In this episode of The Evidence‑Based Chiropractor, Dr. Jeff Langmaid reviews a 2025 randomized controlled trial published in Musculoskeletal Science & Practice that examined whether the verbal suggestions given to patients before a standardized lumbar spinal manipulation affect short‑term outcomes in young adults with chronic nonspecific low back pain. The study enrolled manipulation‑naïve participants (average age 21, 76% female) and randomized them to receive the same spinal adjustment preceded by either a positive, neutral, or negative pre‑treatment message. Outcomes were measured before the adjustment, immediately after, and 24 hours later, including primary pain intensity (NRS) and secondary measures such as stress, disability, fear‑avoidance, sleepiness, expectations, pressure pain threshold (PPT), tissue temperature, lumbar range of motion, and blood biomarkers (cortisol, serotonin, oxytocin). All groups showed pain reduction, but the positive‑suggestion group experienced significantly greater and more durable pain relief (3.5‑point reduction persisting at 24 h) compared with the neutral (≈2.5‑point) and negative (≈1‑point) groups. Positive messaging also yielded lower stress scores and higher PPT values versus negative messaging, while no significant differences were observed for disability, ROM, or biomarkers. Dr. Langmaid interprets these findings as evidence that clinicians’ pre‑treatment communication—specifically delivering concise, positive, and confidence‑building language—can enhance patient outcomes beyond the mechanical effect of the adjustment itself. He emphasizes that communication is a skill akin to the adjustment technique and offers practical advice for integrating positive framing into routine patient interactions. The episode also includes sponsor messages for chiropractic equipment and ancillary health programs.
Welcome to The Evidence Based Chiropractor, where each week we deliver the latest chiropractic research and marketing strategies, all in the time it takes to get to your office. Now here's your host, Dr. Jeff Langmaid.
Hello and welcome to The Evidence-Based Chiropractor. I'm your host, Dr. Jeff Langmaid. On today's episode, we are back with more research, and this is one I really love. It's about how your communication can impact your results. We're gonna dive into a really cool study that I think has a lot of implications for how you go about conversations in your practice each and every day. On today's episode, before we get started, big shout out to a few partners. Leander Tables, $1,000 off their Series 950 using the code EBC2026 or connecting with their team. In addition to Shockwave Centers of America, $500 off one of their Shockwave units and a free cart. And they have recently expanded their line, so be sure to check each of them out. $1,500 in savings right there. But as I said at the top on today's episode, it's all about the research. The study we're going to highlight, I'll drop a link down in the show notes. The title is, "Can Pre-Treatment Verbal Suggestions Influence the Short-Term Effects of Spinal Manipulation in Young Adults with Chronic Nonspecific Low Back Pain?" And this is a randomized controlled trial. So probably something, you know, you, you do every day is Talk to your patients, right? And this is something that is rarely highlighted in the research but critically important. And specifically, the words you say before you ju— adjust a patient. Not the adjustment itself, not the technique. I know we all really get into the technique, which is great. Diversified constant, Thompson, activator, drop, whatever the technique you bring to the table is. But today's episode is really going to focus on the simple, casual, everyday words that you use right before care begins. Because according to this study, the words that you choose, how you select them, what you say may actually— it's no surprise, it's actually going to change how your patient experiences pain or not after that spinal adjustment. That's a massive big deal. So This is not saying clearly that the care you deliver with your hands doesn't matter. It's not saying it's all placebo. What it is saying is that the context around the care really, really matters. The clinical environment matters. The confidence that you bring into the room really matters. And of course, the specific words that you say. And this study looked at young adults with chronic nonspecific low back pain. And asked a pretty interesting question. If everybody receives the same lumbar spinal adjustment, but one group gets a positive message before the adjustment, one group gets a neutral message, and one group gets a negative message, do their outcomes change? Well, you know, spoiler alert, the answer is gonna be yes, which is probably not a shock to you, but we'll dive into the details. And the details of this, I think, are nuanced. They matter and they should be something that you keep top of mind. This is not something for many of us that's totally automatic yet. It really is a skill. Conversation is a skill, just like the adjustments that you deliver. So, and the answer to the question was yes. And that was especially when it came to things that are really important, pain levels, stress, pressure pain sensitivity. So we're going to unpack all of it. Again, I'll drop a link down in the show notes. And, you know, when we talk about wording and things like that, this isn't about being like weird or scripted or over the top. It's really just about having positive, natural communication and also clear and simple communication. I actually find many docs overdo it, meaning there's just like way too much. There's like technical inside baseball kind of language that should go in your documentation. But is not relevant to how normal people communicate in the real world. And that's a hindrance to your care if you're speaking over your patient. And I always just think of the old statement, you know, journey of a thousand miles starts with one step. If you're jumping a mile down, if you're jumping 10 steps and your patient is on their first step, they can't catch up. This is one step at a time. And that is true of the care itself, but it also is true of the conversations around that. So this study, great one, came out in Musculoskeletal Science Practice 2025. The researchers did focus on chronic nonspecific low back pain. So that means everybody in the study had low back pain lasting more than 3 months without a specific identifiable cause. So no fracture, no tumor, no infection, no inflammatory disease, or radiculopathy. So this is pretty much the kind of low back pain you see in young adults all the time. So the average age was 21 years old. 76% of the individuals were female. So of all, all participants, again, chronic nonspecific low back pain, and importantly, they had not previously received spinal adjustments. So that last part is really important. So these people did not have a long history of chiropractic care. So they did not come in with like strong preexisting beliefs from past experiences. They weren't like, "Ah yeah, adjustments help me," or, "I had a bad experience," or, "I don't know, my friend told me it worked." They came in with none of that. So the researchers, as we highlight at the top, they split all of the participants into 3 distinct groups. Each group received the same spinal adjustment, lumbar, but before the adjustment, each group received a very different verbal suggestion. The positive suggestion group was told something along the lines of like, spinal adjustments are a very effective method of taking care of spinal issues, which can significantly reduce the low back pain you are experiencing. The negative suggestion group was told, you know, spinal adjustments are not a very effective method of treating spinal issues, "Uh, so it may temporarily increase the pain you are experiencing." And neutral group was told, "Spinal adjustments, they have not been verified for effectiveness in how they can affect your pain level." So same treatment, totally different, as you can see, pretreatment message. Now, for many of us, you know, that's not probably complete natural language to how we would say it. This was a research study, so they wanted to use very specific language. And quite frankly, probably none of us are giving negative suggestions. But the real question in my mind, and we're going to dive into, is are you giving the positive suggestion? Like, neutral is may— probably better than negative. We'll find out as we unpack this. But it certainly isn't positive. And any time you have the opportunity to speak into positivity, to speak into outcomes, to speak into results, it's a really, really good idea. Uh, this study, the researchers measured outcomes at 3 different points: before the adjustment, immediately after the adjustment, and 24 hours later. Primary outcome was pain intensity, and that was measured with, um, an NPS scale, classic 0 to 10 pain scale. And they also measured a few secondary outcomes. Those were stress, disability, uh, fear of movement, sleepiness, expectations, pressure, pain threshold— always a tongue twister— tissue temperature, lumbar range of motion, and some blood biomarkers like cortisol, serotonin, oxytocin. So it wasn't just how do you feel. They really looked at both patient-reported outcomes and more mechanistic outcomes, which I think gives this paper a pretty good amount of depth in terms of what they were able to see and find. So the researchers wanted to know ultimately whether the language could really influence both the subjective experiences of pain and potentially even some of the measurable physiological responses as well. So the headline finding was that all 3 groups improved in pain after spinal adjustment. Uh, now that's pretty important. The positive group improved, the neutral group improved, and quite frankly, even, even, even shockingly in some ways, the negative suggestion group also improved. So it's, it's It's not saying the adjustment only works if you give somebody a positive suggestion, but the amount of improvement was different. And that's where things start to get interesting. The positive suggestion group had greater pain reduction than the negative suggestion group immediately after the adjustment and again 24 hours later. Immediately after the adjustment, positive group, 1.41 point greater reduction in pain compared to the negative group. After 24 hours, the difference was even bigger. The positive group had over a 2-point greater reduction in pain compared to the negative group. And that is on a 0 to 10 scale. That's significant. It's actually clinically meaningful. And we're talking about low back pain. A 2-point difference can really matter to a patient. And that could be the difference between them thinking to themselves, it helped a little, and man, I really feel better. 2-point difference is a 20% difference on a, on a pain scale. And that's— that is really, really significant. So if we look at the within-group pain changes, the positive group had a 3.5-point reduction in pain immediately after the adjustment. And that same 3.5-point reduction was present 24 hours later. Neutral group did pretty well as well with about— just about a 2.5 reduction immediately afterward. And a 2.4 reduction after 24 hours. Negative group improved, but less, as you can imagine. 1.8 point reduction immediately after the adjustment, but by 24 hours, it dropped to just 1 point. So if you're kind of keeping score there, the pattern looked like this. Positive suggestion produced the biggest result and the most durable short-term pain improvement. Neutral suggestion, solid improvement. Negative suggestion, some improvement, but clearly Lassen kind of fell off pretty quickly. And that's a really powerful clinical pattern for us to be aware of. Now stress also changed. Positive verbal suggestion group, significantly lower stress compared to the negative suggestion group at 24 hours. And the difference was nearly 2.5 points. That's meaningful. Patients don't, you know, have pain in isolation. This is, oh, nearly always comes with worry and stress. You know, pain with fear, pain with stress, pain with worry, pain with uncertainty. You know, what's wrong with me? Will this get worse? Am I going to deal with this forever? Especially people in chronic pain, right? Remember these people, okay, we're coming in with chronic pain. So when positive, confident, and appropriate clinical communication is used, you can see a reduction in stress, and that can really change the patient experience in your practice. Researchers also looked, remember, at pressure pain thresholds, and that's basically how much pressure someone could tolerate before it becomes painful. Positive suggestion group had better PPT results than the negative suggestion group. So very important there. And additionally, it's really important to highlight the fact that that, that's something— the PPT is something that's utilized a lot. You're measuring pressure. But when somebody says that's painful, it's influenced by things like attention, expectation, emotion, and perception. So there's these really indirect components to the pressure pain threshold test that are important. Now, when they looked at things like disability, fear avoidance behavior, sleepiness, lumbar range of motion, tissue temperature, blood biomarkers, they didn't significantly change between, between the groups. So the words that mattered most really affected pain, stress, and pain sensitivity. They didn't magically change like every single outcome, which is totally cool. So clinically, I think it makes a lot of sense. You know, when you can positively reinforce what's going to happen, you're setting the expectation of what you— that you've been there, you've seen this before, and that the care that you're going to deliver really matters. So if we dig a little bit deeper, with pain, we can start again, all 3 groups improved. And that supports the idea that spinal adjustments have real short-term benefits for chronic nonspecific pain. Even when they were prompted negatively, there still was a positive outcome, just not as much as if they were prompted positively. So that's really, really important. When patients come into your practice, they may have an MRI, maybe they have imaging, they've been told they have a spine that looks like an 80-year-old. We all heard patients say these things. Maybe they Googled their symptoms. And they're convinced they're falling apart. And then they walk into your practice. Before you adjust them, you have a moment, you have more than one moment, but you have a moment. And in that moment, you can either reinforce fear or reduce it. You could create confidence or you can create confusion. And you can frame the adjustment as something safe, purposeful, or helpful, or you can make it unintentionally sound like risky or maybe minimize even the significance of it. So this research I loved, as you can imagine, as somebody who loves marketing, sales, and communication, that words really matter with pain, with stress, with PPT. All of this matters. And for all of us, including you listening, this should be exciting, right? We talk about the nervous system all the time. We talk about the brain-body connection, how pain is just not tissue. And this study gives us a really practical example of that concept. That the patients, when they come into your practice, their expectations, emotional states, and interpretation of the care you wanna deliver have a big influence over their outcomes. So pain is not just the output, so to speak, of the nervous system. It is really about context. It's about safety. It's about expectations. And it's about stress. So when you can get in there and really start to use compelling, simple, and direct language pre-care, it is something that is really, really impactful. People come in, and this is something also, it doesn't change with one sentence. Now, one sentence matters. You know, zero to one is a big deal. Not giving any positive information to giving one bit of positive information is a world of difference. But people are coming in thinking part of their identity, right, is my spine is not good, my discs are gone, my neck is a mess, I have a bad back. So they're coming in with this pre-engrained in their neurology, ultimately. So helping people understand, here's what we found, here's what it means, and here's the plan that we're gonna use to help you move forward, is really, really important. It sounds so simple and so obvious, but for many individuals, that can make the difference night and day between whether they kind of linger along in chronic pain or whether you have a, I'm gonna say, a compounding benefit of not only the care that you deliver, really critical, but let's enhance that. And let's enhance that by being proactive with our communication, by being positive with our communication, and being consistent with our communication. To me, those are the big take-home messages of this study. And as we wrap up today, a few other words from some of our other partners. Novopulse OA Recovery Program. Osteoarthritis, big deal out there affecting tens of millions of individuals. NovoPulse has a hardware, software, and a complete program with including patient attraction. You could check that out at the link below. Diabetes Reversal Group. Type 2 diabetes, a big deal. Probably something you're not directly impacting in your practice. Diabetes Reversal Group can be your partner. You don't have to bring things into your practice that complicate things. You get to refer them out. It's in the patient's best interest and it's in your best interest as a business. So be sure to check out Diabetes Reversal Group. As well as the RehabFix Hybrid Program. If you've been thinking about extending your reach beyond the four walls of your practice and generating a lot more income, be sure to check out RehabFix's new Hybrid Program, which really enables you to do that as quickly as possible. So thank you so much for tuning in to this episode. If you have not left a rating or review, I would deeply appreciate it if you would take a moment and do so. Other than that, I hope you have a fantastic week in practice, and I will talk to you soon.
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