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.