Chiropractic & Manual Therapies 2026 (Aug 10); 34: 35

Table 3 Modifiable contextual factor domains in therapeutic encounters

Prediction, pain, and the power of context: toward a contemporary identity for the chiropractic profession

Domain
Summary
Key References

Clinician–patient interactions
High-quality interactions (communication, empathy, trust, therapeutic alliance) consistently improve pain outcomes. Interaction is not just adjunctive but a core therapeutic component
[100, 107,108,109,110,111]

Clinician characteristics
Clinician empathy, warmth, communication style, and expectations shape patient outcomes. Positive interpersonal skills lower pain and increase satisfaction. Clinician beliefs about pain influence patient expectations and recovery
[110, 112,113,114,115]
Patient characteristics
Patients’ beliefs, expectations, and psychological traits are strong predictors of pain outcomes. High expectations, resilience, and active coping predict recovery; while catastrophizing and fear-avoidance predict poorer outcomes
[116,117,118,119,120,121,122]
Clinical environment
Care setting, safety perceptions, and contextual cues shape treatment outcomes. Environments signalling credibility or safety foster engagement and recovery. Natural scenes (physical or VR) can reduce pain and anxiety
[34, 123,124,125,126,127,128]
Treatment characteristics
More invasive procedures often produce stronger placebo effects. Invasiveness heightens expectations and ritualistic cues, engaging descending modulatory systems. Skilled affective touch may itself function as a salient interoceptive cue, signalling safety and supporting adaptive regulation

[2, 4, 35]

Domain	Summary	Key References
Clinician–patient interactions	High-quality interactions (communication, empathy, trust, therapeutic alliance) consistently improve pain outcomes. Interaction is not just adjunctive but a core therapeutic component	[100, 107,108,109,110,111]
Clinician characteristics	Clinician empathy, warmth, communication style, and expectations shape patient outcomes. Positive interpersonal skills lower pain and increase satisfaction. Clinician beliefs about pain influence patient expectations and recovery	[110, 112,113,114,115]
Patient characteristics	Patients’ beliefs, expectations, and psychological traits are strong predictors of pain outcomes. High expectations, resilience, and active coping predict recovery; while catastrophizing and fear-avoidance predict poorer outcomes	[116,117,118,119,120,121,122]
Clinical environment	Care setting, safety perceptions, and contextual cues shape treatment outcomes. Environments signalling credibility or safety foster engagement and recovery. Natural scenes (physical or VR) can reduce pain and anxiety	[34, 123,124,125,126,127,128]
Treatment characteristics	More invasive procedures often produce stronger placebo effects. Invasiveness heightens expectations and ritualistic cues, engaging descending modulatory systems. Skilled affective touch may itself function as a salient interoceptive cue, signalling safety and supporting adaptive regulation	[2, 4, 35]