Chiropractic and
Spinal Pain Management

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

Pain-related Articles

	Low-value Care in Musculoskeletal Health Care: Is There a Way Forward? Pain Practice 2022 (Sep); 22 (Suppl 2): 65–70 ~ FULL TEXT Low-value care that wastes resources and harms patients is prevalent in health systems worldwide. Low-value care affects the millions of people who suffer from MSK pain and disability who receive care that is contrary to recommendations in evidence-based clinical practice guidelines. Low-value care is provided by all health professions. If the trend of pervasive low-value care is to be reversed, a concerted effort that involves all stakeholders including patients, clinicians, professional organizations, funders, decision makers, and health system administrators is needed. Such efforts should build on transparent investigation of barriers and enablers to best practice care delivery and designed using established conceptual and theoretical frameworks.
	Effectiveness of Multimodal Chiropractic Care Featuring Spinal Manipulation for Persistent Spinal Pain Syndrome Following Lumbar Spine Surgery: Retrospective Chart Review of 31 Adults in Hong Kong Medical Science Monitor 2022 (Aug 2); 28: e937640 ~ FULL TEXT The term "persistent spinal pain syndrome type 2" (PSPS-2) has been proposed by the International Association for the Study of Pain to replace the term "failed back surgery syndrome". This retrospective study aimed to evaluate effectiveness of multimodal care featuring chiropractic spinal manipulation (CSMT) in 31 adults in Hong Kong with PSPS-2. Patients with PSPS-2 improved with multimodal care featuring CSMT, which was more effective in patients with younger age, shorter symptom duration, and higher baseline pain or disability levels.
	Swiss Chiropractic Practice-based Research Network and Musculoskeletal Pain Cohort Pilot Study: Protocol of a Nationwide Resource to Advance Musculoskeletal Health Services Research BMJ Open 2022 (Jul 13); 12 (7): e059380 ~ FULL TEXT Musculoskeletal (MSK) pain conditions, a leading cause of global disability, are usually first managed in primary care settings such as medical, physiotherapy, and chiropractic community-based practices. While chiropractors often treat MSK conditions, there is limited real-world evidence on the topic of health service outcomes among patients receiving this type of care. A nationwide Swiss chiropractic practice-based research network (PBRN) and MSK pain patient cohort study will have potential to monitor the epidemiological trends of MSK pain conditions and contribute to healthcare quality improvement. The primary aims of this protocol are to (1) describe the development of an MSK-focused PBRN within the Swiss chiropractic setting, and (2) describe the methodology of the first nested study to be conducted within the PBRN-an observational prospective patient cohort pilot study.
	Acute Inflammatory Response via Neutrophil Activation Protects Against the Development of Chronic Pain Science Translational Medicine 2022 (May 11); 14 (644): eabj9954 “This paper paints a very clear picture that early neutrophil activation is very important for preventing the sensitization of pain pathways. [The authors] lay out a beautiful roadmap to explore this. I would want to know how S100A8 and S100A9 are eventually acting on neurons to resolve pain, and how we could exploit neutrophils in other ways to decrease the excitability of neurons in pain pathways,” said Price.
	Discomfort, Pain and Stiffness: What Do These Terms Mean to Patients? A Cross-sectional Survey with Lexical and Qualitative Analyses BMC Musculoskelet Disord 2022 (Mar 24); 23 (1): 283 Findings from this study suggest that although patients perceive discomfort, pain and stiffness as different constructs, there is some overlap. This preliminary work contributes to better understanding of how patients conceptualize these constructs. By advancing our knowledge regarding what patients actually mean when reporting these experiences in the clinical encounter, a more accurate interpretation and utilization of such reported experiences is facilitated, which may improve clinician-patient communication.
	Utilization of Chiropractic Services in Patients with Osteoarthritis and Spine Pain at a Publicly Funded Healthcare Facility in Canada: A Retrospective Study J Back Musculoskelet Rehabil 2022 (Feb 25) [EPUB] ~ FULL TEXT Patients diagnosed with OA in a socioeconomically disadvantaged community demonstrated reductions in mean pain scores in both a clinically meaningful and statistically significant manner concurrent with a course of chiropractic care.
	Association Between Chiropractic Care and Use of Prescription Opioids Among Older Medicare Beneficiaries with Spinal Pain: A Retrospective Observational Study Chiropractic & Manual Therapies 2022 (Jan 31); 30: 5 ~ FULL TEXT Older Medicare enrollees with spinal pain who saw both a chiropractor and a primary care physician had less than half the risk of filling an opioid prescription, as compared to those who received primary medical care alone. The association was most pronounced among those who saw a chiropractor within the first 30 days of care.
	Clinical Effectiveness and Efficacy of Chiropractic Spinal Manipulation for Spine Pain Frontiers in Pain Ressearch 2021 (Oct 25); 2: 765921 ~ FULL TEXT For the management of LBP, most guidelines recommend SMT, with some discrepancies regarding the circumstances in which it should be administered. [19, 125] For example, the United Kingdom's National Institute for Health and Care Excellence (NICE) guidelines make it imperative that SMT be offered alongside exercise therapy for LBP irrespective of the stage. [113] In contrast, the American College of Physicians' guidelines endorse SMT as a frontline non-invasive intervention, partly because patients with acute LBP improve over time regardless of treatment. [17] Specifically, for acute stages with or without radiculopathy, clinical practice guidelines recommend the addition of SMT to education, advice to remain active, and self-management. [112, 114, 116] For chronic LBP, the guidelines tend to recommend the use of SMT either alone or preferably in combination with other approaches (frequently second to advice, education, and reassurance) for patients with or without leg pain. [114, 115] Recently, a decision aid developed for managing chronic back pain by Canadian colleges of family physicians endorsed exercise and SMT as the only interventions for which benefits likely exceed harms. [15] For low- and middle-income countries, the Global Spine Care Initiative produced guidelines taking into consideration practical aspects such as cost. [18] Their recommendations are to consider the use of manual therapy (SMT and mobilizations) as one of the primary treatment options in patients with both acute and chronic spine pain and SMT specifically for radicular pain. [18]
	Integrating a Multidisciplinary Pain Team and Chiropractic Care in a Community Health Center: An Observational Study of Managing Chronic Spinal Pain J Primary Care & Community Health 2020 (Sep 10)~ FULL TEXT This observational study within a community health center resulted in improvement in spinal pain and disability with chiropractic care versus a multidisciplinary pain team. Offering similar services in primary care may help to address pain and disability, and hopefully limit external referrals, advanced imaging, and opioid prescriptions.
	Implementation of the Primary Spine Care Model in a Multi-Clinician Primary Care Setting: An Observational Cohort Study J Manipulative Physiol Ther 2020 (Sep); 43 (7): 667–674 Among patients with spine-related disorders (SRDs) included in this study, implementation of the primary spine care (PSC) model within a conventional primary care setting was associated with a trend toward reduced total expenditures for spine care compared with usual primary care. Implementation of PSC may lead to reduced costs and resource utilization, but may be no more effective than usual care regarding clinical outcomes.
	Impact of Chiropractic Care on Use of Prescription Opioids in Patients with Spinal Pain Pain Med. 2020 (Mar 6) [Epub] ~ FULL TEXT Among patients with spinal pain disorders, for recipients of chiropractic care, the risk of filling a prescription for an opioid analgesic over a six-year period was reduced by half, as compared with nonrecipients. Among those who saw a chiropractor within 30 days of being diagnosed with a spinal pain disorder, the reduction in risk was greater as compared with those who visited a chiropractor after the acute phase had passed.
	What Does Best Practice Care for Musculoskeletal Pain Look Like? Eleven Consistent Recommendations From High-quality Clinical Practice Guidelines: Systematic Review Br J Sports Med 2020 (Jan); 54 (2): 79–86 ~ FULL TEXT Variation in the quality of care is a barrier to providing high value musculoskeletal pain (MSK) care. Clinical practice guidelines (CPGs) are an important tool to address MSK pain care quality. We identified 11 consistent recommendations (Box 2) for the management of MSK conditions. These recommendations can be used by consumers, clinicians and at health services and policy levels to improve the quality of MSK pain care. Optimising the implementation of these recommendations comprises the next challenge.
	Inappropriate Use of Skeletal Muscle Relaxants in Geriatric Patients Systematic Reviews 2019 (Nov 8); 8 (1): 267 ~ FULL TEXT Skeletal muscle relaxants are a sedating class of medications used to treat spasticity and pain. Their sedative properties can pose a risk for geriatric patients who are predisposed to falls. It is important for the pharmacist to assess the patient before dispensing medications. Short-term use of skeletal muscle relaxants may be appropriate for certain conditions but should not be used long-term, regardless of interaction. Alternative pharmacologic options exist, but most have drawbacks. Nonpharmacologic therapy may be a better option in both the short term and the long term. Nonpharmacologic education on fall prevention is essential in patients being given skeletal muscle relaxants, regardless of duration of therapy. Not only will appropriate use of skeletal muscle relaxants improve patient outcomes, it can also improve star ratings for both insurance providers and pharmacies.
	The European Epidemic: Pain Prevalence and Socioeconomic Inequalities in Pain Across 19 European Countries European J Pain 2019 (Sep); 23 (8): 1425–1436 ~ FULL TEXT High prevalence rates were reported for all three types of pain (back/neck pain, hand/arm pain, or foot/leg pai) across European countries. At a pan-European level, back/neck pain was the most prevalent with 40% of survey participants experiencing pain; then hand/arm pain at 22%, and then foot/leg pain at 21%. There was considerable cross-national variation in pain across European counties, as well as significant socioeconomic inequalities in the prevalence of pain-with social gradients or socioeconomic gaps evident for both men and women; socioeconomic inequalities were most pronounced for hand/arm pain, and least pronounced for back/neck pain. The magnitudes of the socioeconomic pain inequalities differed between countries, but were generally higher for women.
	Association Between Chiropractic Use and Opioid Receipt Among Patients with Spinal Pain: A Systematic Review and Meta-analysis Pain Medicine 2019 (Sep 27) [Epub] ~ FULL TEXT This systematic review demonstrated an inverse association between chiropractic use and opioid receipt among patients with spinal pain. Overall, chiropractic users had a 64% lower odds of receiving an opioid prescription than nonusers. Further research is warranted to assess this association and the implications it may have for case management strategies to decrease opioid use.
	Conservative Spine Care Pathway Implementation Is Associated with Reduced Health Care Expenditures in a Controlled, Before-After Observational Study J General Internal Medicine 2019 (Aug); 34 (8): 1381-1382 ~ FULL TEXT In this retrospective, controlled, before-after study, we found that implementation of a conservative spine pain treatment pathway was associated with significant reductions in per-member-per-month (PMPM) healthcare expenditures for spine pain care; most cost savings were attributable to reduction in spine surgery costs. Our Poisson model found relatively reduced opioid utilization and relatively increased manual care costs, both anticipated by-products of guideline implementation. [4] While our findings are preliminary, in an era of increasing healthcare costs and use of complex and expensive spine surgery techniques they show promise for meaningful care cost reduction and value enhancement when providers conservatively manage spine pain. Importantly, our analysis underscores the value of using control groups, formal analytics, and academic partnerships to understand the impact of quality improvement and clinical effectiveness projects, measures that have been recommended to improve the robustness of quality improvement efforts. [5]
	Prevalence and Characteristics of Chronic Spinal Pain Patients with Different Hopes (Treatment Goals) for Ongoing Chiropractic Care J Alternative and Complementary Medicine 2019 (Aug 27) [Epub] ~ FULL TEXT Although much of health policy is based on a curative model, less than a third of a large sample of patients with CLBP and CNP under ongoing chiropractic care have a stated hope or goal of cure—their pain going away permanently. Instead, most patients have goals related to the ongoing successful management of their chronic spinal pain. How can this goal of provider-based pain management be viably supported and sustained? Policy makers need more information about how patients are using ongoing providerbased care to develop policies regarding this care. This study provides some of this information.
	Observed Patterns of Cervical Radiculopathy: How Often Do They Differ From a Standard, "Netter Diagram" Distribution? Spine J. 2019 (Jul); 19 (7): 1137–1142 ~ FULL TEXT In conclusion, standard patterns of cervical radiculopathy were found in only 54% of patients undergoing single level ACDF. This divergence from the accepted standard highlights the need for careful assessment of associated neurological, physical, radiological, and other findings, as a non-standard clinical pattern is frequently encountered. It is not only possible, but actually relatively common, for patients with C3–4 or C4–5 radiculopathy to complain of distal symptoms that seemingly do not make “sense.” Similarly, we found that it is also relatively common for patients with C5–6 or C6–7 radiculopathy to complain only of proximal symptoms. In order to appropriately treat patients presenting with cervical radiculopathy, practitioners must think broadly when identifying causative levels because they frequently do not adhere to the accepted standard in actual clinical practice.
	Patient-reported Improvements of Pain, Disability, and Health-related Quality of Life Following Chiropractic Care for Back Pain - A National Observational Study in Sweden J Bodyw Mov Ther. 2019 (Apr); 23 (2): 241–246 ~ FULL TEXT 246 back pain patients answered baseline questionnaires and 138 (56%) completed follow-up after four weeks. Statistically significant improvements over the four weeks were reported for all PRO by acute back pain patients (n = 81), mean change scores: NRS -2.98 (p < 0.001), ODI -13.58 (p < 0.001), EQ VAS 9.63 (p < 0.001), EQ-5D index 0.22 (p < 0.001); and for three out of four PRO for patients with chronic back pain (n = 57), mean change scores: NRS -0.90 (p = 0.002), ODI -2.88 (p = 0.010), EQ VAS 3.77 (p = 0.164), EQ-5D index 0.04 (p = 0.022).
	Manipulation and Mobilization for Treating Chronic Nonspecific Neck Pain: A Systematic Review and Meta-Analysis for an Appropriateness Panel Pain Physician. 2019 (Mar); 22 (2): E55–E70 ~ FULL TEXT Studies published since January 2000 provide low-moderate quality evidence that various types of manipulation and/or mobilization will reduce pain and improve function for chronic nonspecific neck pain compared to other interventions. It appears that multimodal approaches, in which multiple treatment approaches are integrated, might have the greatest potential impact. The studies comparing to no treatment or sham were mostly testing the effect of a single dose, which may or may not be helpful to inform practice. According to the published trials reviewed, manipulation and mobilization appear safe. However, given the low rate of serious adverse events, other types of studies with much larger sample sizes would be required to fully describe the safety of manipulation and/or mobilization for nonspecific chronic neck pain.
	Guideline Recommendations on the Pharmacological Management of Non-specific Low Back Pain in Primary Care – Is There a Need to Change? Expert Rev Clin Pharmacol. 2019 (Feb); 12 (2): 145–157 ~ FULL TEXT Upcoming guideline updates should explicitly shift their focus from pain to function and from pharmacotherapy to non-pharmacological treatments; patient education is important to make sure NSLBP patients accept these changes. To improve the quality of NSLBP care, the evidence-practice gap should be closed through guideline implementation strategies.
	Pain-Related Fear-Dissociable Neural Sources of Different Fear Constructs eNeuro. 2019 (Jan 3); 5 (6) pii: ENEURO.0107-18.2018 ~ FULL TEXT Fear of pain demonstrates significant prognostic value regarding the development of persistent musculoskeletal pain and disability. Its assessment often relies on self-report measures of pain-related fear by a variety of questionnaires. However, based either on "fear of movement/(re)injury/kinesiophobia," "fear avoidance beliefs," or "pain anxiety," pain-related fear constructs plausibly differ while it is unclear how specific the questionnaires are in assessing these different constructs. Furthermore, the relationship of pain-related fear to other anxiety measures such as state or trait anxiety remains ambiguous. Advances in neuroimaging such as machine learning on brain activity patterns recorded by functional magnetic resonance imaging might help to dissect commonalities or differences across pain-related fear constructs. We applied a pattern regression approach in 20 human patients with nonspecific chronic low back pain to reveal predictive relationships between fear-related neural pattern information and different pain-related fear questionnaires.
	Stakeholder Expectations from the Integration of Chiropractic Care into a Rehabilitation Setting: A Qualitative Study BMC Complementary and Alternative Medicine 2018 (Dec 4); 18 (1): 316 ~ FULL TEXT Stakeholders expected the addition of chiropractic care to a rehabilitation specialty hospital to benefit patients through pain management and functional improvements leading to whole person healing. They also expected chiropractic to benefit the healthcare team by facilitating other therapies in pursuit of the hospital mission, that is, moving patients towards discharge. Understanding stakeholder expectations may allow providers to align current expectations with what may be reasonable, in an effort to achieve appropriate clinical outcomes and patient and staff satisfaction.
	Cost-effectiveness of Spinal Manipulation, Exercise, and Self-management for Spinal Pain Using an Individual Participant Data Meta-analysis Approach: A Study Protocol Chiropractic & Manual Therapies 2018 (Nov 13); 26: 46 ~ FULL TEXT Combined analyses of economic data are rarely possible due to differences in resource utilization outcomes, costs and healthcare settings. [56, 57] Additionally, individual clinical trials rarely include a sufficient number of participants to detect important differences in economic outcomes. This project represents a unique opportunity to potentially combine clinical and economic data collected in eight randomized clinical trials using an IPDMA approach. This will provide more precise estimates of the cost-effectiveness of spinal manipulation, exercise therapy, and self-management compared to analysis of the individual trials. Further, an IPDMA approach has many advantages over traditional meta-analysis including the ability to conduct standardized within-study analyses, account for missing data at the individual level, and investigate potential sub-group effects at the participant level which may account for heterogeneity in estimates across studies. [52]
	Coverage of Nonpharmacologic Treatments for Low Back Pain Among US Public and Private Insurers JAMA Network Open 2018 (Oct 5); 1 (6): e183044 ~ FULL TEXT Insurers are increasingly recognized as influential stakeholders that are well positioned to drive changes in pain treatment practices. One key component of such changes is the greater use of nonpharmacologic approaches to managing chronic, noncancer pain, as has been recommended by the Centers for Disease Control and Prevention, [10] the President’s Commission on Combating Drug Addiction and the Opioid Crisis, [8] and others. [25] To our knowledge, our work represents the most comprehensive assessment of coverage policies regarding the medical necessity, coverage, and management of nonpharmacologic treatments for back pain.
	A SMART Design to Determine the Optimal Treatment of Chronic Pain Among Military Personnel Contemp Clin Trials. 2018 (Oct); 73: 68–74 ~ FULL TEXT Chronic pain is a leading cause of disability among active duty service members in the U.S. armed forces. Standard rehabilitative care and complementary and integrative health therapies are used for chronic pain rehabilitation. However, the optimal sequence and duration of these therapies has yet to be determined. This article describes a sequential multiple assignment randomized trial (SMART) protocol being used to identify the optimal components and sequence of standard rehabilitative care and complementary and integrative health therapies for reducing pain impact and improving other patient outcomes. Active duty service members referred to Madigan Army Medical Center for treatment of chronic pain are being recruited to the Determinants of the Optimal Dose and Sequence of Functional Restoration and Integrative Therapies study.
	The Global Spine Care Initiative: Classification System for Spine-related Concerns European Spine Journal 2018 (Sep); 27 (Suppl 6): 889–900 ~ FULL TEXT An international and interprofessional group developed a comprehensive classification system for all potential presentations of people who may seek care or advice at a spine care program. This classification can be used in the development of a spine care pathway, in clinical practice, and for research purposes. This classification needs to be tested for validity, reliability, and consistency among clinicians from different specialties and in different communities and cultures. These slides can be retrieved under Electronic Supplementary Material.
	What Does Best Practice Care for Musculoskeletal Pain Adverse Impacts of Chronic Pain on Health-related Quality of Life, Work Productivity, Depression and Anxiety in a Community-based Study Family Practice 2017 (Nov 16); 34 (6): 656–661 ~ FULL TEXT We assessed the burden of chronic pain from patients’ perspective in multiple domains of physical, psychological, and social functioning and well-being. Chronic pain, particularly multisite pain and neuropathic pain, significantly affected physical and psychological health. In addition to the negative impacts on the psychological and physical of the individual, chronic pain places a significant burden on society through lost work productivity and reduced performance at work. Our study emphasizes the importance of understanding chronic pain as a multifaceted health condition that requires a multidisciplinary treatment approach.
	The Relationship Between Spinal Pain and Comorbidity: A Cross-sectional Analysis of 579 Community-Dwelling, Older Australian Women J Manipulative Physiol Ther 2017 (Sep); 40 (7): 459–466 ~ FULL TEXT Spinal pain is common in community-dwelling, older Australian women and is associated with greater disability and poorer quality of life. Diabetes, cardiovascular disease, pulmonary disease, and obesity appear to have a relationship with spinal pain. There was an incremental increase in the risk of spinal pain associated with increasing comorbidity count.
	Looking Ahead: Chronic Spinal Pain Management J Pain Research 2017 (Aug 30); 10: 2089–2095 ~ FULL TEXT Health care practitioners involved in the triage and management of patients with persistent spinal pain will need to become more vigilant about individualizing and coordinating care for each patient, to achieve the best possible outcomes. For example, Cecchi et al concluded that patients with chronic (persistent) lower baseline pain (LBP)- related disability predicted “nonresponse” to standard physiotherapy, but not to spinal manipulation (an intervention commonly employed by chiropractors [7–9]), implying that spinal manipulation should be considered as a first-line conservative treatment. [9] We note that spinal manipulation is now suggested as the first-line intervention by Deyo, [10] since not a single study examined in a recent systematic review found that spinal manipulation was less effective than conventional care. [11]
	Cannabis for Pain and Headaches: Primer Curr Pain Headache Rep. 2017 (Apr); 21 (4): 19 ~ FULL TEXT Synthetic cannabinoids are being developed and synthesized from the marijuana plant such as dronabinol and nabilone. The US Food and Drug Administration approved the use of dronabinol and nabilone for chemotherapy-associated nausea and vomiting and HIV (Human Immunodeficiency Virus) wasting. Nabiximols is a cannabis extract that is approved for the treatment of spasticity and intractable pain in Canada and the UK. Further clinical trials are studying the effect of marijuana extracts for seizure disorders. Phytocannabinoids have been identified as key compounds involved in analgesia and anti-inflammatory effects. Other compounds found in cannabis such as flavonoids and terpenes are also being investigated as to their individual or synergistic effects. This article will review relevant literature regarding medical use of marijuana and cannabinoid pharmaceuticals with an emphasis on pain and headaches.
	Severe Pain in Veterans: The Effect of Age and Sex, and Comparisons With the General Population J Pain 2017 (Mar); 18 (3): 247–254 ~ FULL TEXT This study provides national prevalence estimates of US military veterans with severe pain, and compares veterans with nonveterans of similar age and sex. Data used are from the 2010 to 2014 National Health Interview Survey on 67,696 adults who completed the Adult Functioning and Disability Supplement. Participants with severe pain were identified using a validated pain severity coding system imbedded in the National Health Interview Survey Adult Functioning and Disability Supplement. It was estimated that 65.5% of US military veterans reported pain in the previous 3 months, with 9.1% classified as having severe pain. Compared with veterans, fewer nonveterans reported any pain (56.4%) or severe pain (6.4%). Whereas veterans aged 18 to 39 years had significantly higher prevalence rates for severe pain (7.8%) than did similar-aged nonveterans (3.2%), veterans age 70 years or older were less likely to report severe pain (7.1%) than nonveterans (9.6%).

The Non-pharmacologic Therapies Low Back Pain Guidelines A Unique Series of Articles All 6 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:   save money,   will increase patient satisfaction,   will improve patient outcomes and   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 European Spine Journal 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.”
	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.
	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. You will also enjoy the introductory Editorial, titled: Management of Low Back Pain: Getting From Evidence-Based Recommendations to High-Value Care Annals of Internal Medicine 2017 (Apr 4); 166 (7): 533-534
	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).

	The Impact of Pain-related Fear on Neural Pathways of Pain Modulation in Chronic Low Back Pain Pain Rep. 2017 (Apr 11); 2 (3): e601 ~ FULL TEXT Our results might indicate a maladaptive psychobiological interaction in chronic LBP characterized by an attenuation of amygdala-PAG-FC that is modulated by the degree of pain-related fear. Besides the established role of the PAG in the modulation of nociceptive inputs, our results add further evidence to the involvement of the PAG in negative emotional processing not directly related to nociception. [9, 28] Furthermore, while we have previously shown that pain-related fear is positively correlated with amygdala activity in chronic LBP, [16] enhanced pain-related fear seems to simultaneously dampen the neural cross-talk between the amygdala and the PAG. This decreased informaion exchange between 2 key pain modulatory structures might ultimately tip the balance of PAG function to facilitation, ie, increased pronociception. [11] Thus, the decreased cross-talk between the amygdala and the PAG, in conjunction with increased amygdala activity, might be the neurobiological basis of how pain-related fear contributes to pain and its chronification.
	Elevated Production of Nociceptive CC-chemokines and sE-selectin in Patients with Low Back Pain and the Effects of Spinal Manipulation: A Non-randomized Clinical Trial Clin J Pain. 2017 (Apr 19) [Epub] ~ FULL TEXT The production of chemotactic cytokines is significantly and protractedly elevated in LBP patients. Changes in chemokine production levels, which might be related to SMT, differ in the acute and chronic LBP patient cohorts.
	Provider and Patient Perspectives on Opioids and Alternative Treatments for Managing Chronic Pain: A Qualitative Study BMC Fam Pract. 2017 (Mar 24); 17 (1): 164 ~ FULL TEXT Despite widespread dissatisfaction with opioid medications for pain management, many practical barriers challenged access to other options. Most of the participants' perceived acupuncture and chiropractic (A/C) care as helpful for short term pain relief. We identified that problems with timing, expectations, and plan coverage limited A/C care potential for pain relief treatment. CONCLUSIONS: These results suggest that education about realistic expectations for chronic pain management and therapy options, as well as making acupuncture and chiropractic (A/C) care more easily accessible, might lead to more satisfaction for patients and providers, and provide important input to policy makers.
	Complementary and Alternative Medicine Use by Children with Pain in the United States Acad Pediatr. 2017 (Feb 20). pii: S1876-2859(17)30063-3 Parents reported that 26.6% of children had pain conditions (e.g. headache, abdominal, musculoskeletal pain) in the past year; of these children, 21.3% used CAM. In contrast only 8.1% of children without pain conditions used CAM (χ2: p<.001). CAM use among children with pain was associated with female sex (adjusted odds ratio (aOR)=1.49, p=0.005), higher income (aOR=1.61, p=0.027), and presence of 4+ comorbidities (aOR=2.01, p=0.013). Among children with pain who used CAM the 2 most commonly used CAM modalities were biologically-based therapies (47.3%) (e.g., special diets and herbal supplements) and manipulative or body-based therapies (46.3%) (e.g., chiropractic and massage). CONCLUSIONS: CAM is frequently used by children with pain in the USA and many parents report benefits for their child's symptoms.
	Non-steroidal Anti-inflammatory Drugs for Spinal Pain: A Systematic Review and Meta-analysis Annals of the Rheumatic Diseases 2017 (Jul); 76 (7): 1269–1278 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.
	Regular Use of Medication for Musculoskeletal Pain and Risk of Long-term Sickness Absence: A Prospective Cohort Study Among the General Working Population European J Pain 2017 (Feb); 21 (2): 366–373 ~ 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.
	Multivariable Modeling of Factors Associated with Spinal Pain in Young Adolescence European Spine Journal 2016 (Sep); 25 (9): 2809–2821 ~ FULL TEXT Psychosomatic symptoms and pain comorbidities had the strongest association with 1-month period prevalence of spinal pain in young adolescents, followed by factors from the physical and psychosocial domains. The role that "physical factors" play in non-adult spinal pain may have been underestimated by previous studies.
	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".
	Evidence-Based Evaluation of Complementary Health Approaches for Pain Management in the United States Mayo Clin Proc. 2016 (Sep); 91 (9): 1292–1306 ~ FULL TEXT Although most pain is acute and resolves within a few days or weeks, millions of Americans have persistent or recurring pain that may become chronic and debilitating. Medications may provide only partial relief from this chronic pain and can be associated with unwanted effects. As a result, many individuals turn to complementary health approaches as part of their pain management strategy. This article examines the clinical trial evidence for the efficacy and safety of several specific approaches-acupuncture, manipulation, massage therapy, relaxation techniques including meditation, selected natural product supplements (chondroitin, glucosamine, methylsulfonylmethane, S-adenosylmethionine), tai chi, and yoga-as used to manage chronic pain and related disability associated with back pain, fibromyalgia, osteoarthritis, neck pain, and severe headaches or migraines.
	Multidimensional Diagnostic Criteria for Chronic Pain: Introduction to the ACTTION-American Pain Society Pain Taxonomy (AAPT) J Pain. 2016 (Sep); 17 (9 Suppl): T1–9 ~ FULL TEXT A variety of approaches have been used to develop diagnostic criteria for chronic pain. The published evidence of the reliability and validity of existing diagnostic criteria is limited, and these criteria have typically not been used in clinical practice. The availability of a widely accepted, consistently applied, and evidence-based taxonomy of diagnostic criteria would improve the quality of clinical research on chronic pain and would be of great value in clinical practice. To address the need for evidence-based diagnostic criteria for the major chronic pain conditions, the Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks (ACTTION) public-private partnership with the US Food and Drug Administration and the American Pain Society (APS) have collaborated on the development of the ACTTION-APS Pain Taxonomy (AAPT).
	Whose Pain Is It Anyway? Comparability of Pain Reports From Children and Their Parents Chiropractic & Manual Therapies 2016 (Aug 1); 24: 24 ~ FULL TEXT Percentage agreement between parent and child assessment was around 50% in Sample 1 and 68% in Sample 2. The poor agreement was due to children reporting pain when their parent did not, the reverse very rarely occurred. Pain of greater intensity or longer duration resulted in better agreement between the child and parent. Child age and gender did not influence the likelihood of agreement.
	Neural Correlates of Fear of Movement in Patients with Chronic Low Back Pain vs. Pain-Free Individuals Front Hum Neurosci. 2016 (Jul 26); 10: 386 ~ FULL TEXT In the current fMRI study, we applied a novel approach encompassing: (1) video clips of potentially harmful activities for the back as fear of movement (FOM) inducing stimuli; and (2) the assessment of FOM in both, chronic low back pain (cLBP) patients (N = 20) and age- and gender-matched pain-free subjects (N = 20). Derived from the fear avoidance (FA) model, we hypothesized that FOM differentially affects brain regions involved in fear processing in patients with cLBP compared to pain-free individuals due to the recurrent pain and subsequent avoidance behavior.
	Cross-Sectional Analysis of Per Capita Supply of Doctors of Chiropractic and Opioid Use in Younger Medicare Beneficiaries J Manipulative Physiol Ther. 2016 (May); 39 (4): 263–266 ~ FULL TEXT In this exploratory analysis, we found a strong inverse correlation between the per-capita supply of DCs and the proportion of younger Medicare beneficiaries who filled opioid prescriptions. Further, we found a strong inverse correlation between the per-capita spending on CMT and the proportion of younger Medicare beneficiaries who filled opioid prescriptions. Based upon our findings, we suggest that Medicare consider promoting a trial of CMT prior to use of conventional medical care for patients with neck or back pain. The rationale for use of CMT prior to medical care is that concurrent medical care might result in opioid prescriptions; however, further study that examines opioid use when CMT and conventional medical care are concurrently provided is warranted.
	Does Cervical Spine Manipulation Reduce Pain in People With Degenerative Cervical Radiculopathy? A Systematic Review of the Evidence, and a Meta-analysis Clinical Rehabilitation 2016 (Feb); 30 (2): 145–155 Three trials with 502 participants were included. Meta-analysis suggested that cervical spine manipulation (mean difference 1.28, 95% confidence interval 0.80 to 1.75; P < 0.00001; heterogeneity: Chi(2) = 8.57, P = 0.01, I(2) = 77%) improving visual analogue scale for pain showed superior immediate effects compared with cervical computer traction. The overall strength of evidence was judged to be moderate quality. One out of three trials reported the adverse events and none with a small sample size.
	Attenuation Effect of Spinal Manipulation on Neuropathic and Postoperative Pain Through Activating Endogenous Anti-Inflammatory Cytokine Interleukin 10 in Rat Spinal Cord J Manipulative Physiol Ther. 2016 (Jan); 39 (1): 42–53 ~ FULL TEXT After CCD and de-CCD treatments, the animals exhibited behavioral and neurochemical signs of neuropathic pain manifested as mechanical allodynia and thermal hyperalgesia, DRG inflammation, DRG neuron hyperexcitability, induction of c-Fos, and the increased expression of PKCγ in the spinal cord as well as increased level of IL-1β and TNF-α in DRG and the spinal cord. Repetitive Activator-assisted spinal manipulative therapy significantly reduced simulated neuropathic and postoperative pain, inhibited or reversed the neurochemical alterations, and increased the anti-inflammatory IL-10 in the spinal cord.
	On The Origin of Atraumatic Neuromusculoskeletal Pain Chiropractic Journal of Australia 2016 (Jan); 44 (1): 1–8 ~ FULL TEXT The purpose of this study was to examine the possible origins of non-specific or atraumatic back pain by applying the Gate Theory of pain and current physiologic concepts. I present a theory that accounts for the initiation and potential consequences of neuromusculoskeletal pain incorporating failure of the mechanism of muscle relaxation and resulting in pain and compromise of the lymphatic system. The theory provides an alternative to current theories and hypotheses of the cause and consequences of neuromusculoskeletal pain.
	The Effect of Spinal Manipulation on Deep Experimental Muscle Pain in Healthy Volunteers Chiropractic & Manual Therapies 2015 (Sep 7); 23: 25 ~ FULL TEXT The current findings do not support the theory that HVLA-manipulation has a non-specific, reflex-mediated local or generalized analgesic effect on experimentally induced deep muscle pain. This in turn suggests, that any clinical analgesic effect of HVLA-manipulation is likely related to the amelioration of a pre-existing painful problem, such as reduction of biomechanical dysfunction.
	Pain Characteristics of Adolescent Spinal Pain BMC Pediatr. 2015 (Apr 17); 15 (1): 42 ~ FULL TEXT Adolescents who suffered from pain in more than one spinal area reported higher pain intensity and frequency than those with pain in only one spinal area. Sleep disorders were a significant predictor for pain in more than one spinal area (p < 0.01) as well as a trend for frequent pain (p = 0.06). Adolescents with frequent pain showed impaired balance on one leg standing with closed eyes (p = 0.02).
	Patients' Experiences and Expectations of Chiropractic Care: A National Cross-sectional Survey Chiropractic & Manual Therapies 2015 (Jan 16); 23 (1): 3 ~ FULL TEXT Overall, patients reported a high level of satisfaction with the benefits of their chiropractic care, although there is a likelihood of bias towards patients with a positive experience of chiropractic. There were no serious adverse reactions; however, patients reported concern about pain, tingling and numbness in the limbs after chiropractic. In general, patients' expectations were being well met.
	A Modern Neuroscience Approach to Chronic Spinal Pain: Combining Pain Neuroscience Education with Cognition-targeted Motor Control Training Phys Ther. 2014 (May); 94 (5): 730–738 ~ FULL TEXT Chronic spinal pain (CSP) is a severely disabling disorder, including nontraumatic chronic low back and neck pain, failed back surgery, and chronic whiplash-associated disorders. Much of the current therapy is focused on input mechanisms (treating peripheral elements such as muscles and joints) and output mechanisms (addressing motor control), while there is less attention to processing (central) mechanisms. In addition to the compelling evidence for impaired motor control of spinal muscles in patients with CSP, there is increasing evidence that central mechanisms (ie, hyperexcitability of the central nervous system and brain abnormalities) play a role in CSP. Hence, treatments for CSP should address not only peripheral dysfunctions but also the brain. Therefore, a modern neuroscience approach, comprising therapeutic pain neuroscience education followed by cognition-targeted motor control training, is proposed.
	Spinal Pain in Adolescents: Prevalence, Incidence, and Course: A School-based Two-year Prospective Cohort Study in 1,300 Danes Aged 11–13 BMC Musculoskelet Disord. 2014 (May 29); 15: 187 ~ FULL TEXT Spinal pain is common at the age of 11–15 years, but some have more pain than others. The pain is likely to progress, i.e., to more locations, higher frequency, and higher pain intensity over a two-year period.
	Spinal Manipulative Therapy-specific Changes in Pain Sensitivity in Individuals with Low Back Pain J Pain 2014 (Feb); 15 (2): 136–148 ~ FULL TEXT Participants receiving the SMT and placebo SMT received their assigned intervention 6 times over 2 weeks. Pain sensitivity was assessed prior to and immediately following the assigned intervention during the first session. Clinical outcomes were assessed at baseline and following 2 weeks of participation in the study. Immediate attenuation of suprathreshold heat response was greatest following SMT (P = .05, partial η2 = .07). Group-dependent differences were not observed for changes in pain intensity and disability at 2 weeks. Participant satisfaction was greatest following the enhanced placebo SMT.
	Short-term Usual Chiropractic Care for Spinal Pain: A Randomized Controlled Trial Spine (Phila Pa 1976). 2013 (Nov 15); 38 (24): 2071–2078 ~ FULL TEXT One hundred eighty three participants (chiropractic, n = 92; sham, n = 91) were recruited and included in the analyses. Participants receiving chiropractic therapy reported greater improvements in pain (mean difference, 95% confidence interval [CI] = 0.5 [0.1–0.9]), physical function (mean difference [95% CI] = 2.1 [0.3–4.0]), and were more likely to experience global improvement (48% vs. 24%, P = 0.01) and treatment satisfaction (78% vs. 56%, P < 0.01). There was no between-group difference in achieving a minimally acceptable outcome (34% sham vs. 29% chiropractic, P = 0.42). Awareness of treatment assignment and achieving minimally important improvement in pain intensity were associated with chiropractic treatment satisfaction.
	Chiropractic Management of Postoperative Spine Pain: A Report of 3 Cases J Chiropractic Medicine 2013 (Sep); 12 (3): 168–175 ~ FULL TEXT Chronic pain after surgery is common. [1, 2] It has been reported that about 1 in 5 patients who have undergone various surgical procedures experiences severe postoperative pain or only poor to fair pain relief despite pain management therapies. [2] With regard to spinal surgery, it is estimated that 15% to 61% of patients report persistent or recurrent pain postsurgically depending on the specific intervention. [3–5] Moreover, up to two-thirds of all chronic pain patients enrolled in pain centers in the United States are believed to experience failed back surgery syndrome. [6] Data suggest that chronic back pain post–spinal surgery should be treated nonoperatively unless progressive neurologic deficits exist. [7]
	Changes In Primary Care Physician's Management of Low Back Pain in a Model of Interprofessional Collaborative Care: An Uncontrolled Before-after Study Chiropractic & Manual Therapies 2013 (Feb 1); 21 (1): 6 ~ FULL TEXT There were twice as many patients in the pre-study group who were prescribed medication compared to the study group. Almost 33% of patients in the pre-study group were concurrently prescribed a second, and 4% a third medication, compared to 6% of patients in study group who received only a second prescription. Despite the similarity in recorded pain severity, there were about 2.6 times more medications prescribed in the pre-study group compared to those in the study group.
	Changes in Pain Sensitivity Following Spinal Manipulation: A Systematic Review and Meta-analysis J Electromyogr Kinesiol. 2012 (Oct); 22 (5): 752–767 ~ FULL TEXT Spinal manipulation (SMT) demonstrated a favorable effect over other interventions on increasing PPT. Subgroup analysis showed a significant effect of SMT on increasing mechanical pressure pain threshold (PPT) at the remote sites of stimulus application supporting a potential central nervous system mechanism. Future studies of SMT related hypoalgesia should include multiple experimental stimuli and test at multiple anatomical sites.
	The Effect of Spinal Manipulative Therapy on Experimentally Induced Pain: A Systematic Literature Review Chiropractic & Manual Therapies 2012 (Aug 10); 20 (1): 26 ~ FULL TEXT A systematic search was performed for experimental studies on healthy volunteers and people without chronic syndromes, in which the immediate effect of SMT was tested. Articles selected were reviewed blindly by two authors. A summary quality score was calculated to indicate level of manuscript quality. Outcome was considered positive if the pain-reducing effect was statistically significant. Separate evidence tables were constructed with information relevant to each research question. Results were interpreted taking into account their manuscript quality.
	Advancements in the Management of Spine Disorders Best Pract Res Clin Rheumatol. 2012 (Apr); 26 (2): 263–280 ~ FULL TEXT Despite, or perhaps because of its impact, spinal disorders remain one of the most controversial and difficult conditions for clinicians, patients and policymakers to manage. This paper provides a brief summary of advances in the understanding of back and neck pain over the past decade as evidenced in the current literature. This paper includes the following sections: a classification of spinal disorders; the epidemiology of spine pain in the developed and developing world; key advancements in biological and biomechanical sciences in spine pain; the current status of potential methods for the prevention of back and neck pain; rheumatological and systemic disorders that impact the spine; and evidence-based surgical and non-surgical management of spine pain. The final section of this paper looks to the future and proposes actions and strategies that may be considered by the international Bone and Joint Decade (BJD), by providers, institutions and by policymakers so that we may better address the burden of spine disorders at global and local levels.
	Pain in the Three Spinal Regions: The Same Disorder? Data From a Population-based Sample of 34,902 Danish Adults Chiropractic & Manual Therapies 2012 (Apr 5); 20: 11 ~ FULL TEXT In all, 34,902 (74%) twin individuals representative of the general Danish population, aged 20 to 71, participated in a cross-sectional nation-wide survey. Identical questions from the Standardised Nordic Questionnaire for each of the three spinal regions were used for lumbar, mid-back and neck pain respectively: Pain past year, pain ever, radiating pain, and consequences of back pain (care-seeking, reduced physical activities, sick-leave, change of work/work duties and disability pension). The relative prevalence estimates of these variables were compared for the three spinal regions.
	Spinal Manipulative Therapy and Its Role in the Prevention, Treatment and Management of Chronic Pain J Canadian Chiro Assoc 2012 (Mar); 56 (1): 5-7 ~ FULL TEXT Chronic pain is a worldwide epidemic. It is characterized as “pain that persists beyond normal tissue healing time” [1] and is physiologically distinct from acute nociceptive pain. The current research estimates the prevalence of chronic pain in the general population to be anywhere from 10–55%, [2] predominantly affecting the adult population. Studies indicate that the prevalence of chronic pain in the over-60 age group is double that for younger adults. [3] Furthermore, over 80% of elderly (over 65) adults suffer from some form of painful chronic joint disease [4] and greater than 85% of the general population will experience some form of chronic myofascial pain during their lifetime. [5]
	Elevated Production of Inflammatory Mediators Including Nociceptive Chemokines in Patients With Neck Pain: A Cross-Sectional Evaluation J Manipulative Physiol Ther. 2011 (Oct); 34 (8): 498–505 ~ FULL TEXT Production of inflammatory mediators was consistently elevated in NP patients in this study, both in vitro and in vivo, and activation of inflammatory pathways was accompanied by up-regulation of CC chemokine synthesis. This suggests that, in NP patients, CC chemokines may be involved in regulation of local inflammatory response through recruitment of immune cells to the inflamed tissue and exert pronociceptive effects.
	Pain in Children and Adolescents: Prevalence, Impact on Daily Life, and Parents' Perception, A School Survey Scand J Caring Sci. 2011 (Mar); 25 (1): 27–36 Sixty per cent of the children and adolescents reported pain within the previous 3 months. Pain increased with age, where girls aged 16–18 years reported the most pain. Total prevalence of chronic pain was 21%. Children reported impact on social life; inability to pursue hobbies, disturbed sleep, absence from school, and inability to meet friends because of pain. The girls reported significantly more frequently disturbed sleep, loss of appetite, and use of medication, compared to the boys. There was little agreement between parents and children regarding pain.
	Consequences of Spinal Pain: Do Age and Gender Matter? A Danish Cross-sectional Population-based Study of 34,902 Individuals 20–71 Years of Age BMC Musculoskelet Disord. 2011 (Feb 8); 12: 39 ~ FULL TEXT Almost two-thirds of individuals with spinal pain did not report any consequence. Generally, consequences due to LBP were more frequently reported than those due to NP or MBP. Regardless of area of complaint, care seeking and reduced physical activities were the most commonly reported consequences, followed by sick-leave, change of work, and disability pension. There was a small mid-life peak for care-seeking and a slow general increase in reduced activities with increasing age. Increasing age was not associated with a higher reporting of sick-leave but the duration of the sick-leave increased somewhat with age. Disability pension due to spinal pain was reported exceedingly rare before the age of 50. Typically, women slightly more often than men reported some kind of consequences due to spinal pain.
	Inclusion of a CAM Therapy (Chiropractic Care) for the Management of Musculoskeletal Pain in an Integrative, Inner City, Hospital-based Primary Care Setting J Alternative Medicine Research 2010 (Dec); 2 (1) 61–74 ~ FULL TEXT We have reported on an innovative program to integrate a CAM treatment service, chiropractic, into the primary care musculoskeletal services provided by a Canadian hospital to its inner city population. The success of this program has been confirmed through a mixed-methods evaluative process. Programmatic success was achieved by the concerted efforts of all stakeholders, especially when led by an institutional champion. High satisfaction with the program was reported by administrators, practitioners and patients. Clinical outcomes were evaluated by a standardized outcomes protocol. Our findings demonstrate that the majority of patients with MSK complaints obtained clinically important improvements when able to access chiropractic care. This is especially important given the frequency of chronic, complex complaints with numerous co-morbidities in our study population and the significant barriers these people face in accessing traditional hospital services. Our team found that CAM therapies may be useful adjuncts in the management of MSK pain conditions, even in highly systematized settings of primary care hospital clinics and for clinically complex and marginalized populations.
	Manual Therapy and Exercise for Neck Pain: A Systematic Review Manual Therapy 2010 (Aug); 15 (4): 334–354 Manual therapy is often used with exercise to treat neck pain. This cervical overview group systematic review update assesses if manual therapy, including manipulation or mobilisation, combined with exercise improves pain, function/disability, quality of life, global perceived effect, and patient satisfaction for adults with neck pain with or without cervicogenic headache or radiculopathy. Computerized searches were performed to July 2009. Two or more authors independently selected studies, abstracted data, and assessed methodological quality. Pooled relative risk (pRR) and standardized mean differences (pSMD) were calculated. Of 17 randomized controlled trials included, 29% had a low risk of bias. There are more articles like this at our: Exercise and Chiropractic Care Page
	Pain Management by Primary Care Physicians, Pain Physicians, Chiropractors, and Acupuncturists: A National Survey Southern Medical Journal 2010 (Aug); 103 (8): 738–747 Of the chronic pain patients seen for evaluation, the percentages subsequently treated on an ongoing basis range from 51% (PCPs) to 63% (pain physicians). Pain physicians prescribe long-acting opioids such as methadone, antidepressants or anti-convulsants, and other nontraditional analgesics approximately 50–100% more often than PCPs. Twenty-nine percent of PCPs and 16% of pain physicians reported prescribing opioids less often than they deem appropriate because of regulatory oversight concerns. Of the four groups, PCPs are least likely to feel confident in their ability to manage musculoskeletal pain and neuropathic pain, and are least likely to favor mandatory pain education for all PCPs.
	Spinal Manipulative Therapy Has an Immediate Effect on Thermal Pain Sensitivity in People With Low Back Pain: A Randomized Controlled Trial Phys Ther. 2009 (Dec); 89 (12): 1292–1303 Hypoalgesia to A-delta fiber-mediated pain perception was not observed. Group-dependent hypoalgesia of temporal summation specific to the lumbar innervated region was observed. Pair-wise comparisons indicated significant hypoalgesia in participants who received SMT, but not in those who rode a stationary bicycle or performed low back extension exercises. Psychological factors did not significantly correlate with changes in temporal summation in participants who received SMT.
	Chronic Pain Reconsidered Pain. 2008 (Aug 31); 138 (2): 267–276 ~ FULL TEXT Chronic pain has been traditionally defined by pain duration, but this approach has limited empirical support and does not account for chronic pain's multi-dimensionality. This study compared duration-based and prospective approaches to defining chronic pain in terms of their ability to predict future pain course and outcomes for primary care patients with three common pain conditions: back pain (n=971), headache (n=1078), or orofacial pain (n=455). At baseline, their chronic pain was classified retrospectively based on Pain Days in the prior six months and prospectively with a prognostic Risk Score identifying patients with "possible" or "probable" chronic pain.\
	Recognizing the Value of Chiropractic for Chronic Pain Dynamic Chiropractic 2008 (Sep 23); 26 (20): The guidelines actually recommend manipulation for chronic, persistent low back or neck pain and cervicogenic headache. [2] This is significant because in the past, the guidelines failed to recommend manipulation, even when other treatment strategies (medication, etc.) were rated as less effective.
	Efficacy of Selected Complementary and Alternative Medicine Interventions For Chronic Pain J Rehabil Res Dev. 2007; 44 (2): 195–222 ~ FULL TEXT Complementary and alternative medicine (CAM) is a group of diverse medical and healthcare systems, therapies, and products that are not presently considered part of conventional medicine. This article provides an up-to-date review of the efficacy of selected CAM modalities in the management of chronic pain. Findings are presented according to the classification system developed by the National Institutes of Health National Center for Complementary and Alternative Medicine (formerly Office of Alternative Medicine) and are grouped into four domains: biologically based medicine, energy medicine, manipulative and body-based medicine, and mind-body medicine.
	Immediate Effects on Pressure Pain Threshold Following a Single Cervical Spine Manipulation in Healthy Subjects J Orthop Sports Phys Ther. 2007 (Jun); 37 (6): 325–329 The application of a manipulative intervention directed at the posterior joint of the C5–6 vertebral level produced an immediate increase in PPT over the lateral epicondyle of both elbows in healthy subjects. Effect sizes for the HVLA thrust manipulation were large, suggesting a strong effect of unknown clinical importance at this stage, whereas effect sizes for both placebo and control procedures were small, suggesting no significant effect.
	Alternatives in Cancer Pain Treatment: The Application of Chiropractic Care Semin Oncol Nurs 2005 (Aug); 21 (3): 184–189 The judicial use of chiropractic services in cancer patients appears to offer many economical and effective strategies for reducing the pain and suffering of cancer patients, as well as providing the potential to improve patient health overall. You'll find more articles like this in the Chiropractic And Cancer Page.
	Pain Has Significant Negative Effects on Health and Workplace Productivity J Occupational and Environmental Medicine 2005 (Jul); 47 (7): 658–670 Pain is one of the leading causes of both worker absenteeism, in which an employee must take time away from work, and worker "presenteeism," in which an employee's overall effectiveness at work is limited as a result from physical and/or mental health problems. The effect pain can have on both employees and employers continues to increase significantly; by some estimates, common pain conditions now account for more than $62 billion per year in lost productivity.
	Psychosocial Factors and their Role in Chronic Pain: A Brief Review of Development and Current Status Chiropractic & Osteopathy 2005 (Apr 27); 13 (1): 6 ~ FULL TEXT The belief that pain is a direct result of tissue damage has dominated medical thinking since the mid 20th Century. Several schools of psychological thought proffered linear causal models to explain non-physical pain observations such as phantom limb pain and the effects of placebo interventions. Psychological research has focused on identifying those people with acute pain who are at risk of transitioning into chronic and disabling pain, in the hope of producing better outcomes.
	Chronic Pain in Persons With Neuromuscular Disease Clin J Pain 2005 (Jan); 21 (1): 18–26 In this paper, researchers in a medical school rehabilitation department were interested in finding out what treatments were most effective at reducing pain for neuromuscular diseases (like amyotrophic lateral sclerosis and myotonic muscular dystrophies). Interestingly, chiropractic scored with the highest pain relief rating (7.33 out of 10), scoring higher than the relief provided by either: nerve blocks   (6.75), opioid analgesics   (6.37), Muscle relaxants (5.78), Massage   (5.48), Acupuncture   (5.29), or Ibuprofen, aspirin   (5.22). WOW!!!
	Treatment Expectancy Affects the Outcome of Cognitive-Behavioral Interventions in Chronic Pain Clin J Pain 2005 (Jan); 21 (1): 18–26 Patients' initial beliefs about the success of a given pain treatment are shown to have an important influence on the final treatment outcome. The aims of the paper are to assess determinants of patients' treatment expectancy and to examine the extent to which treatment expectancy predicts the short-term and long-term outcome of cognitive-behavioral treatment of chronic pain.
	Qualitative Review of Studies of Manipulation-induced Hypoalgesia J Manipulative Physiol Ther 2000 (Feb); 23 (2): 134–138 From the early 1990s, there are several reports involving the use of the pressure algometer initially devised by Fischer. [24] Vernon [25] was the first to report the improvement in paraspinal pressure pain threshold (PPT) levels after manipulation. Six tender muscle spots were measured bilaterally in a subject with chronic right-sided neck and scapular pain. The right side muscle values were all significantly lower than those on the left and were lower than the normal cut-off value of 3.5 kg/cm2 established by Fischer. [24] After a cervicoscapular manipulation, PPT levels rose by an average of 45%, whereas the patient's pain score dropped from 6 to 1/10 on a 10-centimeter VAS. In 1992, Vernon et al [12] reported on 9 subjects with chronic neck pain. Baseline PPT values were obtained bilaterally around the painful segment (fixation) for a total of 4 measured sites. Five subjects were randomly assigned to receive a rotary manipulation, and 4 subjects received the same sort of oscillatory mobilization that had been used in the endorphin study. [21] In the group receiving manipulation, PPT levels at 5 minutes after treatment rose at all 4 sites (ie, bilaterally) an average of 45%, whereas in the control group there was no increase. This difference was statistically significant at all 4 points.
	Clinical Study on Manipulative Treatment of Derangement of the Atlantoaxial Joint J Tradit Chin Med 1999 (Dec); 19 (4): 273–278 The derangement of the atlantoaxial joint is one of main cervical sources of dizziness and headache, which were based on the observation on the anatomy of the upper cervical vertebrae, analysis of X-ray film of the atlantoaxial joint, and the manipulative treatment in 35 patients with cervical spondylosis.
	Spinal Pain Syndromes: Nociceptive, Neuropathic, and Psychologic Mechanisms J Manipulative Physiol Ther 1999 (Sep); 22 (7): 458–472 ~ FULL TEXT Although the treatment of neuropathic pain is difficult, sufficient evidence in the literature demonstrates that the treatment of nociceptive pain should be multimodal and involve spinal manipulation, muscle lengthening/stretching, trigger point therapy, rehabilitation exercises, electrical modalities, a variety of nutritional factors, and mental/emotional support.
	Chronic Spinal Pain Syndromes: A Clinical Pilot Trial Comparing Acupuncture, A Nonsteroidal Anti- inflammatory Drug, and Spinal Manipulation J Manipulative Physiol Ther 1999 (Jul); 22 (6): 376–381 ~ FULL TEXT The consistency of the results provides, in spite of several discussed shortcomings of this pilot study, evidence that in patients with chronic spinal pain syndromes spinal manipulation, if not contraindicated, results in greater improvement than acupuncture and medicine.
	From the Gate to the Neuromatrix Pain 1999; Suppl 6 Aug: S121–126 The gate control theory's most important contribution to understanding pain was its emphasis on central neural mechanisms. The theory forced the medical and biological sciences to accept the brain as an active system that filters, selects and modulates inputs. The dorsal horns, too, were not merely passive transmission stations but sites at which dynamic activities (inhibition, excitation and modulation) occurred. The great challenge ahead of us is to understand brain function.
	1999 National Pain Survey ~ Executive Summary Ortho-McNeil Pharmaceutical Approximately 24 percent of Americans, or roughly 48 million people, suffer from chronic pain; 21.6 million Americans, or one in ten (11%) adults, take prescription pain medication regularly to manage chronic pain; Among individuals taking prescription pain medication, the most common types of chronic pain are arthritis (31%), lower back pain (25%), other types of bone/joint pain (17%), muscle pain or stiffness (13%) and fibromyalgia (12%).
	Recent Considerations in Nonsteroidal Anti-inflammatory Drug Gastropathy American Journal of Medicine 1998 (Jul 27); 105 (1B): 31S–38S Conservative calculations estimate that approximately 107,000 patients are hospitalized annually for nonsteroidal anti-inflammatory drug (NSAID)-related gastrointestinal (GI) complications and at least 16,500 NSAID-related deaths occur each year among arthritis patients alone. The figures for all NSAID users would be overwhelming, yet the scope of this problem is generally under-appreciated. Analysis of these data indicates that: (1)   osteoarthritis (OA) and rheumatoid arthritis (RA) patients are 2.5–5.5 times more likely than the general population to be hospitalized for NSAID-related GI events; (2)   the absolute risk for serious NSAID-related GI toxicity remains constant and the cumulative risk increases over time; (3)   there are no reliable warning signals- >80% of patients with serious GI complications had no prior GI symptoms; (4)   independent risk factors for serious GI events were age, prednisone use, NSAID dose, disability level, and previous NSAID-induced GI symptoms; and (5)   antacids and H2 antagonists do not prevent NSAID-induced gastric ulcers, and high-risk NSAID users who take gastro-protective drugs are more likely to have serious GI complications than patients not taking such medications. Currently, limiting NSAID use is the only way to decrease the risk of NSAID-related GI events.
	Dysafferentation: A Novel Term to Describe the Neuropathophysiological Effects of Joint Complex Dysfunction. A Look at Likely Mechanisms of Symptom Generation J Manipulative Physiol Ther 1998 (May); 21 (4): 267–280 ~ FULL TEXT Joint complex dysfunction should be included in the differential diagnosis of pain and visceral symptoms because joint complex dysfunction can often generate symptoms which are similar to those produced by true visceral disease. You may also enjoy this response from another chiropractic researcher.
	Neuroanatomy of the Pain System and of the Pathways that Modulate Pain J Clin Neurophysiol 1997 (Jan); 14 (1): 2–31 We review many of the recent findings concerning mechanisms and pathways for pain and its modulation, emphasizing sensitization and the modulation of nociceptors and of dorsal horn nociceptive neurons.
	Chronic Cervical Zygapophysial Joint Pain After Whiplash: A Placebo–Controlled Prevalence Study Spine 1996 (Aug 1); 21 (15): 1737–1744 The prevalence of cervical zygapophysial joint pain after whiplash has been studied by means of comparative local anesthetic blocks. The concern is that such blocks may be compromised by placebo responses and that prevalence estimates based on such blocks may exaggerate the importance of this condition. In this study, sixty-eight consecutive patients referred for chronic neck pain after whiplash were studied. Those who did not experience pain relief together with the patients with dominant neck pain proceeded to undergo placebo-controlled local anesthetic blocks. Two different local anesthetics and a placebo injection of normal saline were administered in random order and under double-blindfolded conditions. A positive diagnosis was made if the patient's pain was completely and reproducibly relieved by each local anesthetic but not by the placebo injection. Overall, the prevalence of cervical zygapophysial joint pain (C2-C3 or below) was 60% (95% confidence interval, 46%, 73%).
	Substance P Induced by Peripheral Nerve Injury in Primary Afferent Sensory Neurons and its Effect on Dorsal Column Nucleus Neurons J Neurosci 1995 (Nov); 15 (11): 7633–7643 These data indicate that the de novo synthesized SP in the lesioned primary afferent neurons may be involved in an augmentation of excitability in the dorsal column-medial lemniscus sensory pathway. This hyperexcitability may play a role in the pathogenesis of abnormal neuropathic sensations following peripheral nerve injury.
	Long-term Outcome After Whiplash Injury: A 2-year Follow-up Considering Features of Injury Mechanism and Somatic, Radiologic, and Psychosocial Findings Medicine (Baltimore) 1995 (Sep); 74 (5): 281–297 Previous studies, however, focused on somatic symptoms on the one hand or considered only psychological or neuropsychological variables on the other hand, often in loosely defined or selected groups of patients. No study so far has analyzed the long-term outcome in a nonselected group of patients using a clear injury definition considering patient history; somatic, radiologic, and neuropsychological findings; and features of the injury mechanisms assessed soon after trauma and during follow-up. With regard to baseline findings the following significant differences were found (on this cohort): Symptomatic patients were older, had higher incidence of rotated or inclined head position at the time of impact, had higher prevalence of pretraumatic headache, showed higher intensity of initial neck pain and headache, complained of a greater number of symptoms, had a higher incidence of symptoms of radicular deficit and higher average scores on a multiple symptom analysis, and displayed more degenerative signs (osteoarthrosis) on X ray.
	Validity of Five Common Manual Neck Pain–provoking Tests Scand J Rehabil Med 1995 (Sep); 27 (3): 131–136 This study revealed that palpation for pain was the most reproducable and accurate assessment of reported neck pain. They state: "Palpation over the facet joints in the cervical spine was found to be the most appropriate screening test to corroborate the replies in self–reported questionnaires on dysfunctions of the neck."
	Interexaminer Reliability of Palpation for Cervical Spine Tenderness Scand J Rehabil Med 1995 (Sep); 27 (3): 131–136 As with the study above, spinal palpation for tenderness was found to ba a valid examinatioin tool. They stated: "In this population, palpation for cervical spine tenderness is a highly reliable examination tool."
	The Prevalence of Chronic Cervical Zygapophysial Joint Pain After Whiplash Spine Journal 1995 (Jan 1); 20 (1): 20–26 In a significant proportion of patients with whiplash, chronic, refractory neck pain develops. Provisional data suggest many of these patients have zygapophysial joint pain, but the diagnosis has been established by single, uncontrolled diagnostic block. In this study, fifty consecutive, referred patients with chronic neck pain after whiplash injury were studied using double-blind, controlled, diagnostic blocks of the cervical zygapophysial joints. On separate occasions, the joint was blocked with either lignocaine or bupivacaine in random order. A positive diagnosis was made only if both blocks relieved the patient's pain and bupivacaine provided longer relief. In this population, cervical zygapophysial joint pain was the most common source of chronic neck pain after whiplash.
	Contribution of Central Neuroplasticity to Pathological Pain: Review of Clinical and Experimental Evidence Pain 1993 (Mar); 52 (3): 259–285 Peripheral tissue damage or nerve injury often leads to pathological pain processes, such as spontaneous pain, hyperalgesia and allodynia, that persist for years or decades after all possible tissue healing has occurred. Although peripheral neural mechanisms, such as nociceptor sensitization and neuroma formation, contribute to these pathological pain processes, recent evidence indicates that changes in central neural function may also play a significant role.
	Cartilage Maintenance in Osteoarthritis: Interaction of Cytokines, NSAID and Prostaglandins in Articular Cartilage Damage and Repair J Rheumatol Suppl 1991 (Mar); 28: 30–37 The structural integrity of the matrix of human articular cartilage is maintained by a dynamic equilibrium between synthesis and degradation. In osteoarthritis (OA), synthesis may be inhibited by the presence of subnanogram quantities of the cytokine interleukin 1 (IL-1), leading in the longterm to loss of matrix and susceptibility to mechanical damage. IL-1 may also inhibit the potential for repair processes to take place in this cartilage if continued synthesis and secretion of the cytokine occurs. Evidence is presented that animal and human cartilages are sensitive to the action of certain nonsteroidal antiinflammatory drugs (NSAID) in inhibiting the synthesis of cartilage proteoglycan and also diminishing the repair activity of cartilage recovering after IL-1.
	Pain Costs Employers Billions in Lost Wages for Sick Days Business and Health Magazine American employers lose billions of dollars each year because pain keeps workers off the job, according to a 1996 survey by Louis Harris & Associates. "Pain is a major cause of absenteeism in the workforce," said Robert Leitman, Executive Vice President, Louis Harris. "In 1995, pain caused 50 million lost work days at a cost to employers of at least $3 billion in wages for employees who called in sick."

In The Opinion of Drug Companies

	Pain and Older Americans Survey The National Council on the Aging One in five Americans over age 60 takes medication to control pain that lasts for six months or more (chronic pain). This represents 18% of Americans in this age group, or 7.5 million people.
	Nearly One in Five Seniors Takes Medication for Chronic Pain The National Council on the Aging Nearly one in five Americans over age 60 regularly takes medication for chronic pain, according to a 1997 survey. The majority of the 7.5 million seniors who take medication for chronic pain say their medications are effective, but one in four suffers from side effects caused by the drugs. Nearly 40 percent say doctors don't discuss possible side effects of pain medication they prescribe, and half say doctors don't warn them about potential drug interactions.
	Pain Is Undertreated in Seniors, Experts Say The National Council on the Aging Safer, more effective therapy could improve the quality of life of older Americans who take pain medication. This conclusion was shared by pain specialists and experts on aging who reviewed findings of a survey released in June 1997 by The National Council on the Aging, Inc. (NCOA). The survey, conducted by Louis Harris & Associates on behalf of NCOA, examined how pain and its treatment affect the lives of the nearly one in five Americans over age 60 who regularly take pain medication for arthritis and other chronic pain conditions.

End of Opinion

Patient Expectations of Relief

	Expectations Influence Treatment Outcomes in Patients with Low Back Pain. A Secondary Analysis of Data from a Randomized Clinical Trial European Journal of Pain 2019 (Aug); 23 (7): 1378–1389 ~ FULL TEXT This study confirms the importance of patient expectations in a clinical setting. Patient expectations predicts the short-term outcome of chiropractic care for LBP. Pain intensity, psychological profile and self-rated health did not modify this relationship.
	Patients' Perceived Needs of Health Care Providers for Low Back Pain Management: A Systematic Scoping Review Spine J. 2018 (Apr); 18 (4): 691–711 ~ FULL TEXT Patients with LBP want patient-centered care, to be actively involved, and they have identified characteristics of HCP that foster a good provider-patient relationship. They noted areas of dissatisfaction with HCP and perceived obstacles to care. Given limited health care resources, HCP and policy makers need to implement novel methods of health care delivery that address these issues to facilitate improved patient satisfaction and achieve better patient and health system outcomes.
	A Qualitative Study of Changes in Expectations Over Time Among Patients with Chronic Low Back Pain Seeking Four CAM Therapies BMC Complement Altern Med. 2015 (Feb 5); 15: 12 ~ FULL TEXT Pre-treatment expectations consisted of conjecture about whether or not the CAM therapy could relieve pain and improve participation in meaningful activities. Expectations tended to shift over the course of treatment to be more inclusive of broader lifestyle factors, the need for long-term pain management strategies and attention to long-term quality of life and wellness. Although a shift toward greater acceptance of chronic pain and the need for strategies to keep pain from flaring was observed across participants regardless of therapy, participants varied in their assessments of whether increased awareness of the need for ongoing self-care and maintenance strategies was considered a "positive outcome". Regardless of how participants evaluated the outcome of treatment, participants from all four therapies reported increased awareness, acceptance of the chronic nature of pain, and attention to the need to take responsibility for their own health.
	A Path Analysis of the Effects of the Doctor-patient Encounter and Expectancy in an Open-label Randomized Trial of Spinal Manipulation for the Care of Low Back Pain   NCT00376350 BMC Complement Altern Med. 2014 (Jan 13); 14: 16 ~ FULL TEXT The doctor-patient encounter (DPE) can have a relatively important effect on outcomes in open-label randomized trials of treatment efficacy. Therefore, attempts should be made to balance the DPE across treatment groups and report degree of success in study publications. We balanced the DPE across groups with minimal training of treatment providers.
	Expectation of Recovery from Low Back Pain: A Longitudinal Cohort Study Investigating Patient Characteristics Related to Expectations and the Association Between Expectations and 3-month Outcome Spine (Phila Pa 1976). 2014 (Jan 1); 39 (1): 81–90 ~ FULL TEXT Patients' recovery expectations were associated mainly with LBP history and were generally, but not consistently, similar to an empirically predicted prognosis. Expectations were significantly associated with outcome, and may, at least for some outcomes, be a relevant proxy for more complex models. Future studies should explore the effect of addressing negative recovery expectations.
	Beliefs and Expectations for Recovery, Coping, and Depression in Whiplash-Associated Disorders: Lessening the Transition to Chronicity Spine (Phila Pa 1976) 2011 (Dec 1); 36 (25 Suppl): S250–S256 ~ FULL TEXT Beliefs, expectations, coping, and depression all predict WAD recovery. Efforts to address these factors should take a broad-based approach. These psychological constructs should be viewed as being developed and maintained within the broader social context of family, social networks, employment, and societal processes in general. There is need for a research and clinical paradigm, which acknowledges the interrelationships between internal processes and the social context in attempts to optimize recovery and functioning in those with WAD.
	Patient Expectations of Benefit from Common Interventions for Low Back Pain and Effects on Outcome: Secondary Analysis of a Clinical Trial of Manual Therapy Interventions J Man Manip Ther. 2011 (Feb); 19 (1): 20–25 ~ FULL TEXT The findings of this secondary analysis indicate that patients seeking intervention for LBP expect active interventions and manual therapy to significantly help improve their pain more than interventions like traction, rest, surgery, or medication. Additionally, in patients who meet the clinical prediction rule for good prognosis when managed with thrust techniques, treating with thrust techniques is more important than matching treatment to patient expectation.
	Individual Expectation: An Overlooked, But Pertinent, Factor in the Treatment of Individuals Experiencing Musculoskeletal Pain Phys Ther. 2010 (Sep); 90 (9): 1345–1355 ~ FULL TEXT Physical therapists consider many factors in the treatment of patients with musculoskeletal pain. The current literature suggests expectation is an influential component of clinical outcomes related to musculoskeletal pain for which physical therapists frequently do not account. The purpose of this clinical perspective is to highlight the potential role of expectation in the clinical outcomes associated with the rehabilitation of individuals experiencing musculoskeletal pain. The discussion focuses on the definition and measurement of expectation, the relationship between expectation and outcomes related to musculoskeletal pain conditions, the mechanisms through which expectation may alter musculoskeletal pain conditions, and suggested ways in which clinicians may integrate the current literature regarding expectation into clinical practice.
	A Preliminary Path Analysis of Expectancy and Patient-Provider Encounter in an Open-Label Randomized Controlled Trial of Spinal Manipulation for Cervicogenic Headache J Manipulative Physiol Ther 2010 (Jan); 33 (1): 5–13 ~ FULL TEXT Clearly, blinding is often not possible in efficacy and relative efficacy studies seeking to evaluate the independent effects of a single component of care (such as SMT). It is therefore important to control the effects of the patient-provider interaction on study outcomes to help optimize study internal validity. It appears that equipoise by the same providers across intervention types can be accomplished. It also appears that it is possible to reduce the confounding effect of the PPE to a relatively small proportion of the treatment effect found for the interventions under study. A challenging methodological issue that remains is determining to what extent equipoise in the PPE across treatment arms can serve as a surrogate for double blinding in randomized controlled trials.
	Expectations for Recovery Important in the Prognosis of Whiplash Injuries PLoS Med. 2008 (May 13); 5 (5): e105 ~ FULL TEXT In conclusion, we suggest early assessment of expectations for recovery to be made, in order to identify people at risk for poor prognosis after WAD. Furthermore, controlled studies on interventions aimed at modifying expectations are warranted. Such studies could be conducted on the population level, similar to the successful media campaign on back pain beliefs, which decreased disability claims, both in terms of incidence and time on benefits. [31, 32] Alternatively interventions targeting persons in the acute phase of an injury should be evaluated. Finally, it is not inconceivable that our findings can be extended to persons with pain conditions other than WAD.
	Patient Expectations as Predictors of Outcome in Patients with Acute Low Back Pain J General Internal Medicine 2008 (Feb); 23 (2): 148–153 ~ FULL TEXT In patients with acute LBP, higher expectations for recovery are associated with greater functional improvement. Eliciting patient expectations for improvement may be a simple way to identify patients with the highest (or lowest) likelihood of experiencing functional improvement. Incorporating questions about patient expectations in future trials may clarify the role of this important correlate of clinical outcomes.
	The Influence of Expectation on Spinal Manipulation Induced Hypoalgesia: An Experimental Study in Normal Subjects BMC Musculoskelet Disord. 2008 (Feb 11); 9: 19 ~ FULL TEXT The current study replicates prior findings of c- fiber mediated hypoalgesia in the lower extremity following SMT and this occurred regardless of expectation. A significant increase in pain perception occurred following SMT in the low back of participants receiving negative expectation suggesting a potential influence of expectation on SMT induced hypoalgesia in the body area to which the expectation is directed.
	Patient Expectations of Treatment for Back Pain: A Systematic Review of Qualitative and Quantitative Studies Spine (Phila Pa 1976). 2004 (Oct 15); 29 (20): 2309–2318 ~ FULL TEXT Patients have explicit expectations on diagnosis, instructions, and interpersonal management. New strategies need to be developed in order to meet patients' expectations better. Practice guidelines should pay more attention to the best way of discussing the causes and diagnosis with the patient and should involve them in the decision-making process.
	Expectations of Chiropractic Treatment: What Are the Expectations of New Patients Consulting a Chiropractor, and Do Chiropractors and Patients Have Similar Expectations? J Manipulative Physiol Ther 2002 (Jun); 25 (5): 300–305 ~ FULL TEXT This survey of 30 chiropractors and 336 patients in Sweden showed that both groups had many similar goals and expectations for treatment. There were several differences in treatment expectations, however. Patients had significantly lower expectations of treatment success than their doctors, yet higher expectations for advice and exercise. Patients also disagreed with their doctors of chiropractic on how many treatments were necessary, expecting significant relief in 1–2 visits rather than the 4–5 visits chiropractors felt necessary for relief. Expectations can impact care outcomes, so this paper suggests that chiropractors may have to address this issue with patients.

Chiropractic in an Integrative Health Care Model

Principles of Integrative Medicine Creating an integrative medicine model for patient care is about more than randomly choosing between methods of the traditional healthcare system and the alternative medicine sector. Integrative healthcare, to effectively treat chronic pain, combines any and all safe and effective treatment modalities, without regard for whether the modality originated in the allopathic, pharmaceutical or CAM arena.

	Integrated Health Care and Chiropractic A Chiro.Org article collection Enjoy these articles about chiropractic integration into HMOs, IPAs and the Veterans program.
	Use of Integrative Medicine in the United States Military Health System Evid Based Complement Alternat Med 2017 (Jun 13); 2017: 9529257 Integrative medicine (IM) is a model of care which uses both conventional and nonconventional therapies in a "whole person" approach to achieve optimum mental, physical, emotional, spiritual, and environmental health, and is increasingly popular among patients and providers seeking to relieve chronic or multifactorial conditions. The US Department of Defense (DoD) shows particular interest in and usage of IM for managing chronic conditions including the signature "polytrauma triad" of chronic pain, traumatic brain injury (TBI), and posttraumatic stress disorder (PTSD) among its beneficiaries in the Military Health System (MHS).
	An Integrated Approach to Chronic Pain Dynamic Chiropractic ~ May 2017 ~ FULL TEXT Findings from a unique Medicaid pilot project in Rhode Island involving high-use Medicaid recipients from two health plans were recently presented to the state's Department of Health, [1] demonstrating stellar outcomes with regard to medication use, ER visits, health care costs and patient satisfaction. Since 2012, Rhode Island Medicaid "Community of Care" enrollees suffering from chronic pain have participated in an integrated chronic pain program administered by Advanced Medicine Integration. Longtime readers will recall that for nearly two decades, AMI has been coordinating chiropractic and integrated care services in various states to help address the chronic pain epidemic in a community-based, integrated fashion. [2-3]
	The Chiropractic Hospital-Based Interventions Research Outcomes Study: Consistency of Outcomes Between Doctors of Chiropractic Treating Patients With Acute Lower Back Pain J Manipulative Physiol Ther. 2015 (Jun); 38 (5): 311–323 ~ FULL TEXT The findings of this study show that regardless of the treating DC, most patients with acute LBP without radiculopathy appear to experience consistent levels of improvement in terms of back pain and general physical functioning (PF) after receiving guidelines-based treatment that includes a component of standardized HVLA SMT.
	Chiropractors as Primary Care Providers Dynamic Chiropractic ~ June 4, 2007 ~ FULL TEXT The latest issue of the Journal of Manipulative and Physiological Therapeutics features an update to Sarnat and Winterstein's 2004 research paper that assessed chiropractors' effectiveness as primary care providers (PCPs). As with the 2004 report, the latest research concludes that a managed care network with chiropractic gatekeepers saves substantial costs and results in decreased utilization as compared to PCPs using conventional medicine alone.
	Clinical Utilization and Cost Outcomes from an Integrative Medicine Independent Physician Association: An Additional 3-year Update J Manipulative Physiol Ther 2007 (May); 30 (4): 263–269 ~ FULL TEXT The initial report (JMPT 2004 (Jun) ; 27 (5): 336–347) analyzed clinical and cost utilization data from the years 1999 to 2002 for an integrative medicine independent physician association (IPA) whose primary care physicians (PCPs) were exclusively doctors of chiropractic. This report updates the subsequent utilization data from the IPA for the years 2003 to 2005 and includes first-time comparisons in data points among PCPs of different licensures who were oriented toward complementary and alternative medicine (CAM). The authors found that: “During the past 7 years, and with a larger population than originally reported, the CAM-oriented PCPs using a nonsurgical/nonpharmaceutical approach demonstrated reductions in both clinical and cost utilization when compared with PCPs using conventional medicine alone.” The savings? Clinical and cost utilization based on 70,274 member-months over a 7-year period demonstrated decreases of: 60.2% in-hospital admissions 59.0% less hospital days 62.0% less outpatient surgeries and procedures and 85% less pharmaceutical costs when compared with conventional medicine IPA performance for the same health maintenance organization product in the same geography and time frame.
	Clinical and Cost Outcomes of an Integrative Medicine IPA J Manipulative Physiol Ther 2004 (Jun) ; 27 (5): 336–347 ~ FULL TEXT In 1999, a large Chicago HMO began to utilize doctors of chiropractic (DCs) in a primary care provider role. The DCs focused on assessment and evaluation of risk factors and practiced with a non-pharmaceutical/non-surgical approach. Insurance claims and patient surveys were analyzed to compare clinical outcomes, costs and member satisfaction with a normative control group. During the 4-year study, this integrative medical approach, emphasizing a variety of complimentary and alternative medical (CAM) therapies, resulted in lower patient costs and improved clinical outcomes for patients. The patients who went to DCs as their primary care providers had 43 percent decreases in hospital admissions, 52 percent reductions in pharmaceutical costs and 43 percent fewer outpatient surgeries and procedures. If you like these results, you will absolutely LOVE the 7-Year Follow-Up!

Pain-related Resources

	Chiropractors as the Spinal Health Care Experts A Chiro.Org article collection Enjoy these learned articles about chiropractors as first-contact Spinal Health Care Experts.
	Chronic Neck Pain and Chiropractic A Chiro.Org article collection Review this extensive collection of studies detailing how chiropractic and spinal manipulation are effective for the relief of spinal pain.
	Chiropractic Care For Veterans A Chiro.Org article collection Review this collection of studies detailing the slowly expanding use of chiropractic care for vererans and active military.
	Pregnancy-related Spinal Pain and Chiropractic A Chiro.Org article collection Review this growing collection of studies detailing how effective chiropractic management is for pregancy-related low back and pelvic pain.
	Neck and Back Pain in Children A Chiro.Org article collection We hope you will enjoy this extensive collection of articles and studies demonstrating the benefits of chiropractic care for spinal pain in children.
	Radiculopathy and Chiropractic Page A Chiro.Org article collection We hope you will enjoy this extensive collection of articles and studies demonstrating the benefits of chiropractic care for radiculopathy.
	Low Back Pain and Chiropractic A Chiro.Org article collection We hope you will enjoy this extensive collection of articles and studies demonstrating the benefits of chiropractic care for low back pain.
	Low Back Pain Guidelines from Around the World A Chiro.Org article collection A new addition from the American College of Physicians (2017) recommends 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. This section also includes recommendations from the California Industrial Medical Council, the Royal College of General Practitioners, the 1994 AHCPR guides, the "Mercy Conference Document", and the New Zealand "Psychosocial Yellow Flags" Page.
	Neck Disorder Guidelines from Around the World A Chiro.Org article collection Bew additions include guidelines for Whiplash-associated Disorders and Neck Disorders (not due to whiplash) from the Canadian Chiropractic Guideline Initiative (CCGI).

Pain ~ Links of Interest

   American Pain Society (APS)

   International Association for the Study of Pain

   National Headache Foundation

   NIH Consensus Statement on the Use of Acupuncture

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Updated 1-27-2023