therapy in Chronic Low Back Pain

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SOURCE: J Pain 2018 (Nov); 19 (11): 1352–1365

Dan-Mikael Ellingsen • Vitaly Napadow • Ekaterina Protsenko • Ishtiaq Mawla • Matthew H Kowalski • David Swensen • Deanna O’Dwyer-Swensen • Robert R Edwards • Norman Kettner • Marco L Loggia

A. A. Martinos Center for Biomedical Imaging,
Department of Radiology,
Massachusetts General Hospital,
Harvard Medical School,
Boston, Massachusetts.

Heightened anticipation and fear of movement-related pain has been linked to detrimental fear-avoidance behavior in chronic low back pain (cLBP). Spinal manipulative therapy (SMT) has been proposed to work partly by exposing patients to nonharmful but forceful mobilization of the painful joint, thereby disrupting the relationship among pain anticipation, fear, and movement. Here, we investigated the brain processes underpinning pain anticipation and fear of movement in cLBP, and their modulation by SMT, using functional magnetic resonance imaging. Fifteen cLBP patients and 16 healthy control (HC) subjects were scanned while observing and rating video clips depicting back-straining or neutral physical exercises, which they knew they would have to perform at the end of the visit. This task was repeated after a single session of spinal manipulation (cLBP and HC group) or mobilization (cLBP group only), in separate visits. Compared with HC subjects, cLBP patients reported higher expected pain and fear of performing the observed exercises. These ratings, along with clinical pain, were reduced by SMT. Moreover, cLBP, relative to HC subjects, demonstrated higher blood oxygen level-dependent signal in brain circuitry that has previously been implicated in salience, social cognition, and mentalizing, while observing back straining compared with neutral exercises. The engagement of this circuitry was reduced after SMT, and especially the spinal manipulation session, proportionally to the magnitude of SMT-induced reduction in anticipated pain and fear. This study sheds light on the brain processing of anticipated pain and fear of back-straining movement in cLBP, and suggests that SMT may reduce cognitive and affective-motivational aspects of fear-avoidance behavior, along with corresponding brain processes. PERSPECTIVE: This study of cLBP patients investigated how SMT affects clinical pain, expected pain, and fear of physical exercises. The results indicate that one of the mechanisms of SMT may be to reduce pain expectancy, fear of movement, and associated brain responses.

Keywords: Expectation; Fear-avoidance; Pain anticipation; Physical exercise; Spinal Manipulative Therapy; chronic Low Back Pain; functional Magnetic Resonance Imaging.

From the FULL TEXT Article:

Background

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Spinal Manipulative Therapy in Older Adults with Chronic Low Back Pain: An Individual Participant Data Meta-analysis

By Frank M. Painter|June 5, 2022|Chiropractic Care, Chiropractic Management, Chronic Low Back Pain|

Spinal Manipulative Therapy in Older Adults with Chronic Low Back Pain: An Individual Participant Data Meta-analysis

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SOURCE: European Spine Journal 2022 (May 28) [EPUB]

OPEN ACCESS

Alan Jenks, Annemarie de Zoete, Maurits van Tulder, Sidney M Rubinstein, International IPD-SMT group

Faculty of Science,
Department of Health Sciences,
Vrije Universiteit,
Gebouw MF, Flexruimte,
Van der Boechorststraat 7,
1081 BT, Amsterdam,
The Netherlands.

Purpose: Many systematic reviews have reported on the effectiveness of spinal manipulative therapy (SMT) for low back pain (LBP) in adults. Much less is known about the older population regarding the effects of SMT.

Objective: To assess the effects of SMT on pain and function in older adults with chronic LBP in an individual participant data (IPD) meta-analysis.

Setting: Electronic databases from 2000 until June 2020, and reference lists of eligible trials and related reviews.

Design and subjects: Randomized controlled trials (RCTs) which examined the effects of SMT in adults with chronic LBP compared to interventions recommended in international LBP guidelines.

Methods: Authors of trials eligible for our IPD meta-analysis were contacted to share data. Two review authors conducted a risk of bias assessment. Primary results were examined in a one-stage mixed model, and a two-stage analysis was conducted in order to confirm findings.

Main outcomes and measures: Pain and functional status examined at 4, 13, 26, and 52 weeks.

Results: 10 studies were retrieved, including 786 individuals, of which 261 were between 65 and 91 years of age. There is moderate-quality evidence that SMT results in similar outcomes at 4 weeks (pain: mean difference [MD] – 2.56, 95% confidence interval [CI] – 5.78 to 0.66; functional status: standardized mean difference [SMD] – 0.18, 95% CI – 0.41 to 0.05). Second-stage and sensitivity analysis confirmed these findings.

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Care Outcomes for Chiropractic Outpatient Veterans (COCOV): A Single-arm, Pragmatic, Pilot Trial of Multimodal Chiropractic Care for U.S. Veterans with Chronic Low Back Pain

By Frank M. Painter|March 11, 2022|Chiropractic Management, Chronic Low Back Pain|

Care Outcomes for Chiropractic Outpatient Veterans (COCOV): A Single-arm, Pragmatic, Pilot Trial of Multimodal Chiropractic Care for U.S. Veterans with Chronic Low Back Pain

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SOURCE: Pilot and Feasibility Studies 2022 (Mar 7); 8 (1): 54

Cynthia R. Long, PhD, Stacie A. Salsbury, PhD, RN, Robert D. Vining, DC, Anthony J. Lisi, DC, et al.

Palmer Center for Chiropractic Research, Davenport,
Palmer College of Chiropractic,
741 Brady St, Davenport, IA, 52803

Background: Over 25% of veterans seeking care at U.S. Veterans Health Administration facilities have chronic low back pain (LBP), with high rates of mental health comorbidities. The primary objective of this study was to assess the feasibility of participant recruitment, retention, and electronic data collection to prepare for the subsequent randomized trial of multimodal chiropractic care for pain management of veterans with chronic low back pain. The secondary objectives were to estimate effect sizes and variability of the primary outcome and choose secondary outcomes for the full-scale trial.

Methods: This single-arm pilot trial enrolled 40 veterans with chronic LBP at one Veterans Health Administration facility for a 10–week course of pragmatic multimodal chiropractic care. Recruitment was by (1) provider referral, (2) invitational letter from the electronic health record pre-screening, and (3) standard direct recruitment. We administered patient-reported outcome assessments through an email link to REDCap, an electronic data capture platform, at baseline and 5 additional timepoints. Retention was tracked through adherence to the treatment plan and completion rates of outcome assessments. Descriptive statistics were calculated for baseline characteristics and outcome variables.

Results: We screened 91 veterans over 6 months to enroll our goal of 40 participants. Seventy percent were recruited through provider referrals. Mean age (range) was 53 (22–79) years and 23% were female; 95% had mental health comorbidities. The mean number of chiropractic visits was 4.5 (1–7). Participants adhered to their treatment plan, with exception of 3 who attended only their first visit. All participants completed assessments at the in-person baseline visit and 80% at the week 10 final endpoint. We had no issues administering assessments via REDCap. We observed clinically important improvements on the Roland-Morris Disability Questionnaire [mean change (SD): 3.6 (6.1)] and on PROMIS® pain interference [mean change (SD): 3.6 (5.6)], which will be our primary and key secondary outcome, respectively, for the full-scale trial.

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Prevalence and Characteristics of Chronic Spinal Pain Patients with Different Hopes (Treatment Goals) for Ongoing Chiropractic Care

By Frank M. Painter|January 14, 2022|Chronic Low Back Pain, Chronic Neck Pain, Spinal Pain Management|

Prevalence and Characteristics of Chronic Spinal Pain Patients with Different Hopes (Treatment Goals) for Ongoing Chiropractic Care

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SOURCE: J Alternative and Complementary Medicine 2019 (Oct 1); 25 (10): 1015–1025

Patricia M. Herman, ND, PhD, Sarah E. Edgington, MA, Gery W. Ryan, PhD, and Ian D. Coulter, PhD

RAND Corporation,
Santa Monica, CA.

Objectives: The treatment goals of patients successfully using ongoing provider-based care for chronic spinal pain

Design: Multinomial logistical hierarchical linear models were used to examine the characteristics of patients with

Settings/Location: Observational data from a large national sample of patients from 125 chiropractic clinics clustered in 6 U.S. regions.

Subjects: Patients with nonwork-injury-related nonspecific chronic low-back pain (CLBP) and chronic neck pain (CNP).

Interventions: All were receiving ongoing chiropractic care.

Outcome measures: Primary outcomes were patient endorsement of one of four goals for their treatment. Explanatory variables included pain characteristics, pain beliefs, goals for mobility/flexibility, demographics, and other psychological variables.

Results: Across our sample of 1614 patients (885 with CLBP and 729 with CNP) just under one-third endorsed a treatment goal of having their pain go away permanently (cure). The rest had goals of preventing their pain from coming back (22% CLBP, 16% CNP); preventing their pain from getting worse (14% CLBP, 12% CNP); or temporarily relieving their pain (31% CLBP, 41% CNP). In univariate analysis across these goals, patients differed significantly on almost all variables. In the multinomial logistic models, a goal of cure was associated with shorter pain duration and more belief in a medical cure; a goal of preventing pain from coming back was associated with lower pain levels; and those with goals of preventing their pain from getting worse or temporarily relieving pain were similar, including in having their pain longer.

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Risk Factors Associated With Transition From Acute to Chronic Low Back Pain in US Patients Seeking Primary Care

By Frank M. Painter|January 12, 2022|Chronic Low Back Pain|

Risk Factors Associated With Transition From Acute to Chronic Low Back Pain in US Patients Seeking Primary Care

The Chiro.Org Blog

SOURCE: JAMA Netw Open 2021 (Feb 1); 4 (2): e2037371

Joel M. Stevans, DC, PhD, Anthony Delitto, PT, PhD, Samannaaz S. Khoja, PT, PhD, Charity G. Patterson, PhD, Clair N. Smith, MS, Michael J. Schneider, DC, PhD, Janet K. Freburger, PT, PhD, et. al.

School of Health and Rehabilitation Sciences,
University of Pittsburgh,
Pittsburgh, Pennsylvania

Importance: Acute low back pain (LBP) is highly prevalent, with a presumed favorable prognosis; however, once chronic, LBP becomes a disabling and expensive condition. Acute to chronic LBP transition rates vary widely owing to absence of standardized operational definitions, and it is unknown whether a standardized prognostic tool (ie, Subgroups for Targeted Treatment Back tool [SBT]) can estimate this transition or whether early non-guideline concordant treatment is associated with the transition to chronic LBP.

Objective: To assess the associations between the transition from acute to chronic LBP with SBT risk strata; demographic, clinical, and practice characteristics; and guideline nonconcordant processes of care.

Design, setting, and participants: This inception cohort study was conducted alongside a multisite, pragmatic cluster randomized trial. Adult patients with acute LBP stratified by SBT risk were enrolled in 77 primary care practices in 4 regions across the United States between May 2016 and June 2018 and followed up for 6 months, with final follow-up completed by March 2019. Data analysis was conducted from January to March 2020.

Exposures: SBT risk strata and early LBP guideline nonconcordant processes of care (eg, receipt of opioids, imaging, and

Main outcomes and measures: Transition from acute to chronic LBP at 6 months using the National Institutes of Health Task Force on Research Standards consensus definition of chronic LBP. Patient demographic characteristics, clinical factors, and LBP process of care were obtained via electronic medical records.

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