Thoracolumbar fascia (TLF) alterations may contribute to nonspecific low back pain (NSLBP). We evaluated the effects of acupuncture, chiropractic care, and massage on TLF biomechanics, microstructure, and clinical outcomes in NSLBP. In this exploratory mechanistic hybrid trial, sixty participants (median age: 47 years [interquartile range 39-63]; 63% women) were randomized (1:1:1) to acupuncture, chiropractic, or a 3-week waitlist control, providing between-group comparisons. After the waitlist, control participants received massage therapy, enabling a sequential within-subject evaluation. Pre- and post-intervention assessments included TLF shear strain (ShS)-cumulated (C|ShS|L) and maximum (Max|ShS|L) absolute lateral strain-homodyned K-distribution (HKD) parameters, and clinical scores. Analyses used linear mixed-effects models, Fisher's exact test, and Spearman's rank correlation. In the randomized comparison, C|ShS|L decreased with chiropractic (β: -16%, 95% confidence interval [-29, -2]; p = 0.021; d = -0.322), but not with acupuncture (p = 0.130), and increased in controls (β: +19%, p = 0.003; d = +0.387), with a smaller rise in Max|ShS|L (β: +0.4%, p = 0.048). Massage following the control phase reduced C|ShS|L (β: -32%, p < 0.001; d = -0.673) and Max|ShS|L (β: -0.5%, p = 0.010). The control-massage phase interaction effect size for C|ShS|L was large (d = 1.082). HKD parameters remained unchanged. Only chiropractic yielded improvement in the Oswestry disability index (ODI) (p = 0.041). No correlation was observed between changes in C|ShS|L and ODI (ρ = 0.261; p = 0.054). Chiropractic and massage, unlike acupuncture, elicited detectable biomechanical changes, while chiropractic also enhanced disability outcomes. HKD detected no microstructural changes. Clinicaltrials.gov, NCT04843800. Registered April 14, 2021 ( https://clinicaltrials.gov/study/NCT04843800 ). This study shows that ultrasound-derived shear strain captures the short-term mechanical responses of the thoracolumbar fascia to chiropractic care or massage therapy in participants with chronic nonspecific low back pain, supporting the potential role of quantitative fascial imaging biomarkers for mechanistic assessment and treatment monitoring of this prevalent, debilitating disorder. Recent research suggests that altered microstructure and biomechanics of the thoracolumbar fascia may contribute to nonspecific low back pain. In this randomized trial, chiropractic care, but not acupuncture, reduced thoracolumbar shear strain, while controls showed increased strain. In the within-subject sequential analysis, thoracolumbar shear strain increased during the waitlist phase and decreased after massage therapy. No microstructural changes were detected over 3 weeks, potentially reflecting biological constraints and/or limitations in measurement sensitivity. Small sample size and low baseline disability likely limited the trial's power to detect significant effects on clinical outcomes.

Functional Neurological Disorders (FNDs) are a frequent condition in childhood and adolescence, but data on hospitalized pediatric populations remain limited. In this study, we conducted a retrospective analysis of 136 pediatric patients (< 18 years) admitted to a tertiary neurological center over 11 years with a confirmed diagnosis of FND. Demographic, clinical history, and neurophysiological data were collected, and patients were classified according to their clinical phenotype. Mean age at symptom onset was 12.5 years, with prepubertal onset observed in 22% of cases. Multiple FNDs were present in 60% of patients. The predominant phenotypes were movement disorders (27%), seizures (27%), weakness (24%), and sensory disorders (20%). Comorbidities were highly prevalent (68%), including chronic headache (46%), neurological diseases (24%), psychiatric conditions (18%), and other systemic disorders (12%). Extensive diagnostic investigations were frequently required to confirm the functional nature of symptoms, particularly in patients with coexisting neurological conditions. FNDs requiring hospitalization constitute a clinically complex population characterized by high disability and frequent neurological comorbidities. In this context, specialized diagnostic evaluations play a crucial role in supporting a positive diagnosis. Despite several limitations of this study, particularly the limited availability of neuropsychological assessments, follow-up data, and treatment information, this cohort represents a complex and clinically relevant population that provides valuable insights into severe pediatric FND. Further prospective studies are needed to better characterize long-term outcomes, identify prognostic factors and potential biomarkers, and optimize multidisciplinary management strategies.

ABSTRACTBackgroundFunctional neurological disorder (FND) is a disabling condition often presenting with motor impairments, including gait disturbance and postural instability. Data on the prevalence and predictors of falls in people with FND are limited. This study aimed to investigate the prevalence of self‐reported falls among individuals with motor FND and identify factors associated with falling.MethodsAdults with motor FND were recruited from a tertiary neurology centre in London, UK, December 2021 to August 2024. Participants reported falls within the previous 6 months and completed assessments of sensory impairment, mobility, pain, fatigue, depression and anxiety. Group differences between recurrent fallers (≥ 2 falls) and those with one or no falls were examined, and logistic regression analyses identified predictors of recurrent falls.ResultsOne hundred participants (81% female, mean age 43.7 ± 14.2 years) were included. Falls were reported by 62%, and 56% reported recurrent falls. Among fallers, 64% reported injuries including bruising (39%), laceration (8%) and fracture (6%). Recurrent fallers had poorer plantar sensation and vibration detection, as well as worse scores for anxiety, depression, pain and functional mobility. A multivariable regression model indicated that absent plantar sensation (OR = 5.30, 95% CI [1.37, 20.44], p = 0.015), greater pain severity (OR = 1.25, 95% CI [1.05, 1.48], p = 0.011) and greater anxiety (OR = 1.09, 95% CI [1.004, 1.18], p = 0.040) were associated with increased odds of recurrent falls.ConclusionFalls are common among individuals with motor FND. Absent plantar sensation, pain and anxiety were independently associated with recurrent falls, supporting a multidimensional approach to falls assessment and rehabilitation.

Functional Neurological Disorder (FND) is a common and disabling condition at the interface of neurology and psychiatry, characterized by motor, sensory, seizure-like, or cognitive symptoms that are incongruent with recognized neurological disease but associated with substantial impairment. Despite its frequency and marked female predominance, FND remains underdiagnosed and often misunderstood. This narrative review synthesizes evidence from neurobiological, biomarker, and treatment studies, with attention to predictive coding, salience network dysfunction, impaired sense of agency, stress-related mechanisms, and sex- and gender-related vulnerability. Current evidence supports a model of FND as a disorder of distributed brain network dysfunction involving abnormal interactions among salience, limbic, motor, and self-monitoring systems. Predictive coding and impaired agency models provide clinically useful frameworks for understanding symptom generation, although they remain mechanistic hypotheses rather than definitive causal explanations. Candidate biomarkers, including functional connectivity alterations, autonomic dysregulation, and HPA axis measures, offer pathophysiological insight but remain insufficiently validated for routine diagnosis. Female predominance likely reflects interacting biological, psychological, and sociocultural mechanisms rather than a single neuroendocrine pathway. This review contributes an integrated, clinically oriented framework linking neurobiology, biomarkers, sex/gender vulnerability, and treatment in FND. Current evidence supports multidisciplinary care combining diagnostic communication, specialized physiotherapy, psychotherapy, and coordinated follow-up, while future research should prioritize standardized phenotyping, longitudinal designs, and multimodal biomarker validation.

Functional neurological disorder (FND) conceptualization and treatment have rapidly evolved with mental health treatment representing a primary intervention target. Specific mental health treatment consensus recommendations have yet to be established as a standard of care. Clarifying current mental health treatment trends assists in programmatic planning while providing practical direction for clinical providers and researchers. A novel Qualtrics designed online survey was distributed to providers delivering FND mental health treatment services. Survey items addressed psychotherapeutic protocols, techniques, intervention strategies, and methods of determining treatment effectiveness and benefit. A total of 63 participants completed the survey from 12 countries, with the highest number being clinical psychologists/neuropsychologists in academic medical centers in the United States. Variability was demonstrated in mental health treatment frameworks and modalities, though Cognitive Behavior Therapy (CBT) represented the most utilized, consistent with previous research. Specific therapeutic techniques included trigger chart/tracking of symptoms, symptom/episode response plan/health behavior monitoring and relaxation training. Daily functional status was the top post-treatment outcome, exceeding patient report of symptom frequent/severity. Numerous barriers to implementation of FND mental health treatment were also described. This survey highlights the lack of consensus in mental health treatment for FND, including treatment implementation, outcome tracking, and defining successful outcomes. Future research is necessary to establish treatment guidelines via collaborative multi-site trials as well as determine treatment effectiveness.

Functional neurological disorders (FND) present diagnostic challenges in pediatrics, with an actual incidence likely higher than reported. This study aims to analyze FND cases in our center to optimize patient management and treatment. We conducted a retrospective, single-center observational study of pediatric patients diagnosed with FND from January 2020 to January 2024. Data were collected from electronic medical records, focusing on patient demographics, symptoms, diagnostic tests, treatments, and outcomes. Statistical analysis included descriptive and inferential statistics to determine associations with recovery. We reviewed 37 patients, with a median age of 11 years and a predominance of females. Motor symptoms were most common (40.5%), followed by sensory disturbances and altered consciousness (29.7%). About 50% of patients presented more than one conversion symptom initially, increasing to 70% over all episodes. Complete symptom recovery was observed in 62% of patients, with recovery associated with motor and visual disorders. No significant associations were found between recovery and sex, psychiatric history, number of tests, or number of concomitant symptoms. Multiple complementary tests were performed in 78.3% of patients. Stress factors were identified in 59.4% of cases, mainly related to school problems. FND in children is complex, often involving multiple symptoms. Recovery was positively associated with motor and visual disorders. The high frequency of complementary tests suggests an exclusion-based diagnostic approach. Stress factors, particularly school-related issues, are common. These findings highlight the need for increased follow-up and multidisciplinary interventions to improve outcomes. Further research is necessary to enhance diagnostic and treatment strategies for pediatric FND.

Musculoskeletal disorders are the leading cause of disability in Canada, and chiropractic care is among the most commonly used healthcare services for their management. Despite this, little is known about the quality of care and adherence to clinical practice guidelines in chiropractic educational settings. This study aimed to describe the Université du Québec à Trois-Rivières university-based chiropractic clinic cohort (UQTRChiCo) and summarize its patient characteristics, care provided, and available outcome data. We conducted a retrospective cohort study of patients who first consulted at the Université du Québec à Trois-Rivières (UQTR) chiropractic clinic in 2017, with longitudinal follow-up through 2019. Reasons for clinical consultation (i.e., specific chief complaints) were treated as separate observations. Data were extracted from clinical records and included patient demographics, clinical presentations, care provided, and outcomes measured using validated questionnaires. Follow-up assessments were obtained from re-evaluations conducted at multiple time points between 1 January 2017 and 31 December 2019. The UQTRChiCo comprises 2,148 distinct reasons for consultation from 1,305 unique patients (59% female, mean age 31 ± 18 years). The most common presentations were lumbar spine (28%), cervical spine (18%), and thoracic spine complaints (10%). Multiple concurrent complaints were reported in 44% of patients, and 43% of conditions were chronic. Care commonly included spinal manipulative therapy (88%) and soft tissue treatments (93%). Patient education and exercise prescription were documented in 67% and 48% of consultations, respectively. Diagnostic imaging was performed in 19% of consultations. Follow-up outcome documentation was available for 58% of consultations at the first re-evaluation, decreasing to 16% by the third re-evaluation. The UQTRChiCo provides a comprehensive description of an academic chiropractic clinical population primarily seeking care for spinal musculoskeletal complaints. Care delivery reflected a multimodal approach with restrained use of diagnostic imaging. While short-term outcome monitoring proved feasible, substantial attrition over time underscores a key challenge for longitudinal practice-based research in educational clinics. The UQTRChiCo represents a valuable resource for advancing research on care quality, guideline adherence, and patient outcomes in chiropractic training environments.

Chiropractic care for common musculoskeletal conditions such as low back pain typically includes guideline-concordant first-line nonpharmacologic treatments. However, geographic variability in access to chiropractic care and whether variability relates to neighborhood socioeconomic status (SES) is understudied. In this geospatial analysis, we evaluated the association between neighborhood SES and the number of chiropractic providers in two U.S. geographic regions. Neighborhood SES was defined using the area deprivation index (ADI) for each neighborhood (defined as a census block group) in Suffolk County, MA, and Cuyahoga County, OH. Higher ADI scores (range 1-10) indicate worse neighborhood SES. Chiropractic providers were identified through triangulation of publicly available sources and geocoded to map provider locations. From each neighborhood centroid, we identified providers within nine catchment areas based on distance or travel times. Associations between ADI rank and the number of providers were evaluated using Poisson regression to estimate incident rate ratios (IRRs), adjusting for neighborhood population size. We identified 92 providers across 628 neighborhoods in Suffolk County and 214 providers across 1135 neighborhoods in Cuyahoga County. In Suffolk County, using the smallest distance-based catchment area (0.5 miles), compared to the low ADI tertile (mean = 3.9 providers), access was lower in the middle (mean = 1.3 providers; IRR = 0.31, 95% confidence intervals [CI] = 0.27-0.35) and high (mean = 0.9 providers; IRR = 0.21, 95% CI = 0.18-0.25) tertiles. We observed a similar graded association when considering broader catchment areas and those defined by walking and driving times. Results were similar in Cuyahoga County, although there was no difference in the middle tertile, and the association was attenuated in the high ADI tertile for individuals in the 15-min drive catchment area. Geographic areas with worse neighborhood SES had fewer chiropractic providers after controlling for population size. Further work is needed to evaluate and encourage equitable geographic distributions of chiropractic providers.

Comorbidities and Outcomes in People With Functional Neurological Disorder

Health care systems and insurers are expanding coverage for practitioner-delivered and self-care complementary and integrative health (CIH) therapies for chronic pain. To determine if combining practitioner-delivered and self-care CIH therapies (PD/SC-CIH) improves pain outcomes more than practitioner-delivered CIH (PD-CIH) therapies alone. Pragmatic nonrandomized trial. Structural nudges and the availability of CIH therapies were used as a surrogate to randomization. Of 3306 veterans with chronic musculoskeletal pain at 18 medical centers in the Veterans Health Administration between March 2021 and March 2023. PD-CIH therapies included acupuncture, chiropractic care, or massage therapy. Participants in the PD/SC-CIH arm also received yoga, mindfulness/meditation, and/or Tai Chi/Qigong. The primary outcome was the change in pain-related functional interference at 6 months. Pain interference improved in both arms (-0.62 and -0.70), with 39.5% and 41.1%, respectively, achieving clinically meaningful improvement with no difference between arms in improvement in pain interference: -0.12 (-0.28 to 0.05). At 6 months, more participants in the PD/SC-CIH arm reported their use of CIH therapies specifically led to perceived improvements across 4 global patient-centered measures: pain (11%; 5%-18%); fatigue (28%; 17%-40%); mental health (24%; 14%-35%); and overall well-being (27%; 18%-35%). Both approaches to offering CIH therapies were equally associated with improvements in pain interference among this large cohort with real-world CIH therapy engagement. More patients in the PD/SC-CIH arm perceived that their use of CIH therapies improved multiple health dimensions. Patients with chronic musculoskeletal pain should be encouraged to add self-care CIH therapies and health care systems should expand their availability. ClinicalTrials.gov Identifier: NCT05097521.

Understanding the gap: How much do healthcare professionals know about functional neurological disorders?

Mapping the Hierarchical Brain Architecture of Functional Neurological Disorders.

Care of the breastfeeding dyad involves an interprofessional and multidisciplinary team that may include lactation consultants, physicians, bodyworkers, and more. One often underutilized resource in the care of both breastfeeding parents and their infants is osteopathic physicians (Doctors of Osteopathic Medicine or DOs). DOs are full-scope physicians who have additional training in osteopathic manipulative treatment (OMT). Osteopathic manipulative treatment is a form of manual medicine that can be utilized to optimize the breastfeeding relationship. It can be useful to address latch challenges, tongue dysfunction, torticollis, plagiocephaly, colic, reflux, and more in breastfeeding infants. Osteopathic manipulative treatment can also be incorporated into the management of the breastfeeding parents to help with engorgement, low milk supply, mastitis, associated postural issues, and/or address other sources of pain. There is a growing body of evidence to support the use of osteopathic manipulative treatment in this population. This paper aims to provide insight and education on osteopathic manipulative treatment and how osteopathic physicians can uniquely contribute to the care of the breastfeeding dyad as both physicians and manual medicine practitioners.

Background: Federally Qualified Health Centers (FQHCs) deliver comprehensive primary care and supportive services to underserved populations. However, current care models have been unable to meet demand for spinal and musculoskeletal (MSK) care, a leading cause of disability and driver of opioid prescribing. Purpose: Chiropractors are well positioned to help FQHCs manage the burden of acute and chronic spinal and MSK pain, supporting primary care providers while expanding access to nonpharmacologic treatment. Yet integration of chiropractic services into FQHCs remains limited. Discussion: Although chiropractors are eligible to provide qualifying Medicare Prospective Payment System visits in FQHCs, chiropractic adoption appears to be enabled primarily by Medicaid coverage, with integration concentrated in states that reimburse chiropractic services and where approximately 50% of chiropractic FQHC patients have Medicaid coverage. This article examines the financing and policy environment shaping chiropractic integration in FQHCs, compares fee-for-service and value-based payment models, and explores alternative pathways, including shared savings, capitation, and grant funding. Drawing on parallels to successful integration from dentistry, podiatry, and optometry, we describe how chiropractors can function as embedded spinal and MSK specialists contributing to quality and cost outcomes. Conclusion: We argue that with supportive Medicaid and Medicare policies, chiropractic services can improve pain outcomes for spinal and MSK disorders while reducing downstream health care utilization in safety-net settings.

Mediators of the effect of chiropractic care on 12- and 52-week outcomes for U.S. active-duty military personnel with low back pain: secondary analysis of a clinical trial.

Patients with degenerative lumbar spinal stenosis (LSS) commonly use analgesics despite not being recommended by clinical guidelines. However, detailed knowledge of utilisation patterns is limited. This study aimed to describe prescribed analgesic use before, during, and after enrolment in a standardised chiropractic care programme, and to examine associations between patient characteristics and continued analgesic use after the programme. This cohort study included patients with LSS enrolled in the chiropractic care programme between 1 April 2017 and 31 December 2022, identified via the Danish National Health Service Register. The programme provides guideline-based non-pharmacological care, structured follow-up, and coordination with the patient's general practitioner. Data on dispensed analgesics were retrieved from the Danish National Prescription Registry. Quarterly prevalence of analgesic use (≥ 1 dispensed prescriptions) and defined daily doses per 1000 individuals were calculated for the year before enrolment, 3 months during, and the year after the programme. The distribution of use was assessed using Lorenz curves and Gini coefficients. Associations between patient characteristics and continued analgesic use (≥ 1 dispensed prescriptions in ≥ 2 of 4 consecutive quarters) after the programme among existing users were examined using robust Poisson regression. Of the 7294 included patients, 45% used analgesics in the year before enrolment. Use of paracetamol, non-steroidal anti-inflammatory drugs (NSAID), opioids, and gabapentinoids increased in the year before enrolment, peaked during the programme, and generally declined after. Ten percent of analgesic users accounted for approximately 43%, 49%, 68%, and 57% of the total use of paracetamol, NSAIDs, opioids, and gabapentinoids, respectively. Female sex, having one comorbidity, and pre-existing use of paracetamol, opioid, or gabapentinoid were associated with a 5-16% higher risk of continued use, whereas long-cycle higher education was associated with a 13% lower risk. Analgesic use increased before enrolment, peaked during the programme, and then declined after. A small proportion of analgesic users accounted for a large share of the total use. Sociodemographic and health-related factors, and pre-existing analgesic use were associated with continued use. These findings highlight the complexity of analgesic use in this population and emphasise the need for deprescribing strategies that take this complexity into account.

Longer-term chiropractic care outcomes for US active-duty military personnel with low back pain: secondary analysis of a pragmatic clinical trial

The authors conducted a systematic review and meta-analysis of clinical trials testing rehabilitation therapies for treating functional neurological disorder (FND). The authors searched databases for clinical trials of patients with FND who received rehabilitation therapies. Some trials included a mental health intervention, but psychotherapy-only trials were excluded. Study quality was assessed by using a modified version of the NIH quality assessment tool for a before-after (pre-post) study with no control group. In total, 8,162 studies were screened for eligibility. Among these, 30 articles (N=1,581 participants) were included. Results of a meta-analysis of proportions revealed that 74% of the participants in FND rehabilitation trials had clinical improvement, but effect sizes varied significantly across studies. Twenty-three studies provided sufficient data to calculate pre-post rehabilitation effect sizes, which were uniformly positive for FND symptoms and physical function. Meta-analysis of seven available randomized controlled trials (RCTs) indicated a significant treatment effect on FND symptoms and that effects on physical function, fatigue, and mental health were not statistically significant. The generalizability of these findings was limited by heterogeneity across studies, attributed to differences in populations, treatment protocols, study designs, and outcome measures. Rehabilitation therapies are a promising approach for improving FND symptoms, and calculated estimates indicate that >70% of patients experience clinical improvement after rehabilitative treatment. However, additional high-quality RCTs are needed to clarify the overall efficacy of rehabilitation for FND and to identify which aspects of clinical improvement are most responsive to rehabilitation interventions.

Functional Neurological Disorder in a Patient With Schizoaffective Disorder: Challenges in Diagnosis, Management, and Disposition.

Trends in Opioids and Nonpharmacologic Pain Management Among U.S. Cancer Survivors, 2011-2020.