What Has Changed For Lower Back Pain - Chewing It Over with David Evans

In this episode of Chewing It Over, Jack speaks with researcher and osteopath David Evans about what has actually changed in low back pain care over the past 20 years — and what hasn’t. Using data from a unique follow-up study comparing physiotherapists, osteopaths, and chiropractors, David reveals that the story is more nuanced than the usual “hands-on vs hands-off” narrative.

Spinal manipulation use has fallen across all three professions — not just physios — while massage and acupuncture have increased, suggesting clinicians haven’t abandoned hands-on care, but have shifted the type of intervention used. Specific exercises have declined while general exercise has risen, aligning more closely with guideline messaging around activity and self-management. Interestingly, these trends don’t map neatly onto clinical guidelines, raising questions about what really drives practice change: pain science discourse, safety concerns, professional identity, training exposure, and system pressures all emerge as possible influences.

The conversation moves beyond techniques to bigger issues in MSK care: the limits of pathway-based models, the “average effect” problem in RCTs, and why back pain research may be set up to underestimate treatment impact by measuring outcomes many months later. A major theme is the long-standing struggle to move beyond “non-specific low back pain.” David argues the future may lie in mechanism-based subgrouping (nociceptive, neuropathic, nociplastic, inflammatory) — if diagnostic precision can improve enough to meaningfully guide treatment.