Welcome to the Non-pharmacologic Therapy section @ Chiro.Org   This section contains
a collection of articles reviewing how chiropractic can and does contribute.

Non-pharmacologic Therapy and Chiropractic

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

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Recent Studies

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	Cost-Effectiveness of Chiropractic A Chiro.Org article collection Take a close look at the 3 Cost-Effectiveness Triumvirate articles, as they detail how other studies have under-valued chiropractic care, by simply ignoring other medical and social costs, like extended unemoployment, drug costs and side-effects, and referred care patterns. They are a real eye-opener.
	Chronic Neck Pain and Chiropractic A Chiro.Org article collection This section contains articles going back to the early 90s, and also provides an impressive Reference Materials section.
	Low Back Pain and Chiropractic A Chiro.Org article collection This section contains articles going back to 1985, and also provides some helpful sub-sections on Patient Expectations of Relief, the Trajectories of Low Back Pain and a detailed section on What is Usual (medical) Care? .
	Headache and Chiropractic A Chiro.Org article collection This section contains articles going back to 1988, and also provides some helpful sub-sections on the sub-types of headaches, including Cervicogenic, Chronic Tension, and Migraine Headache.
	Chiropractic Care For Veterans A Chiro.Org article collection Enjoy this collection of articles by DCs who treat our Vets, going back to 2002. It ALSO contains a section with the collected Congressional Acts and Veterans Affairs Documents as a reference.
	Workers' Compensation and Chiropractic A Chiro.Org article collection Studies going back to the 1980s reveal that chiropractic care gets workers back to work faster and cheaper than standard medical care. Drop by and enjoy this new topical collection.

Recent Studies

	Back and Neck Pain: In Support of Routine Delivery of Non-pharmacologic Treatments as a way to Improve Individual and Population Health Translational Research 2021 (Apr 24);   S1931-5244 (21) 00088-8~ FULL TEXT Chronic back and neck pain are highly prevalent conditions that are among the largest drivers of physical disability and cost in the world. Recent clinical practice guidelines recommend use of non-pharmacologic treatments to decrease pain and improve physical function for individuals with back and neck pain. However, delivery of these treatments remains a challenge because common care delivery models for back and neck pain incentivize treatments that are not in the best interests of patients, the overall health system, or society. This narrative review focuses on the need to increase use of non-pharmacologic treatment as part of routine care for back and neck pain.
	"Like Peanut Butter and Jelly": A Qualitative Study of Chiropractic Care and Home Exercise Among Older Adults with Spinal Disability BMC Geriatrics 2021 (Apr 23);   21 (1):   271 Older adults valued non-pharmacological treatment options that aided them in controlling spine-related symptoms, while empowering them to maintain clinical benefit gained after a course of chiropractic spinal manipulation and exercise. The complimentary nature of provider-delivered and active care modalities may be an important consideration when developing care plans. This study underscores the importance of understanding participants' values and experiences when interpreting study results and applying them to practice.
	Non-Surgical Interventions for Lumbar Spinal Stenosis Leading To Neurogenic Claudication: A Clinical Practice Guideline Journal of Pain 2021 (Apr 1)   2;   S1526-5900(21)00188-7 Lumbar spinal stenosis (LSS) causing neurogenic claudication (NC) is increasingly common with an aging population and can be associated with significant symptoms and functional limitations. We developed this guideline to present the evidence and provide clinical recommendations on nonsurgical management of patients with LSS causing NC. Using the GRADE approach, a multidisciplinary guidelines panel based recommendations on evidence from a systematic review of randomized controlled trials and systematic reviews published through June 2019, or expert consensus. The literature monitored up to October 2020. Clinical outcomes evaluated included pain, disability, quality of life, and walking capacity. The target audience for this guideline includes all clinicians, and the target patient population includes adults with LSS (congenital and/or acquired, lateral recess or central canal, with or without low back pain, with or without spondylolisthesis) causing NC.
	Doctors of Chiropractic Working with or within Integrated Healthcare Delivery Systems: A Scoping Review Protocol BMJ Open 2021 (Jan 25);   11 (1):   e043754 ~ FULL TEXT Musculoskeletal conditions, including back and neck pain, are the leading causes of disability worldwide. [1] In the USA, the use of pharmacological treatments, such as opioids and invasive procedures, such as steroid injections and surgery, for low back pain, increased from 1997 to 2010. [2] During the same time period disability and costs from low back pain also increased. [2, 3] In contrast to these patterns of care for spinal disorders, clinical practice guidelines emphasise the use of non-pharmacological approaches before the use of over the counter medications, prescribed medications or invasive procedures. [4–7] Yet patients who seek care in integrated healthcare delivery systems, at specific medical settings such as primary care clinics in hospitals or community health centres, still frequently receive prescribed medications as first line care. [8, 9] Limited familiarity with the efficacy and role of non-pharmacological treatments, few opportunities to practise in the same location as non-pharmacological providers, and inadequate channels of communication between these providers have been identified as important clinician-level barriers that prevent referrals to non-pharmacological treatments. [10–12] Increasing collaboration between primary care providers and providers of non-pharmacological treatment will improve access to non-pharmacological treatments and may improve outcomes.
	Veteran Response to Dosage in Chiropractic Therapy (VERDICT): Study Protocol of a Pragmatic Randomized Trial for Chronic Low Back Pain Pain Medicine 2020 (Dec 12);   21 (Suppl 2):   S37–S44 ~ FULL TEXT Lack of information on optimal dosing is a significant barrier to planning and operationalizing the continued implementation of VA chiropractic services. Currently, few published data are available to guide the development of DC staffing models that would provide optimal access to care for veterans with cLBP. The extended-care approach of CCPM is not currently used in the VA, in part because of the lack of studies conducted in the United States demonstrating its effectiveness. Accurate information on the effectiveness of different dosing regimens of chiropractic care could greatly assist health systems, including the VA, in modeling the number of DCs that will best meet the needs of patients with cLBP.
	Best Practices for Chiropractic Management of Patients with Chronic Musculoskeletal Pain: A Clinical Practice Guideline J Altern Complement Med 2020 (Oct);   26 (10):   884–901 ~ FULL TEXT The Delphi process was conducted January-February 2020. The 62-member Delphi panel reached consensus on chiropractic management of five common chronic MSK pain conditions: low-back pain (LBP), neck pain, tension headache, osteoarthritis (knee and hip), and fibromyalgia. Recommendations were made for nonpharmacological treatments, including acupuncture, spinal manipulation/mobilization, and other manual therapy; modalities such as low-level laser and interferential current; exercise, including yoga; mind-body interventions, including mindfulness meditation and cognitive behavior therapy; and lifestyle modifications such as diet and tobacco cessation. Recommendations covered many aspects of the clinical encounter, from informed consent through diagnosis, assessment, treatment planning and implementation, and concurrent management and referral. Appropriate referral and comanagement were emphasized.
	The Lancet Series Call to Action to Reduce Low Value Care for Low Back Pain: An Update Pain. 2020 (Sep);   161 (1):   S57–S64 ~ FULL TEXT The 2018 Lancet Low Back Pain Series, comprising 3 papers written by 31 authors from disparate disciplines and 12 different countries, raised unprecedented awareness of the rising global burden of low back pain partly attributable to poor quality health care. [12, 30, 44] Many people with low back pain get the wrong care, causing harm to millions across the world and wasting valuable health care resources. Based upon an up-to-date, evidence-based synthesis, the series described current guideline recommended care of low back pain, and new strategies that show promise, but require further testing, to reduce low value care. We also proposed a series of actions needed to reverse the alarming global rise in low back pain disability. A better understanding of low back pain in different cultures and changes to the way care for low back pain is delivered and the way clinicians are reimbursed are key to reversing this problem.
	Association of Initial Provider Type on Opioid Fills for Individuals With Neck Pain Archives of Phys Med and Rehabilitation 2020 (Aug);   101 (8):   1407–1413 ~ FULL TEXT Compared to patients with neck pain who saw a primary health care provider, patients with neck pain who initially saw a conservative therapist were 72%–91% less likely to fill an opioid prescription in the first 30 days, and between 41%–87% less likely to continue filling prescriptions for 1 year. People with neck pain who initially saw emergency medicine physicians had the highest odds of opioid use during the first 30 days (OR, 3.58; 95% CI, 3.47–3.69; P<.001).
	Integrating a Multidisciplinary Pain Team and Chiropractic Care in a Community Health Center: An Observational Study of Managing Chronic Spinal Pain Journal of Primary Care & Community Health 2020 (Sep 10) ~ FULL TEXT This study analyzed these two strategies and showed that in the short term, chiropractic care is a more cost-effective alternative compared to PT for the treatment of acute low back pain. Chiropractic resulted in a lower cost ($48.56) and higher DALY (0.0043) than the PT over a one-month treatment period and five months follow-up. However, the marginal cost-effectiveness of chiropractic over PT suggests that both treatments were quite similar. Such findings are in line with the earlier studies, which found that the effectiveness and total costs of chiropractic and PT as primary treatments were similar to each other right after treatment and after 6 months follow-up. [3, 22, 32]
	Complementary, Integrative, and Nondrug Therapy Use for Pain Among US Military Veterans on Long-term Opioids Medical Care 2020 (Sep);   58 Supp l 2 9S:   S116–S124 ~ FULL TEXT In conclusion, our study found that US VA patients on long-term opioid therapy (LTOT) for chronic pain commonly use nondrug therapies to manage pain, that observed nondrug therapy use classes reflect clinically relevant functional groups, and that patient characteristics are associated with use of different nondrug therapies. Further exploration of factors affecting nondrug therapy access and use for specific subpopulations, such as use of exercise/movement therapy by people with high pain interference, may enable implementation of nondrug and complementary and integrative health (CIH) therapy for chronic pain and expand safe, effective pain treatment options for people prescribed LTOT.
	Noninvasive Nonpharmacological Treatment for Chronic Pain: A Systematic Review Update Agency for Healthcare Research and Quality 2020 (Apr)~ FULL TEXT Psychological therapies were associated with small improvements compared with usual care or an attention control for both function and pain at short-term, intermediate-term, and long-term followup (SOE: moderate). Function improved over short and/or intermediate term for exercise, low-level laser therapy, spinal manipulation, massage, yoga, acupuncture, and multidisciplinary rehabilitation (SOE moderate at short term for exercise, massage, and yoga; low for all others). Improvements in pain at short term were seen for massage, mindfulness-based stress reduction, acupuncture, and multidisciplinary rehabilitation (SOE: moderate), and exercise, low-level laser therapy, and yoga (SOE: low). At intermediate term, spinal manipulation, yoga, multidisciplinary rehabilitation (SOE: moderate) and exercise and mindfulness-based stress reduction (SOE: low) were associated with improved pain. Compared with exercise, multidisciplinary rehabilitation improved both function and pain at short and intermediate terms (small effects, SOE: moderate.)
	Nonpharmacological Treatment of Army Service Members with Chronic Pain Is Associated with Fewer Adverse Outcomes After Transition to the Veterans Health Administration J General Internal Medicine 2020 (Mar);   35 (3):   775–783 ~ FULL TEXT Our results suggest that nonpharmacological treatments (NPT) provided to active duty service members with chronic pain may reduce their odds of longterm adverse outcomes. Given known associations of these adverse outcomes with morbidity and mortality, providing NPT to service members with chronic pain could potentially save lives. Our results provide further support for the role of NPT as a risk mitigation strategy when long-term opioid therapy is initiated, which is only briefly mentioned in the VA/DoD Clinical Practice Guideline for Opioid Therapy for Chronic Pain. [16] Given that our findings may have been drivenby some NPT modalities more than others, the dose in which these modalities were received, or unmeasured confounding, more research is needed to clarify these effects. As confounders may change during NPT (e.g., daily dose of opioids), it may be important to include time-varying covariates in follow-up research.
	Association Between Chiropractic Use and Opioid Receipt Among Patients with Spinal Pain: A Systematic Review and Meta-analysis Pain Medicine 2020 (Feb 1);   21 (2):   e139–e145 ~ 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.
	Best-Practice Recommendations for Chiropractic Management of Patients With Neck Pain J Manipulative Physiol Ther. 2019 (Nov);   42 (9):   635–650 ~ FULL TEXT A set of best-practice recommendations for chiropractic management of patients with neck pain based on the best available evidence reached a high level of consensus by a large group of experienced chiropractors. The recommendations indicate that manipulation and mobilization as part of a multimodal approach are front-line approaches to patients with uncomplicated neck pain.
	Prevalence and Characteristics of Chronic Spinal Pain Patients with Different Hopes (Treatment Goals) for Ongoing Chiropractic Care J Alternative and Complementary Medicine 2019 (Oct 1);   25 (10):   1015–1025 ~ 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.
	Observational Retrospective Study of the Association of Initial Healthcare Provider for New-onset Low Back Pain with Early and Long-term Opioid Use BMJ Open. 2019 (Sep 20);   9 (9):   e028633 ~ FULL TEXT Initial visits to chiropractors or physical therapists is associated with substantially decreased early and long-term use of opioids. Incentivising use of conservative therapists may be a strategy to reduce risks of early and long-term opioid use.
	Conservative Spine Care Pathway Implementation Is Associated with Reduced Health Care Expenditures in a Controlled, Before-After Observational Study Journal of 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]
	Non-pharmacological Management of Persistent Headaches Associated with Neck Pain: A Clinical Practice Guideline from the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration European Journal of Pain 2019 (Jul);   23 (6):   1051–1070 This clinical practice guideline is based on comprehensive literature searches, and its recommendations were developed from high-quality evidence. When developing clinical recommendations, the Guideline Expert Panel considered effectiveness, safety, cost-effectiveness and consistency with societal and ethical values. Moreover, the lived experiences of patients with their care were used when developing recommendations (Lindsay et al., 2016). Our recommendations also included consideration of effect sizes; minimal clinically important differences were used to assess the magnitude of benefit of an intervention on patient outcomes. Finally, the Guideline Expert Panel disclosed any conflicts of interest and maintained editorial independence.
	Whole Health in the Whole System of the Veterans Administration: How Will We Know We Have Reached This Future State? J Altern Complement Med 2019 (Mar);   25 (S1):   S7–S11 ~ FULL TEXT In the early years of whole systems research in integrative health, who imagined 15 years down the road that we would be looking at an effort to transform the whole system of the Veterans Administration (VA) with two long-time integrative health leaders piloting the initiative? This special issue is to separately publish “What Should Healthcare Systems Consider When Implementing Complementary and Integrative Health: Lessons from Veterans Health Administration.” We invited this commentary as a companion piece on the context of the VA's “whole health” model in which that work is imbedded. Specifically, research is needed to show that in fact the system had reached what the authors call this “future state.”
	What Should Health Care Systems Consider When Implementing Complementary and Integrative Health: Lessons from Veterans Health Administration J Altern Complement Med 2019 (Mar);   25 (S1):   S52–S60 ~ FULL TEXT VA medical facilities have been somewhat successful in implementing complementary and integrative health (CIH) programs, despite the numerous challenges they face. Some of those challenges are typical for interventions being implemented into health care systems, whereas others seem particular to CIH approaches. However, regardless of their size, geographic location, and the amount of funding they received, all medical centers had some success with implementing CIH approaches and all were struggling to overcome challenges. In response to those challenges, VA medical facilities and the IHCC have creatively developed a wide range of strategies to support CIH implementations. Many are reproducible by other health care systems or providers wanting to initiate or strengthen their CIH programs. Due to these activities, CIH approaches are continuing their rapid expansion in the VA. Preliminary results from our recent national survey show that VA medical centers provide an average of 6 CIH approaches, with a quarter offering over 10. [27] Currently, the most frequently offered are: yoga, mindfulness-based stress reduction, meditation, guided imagery, acupuncture, t'ai chi, and relaxation responses. With this, the VA is moving closer to transforming from a medical/disease-based system of care to a health care system addressing the whole patient.
	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.
	Veteran Experiences Seeking Non-pharmacologic Approaches for Pain Military Medicine 2018 (Nov 1);   183 (11-12):   e628-e634 ~ FULL TEXT The veterans in this qualitative study expressed interest in using non-pharmacologic approaches to manage pain, but voiced complex multi-level barriers. Limitations of our study include that interviews were conducted only in five clinics and with seven female veterans. These limitations are minimized in that the clinics covered are diverse ranging to include urban, suburban, and rural residents. Future implementation efforts can learn from the veterans' voice to appropriately target veteran concerns and achieve more patient-centered pain care.
	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.
	Insurer Coverage of Nonpharmacological Treatments for Low Back Pain - Time for a Change JAMA Netw Open. 2018 (Oct 5);   1 (6):   e183037 ~ FULL TEXT Finally, future payment policies should decrease patient out-of-pocket expenses to strongly encourage earlier use of evidence-based nonpharmacological treatment options. Heyward et al found that median out-of-pocket costs for covered nonpharmacological treatments ranged from $25 to $60 per visit for commercial insurers. The usual dose of treatments such as physical therapy and chiropractic care is commonly between 6 and 12 visits. Thus, out-of-pocket expenses can vary from $150 to $720 or more. In contrast, Lin et al [10] found that the median cost of a 30-day supply of preferred generic opioids by commercial insurers is $10. Given the significant differences in cost, many patients do not realistically have the option of seeking nonpharmacological treatment.
	Patterns of Conventional and Complementary Non-pharmacological Health Practice Use by US Military Veterans: A Cross-sectional Latent Class Analysis BMC Complement Altern Med. 2018 (Sep 5);   18 (1):   246 ~ FULL TEXT Half of the sample used non-pharmacological health practices. Six classes of users were identified. "Low use" (50%) had low rates of health practice use. "Exercise" (23%) had high exercise use. "Psychotherapy" (6%) had high use of psychotherapy and support groups. "Manual therapies" (12%) had high use of chiropractic, physical therapy, and massage. "Mindfulness" (5%) had high use of mindfulness and relaxation practice. "Multimodal" (4%) had high use of most practices. Use of manual therapies (chiropractic, acupuncture, physical therapy, massage) was associated with chronic pain and female sex. Characteristics that predict use patterns varied by class. Use of self-directed practices (e.g., aerobic exercise, yoga) was associated with the personality trait of absorption (openness to experience). Use of psychotherapy was associated with higher rates of psychological distress. These observed patterns of use of non-pharmacological health practices show that functionally similar practices are being used together and suggest a meaningful classification of health practices based on self-directed/active and practitioner-delivered. Notably, there is considerable overlap in users of complementary and conventional practices.
	Effect of Usual Medical Care Plus Chiropractic Care vs Usual Medical Care Alone on Pain and Disability Among US Service Members With Low Back Pain: A Comparative Effectiveness Clinical Trial   NCT01692275 JAMA Network Open. 2018 (May 18);   1 (1):   e180105 ~ FULL TEXT Chiropractic care, when added to usual medical care (UMC), resulted in moderate short-term treatment benefits in both LBP intensity and disability, demonstrated a low risk of harms, and led to high patient satisfaction and perceived improvement in active-duty military personnel. This trial provides additional support for the inclusion of chiropractic care as a component of multidisciplinary health care for LBP, as currently recommended in existing guidelines. [21, 22, 37] However, study limitations illustrate that further research is needed to understand longer-term outcomes as well as how patient heterogeneity and intervention variations affect patient responses. You will enjoy this Invited Commentary, titled: Innovating to Improve Care for Low Back Pain in the Military: Chiropractic Care Passes Muster You will also enjoy Medscape Medical News' review of this study, titled: Chiropractic Care Improves Usual Management for Low Back Pain
	Spinal Manipulative Therapy and Other Conservative Treatments for Low Back Pain: A Guideline From the Canadian Chiropractic Guideline Initiative J Manipulative Physiol Ther. 2018 (May);   41 (4):   265–293 ~ FULL TEXT For patients with acute (0–3 months) back pain, we suggest offering advice (posture, staying active), reassurance, education and self-management strategies in addition to SMT, usual medical care when deemed beneficial, or a combination of SMT and usual medical care to improve pain and disability. For patients with chronic (>3 months) back pain, we suggest offering advice and education, SMT or SMT as part of a multimodal therapy (exercise, myofascial therapy or usual medical care when deemed beneficial). For patients with chronic back-related leg pain, we suggest offering advice and education along with SMT and home exercise (positioning and stabilization exercises).   A multimodal approach including SMT, other commonly used active interventions, self-management advice, and exercise is an effective treatment strategy for acute and chronic back pain, with or without leg pain.
	Clinical Policy Recommendations from the VHA State-of-the-Art Conference on Non-Pharmacological Approaches to Chronic Musculoskeletal Pain J Gen Intern Med 2018 (May);   33 (Suppl 1):   16–23 ~ FULL TEXT Integration of these non-pharmacological approaches into primary care, pain care, and mental health settings should be a policy priority, and these treatments should be offered early in the course of pain treatment. Multimodal care which incorporates approaches designed to engage and activate patients and to build self-management skills and which utilizes care managers and telehealth strategies should be the standard of care for chronic pain. In addition, we recommend that VHA leadership and policy makers systematically address the barriers to implementation of these approaches by expanding opportunities for clinician and veteran education on the effectiveness of these strategies; supporting and funding further research to determine optimal dosage, duration, sequencing, combination and frequency of treatment; and working to address socioeconomic and cultural barriers to veterans’ access to non-pharmacological approaches. To better evaluate the impact of these approaches, investment in more effective strategies for tracking the use of psychological, behavioral, and mind-body therapies in VHA clinical settings is also critical. Implementation of these recommendations has the potential to make the VHA a national model for improving care for chronic musculoskeletal pain.
	Use of Non-Pharmacological Pain Treatment Modalities Among Veterans with Chronic Pain: Results from a Cross-Sectional Survey J Gen Intern Med. 2018 (May);   33 (Suppl 1):   54–60 ~ FULL TEXT In summary, results from cross-sectional survey data indicated that the majority of veterans with chronic pain reported using at least one NPM in the past year. Some differences were observed in the use of non-pharmacological pain treatment modalities (NPMs), based on demographic and clinical characteristics, which may indicate differences in veteran treatment preferences or provider referral patterns. Our findings may be useful in developing targeted interventions to improve referral processes and treatment uptake. For example, veterans with a mental health history may be more amenable to referrals to psychological/behavioral treatment, and providers should be sure to recommend exercise/movement therapies for women veterans. Most importantly, however, providers should emphasize the overall benefits of using NPMs and use a shared decision making approach to determine which NPMs might work best for each patient. Future research should utilize both self-report and electronic health records (EHR) data to examine pain management strategy use (including pharmacological and non-pharmacological strategies) over time. Looking at these relationships over time may provide insight into how the combination of treatments or sequencing of treatments relates to pain intensity and pain-related functioning.
	Primary Care Management of Non-specific Low Back Pain: Key Messages from Recent Clinical Guidelines Medical J Australia 2018 (Apr 2);   208 (6):   272–275 ~ FULL TEXT Changes in management as a result of the guidelines: emphasising simple first line care with early follow-up; encouraging non-pharmacological treatments over pharmacological treatments; and recommending against the use of surgery, injections and denervation procedures.
	Pain Management by Primary Care Physicians, Pain Physicians, Chiropractors, and Acupuncturists: A National Survey Southern Medical Journal 2010 (Aug);   103 (8):   738–747 Analyses weighted to obtain nationally representative data showed that: PCPs treat approximately   52% of chronic pain patients chiropractors treat   40% acupuncturists treat   7% pain physicians treat   2% 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.

The Non-pharmacologic Therapies Low Back Pain Guidelines     A Unique Series of Articles All 5 of the following guideline-related articles 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.
	National Clinical Guidelines for Non-surgical Treatment of Patients with Recent Onset Low Back Pain or Lumbar Radiculopathy European Spine Journal 2018 (Jan);   27 (1):   60–75 ~ ~ 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.
	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.
	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
	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).

	Influence of Initial Provider on Health Care Utilization in Patients Seeking Care for Neck Pain Mayo Clin Proc Innov Qual Outcomes. 2017 (Oct 19);   1 (3):   226–233 ~ FULL TEXT These findings support that initiating care with a nonpharmacological provider for a new episode of neck pain may present an opportunity to decrease opioid exposure (DC and PT) and advanced imaging and injections (DC only). Although these findings need confirmation in a better controlled study, our results suggest that adopting such a strategy aligns well with recent CDC and ACP recommendations and has the potential to decrease the management burden of neck pain by PCPs. Future research is needed to examine the association of patient-centered outcomes and health care utilization and to explore whether seeking care from a nonpharmacological provider is also associated with cost savings in addition to decreased health care utilization.
	Epidemiology of Chronic Low Back Pain in US Adults: Data From the 2009-2010 National Health and Nutrition Examination Arthritis Care Res (Hoboken) 2016 (Nov);   68 (11):   1688–1694 ~ FULL TEXT In conclusion, US adults with cLBP in 2009–2010 were less educated, less wealthy, and more likely to smoke, have depression, sleep disturbances, and other medical comorbidities than those without cLBP. They made more frequent healthcare visits and more often carried government-sponsored health insurance to cover the costs. Frequent healthcare visits in the cLBP group were strongly associated with depression and sleep disturbances. While causal inference cannot be established from a cross-sectional study design, the clustering of behavioral, psychosocial, and medical issues should be considered in the care and rehabilitation of Americans with cLBP.
	Nonpharmacologic Therapies for Acute and Chronic Low Back Pain: A Review of the Evidence for an American Pain Society/ American College of Physicians Clinical Practice Guideline Annals of Internal Medicine 2007 (Oct 2);   147 (7):   492–504 ~ FULL TEXT Therapies with good evidence of moderate efficacy for chronic or subacute low back pain are cognitive-behavioral therapy, exercise, spinal manipulation, and interdisciplinary rehabilitation.
	Complementary and Alternative Medical Therapies for Chronic Low Back Pain: What Treatments Are Patients Willing To Try? BMC Complement Altern Med. 2004 (Jul 19);   4:   9 ~ FULL TEXT Most patients with chronic back pain in our sample were interested in trying therapeutic options that lie outside the conventional medical spectrum. This highlights the need for additional studies evaluating their effectiveness and suggests that researchers conducting clinical trials of these therapies may not have difficulties recruiting patients.
	Complementary Care: When is it Appropriate? Who Will Provide It? Annals of Internal Medicine 1998 (Jul 1);   129 (1):   65–66 ~ FULL TEXT Born in the U.S. Midwest 100 years ago, chiropractic is a uniquely American contribution to health care. It drew from "vitalist" concepts and "energetic" healing traditions that were then current in the practice of an eclectic U.S. medicine and from the desire for drugless healing in reaction to the toxicity of the materia medica of that era. Despite this rather long history, social, political and economic pressures have limited the chiropractic workforce to 56,000 practitioners in the world (52,000 of them in the United States), plus a much smaller number of "traditional" osteopathic physicians and others who practice spinal manipulation. [10] In comparison, the mainstream medical workforce in the United States consists of about 600,000 physicians. Even with these limitations on its growth, chiropractic is clearly the largest complementary health care force in the United States. Chiropractic is also the most "professionalized" of the complementary healing traditions available in the United States, with licensure in all 50 states, educational accreditation standards, continuing education requirements, and active research and investigation. Less organized and less professionalized disciplines of complementary care may be poorly prepared to develop guidelines and conduct research. In addition, the emphasis on tailoring complementary therapy to the individual patient may be at odds with the biomedical concepts of treatment protocols, practice guidelines, and population-based research. [11]
	British Medical Journal's ABC's of CAM Series British Medical Journal 1986–2003 ~ FULL TEXT Enjoy this series of 17 articles reviewing the pros and cons pf Alt-Med.

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Updated 7-09-2021