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NCT03581123: PACBACK

Spinal Manipulation and Patient Self-Management for Preventing Acute to Chronic Back Pain

Completed Phase 3 Results posted Last updated 16 October 2025
What this trial tests

Phase 3 trial testing Supported-Self Management (SSM) in Acute Pain in 1,000 participants. Completed in 12 June 2024.

Timeline
1 November 2018
Primary endpoint
12 June 2024
12 June 2024

Quick facts

Lead sponsorUniversity of Minnesota
PhasePhase 3
StatusCompleted
Study typeINTERVENTIONAL
Allocationrandomized
Designfactorial
Maskingdouble
Primary purposetreatment
Enrollment1,000
Start date1 November 2018
Primary completion12 June 2024
Estimated completion12 June 2024
Sites3 locations across United States

Drugs / interventions tested

Conditions studied

Sponsor

University of Minnesota

Who can join

18 and older, any sex, with Acute Pain or Low Back Pain, Mechanical. Patients with the condition only — healthy volunteers not accepted.

Results — posted to ClinicalTrials.gov

Per-arm endpoint measurements with 95% confidence intervals where reported. Source: trial results section.

Pain Intensity Primary · Average over weeks 1-52

Measured using the 0-10 numerical rating scale (0=no LBP, 10=the worst LBP possible). Missing weekly outcomes were multiply imputed. Means were estimated using marginal standardization with adjustment for site, time period, risk of chronicity, and baseline pain intensity.

GroupValue95% CI
Supported Self-Management (SSM)2.8± 0.1
Spinal Manipulation Therapy (SMT)3.0± 0.1
Combined SSM/SMT2.8± 0.1
Medical Care (MC)3.0± 0.1
Disability Primary · Average over months 1-12

Measured using the Roland-Morris Disability Questionnaire (RMDQ), a 24-item questionnaire that measures the degree to which a low back problem restricts daily activities. Score ranges from 0 to 24 with higher values indicating more disability. Missing monthly outcomes were multiply imputed. Means were estimated using marginal standardization with adjustment for site, time period, risk of chronicity, and baseline RMDQ.

GroupValue95% CI
Supported Self-Management (SSM)4.7± 0.2
Spinal Manipulation Therapy (SMT)5.5± 0.3
Combined SSM/SMT4.8± 0.3
Medical Care (MC)5.9± 0.2
Low Back Pain (LBP) That is Impactful Primary · Average over months 10 -12

Measured by the LBP impact scale, which includes measures of pain intensity, pain interference, and physical function from the PROMIS-29 Profile v2.0. The scale ranges from 8 (least impact) to 50 (greatest impact). Missing monthly outcomes were multiply imputed. Means were estimated using marginal standardization with adjustment for site, time period, risk of chronicity, and baseline LBP impact score.

GroupValue95% CI
Supported Self-Management (SSM)15.3± 0.4
Spinal Manipulation Therapy (SMT)16.7± 0.5
Combined SSM/SMT15.7± 0.5
Medical Care (MC)17.0± 0.4
Recovery From Acute/Sub-acute Low Back Pain Secondary · 6 months

Measured by the proportion of patients with scores of 0 on the 0-10 pain numeric rating scale (NRS) and a score of less than or equal to 2 on the Roland-Morris Disability Questionnaire (RMDQ), a 24-item questionnaire that measures the degree to which a low back problem restricts daily activities.

GroupValue95% CI
Supported Self-Management (SSM)56
Spinal Manipulation Therapy (SMT)29
Combined SSM/SMT33
Medical Care (MC)38
Low Back Pain Frequency - Percent of Days Over 12 Months Secondary · Weeks 1-52

Participants report the number of days that low back pain has been a problem in the past 7 days for 52 weeks. This measure is the percent of days that low back pain has been a problem. Mean and confidence intervals are estimated using marginal standardization and bootstrapping. Adjustment for site, time period, and risk for chronicity.

GroupValue95% CI
Supported Self-Management (SSM)3936 – 43
Spinal Manipulation Therapy (SMT)4440 – 48
Combined SSM/SMT3834 – 42
Medical Care (MC)4642 – 49
Number of Participants Who Received Care For Low Back Pain Secondary · Months 1-12

Includes provider visits, emergency department visits, diagnostic imaging scans, hospitalizations, injections and surgical procedures. This is a binary indicator of any care from providers outside the study for low back pain.

GroupValue95% CI
Supported Self-Management (SSM)82
Spinal Manipulation Therapy (SMT)67
Combined SSM/SMT53
Medical Care (MC)128
Medication Use - Percent of Months 4-12 Secondary · Months 4-12

Over the counter and prescription medication use for low back pain. Since the MC arm intervention includes medications, only months 4-12 (i.e. after the intervention) are considered for this outcome. The measure is the percent of months 4-12 in which medication was used for low back pain. Mean and confidence intervals are estimated using marginal standardization and bootstrapping. Adjustment for site, time period, and risk for chronicity.

GroupValue95% CI
Supported Self-Management (SSM)3733 – 42
Spinal Manipulation Therapy (SMT)4034 – 46
Combined SSM/SMT3731 – 43
Medical Care (MC)5450 – 58
Bothered by Low Back Pain at Work - Percent of Months Secondary · Months 1-12

Participants indicated in monthly follow-ups if they were bothered by low back pain over the last month. This measure is the percent of months that participants were bothered by low back pain at work. Mean and confidence intervals are estimated using marginal standardization and bootstrapping. Adjustment for site, time period, and risk for chronicity.

GroupValue95% CI
Supported Self-Management (SSM)4339 – 47
Spinal Manipulation Therapy (SMT)4540 – 51
Combined SSM/SMT4338 – 48
Medical Care (MC)5147 – 55
Global Improvement Secondary · 2 months

Measured using a 9-point scale: 0 (vastly worse) to 8 (completely recovered )

GroupValue95% CI
Supported Self-Management (SSM)6.2± 1.2
Spinal Manipulation Therapy (SMT)6.3± 1.0
Combined SSM/SMT6.4± 1.1
Medical Care (MC)5.7± 1.5
Global Improvement Secondary · 6 months

Measured using a 9-point scale: 0 (vastly worse) to 8 (completely recovered )

GroupValue95% CI
Supported Self-Management (SSM)6.1± 1.4
Spinal Manipulation Therapy (SMT)6.0± 1.3
Combined SSM/SMT6.3± 1.4
Medical Care (MC)5.5± 1.7
Global Improvement Secondary · 12 months

Measured using a 9-point scale: 0 (vastly worse) to 8 (completely recovered )

GroupValue95% CI
Supported Self-Management (SSM)6.2± 1.3
Spinal Manipulation Therapy (SMT)5.8± 1.6
Combined SSM/SMT6.3± 1.4
Medical Care (MC)5.5± 1.6
Patient Satisfaction With Treatment Secondary · 2 months

Measured using a 7-point Likert scale: 0 (completely dissatisfied) to 6 (completely satisfied)

GroupValue95% CI
Supported Self-Management (SSM)4.9± 1.0
Spinal Manipulation Therapy (SMT)5.0± 0.9
Combined SSM/SMT5.2± 0.9
Medical Care (MC)4.2± 1.3

Adverse events — posted to ClinicalTrials.gov

Time frame: 1 year from randomization. Reporting threshold: 5%. Adverse-event reports describe events observed during the trial — not all are caused by the drug.

Supported Self-Management (SSM)
Serious: 27/298 (9%)
Deaths: 0/298
Spinal Manipulation Therapy (SMT)
Serious: 13/198 (7%)
Deaths: 0/198
Combined SSM/SMT
Serious: 22/190 (12%)
Deaths: 0/190
Medical Care (MC)
Serious: 22/296 (7%)
Deaths: 0/296

Serious adverse events (28 terms)

ReactionSystemSupported Self-Management …Spinal Manipulation Therap…Combined SSM/SMTMedical Care (MC)
Other surgical/medical procedureSurgical and medical procedures
Cardiac problemsCardiac disorders
Gastrointestinal issuesGastrointestinal disorders
Lumbar back-related procedureSurgical and medical procedures
Fall or accidentInjury, poisoning and procedural complications
Nervous system problemNervous system disorders
Non-COVID infectionInfections and infestations
Diabetes complicationsEndocrine disorders
Respiratory issueRespiratory, thoracic and mediastinal disorders
Back painMusculoskeletal and connective tissue disorders
COVIDInfections and infestations
Suicidal ideationPsychiatric disorders
Substance abusePsychiatric disorders
Inpatient mental health visitPsychiatric disorders
NephrolithiasisRenal and urinary disorders
CancersNeoplasms benign, malignant and unspecified (incl cysts and polyps)
Severe vertigoEar and labyrinth disorders
Diabetic retinopathyEye disorders
Fluid retention in abdomen and lungsGeneral disorders
Jaundice from gallstonesHepatobiliary disorders
Anaphylaxis from known allergyImmune system disorders
Inpatient diagnostic visitInvestigations
Malnutrition due to anorexia nervosaMetabolism and nutrition disorders
Thumb pain/weaknessMusculoskeletal and connective tissue disorders
Ovarian cyst rupturedReproductive system and breast disorders
Other adverse events (4 terms — click to expand)

ReactionSystemSupported Self-Management …Spinal Manipulation Therap…Combined SSM/SMTMedical Care (MC)
Back painMusculoskeletal and connective tissue disorders
COVIDInfections and infestations
Non-COVID infectionInfections and infestations
Gastrointestinal issuesGastrointestinal disorders

Most-reported serious reactions: Other surgical/medical procedure, Cardiac problems, Gastrointestinal issues, Lumbar back-related procedure, Fall or accident, Nervous system problem, Non-COVID infection, Diabetes complications.

Data from ClinicalTrials.gov NCT03581123 adverse events section.

Sponsor's own description

This is a study of adults with acute low back pain flare-up at risk of becoming chronic and disabling. The study tests how well spinal manipulation and guided selfcare work compared to standard medical care. The treatments last up to eight weeks and participants will be followed for one year.

Publications & conference data

4 peer-reviewed publications reference this trial (live from Europe PMC):

  1. Spinal Manipulation and Clinician-Supported Biopsychosocial Self-Management for Acute Back Pain: The PACBACK Randomized Clinical Trial.
    Bronfort G, Meier EN, Leininger B, Schneider M, et al · · 2026 · cited 2× · PMID 41460638 · DOI 10.1001/jama.2025.21990
  2. Effectiveness of spinal manipulation and biopsychosocial self-management compared to medical care for low back pain: a randomized trial study protocol.
    Bronfort G, Delitto A, Schneider M, Heagerty PJ, et al · · 2023 · cited 2× · PMID 37231386 · DOI 10.1186/s12891-023-06549-w
  3. Spinal Manipulation and Clinician-Supported Self-Management for Preventing Chronic Low Back Pain Impact: The PACBACK Randomized Clinical Trial.
    Bronfort G, Meier EN, Leininger B, Schneider M, et al · · 2026 · PMID 42223934 · DOI 10.1001/jamainternmed.2026.1893
  4. Effectiveness of Spinal Manipulation and Biopsychosocial Self-Management compared to Medical Care for Low Back Pain: A Randomized Trial Study Protocol
    Bronfort G, Delitto A, Schneider M, Heagerty P, et al · · 2023 · DOI 10.21203/rs.3.rs-2865633/v1

Verify or expand the search:

Other recruiting trials for Acute Pain

Currently open trials in the same condition.

Other University of Minnesota trials

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