Spinal Manipulation Within a Pain Neuroscience Education Framework: Towards a Synergistic Model of Care

Abstract

Musculoskeletal pain remains a leading global cause of disability, with low back and neck pain contributing disproportionately to personal, societal, and economic burden. Traditional explanations for spinal manipulation (SM) have centered on biomechanical concepts such as vertebral misalignment, joint fixation, or segmental dysfunction. However, contemporary evidence demonstrates that these structural narratives lack empirical support and may inadvertently reinforce fear, fragility beliefs, and nocebo responses. Instead, modern models conceptualize SM as a neurophysiological stimulus that influences pain processing through peripheral, spinal, and supraspinal mechanisms, including changes in sensory integration, descending modulation, and cortical representation.

Pain neuroscience education (PNE) has emerged as an effective cognitive intervention that reduces threat perception, enhances self-efficacy, and reframes pain as a protective output of the nervous system. Despite strong complementary potential, SM and PNE are rarely integrated coherently in clinical practice. Many patients receive manipulation framed through outdated biomechanical metaphors that contradict PNE principles, creating conceptual inconsistency and limiting therapeutic impact.

This editorial proposes that SM should be intentionally embedded within a PNE-based biopsychosocial framework. Educating patients before manual intervention reduces fear, clarifies expectations, and primes neural pathways responsible for endogenous pain inhibition, thereby enhancing the immediate and short-term effects of SM. Evidence shows that PNE combined with active or manual therapies yields superior improvements in pain, disability, and maladaptive cognitions compared to physical treatments alone. Furthermore, contextual factorstherapeutic alliance, clinician communication, and explanatory modelsaccount for a substantial portion of clinical outcomes and must be ethically leveraged to avoid nocebo and reinforce adaptive beliefs.

We argue that an integrated PNE+SM approach is ethically necessary, scientifically grounded, and clinically advantageous. Future research should test this synergy through rigorous trials, mediation analyses, and exploration of expectation-related mechanisms to better define how education and manipulation interact to improve patient outcomes.