THE PRESCRIPTION RIGHTS AND EXPANDED PRACTICE DEBATE PAGE
 
   

The Prescription Rights and
Expanded Practice Debate Page

This section was compiled by Frank M. Painter, D.C.
Send all comments or additions to:
  Frankp@chiro.org

If there are terms in these articles you don't understand, you can get a definition from the Merriam Webster Medical Dictionary. If you want information about a specific disease, you can access the Merck Manual. You can also search Pub Med for more abstracts on this, or any other health topic.


Jump to: Background Materials Most Recent Additions Drug Evidence


Other
Pages:
Patient Satisfaction Cost-Effectiveness Safety of Chiropractic


About Chiropractic Chiropractic Rehab Repetitive Stress


Headache Page Whiplash Section Disc Herniation


Chronic Neck Pain Low Back Pain Stroke & Chiropractic


Iatrogenic Injury Placebo Problems Subluxation Complex


ChiroZine Case Reports Pediatric Section


Conditions That Respond Alternative Medicine Approaches to Disease



Chiro.Org is proud to have supported ICPA and the Logan for their continuous research
into the health benefits of chiropractic care.   Please offer them your financial support.
 
   

   Background Materials   

   (in order of appearance online)


Organized Medicine Attempts To Deny
Chiropractors Right To Diagnose in Texas

A Chiro.Org Editorial ~ 2–04–2010

The AMA has joined the TMA (Texas Medical Association) in trying to challenge Texas chiropractor's "right" to diagnose. They are doing this under the guise of trying to halt expansions of the scope of practice of various alternative pratitioners. The AMA News web site currently brags that they are involved in fighting more than 300 scope-increasing bills around the country.

Live and Let Live?
A Chiro.Org Editorial ~ 3–24–2010

Here's a question I don't have an answer for:   Do chiropractors need to adjust people while the patient is under anesthesia (a.k.a MUA)?   I have no experience to guide me. I have never met a patient whose muscle spasm (or spinal "fixation") was so great that I was not able to adjust them. Of course, that doesn't mean that they might not be out there somewhere. I can only assume that's why someone came up with the idea of MUA in the first place. Until now this never seemed relevant to me, and I didn't pay attention to the evolution of this practice.   What I do know is that organized medicine is in a huge uproar about MUA.

A Constitutional Challenge to DCs Diagnosing –
What This Means for Health Care

ProviderLaw.Com ~ 4–27–2010

In January, 2006, the American Medical Association (AMA) announced an industry consortium known as the “Scope of Practice Partnership” (SOPP).   The consortium was originally formed by the AMA, along with 6 national medical specialty societies and 6 state medical associations, including the Texas Medical Association (TMA).   As part of its formation, the original members of SOPP agreed that they needed to begin reigning in the scope of practices of various professions, the chiropractic profession included.

AMA’s “Contain and Eliminate” Tactics Are Alive and Well
Dynamic Chiropractic ~ 7–15–2010

As a modern-day doctor of chiropractic, you may think this article is born of ancient paranoia. Perhaps you're convinced this is about AMA bashing and yesterday's news. But just look around and you will see clear and compelling evidence that the long-standing war between the AMA and everyone else who does not come under the AMA umbrella is far from over.

Medical Pushback on Provider Nondiscrimination Law
Health Insights Today ~ 7–18–2010

Among the important changes in the recently passed health reform law is Section 2706, which makes it illegal for insurance companies to discriminate against providers acting within the scope of their state licenses. Predictably, medical physicians who have benefited from many decades of discrimination now seek to turn back the clock and reinstate the pro-discrimination policies that have served them so well for so long.

UPDATE: Texas Judge Finally Rules on Diagnosis Issue
Dynamic Chiropractic ~ 9–17–2010

Put yourself in the position of a practicing doctor of chiropractic in Texas right about now (if you are one, this is easy). With the Texas Medical Board and Texas Medical Association breathing down your neck, threatening to take away your right to diagnose (or even use the word diagnosis in your scope-of-practice act, claiming that by medical definition, the word is reserved for medical doctors and doctors of osteopathy), a Texas judge has ruled in your favor - depending on your perspective.

If Not Chiropractic Care, Then What’s Your Alternative?
A Chiro.Org Editorial ~ 9–25–2010

Informed Consent involves discussing the risks and benefits of the treatment you propose (in my case, chiropractic) AND reviewing the risks and benefits of the alternatives, which are "conservative" medical care, which typically involves prescribing muscle relaxers, NSAIDs (nonsteroidal anti-inflammatory drugs), and less frequently, prescribing physical therapy. Many patients who present to a chiropractor for the first time have already gone the medical route, with minimal or negative results. Today I would like to review the risks associated with the most commonly recommended pain relieving analgesics (NASIDs).

Majority of Alabama Chiropractors Favor Limited Prescription Rights
Chiropractic Economics ~ 2–18–2011

The Alabama State Chiropractic Association (ASCA) conducted a survey of member practitioners in 2010 regarding the scope of practice in Alabama. Overall, results indicated that a majority of surveyed chiropractors are in favor of the inclusion of injectable vitamins and nutrients and prescriptive rights in the scope of practice.

Just In Case You Don't Believe Me
Texas Medicine Journal 2011 (Apr 1);   107 (4):   20–26

Medicine Under Attack:   The Texas Medical Association is fending off attacks on the practice of medicine by nonphysician practitioners who want to expand their scope of practice and diagnose and treat patients without going to medical school. Most recently, TMA went to court to protect patients, filing another lawsuit against the Texas Board of Chiropractic Examiners.

The Evidence-based Rap, or
What's Wrong With My Pain Meds?

A Chiro.Org Editorial ~ 4–23–2011

This review, by scientists at the Dutch Institute for Health Care Improvement debunks the myth of the effectiveness of pharmacological interventions [i.e., non-steroid anti-inflammatory drugs (NSAIDs), muscle relaxants, antidepressants, and opioids] for non-specific chronic low-back pain (LBP). Read on!

Point/Counterpoint: Part I
Seeking A Second Opinion on Expanded Chiropractic
A Prescription for Professional Disaster

Dynamic Chiropractic ~ 6–05–2011

The expansion of the scope of practice of chiropractors to prescribe drugs is an absolute non-starter for me. In recent weeks, this conversation has moved to center stage, as evidenced by activities in the states of New Mexico, South Carolina and Alabama, as well as at the biennial gathering of the World Federation of Chiropractic (WFC).

Point/Counterpoint: Part II
Seeking A Second Opinion on Expanded Chiropractic
Best for the Profession or Best for the Public?

Dynamic Chiropractic ~ 6–05–2011

Recently, I had the privilege of testifying for the chiropractic physicians in New Mexico who currently have some prescriptive rights and wished to expand that scope to improve their ability to provide stronger, more complete primary care.   It should be clear that I was asked to appear in behalf of the chiropractic physicians there or I would not have been there. It is not my purpose, as president of National University of Health Sciences, to dictate the direction of the chiropractic profession, but to provide the education that is required by the profession.

Is “Expanded Practice” Our Pandora's Box?
A Chiro.Org Editorial ~ 9–13–2011

I just read a Press Release from the Foundation for Vertebral Subluxation (FVS) this morning, titled
Chiropractors Lash Out in Massive Campaign Against Accrediting Agency.   Previous press releases from this group have denounced (perhaps rightly) any movement to include prescribing rights for DCs, and our Blog has published extensively about both sides of that debate in the past. [1–15]

The Subluxation Complex Saves Diagnosis for Texas Chiropractors
Dynamic Chiropractic ~ 6–14–2012

On April 5, 2012, the Third Court of Appeals of Texas issued a 58-page opinion in Cause No. 03-10-673-CV – the Texas Board of Chiropractic Examiners (TBCE) and the Texas Chiropractic Association (TCA) vs. the Texas Medical Association (TMA), the Texas Medical Board (TMB) and the State of Texas.     According to an April 6, 2012 communication by the Texas Chiropractic Association [1], the case presented three questions for the court:

1)   Are the two TBCE rules that allow chiropractors to make certain "diagnoses" valid?
2)   Can chiropractors perform MUA?
3)   Can chiropractors perform needle EMG?

AMA on Warpath to Overturn Provider Non-discrimination Provision
of the Affordable Care Act

ACA Press Release ~ 7–05–2012

The American Chiropractic Association (ACA) today reaffirmed its commitment to fighting provider discrimination, responding to a recent decision by the American Medical Association’s (AMA) House of Delegates to initiate a lobbying effort against Section 2706, the provider non-discrimination provision in the Patient Protection and Affordable Care Act (PPACA).

Chiropractic Summit Promotes Drug-Free Approach to Health Care
The Chiropractic Summit ~ 11–18–2013

The Chiropractic Summit, an umbrella leadership group of prominent chiropractic organizations, met on Nov. 7 in Seattle, Wash. and approved, by unanimous motion, the following historic statements of agreement:
Summit Promotes Drug-Free Approach:   The drug issue is a non-issue because no chiropractic organization in the Summit promotes the inclusion of prescription drug rights and all chiropractic organizations in the Summit support the drug-free approach to health care.

PRESCRIPTION RIGHTS: The Timex Topic:
It Took A Licking But Kept On Ticking

A Chiro.Org Editorial ~ 8–29–2016

The last I heard, all the significant National and International Associations, who comprise the Chiropractic Summit had all agreed (back in 2013) that chiropractic should maintain Drug-Free. However, I am also a member of a FaceBook group (Evidence-Informed Chiropractic Medicine) and the topic keeps popping up.

The Death Knell for the Prescription Rights Movement?
A Chiro.Org Editorial ~ 2–16–2017

The recent release (2-14-17) of American College of Physician’s new study ”Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain” appears to raise an evidence-based obstacle in the path to adding Rx rights to our profession.   In essence it recommends AGAINST recommending drugs.

 
   

   Most Recent Additions
 
   

Chiropractors as the Spinal Health Care Experts
A Chiro.Org article collection

Enjoy this series of articles that encourage us to re-define ourselves as spinal health care experts in the health care system or as primary care professionals in spinal health and well-being.

The Great Faceoff:
Chiropractic Goes Head-to-Head With NSAIDs and Acupuncture
A Chiro.Org article collection

The following commentary involves reviewing a brilliant series of 3 consecutive studies, comparing popular forms of treatment for chronic spinal pain, including NSAID use, acupuncture, and spinal adjusting for relief.   This author reports that this is the first study of long-term efficacy of 3 distinct and standardized treatment regimens for patients with chronic spinal pain syndromes.

Chiropractic Identity:
A Neurological, Professional, and Political Assessment

Journal of Chiropractic Humanities 2016 (Dec);   23 (1):   35–45 ~ FULL TEXT

Over 120 years since its inception, chiropractic has struggled to achieve an identity for which its foundations could provide optimal health care. Despite recognition of the benefits of spinal manipulation in various government guidelines, advances in US military and Veterans Administration, and persistently high levels of patient satisfaction, the chiropractic profession remains underrepresented in most discussions of health care delivery. Distinguishing characteristics of doctors of chiropractic include the following:

A Commentary on the Implications of Medication Prescription Rights
for the Chiropractic Profession

Chiropractic & Manual Therapies 2016 (Aug 24);   24 (1):   33 ~ FULL TEXT

There is a growing desire within the chiropractic profession to expand the scope of practice to include limited medication prescription rights for the treatment of spine-related and other musculoskeletal conditions. Such prescribing rights have been successfully incorporated into a number of chiropractic jurisdictions worldwide. If limited to a musculoskeletal scope, medication prescription rights have the potential to change the present role of chiropractors within the healthcare system by paving the way for practitioners to become comprehensive specialists in the conservative management of spine/ musculoskeletal disorders.

Chiropractic Identity, Role and Future:
A Survey of North American Chiropractic Students

Chiropractic & Manual Therapies 2015 (Feb 2);   23 (1):   4 ~ FULL TEXT

The last thirty years in health care have brought about many changes in thoughts and practice ideologies. One of these recent trends is an emphasis on cost-effective treatments and interprofessional collaboration. [1–3] Additional changes in health care over this time have included an increase in medical specialization and sub-specialization, the concept and implementation of evidence-based practice, and a greater acceptance of complementary and alternative medicine (CAM) therapies in mainstream medicine. Amid all of these transformations and shifts in the health care arena, a primary spine care specialist role has not been established. The current state of spinal care has been classified as a “supermarket approach” consisting of multiple practitioners including primary care providers, chiropractic physicians, acupuncturists, physical therapists, physiatrists, orthopedic surgeons, neurosurgeons, massage therapists, and naturopathic physicians with multiple treatment philosophies, high salesmanship and little interprofessional communication. [4] Chiropractic physicians possess many attributes that would be required of a primary spine care practitioner, and with specific modifications in education and practice, chiropractors may be in a position to make a relatively lateral transition to occupy this role. [4]

Chiropractors as Primary Spine Care Providers:
Precedents and Essential Measures

J Can Chiropr Assoc. 2013 (Dec);   57 (4):   285–291 ~ FULL TEXT

Chiropractors have the potential to address a substantial portion of spinal disorders; however the utilization rate of chiropractic services has remained low and largely unchanged for decades. Other health care professions such as podiatry/chiropody, physiotherapy and naturopathy have successfully gained public and professional trust, increases in scope of practice and distinct niche positions within mainstream health care. Due to the overwhelming burden of spine care upon the health care system, the establishment of a ‘primary spine care provider’ may be a worthwhile niche position to create for society’s needs. Chiropractors could fulfill this role, but not without first reviewing and improving its approach to the management of spinal disorders. Such changes have already been achieved by the chiropractic profession in Switzerland, Denmark, and New Mexico, whose examples may serve as important templates for renewal here in Canada.

The Establishment of a Primary Spine Care Practitioner And
Its Benefits To Health Care Reform in the United States

Chiropractic & Manual Therapies 2011 (Jul 21);   19 (1):  17 ~ FULL TEXT

It is widely recognized that the dramatic increase in health care costs in the United States has not led to a corresponding improvement in the health care experience of patients or the clinical outcomes of medical care. In no area of medicine is this more true than in the area of spine related disorders (SRDs). Costs of medical care for SRDs have skyrocketed in recent years. Despite this, there is no evidence of improvement in the quality of this care. In fact, disability related to SRDs is on the rise. We argue that one of the key solutions to this is for the health care system to have a group of practitioners who are trained to function as primary care practitioners for the spine. We explain the reasons we think a primary spine care practitioner would be beneficial to patients, the health care system and society, some of the obstacles that will need to be overcome in establishing a primary spine care specialty and the ways in which these obstacles can be overcome.

How Can Chiropractic Become a Respected Mainstream Profession?
The Example of Podiatry

Chiropractic & Osteopathy 2008 (Aug 29);   16:   10 ~ FULL TEXT

The chiropractic profession has great promise in terms of its potential contribution to society and the potential for its members to realize the benefits that come from being involved in a mainstream, respected and highly utilized professional group. However, there are several changes that must be made within the profession if it is going to fulfill this promise. Several lessons can be learned from the podiatric medical profession in this effort.

Chiropractic As Spine Care:   A Model For The Profession
Chiropractic & Osteopathy 2005 (Jul 6);   13:   9 ~ FULL TEXT

This paper presents the spine care model as a means of developing chiropractic cultural authority and relevancy. The model is based on principles that would help integrate chiropractic care into the mainstream delivery system while still retaining self-identity for the profession.

 
   

   Drug Evidence Articles
 
   
A Unique Series of Medical Guidlines

All 5 of the following guidelines reviewed the medical literature on low back pain and strongly advise medical doctors to first recommend non-pharmacologic therapies, including chiropractic, BEFORE resorting to offering NSAIDs, opiates or other more invasive treatments, for low back (spinal) pain patients.

These recommendations will:

  1. save money,
  2. will increase patient satisfaction,
  3. will improve patient outcomes and
  4. will reduce chronicity and potential addiction.

Guideline for Opioid Therapy and Chronic Noncancer Pain
CMAJ. 2017 (May 8);   189 (18):   E659–E666 ~ FULL TEXT

This new Canadian guideline published today (May 8, 2017) in the Canadian Medical Association Journal (CMAJ) strongly recommends doctors to consider non-pharmacologic therapy, including chiropractic, in preference to opioid therapy for chronic non-cancer pain.   The guideline is the product of an extensive review of evidence involving input from medical, non-medical, regulatory, and patient stakeholders.

National Clinical Guidelines for Non-surgical Treatment of
Patients with Recent Onset Low Back Pain
or Lumbar Radiculopathy

Eur Spine J. 2017 (Apr 20)[Epub]   1451–1460 ~ FULL TEXT

In 2012, the Danish Finance Act appropriated a total of €10.8 mio for the preparation of clinical guidelines. The Danish Health Authority (DHA) was subsequently commissioned to formulate 47 national clinical guidelines to support evidence-based decision making within health areas with a high burden of disease, a perceived large variation in practice, or uncertainty about which care was appropriate. [1] Two of these areas were low back pain (LBP) and lumbar radiculopathy (LR). Consequently in 2014, two working groups were formed with the aim of developing national clinical guidelines for non-surgical interventions for recent onset (<12 weeks) LBP and for recent onset (<12 weeks) LR. The primary target groups for these guidelines were primary sector healthcare providers, i.e., general practitioners, chiropractors, and physiotherapists, but also medical specialists or others in the primary or secondary healthcare sector handling patients with LBP or LR.

Association of Spinal Manipulative Therapy With Clinical Benefit and Harm
for Acute Low Back Pain: Systematic Review and Meta-analysis

JAMA. 2017 (Apr 11);   317 (14):   1451–1460 ~ FULL TEXT

For the second time in as many months, a prominent medical journal has endorsed spinal manipulation for the management of low back pain. [1] On April 11th 2017, JAMA published a systematic review of 26 randomized clinical trials in order to evaluate the safety and effectiveness of spinal manipulation for low back pain.   The authors concluded:   “Among patients with acute low back pain, spinal manipulative therapy was associated with improvements in pain and function with only transient minor musculoskeletal harms.”

Nonpharmacologic Therapies for Low Back Pain: A Systematic Review for an
American College of Physicians Clinical Practice Guideline

Annals of Internal Medicine 2017 (Apr 4);   166 (7):   493–505 ~ FULL TEXT

This report updates and expands on the earlier ACP/APS review [105] with additional interventions and newer evidence. We found evidence that mind–body interventions not previously addressed — tai chi (SOE, low) and mindfulness-based stress reduction (SOE, moderate) [45–47] — are effective for chronic low back pain; the new evidence also strengthens previous conclusions regarding yoga effectiveness (SOE, moderate). For interventions recommended as treatment options in the 2007 ACP/APS guideline [2], our findings were generally consistent with the prior review. Specifically, exercise therapy, psychological therapies, multidisciplinary rehabilitation, spinal manipulation, massage, and acupuncture are supported with some evidence of effectiveness for chronic low back pain (SOE, low to moderate). Unlike our previous report, which stated that higher-intensity multidisciplinary rehabilitation seemed to be more effective than lower-intensity programs, a stratified analysis based on currently available evidence [54] did not find a clear intensity effect. Our findings generally are consistent with recent systematic reviews not included in our evidence synthesis [106–117]. Although harms were not well-reported, serious adverse events were not described.

Noninvasive Treatments for Acute, Subacute, and Chronic
Low Back Pain: A Clinical Practice Guideline From
the American College of Physicians

Annals of Internal Medicine 2017 (Apr 4);   166 (7):   514–530 ~ FULL TEXT

Given that most patients with acute or subacute low back pain improve over time regardless of treatment, clinicians and patients should select nonpharmacologic treatment with superficial heat (moderate-quality evidence), massage, acupuncture, or spinal manipulation (low-quality evidence). If pharmacologic treatment is desired, clinicians and patients should select nonsteroidal anti-inflammatory drugs or skeletal muscle relaxants (moderate-quality evidence). (Grade: strong recommendation).


Systemic Pharmacologic Therapies for Low Back Pain: A Systematic Review
for an American College of Physicians Clinical Practice Guideline

Annals of Internal Medicine 2017 (Apr 4);   166 (7):   480–492

The American College of Physicians (ACP) released updated guidelines this week that recommend the use of noninvasive, non-drug treatments for low back pain before resorting to drug therapies, which were found to have limited benefits. One of the non-drug options cited by ACP is spinal manipulation.

Non-steroidal Anti-inflammatory Drugs for Spinal Pain:
A Systematic Review and Meta-analysis

Annals of the Rheumatic Diseases 2017 (Feb 2) [Epub ahead of print]

While it is now clear that paracetamol is ineffective for spinal pain, there is not consensus on the efficacy of non-steroidal anti-inflammatory drugs (NSAIDs) for this condition. We performed a systematic review with meta-analysis to determine the efficacy and safety of NSAIDs for spinal pain. We included 35 randomised placebo-controlled trials. NSAIDs reduced pain and disability, but provided clinically unimportant effects over placebo. Six participants (95% CI 4 to 10) needed to be treated with NSAIDs, rather than placebo, for one additional participant to achieve clinically important pain reduction. When looking at different types of spinal pain, outcomes or time points, in only 3 of the 14 analyses were the pooled treatment effects marginally above our threshold for clinical importance. NSAIDs increased the risk of gastrointestinal reactions by 2.5 times (95% CI 1.2 to 5.2), although the median duration of included trials was 7 days.

Combining Pain Therapy with Lifestyle: The Role of Personalized
Nutrition and Nutritional Supplements According to the
SIMPAR Feed Your Destiny Approach

J Pain Res. 2016 (Dec 8);   9:   1179–1189 ~ FULL TEXT

Recently, attention to the lifestyle of patients has been rapidly increasing in the field of pain therapy, particularly with regard to the role of nutrition in pain development and its management. In this review, we summarize the latest findings on the role of nutrition and nutraceuticals, microbiome, obesity, soy, omega-3 fatty acids, and curcumin supplementation as key elements in modulating the efficacy of analgesic treatments, including opioids. These main topics were addressed during the first edition of the Study In Multidisciplinary Pain Research workshop: "FYD (Feed Your Destiny): Fighting Pain", held on April 7, 2016, in Rome, Italy, which was sponsored by a grant from the Italian Ministry of Instruction on "Nutraceuticals and Innovative Pharmacology".

Regular Use of Medication for Musculoskeletal Pain and Risk of
Long-term Sickness Absence: A Prospective Cohort Study
Among the General Working Population

Eur J Pain. 2016 (Aug 26) [Epub] ~ FULL TEXT

Regular use of pain medication due to musculoskeletal pain is prospectively associated with long-term sickness absence (LTSA) even when adjusted for pain intensity. This study suggests that use of pain medication can be an important factor to be aware of in the prevention of sickness absence. Thus, regular use of pain medication - and not solely the intensity of pain – can be an early indicator that musculoskeletal pain can lead to serious consequences such as long-term sickness absence.

Treatment of Neck Pain: Noninvasive Interventions: Results of the
Bone and Joint Decade 2000–2010 Task Force on Neck Pain and
Its Associated Disorders

J Manipulative Physiol Ther. 2009 (Feb);   32 (2 Suppl):   S141–S175 ~ FULL TEXT

For whiplash-associated disorders, there is evidence that educational videos, mobilization, and exercises appear more beneficial than usual care or physical modalities. For other neck pain, the evidence suggests that manual and supervised exercise interventions, low-level laser therapy, and perhaps acupuncture are more effective than no treatment, sham, or alternative interventions; however, none of the active treatments was clearly superior to any other in either the short- or long-term. For both whiplash-associated disorders and other neck pain without radicular symptoms, interventions that focused on regaining function as soon as possible are relatively more effective than interventions that do not have such a focus.

Treatment of Neck Pain: Injections and Surgical Interventions:
Results of the Bone and Joint Decade 2000–2010 Task Force
on Neck Pain and Its Associated Disorders

J Manipulative Physiol Ther. 2009 (Feb);   32 (2 Suppl):   S176–193 ~ FULL TEXT

Of the 31,878 articles screened, 1203 studies were relevant to the Neck Pain Task Force mandate and of these, 31 regarding treatment by surgery or injections were accepted as scientifically admissible. Radiofrequency neurotomy, cervical facet injections, cervical fusion and cervical arthroplasty for neck pain without radiculopathy are not supported by current evidence. We found there is support for short-term symptomatic improvement of radicular symptoms with epidural corticosteroids. It is not clear from the evidence that long-term outcomes are improved with the surgical treatment of cervical radiculopathy compared to nonoperative measures. However, relatively rapid and substantial symptomatic relief after surgical treatment seems to be reliably achieved. It is not evident that one open surgical technique is clearly superior to others for radiculopathy. Cervical foramenal or epidural injections are associated with relatively frequent minor adverse events (5%-20%); however, serious adverse events are very uncommon (<1%). After open surgical procedures on the cervical spine, potentially serious acute complications are seen in approximately 4% of patients.

Nonpharmacologic Therapies for Acute and Chronic Low Back Pain:
A Review of the Evidence for an American Pain Society/
American College of Physicians Clinical Practice Guideline

Annals of Internal Medicine 2007 (Oct 2);   147 (7):   492–504 ~ FULL TEXT

Therapies with good evidence of moderate efficacy for chronic or subacute low back pain are cognitive-behavioral therapy, exercise, spinal manipulation, and interdisciplinary rehabilitation.

Medications for Acute and Chronic Low Back Pain:
A Review of the Evidence for an American Pain Society/
American College of Physicians Clinical Practice Guideline

Annals of Internal Medicine 2007 (Oct 2);   147 (7):   505–514 ~ FULL TEXT

Medications with good evidence of short-term effectiveness for low back pain are NSAIDs, acetaminophen, skeletal muscle relaxants (for acute low back pain), and tricyclic antidepressants (for chronic low back pain). Evidence is insufficient to identify one medication as offering a clear overall net advantage because of complex tradeoffs between benefits and harms. Individual patients are likely to differ in how they weigh potential benefits, harms, and costs of various medications.

Deconstructing Chronic Low Back Pain in the Older Adult
A Unique Series of Articles


Deconstructing Chronic Low Back Pain in the Older Adult –
Shifting the Paradigm from the Spine to the Person
The Introduction to the Article Series

Pain Medicine 2015 (May);   16 (5):   881–885 ~ FULL TEXT

Over the past decade, the estimated prevalence of low back pain (LBP) among older adults (typically defined as those ≥age 65) has more than doubled [1], and the utilization of advanced spinal imaging (e.g., computerized tomography (CT), magnetic resonance imaging [MRI]) and procedures guided by this imaging (e.g., epidural corticosteroids, spinal surgery) have continued to skyrocket. [1–3]   Treatment outcomes, however, have not improved apace. Why? Part of the answer lies in the fact that treatment may in part be misdirected.   This issue of Pain Medicine contains the first in a series of articles on how to systematically and comprehensively rethink our approach to evaluating and designing management for older adults with chronic low back pain (CLBP).

Deconstructing Chronic Low Back Pain in the Older Adult –
Part I:   Hip Osteoarthritis

Pain Medicine 2015 (May);   16 (5):   886–897 ~ FULL TEXT

An estimated one in two people with hip osteoarthritis (OA) has low back pain (LBP). [1] The Hip-Spine Syndrome (HSS) was first described by Offierski in 1983. [2] Three types of patients were described – those with “simple” HSS who had pathology of both the hip and lumbar spine, but disability related to only one source; those with “complex” HSS who had symptoms from both the hip and spine without a clear single source of disability, such as patients with low back and leg pain and who have clinical evidence of both lumbar spinal stenosis and hip OA [3]

Deconstructing Chronic Low Back Pain in the Older Adult –
Part II:   Myofascial Pain

Pain Medicine 2015 (Jul);   16 (7):   1282–1289 ~ FULL TEXT

Myofascial pain (MP) as first described by Travell and Simons, is defined by a localized region of palpable tightness and tenderness within a muscle that is characterized by resistance to passive elongation, and reproduction of a predictable pattern of referred pain on palpation. [1] The pathogenesis of MP is not fully understood, but can be a local muscle response to underlying mechanical factors (postural abnormalities, biomechanical faults, chronic strain), or a response to altered neurotrophic factors secondary to spondylosis. [2–4]

Deconstructing Chronic Low Back Pain in the Older Adult –
Part III:   Fibromyalgia Syndrome

Pain Medicine 2015 (Sep);   16 (9):   1709–1719 ~ FULL TEXT

Fibromyalgia syndrome (FMS) is a challenging diagnosis for many health care providers given the breadth of symptoms patients have on presentation and the paucity of specific objective findings. Twenty-five years ago, FMS was initially described as a syndrome characterized by widespread musculoskeletal pain that could not be explained by another diagnosis. [1] FMS has been increasingly recognized to encompass additional features such as fatigue and nonrestorative sleep, and these other symptoms are included in the updated 2010 American College of Rheumatology (ACR) criteria. [2] The prevalence of FMS increases with age, has a female preponderance, peaks in the seventh decade, and varies from <1% to 5%. [3]

Deconstructing Chronic Low Back Pain in the Older Adult –
Part IV:  Depression

Pain Medicine 2015 (Nov);   16 (11):   2098–2108 ~ FULL TEXT

Major depressive disorder (MDD) has a reported 1-year prevalence of 6–12% in older adults in both Veterans Affairs and civilian settings. In addition to MDD, the prevalence of clinically significant subsyndromal depressive symptoms in late-life (generally defined as ≥65 years) is estimated to be even higher. This may be due to under-recognition in the context of complex comorbidities. [1, 2] Depression is often a recurrent illness, triggered, and exacerbated by both psychological stress and medical illnesses. High medical burden in older adults contributes to treatment response variability such as delayed response to antidepressant pharmacotherapy and increased likelihood of recurrence. [3]

Deconstructing Chronic Low Back Pain in the Older Adult –
Part V:  Maladaptive Coping

Pain Medicine 2016 (Jan);   17 (1):   64–73 ~ FULL TEXT

Older adults who experience chronic low back pain (CLBP) develop behavioral and cognitive coping strategies to tolerate or reduce pain. These coping strategies have been shown to significantly predict pain, functional capacity, and chronification of LBP. For example, adaptive coping strategies are generally associated with reduced pain, positive affect, and better psychological adjustment [1], whereas maladaptive coping strategies have been linked with negative outcomes such as psychological distress, increased pain, and heightened disability. [2–4] Please see Table 1 for examples of maladaptive and adaptive coping strategies.

Deconstructing Chronic Low Back Pain in the Older Adult –
Part VI:   Lumbar Spinal Stenosis

Pain Medicine 2016 (Mar);   17 (3):   501–510 ~ FULL TEXT

Lumbar spinal stenosis (LSS) is a common source of pain and diminished function among older adults with chronic low back pain (CLBP). Lumbar spinal stenosis results from narrowing of the lumbar spinal canal, and/or intervertebral foramina most often resulting from degenerative changes in the spine including facet joint arthrosis, loss of intervertebral disk height, degenerative spondylolisthesis, ligament thickening, post-surgical fibrosis, etc. [1] The prevalence of LSS based on imaging criteria is estimated to be almost 50% in individuals over age 60, but many older adults with imaging evidence of anatomical stenosis are asymptomatic. [2] Lumbar spinal stenosis is the most common indication for spinal surgery among Medicare recipients, [3, 4] occurring at a rate of 135.5 surgeries per 100,000 Medicare beneficiaries in 2007. [5]

Deconstructing Chronic Low Back Pain in the Older Adult –
Part VII:   Insomnia

Pain Med. 2016 (May);   17 (5):   851–863 ~ FULL TEXT

Sleep problems are a highly prevalent comorbidity and consequence of chronic low back pain (CLBP), impacting an estimated 50–80% of individuals with CLBP. [1–3] Insomnia – dissatisfaction with sleep quantity or quality related to difficulty initiating, maintaining, and/or early morning awakenings [4] – is the most common sleep disorder in the general population and among those with CLBP. [5] Insomnia also significantly increases the risk of developing CLBP, even after controlling for socioeconomic, self-reported health, lifestyle behaviors, and anthropometric variables. [6]

Deconstructing Chronic Low Back Pain in the Older Adult –
Part VIII:   Lateral Hip and Thigh Pain

Pain Med. 2016 (May);   17 (5):   851–863 ~ FULL TEXT

Many physicians assume that an older adult with low back pain (LBP) and concomitant lateral hip/thigh pain has lumbar spinal stenosis. However, in reality there are myriad causes of lateral hip/thigh pain in older adults and the diagnosis of this pain can be challenging due to pain referral patterns. First, the hip and nearby lumbopelvic structures share innervation from common nerve roots, so pain referral patterns from pathology of these structures overlap. [1, 2] Second, faulty mechanics of the lumbar spine and/or hip can lead to compensatory movement patterns and eventually result in multiple pain generators. These challenges are illustrated in a study by Sembrano and colleagues. In a sample of 200 patients presenting for evaluation by a spine surgeon, only 65% had isolated spine pain, whereas 17.5% had a combination of hip, spine, and/or sacroiliac (SI) joint pain. [3] Lastly, diagnosing the etiology of hip and lumbopelvic pain in older adults is challenging in that many people have structural abnormalities on imaging studies that are asymptomatic. For instance, 93% of asymptomatic people 60–80 years old have MRI evidence of disc degeneration, 36% have a herniated disc, and 21% have spinal stenosis. [4] Additionally, only 46.5% of women ages 65 years and older who have radiographic evidence of hip osteoarthritis (OA) report hip pain “on most days for at least 1 month”. [5]

Deconstructing Chronic Low Back Pain in the Older Adult –
Part IX:   Anxiety

Pain Med. 2016 (Aug);   17 (8):   1423–1435 ~ FULL TEXT

Patients with chronic low-back pain (CLBP) commonly exhibit increased levels of emotional distress. [1]   For example, anxious mood and other symptoms of anxiety are commonly seen in patients with CLBP. [2]   Prevalence of anxiety disorders in CLBP patients (19–31%) has been found to be greater than that of the general population (10–25%). [3–5]   Polatin and colleagues (1993) also found that approximately 95% of adults with a lifetime history of anxiety disorders experienced these symptoms prior to the onset of low back pain, with only 5% reporting the development of anxiety after the onset of low-back pain. [3]   Additionally, symptoms of psychological distress (e.g., anxiety and somatization) have been found to predict subsequent onset of new episodes of low back pain. [6, 7]



Return to the LINKS Table of Contents

Since 8–27–2016

Updated 7–12–2017

         © 1995–2017 ~ The Chiropractic Resource Organization ~ All Rights Reserved