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Research Review By Dr. Jeff Muir©


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Date Posted:

September 2021

Study Title:

Best Practices for Chiropractic Management of Patients with Chronic Musculoskeletal Pain: A Clinical Practice Guideline


Hawk C, Whalen W, Farabaugh RJ, Daniels CJ et al.

Author's Affiliations:

Texas Chiropractic College, TX, USA; Advanced Medicine Integration Group, L.P., Columbus, OH, USA; VA Puget Sound Health Care System, Tacoma, WA, USA; Palmer Center for Chiropractic Research, Davenport, IA, USA; Texas Chiropractic College, Pasadena, TX, USA; VA Northern CA Health Care System, Redding, CA, USA; Private Practice locations in the USA

Publication Information:

Journal of Alternative and Complementary Medicine 2020; 26(10): 884-901.

Background Information:

Pain prevalence in the United States has increased by 25% in the last 20 years (1), with at least 70 million adults now reporting chronic pain (2). Among the factors associated with this increase is the rise in the use of pharmacological treatments for common conditions, a consequence of which is the growing opioid crisis (1). With this increase, groups such as the Agency for Healthcare Research and Quality (AHRQ) and the American College of Physicians (ACP) have recommended that back pain and other musculoskeletal (MSK) conditions be treated via nonpharmacological methods, to minimize the potential increase in opioid use and addiction (3).

Chronic pain is a wide-ranging concept, with variants identified in the areas of chronic primary pain, chronic cancer pain and several more, including chronic MSK pain. The AHRQ and other groups have recommended that treatment for chronic pain should be addressed through a biopsychosocial model, with an emphasis on nonpharmacological and self-management approaches (3).

Chiropractic treatment is expected to increase in use in the future, as part of a response to increased chronic pain and a desire amongst patients to seek nonpharmacological care. There are currently clinical guidelines outlining treatment for low back pain (4, 5), neck pain (6, 7) and headaches (8); however, there is currently no single guideline addressing the nonpharmacological treatment of more than one type of MSK pain as the chief complaint. The purpose of this project was to attempt to develop such a guideline.


Literature Search and Evaluation
Systematic Reviews:
From 343 initial articles, 3 were deemed eligible for inclusion. Two were considered high quality and one (9), a review by the AHRQ, was used as a framework for the guidelines.

Clinical Practice Guidelines:
From 147 initial guideline documents, 10 remained after full-text review. All were considered high quality and focused on either neck pain (n = 5), LBP (n = 4) or headache with neck pain (n = 1).

Subsequent Search:
An updated search conducted for articles published after the AHRQ review found 21 new articles, of which 9 were acceptable quality and 11 were high quality and thus included in this review.

Delphi Process:
70 panelists were invited to take part in the guideline process. 62 accepted and participated, of which 58 were DCs, representing jurisdictions across the United States, with 1 each from Canada and Australia. The remaining members included 1 MD and 3 DPTs. A high level of consensus was reached (87-100%) on all statements.

Public Comments:

209 different people reviewed a widely disseminated request for public comment, of which 3 provided comment. All 3 were DC faculty at US chiropractic colleges.

Chronic Musculoskeletal Pain Guidelines
General considerations for chronic pain management:
  1. Emphasize the biopsychosocial model
  2. Prioritize self-management and nonpharmacological approaches
  3. Emphasize active interventions – passive interventions may be helpful in the acute stage, but active interventions are recommended as soon as tolerable
  4. Include both physical and mind-body approaches
  5. Identify the neurophysiological type of pain – differentiate between neuropathic, nociceptive and central sensitization
  6. Consider risk stratification – the StarT Back risk assessment tool (or similar) should be considered for new episodes of pain (10)
Informed consent/risks and benefits:
  1. Engage the patient in the informed consent process – active communication is necessary to ensure complete understanding and consent
  2. Comply with local regulations
  3. Maximize patient safety – nonpharmacological treatments have fewer associated harms and careful assessment for possible contraindications will avoid harmful actions
General diagnostic considerations – history, examination and imaging:
  1. Recognize the effect of psychosocial factors on chronic pain physiology – be aware of mood- or work-related factors that may affect pain
  2. Take a thorough pain history
  3. Consider “yellow flags” (ex. pain catastrophizing, negative attitude/depression, lack of social support, etc.)
  4. Consider referral for co-management – psychological counselling may prove helpful
  5. Conduct an appropriately focused physical examination – both function and pain should be assessed
Diagnostic imaging:
  1. Avoid routine use of imaging – the multifactorial nature of chronic MSK pain renders imaging unable to identify the source of pain in most cases.
General treatment considerations:
  1. Outcome assessment – use a validated Patient-reported Outcome Measure
  2. Care pathway – follow an appropriate care pathway
  3. Avoid a “curative model” approach – emphasize the management of chronic pain over the attempt to “cure” the condition
  4. Set appropriate chronic pain management goals (ex. pain control, functional abilities, medication reliance, satisfaction, etc.)
  5. Consider patient-specific goals, keeping in mind that chronic MSK pain generally falls into 1 of 3 categories: pain where self-management is sufficient; pain where episodic care is necessary; and pain where scheduled ongoing physician-directed care is required.
Condition-Specific Diagnosis and Treatment Recommendations
Chronic Low Back Pain
Diagnostic considerations:
  1. Develop an evidence-based working diagnosis
  2. Consider physiological pain type – i.e. neuropathic, nociceptive and/or due to central sensitization
Diagnostic imaging:
  1. Avoid routine imaging
  2. Consider advanced imaging for some cases of radiculopathy, in which cases CT or MR imaging is preferred over plain film radiography
  1. Consider multiple approaches – physical active interventions; passive interventions; combined/multidisciplinary approaches and mind-body interventions
Chronic Neck Pain
Diagnostic considerations:
See General Diagnostic Considerations – History, Examination and Imaging section.

Diagnostic imaging:
  1. Consider appropriate circumstances for imaging – AP and lateral views may be appropriate. Imaging to identify degeneration is not recommended. Serial radiographs of the cervical spine have not been associated with improved outcomes and are not recommended.
  1. Consider multiple approaches – physical active interventions; passive interventions; and mind-body interventions
Chronic Tension Headache
Diagnostic considerations:
Chronic tension-type headache (TTH) is defined as present for > 15 days each month for > 3 months. Nausea may accompany symptoms. Diagnosis is made based on history, with a focused exam providing clarification.

  1. Consider multiple approaches – physical active interventions; passive interventions; combined/multidisciplinary approaches and mind-body interventions
Knee Osteoarthritis (OA)
Diagnostic considerations:
  1. Rely on history and physical examination – imaging serves to confirm the diagnosis based on history and examination
Diagnostic imaging:
  1. Imaging is not typically required
  2. Consider advanced imaging only in some cases – soft tissues are best diagnosed with ultrasound or MRI without contrast; bone by CT or MRI
  1. Consider multiple approaches – physical active (exercise) and passive (manual therapy, US, acupuncture) interventions
Hip Osteoarthritis (OA)
Diagnostic considerations:
  1. Develop a clinical diagnosis – hip OA is diagnosed based on anterior or posterior hip pain, increased on internal rotation and concurrent morning stiffness < 60 mins (11)
Diagnostic imaging:
  1. First consider plain film radiographs
  2. Consider advanced imaging for signs of cartilage degeneration – MRI is more sensitive that radiographs
  1. Consider multiple approaches – physical active (exercise) and passive (manual therapy) interventions
Fibromyalgia (FM)
Diagnostic considerations:
FM is primarily diagnosed based on history. A cluster of symptoms (widespread chronic pain, fatigue, non-restorative sleep) present when other causes have been excluded is indicative of FM.

  1. Consider multiple approaches – physical active interventions (exercise, healthy lifestyle advice); passive interventions (spinal manipulative therapy, myofascial release, acupuncture); combined interventions; mind-body interventions (yoga, tai chi)

Clinical Application & Conclusions:

The authors provide guidelines for the nonpharmacological treatment of chronic pain, with the expectation that factors such as the opioid crisis will motivate patients to minimize or avoid pharmacological treatments where possible. They provide guidance for multiple diagnoses and areas of pain management and provide recommendations on diagnostic and treatment options, suggesting that the evidence supports a biopsychosocial approach that includes multifactorial treatment approaches but also a strong emphasis on active, self care and patient empowerment.

Study Methods:

The objective this project was to gather evidence and create a consensus document providing guidance for the nonpharmacological treatment of patients with chronic MSK pain. This process incorporated the following (broad) methodological steps:
  • Establishing a Steering Committee to oversee the major steps and milestones in the process, including evidence gathering and examination, recommendation development and organization of the Delphi panelists’ contributions.
  • Identifying and reviewing the current CPGs and systematic reviews in the relevant treatment areas.
  • Identifying gaps in the knowledge based on existing GPGs and systematic reviews.
  • Performing systematic searches for updated sources to determine the best currently available evidence.
  • Making recommendations on the best and most appropriate treatments as part of chiropractic management, based on the available evidence.
  • Coming to a consensus opinion based on a Delphi process, utilizing a panel of practitioners and stakeholders in chronic MSK pain management.
  • Gathering feedback and opinion from the public, based on a public posting of the consensus statements (5).

Study Strengths / Weaknesses:

  • Comprehensive search strategy encompassing all major sources of relevant treatment guidance.
  • Broad Delphi group, while comprised mainly of DCs, included multi-licensed practitioners and DC-researchers.
  • Non-practitioner members plus DC members representing a wide geographic and practice demographics.
  • Relatively low number of high-quality sources of evidence.
  • Low response rate with respect to public comments.

Additional References:

  1. Nahin RL, Sayer B, Stussman BJ, Feinberg TM. Eighteen year trends in the prevalence of, and health care use for, noncancer pain in the United States: Data from the Medical Expenditure Panel Survey. J Pain 2019; 20: 796–809.
  2. Dahlhamer J, Lucas J, Zelaya C, et al. Prevalence of chronic pain and high-impact chronic pain among adults—United States, 2016. MMWR Morb Mortal Wkly Rep 2018; 67: 1001–1006
  3. Qaseem A, Wilt TJ, McLean RM, et al. Noninvasive treatments for acute, subacute, and chronic low back pain: A clinical practice guideline from the American College of Physicians. Ann Intern Med 2017; 166: 514–530.
  4. Bussières AE, Stewart G, Al-Zoubi F, et al. Spinal manipulative therapy and other conservative treatments for low back pain: A guideline From the Canadian Chiropractic Guideline Initiative. J Manipulative Physiol Ther 2018; 41: 265–293.
  5. Globe G, Farabaugh RJ, Hawk C, et al. Clinical practice guideline: Chiropractic care for low back pain. J Manipulative Physiol Ther 2016; 39:1–22.
  6. Bussières AE, Stewart G, Al-Zoubi F, et al. The treatment of neck pain-associated disorders and whiplash-associated disorders: A clinical practice guideline. J Manipulative Physiol Ther 2016;39:523–564 e527
  7. Whalen W, Farabaugh RJ, Hawk C, et al. Best-practice recommendations for chiropractic management of patients with neck pain. J Manipulative Physiol Ther 2019; 42: 635–650.
  8. Côté P, Wong JJ, Sutton D, et al. Management of neck pain and associated disorders: A clinical practice guideline from the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration. Eur Spine J 2016; 25: 2000–2022.
  9. Skelly AC, Chou R, Dettori JR, et al. Noninvasive Nonpharmacological Treatment for Chronic Pain: A Systematic Review. Rockland, MD: AHRQ, 2018.
  10. National Guideline Center. Low Back Pain and Sciatica in Over 16s: Assessment and Management. London: National Institute for Health and Care Excellence, 2016.
  11. Expert Panel on Musculoskeletal I, Mintz DN, Roberts CC, et al. ACR Appropriateness Criteria((R)) Chronic Hip Pain. J Am Coll Radiol 2017; 14(5S): S90–S102.

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