J Altern Complement Med 2020 (Oct); 26 (10): 884–901 ~ FULL TEXT
Cheryl Hawk, DC, PhD, Wayne Whalen, DC, BSN, Ronald J. Farabaugh, DC, Clinton J. Daniels, DC, MS, et al.
Texas Chiropractic College,
Pasadena, TX, USA.
Objective: To develop an evidence-based clinical practice guideline (CPG) through a broad-based consensus process on best practices for chiropractic management of patients with chronic musculoskeletal (MSK) pain.
Design: CPG based on evidence-based recommendations of a panel of experts in chronic MSK pain management.
Methods: Using systematic reviews identified in an initial literature search, a steering committee of experts in research and management of patients with chronic MSK pain drafted a set of recommendations. Additional supportive literature was identified to supplement gaps in the evidence base. A multidisciplinary panel of experienced practitioners and educators rated the recommendations through a formal Delphi consensus process using the RAND Corporation/University of California, Los Angeles, methodology.
Results: 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.
Conclusions: These evidence-based recommendations for a variety of conservative treatment approaches to the management of common chronic MSK pain conditions may advance consistency of care, foster collaboration between provider groups, and thereby improve patient outcomes.
KEYWORDS: chiropractic; chronic musculoskeletal pain; chronic pain; clinical practice guideline; spinal manipulation.
From the FULL TEXT Article:
Pain prevalence has increased among United States
adults by 25% from 1998 to 2014, according to a 2019
report, with 41% reporting pain in the period 2013-2014. 
At least 70 million U.S. adults have chronic pain. [1, 2] Opioid
use has risen along with the increase in pain prevalence. 
Visits to health care providers decreased slightly within this
same time period, perhaps suggesting that people tend to
manage pain with medications rather than provider-based
nonpharmacological approaches. 
Authoritative groups, including the Agency for Healthcare
Research and Quality (AHRQ) and the American College of
Physicians (ACP), have recommended that chronic back pain
and other chronic musculoskeletal (MSK) pain be treated
initially through nonpharmacological approaches. 
Some experts recommend viewing chronic pain as "a
disease entity in itself, rather than merely a symptom of
another condition."  The International Classification of
Disease 11 (ICD-11) has created a new category of "chronic
pain," with the following disorders included:
(1) chronic primary pain, which includes disorders such as fibromyalgia or back pain, which is not otherwise classified;
(2) chronic cancer pain;
(3) chronic post-traumatic and postsurgical pain;
(4) chronic neuropathic pain;
(5) chronic headache and orofacial pain, which includes temporomandibular joint pain;
(6) chronic visceral pain; and
(7) chronic MSK pain. [5, 6]
The AHRQ, Institute of Medicine (IOM), and the National
Pain Strategy Report [6-8] recommend that chronic pain
be addressed through the biopsychosocial model, rather than
solely through the conventional biomedical model. This
includes an emphasis on nonpharmacological and selfmanagement
approaches, with pharmacological approaches
being secondary. [3, 6-8]
The 2018 and 2020 AHRQ systematic reviews recommend
noninvasive, nonpharmacological approaches to
several of the most common chronic MSK pain conditions:
chronic LBP (CLBP), chronic neck pain, osteoarthritis
(OA), fibromyalgia, and chronic tension headache. [6, 9] A
2018 review in the Journal of Family Practice organized
its evidence-based recommendations for common chronic
pain conditions by the treatment approach:
(1) exercisebased therapies such as yoga and tâ€™ai chi;
(2) mind-body therapies such as Cognitive Behavioral Therapy (CBT) and mindfulness-based meditation; and
(3) complementary modalities such as acupuncture and spinal manipulation. 
The purpose of this project was to develop a clinical
practice guideline (CPG) for chiropractic management of
chronic MSK pain. The chiropractic professionâ€™s primary
approach to patient care has traditionally been spinal manipulation, but its scope of practice includes many other
nonpharmacological approaches  Like medical physicians,
chiropractors may not be familiar with many of these approaches
other than spinal manipulation, or may not directly
employ them with patients. It is important that all health care
providers become familiar with evidence-based approaches,
within a biopsychosocial model, to help patients manage
This is important whether the provider directly
employs such approaches, refers the patient to other providers
who do, or advises the patient on self-care activities.
In response to the opioid epidemic, nonpharmacological
approaches to chronic pain management are expected to
become increasingly legitimized.  Because the public expects
Doctors of Chiropractics (DCs) to use such therapies
more than medical physicians do, they may be more likely
to seek out chiropractic practitioners for these therapies.  Thus it is important that DCs become familiar with these approaches within the context of the biopsychosocial model. Currently, although there are CPGs addressing a chiropractic approach to LBP, [14, 15] neck pain, [16, 17] and headaches18
separately, there is not a single CPG addressing nonpharmacological approaches to more than one type of MSK
pain as a primary complaint. The purpose of this project
was therefore to develop such a guideline.
The purpose of the project was to develop an evidencebased
CPG through a broad-based consensus process on best
practices for chiropractic management of patients with
chronic MSK pain.
The development of recommendations followed steps
developed and tested in previous projects [15, 17, 19]:
Establish a Steering Committee (SC) to perform the core project functions of examining the evidence, developing recommendations based on the best available
evidence, and integrating the Delphi panelistsâ€™ ratings
and contributions into the recommendations until a
consensus is reached.
Examine the most current CPGs and/or systematic reviews related to each aspect of management.
Identify gaps in the CPG(s) and/or systematic reviews that may form barriers to best practices.
Perform targeted literature searches for the highest available evidence on the gap topics.
Make recommendations on chiropractic management, based on the best available evidence.
Conduct a Delphi consensus process with a panel of practitioners, faculty, and researchers experienced in chronic MSK pain management.
Gather additional feedback from a public posting of the consensus statements. 
Human subject considerations
The lead institutionâ€™s Institutional Review Board approved
the project before it started. All Delphi panelists
participated voluntarily and without compensation; they
signed an informed consent and agreed to be acknowledged
by name in any publication only if they signed a consent to
Of the 11-member SC, 8 were DCs. All of these have
extensive experience in chiropractic management of chronic
MSK pain and/or knowledge of the evidence base on clinical
care of MSK pain. All have held or currently hold
leadership positions in chiropractic professional organizations,
education and/or research. Three of the DCs are
members of the Scientific Council of the Clinical Compass
(Council on Chiropractic Guidelines and Practice Parameters.
Three of the DCs work full time at the Veterans
Health Administration (VA); two are full-time faculty at
chiropractic institutions; and one DC is cross-trained as a
registered nurse (RN). The project director is a DC with a
PhD in Preventive Medicine and is also a Certified Health
Education Specialist. One SC member is a medical physician
(MD) with many years of experience with chronic pain
management; one is a psychologist (PhD) who works with
chronic pain patients in the VA; and one is a representative
for laypeople and also a journal editor with extensive experience with complementary health care. The SC was responsible for identifying, reviewing, and evaluating the
evidence underlying the development of the initial seed
statements, modifying these statements based on the Delphi
panelistsâ€™ comments, and writing the final article.
The literature search focused on the evidence base for
nonpharmacological, nonsurgical interventions for chronic
MSK pain. A health sciences librarian, working with the SC,
conducted the literature search in two stages. The databases
we searched were Cochrane Database of Systematic Reviews
and PubMed/Medline, because it is unlikely that higher levels of evidence would be found in other databases, but not in these. The search strategy may be accessed in Supplementary Data S1. In addition, we used reference tracking and consulted topic experts on the SC to ensure that relevant articles were not missed.
First stage search.
To identify a "seed" document or documents on which to base development of the initial set of recommendations, we conducted two searches:
(1) identify the most recent systematic reviews for nonpharmacological treatment of chronic MSK pain and
(2) identify CPGs specific to manipulation and manual therapy.
We restricted the searches to recent literature rather than doing a comprehensive search, since CPGs should be based on the most current literature, and current systematic reviews were expected to cover earlier studies. 
Search 1 inclusion criteria:
Published January 1, 2017, to August 15, 2019.
Addressed nondrug, nonsurgical treatment of chronic MSK pain in adults.
Search 1 Exclusion criteria:
Nonrelevant (e.g., addressed interventions outside the scope of U.S. chiropractors or addressed risk factors, but not interventions; did not address chronic MSK pain).
Addressed only one type of MSK pain as a primary complaint (e.g., only back pain) and/or one type of
intervention (e.g., only CBT), to have a comprehensive
seed document to base our recommendations.
Included in another systematic review.
Search 2 inclusion criteria
Guidelines related to spinal manipulation and/or manual therapy.
Search 2 Exclusion criteria:
Nonrelevant (not CPGs; outside chiropractic scope of practice or not related to chronic MSK pain).
Second stage search. evidence-based recommendations based on the results of the
initial search. In cases where recommendations for specific
modalities or procedures were absent due to sparse evidence
for procedures commonly used in chiropractic practice
(as identified by the current Practice Analysis of Chiropractic ), we did a targeted search of the published literature from the end date of the source systematic review or guideline through 2019. We included guidelines, systematic reviews, randomized controlled trials, or outcome cohort studies.
Evaluation of the quality of the evidence
We then evaluated the quality of the articles identified in
our searches. We evaluated CPGs using the Appraisal of
Guidelines for Research & Evaluation instrument (AGREE)
Global Rating Scale (Table 1).  We evaluated systematic
reviews, RCTs, and cohort studies investigating treatments
using modified SIGN (Scottish Intercollegiate Guideline
Network) checklists, which have been used in other studies
by our team. 
22-24 The SIGN checklist rates the studies as
"high quality, low risk of bias,"
"acceptable quality, moderate risk of bias,"
"low quality, high risk of bias, or
See Tables 2–4r details of scoring.
We did not assess the quality of other types of studies, simply
identifying their design and categorizing them as "lower
level." At least two investigators rated each study and discussed
differences in ratings until they reached agreement.
We used the GRADE (Grading of Recommendations
Assessment, Development, and Evaluation) system to assess
the overall quality of the evidence. ,* Table 5 summarizes
GRADE.  At least two investigators performed the GRADE
assessment independently. If they disagreed, they discussed
the assessment and used the majority opinion.
Development of seed statements
The SC drafted a set of seed statements/concepts encompassing
key aspects of the clinical encounter, including
informed consent, diagnosis, treatment, concurrent care and
co-management, and/or referral. Based on the literature, in
addition to statements regarding chronic MSK pain in general,
we addressed five of the most common chronic MSK
pain conditions: LBP, neck pain, knee and hip OA pain, and
fibromyalgia.6 We cited evidence supporting all statements
in the text and provided live links to the full text or abstracts
in the attached reference list, so that during the consensus
process, panelists could conveniently access them to make
an evidence-informed rating.
Delphi consensus panel
We sought to recruit a broad-based panel of DCs and
other health professionals who had experience with managing
patients with chronic MSK pain, valued scientific
evidence, and were geographically dispersed throughout the
United States. We focused on the United States because
practice parameters and reimbursement issues vary among
countries. We also made it clear to participants that they
must be able to respond in a timely manner to the process,
which was conducted by e-mail.
We recruited Delphi panelists by
(1) inviting experts who had participated in our previous consensus projects and
(2) circulating an invitation through the Clinical Compass board, which includes representatives of the Congress of Chiropractic State Associations, the American Chiropractic Association, the International Chiropractors Association, and the Association of Chiropractic Colleges.
The SC reviewed
the resulting volunteers, who submitted both a form
with their practice characteristics and their CV.
Methodology of the Delphi process
The process was conducted electronically, through
e-mail. Throughout the process, panelists remained anonymous,
having been assigned an identification number at the
beginning. This was done to avoid possible bias, since all
ratersâ€™ comments were shared among the SC and the Delphi
panelists. As in all of our previous consensus processes, we
used the RAND-UCLA methodology.  This method employs
an ordinal Likert "appropriateness" rating scale in
which "appropriate" indicates that the expected patient
health benefits exceed expected negative effects by a large
enough margin that the recommended action is worthwhile,
without considering costs.  This 1-9 scale is anchored by
1 = "highly inappropriate and 9 = "highly appropriate, with
"uncertain" placed over the middle of the scale. Panelists had
unlimited space for comments immediately following each
statement. They were also instructed to provide citations to
support their comments, if possible.
Data management and analysis.
The project coordinator
entered the ratings data into an SPSS (v. 25) database,
and she and the project director computed medians and
percentages of agreement. In keeping with the rigorous
RAND-UCLA methodology, we set the threshold for consensus
at 80% agreement with a median rating of at least
seven. This was calculated by categorizing ratings of 1-3 as
"inappropriate" (i.e., disagreement with the statement); 4-6
as "uncertain"; and 7-9 as "appropriate" (i.e., agreement).
The project coordinator organized the panelistsâ€™ comments
by panelist ID, statement number, and rating to facilitate
review. The SC then reviewed the ratings and their accompanying
deidentified comments. Taking the comments
and supporting evidence into account, the SC then revised
the statements that did not reach consensus. The project
coordinator provided these revised statements and the deidentified
comments to the Delphi panel for another round of
External review: Public comments
Influential organizations such as the AGREE Enterprise
recommend incorporating various means for ensuring
stakeholder involvement into a guideline development process.
We already involved stakeholders in the SC and the
Delphi panel. For additional input, we invited public comments
on the draft CPG after completing the Delphi process.
We used several routes to disseminate this invitation:
Clinical Compass e-mailing list through a MailChimp
e-mail blast; this includes the Clinical Compass Board
(comprised United States state chiropractic organizations
and a number of national chiropractic and academic organizations
(about 900 individuals total). It also includes
vendors, whose contacts included interested laypersons.
Invitations were sent through the chiropractic organization
ChiroCongress to its member associations, representing
over 35,000 chiropractors.
Facebook and LinkedIn through the Clinical Compass
page, which is open to both health professionals and
Chiropractic Summit e-mail list; this is a national organization
of chiropractic groups and individuals.
These routes had some overlap, which served to reinforce
the message. In addition, a reminder was sent out 2 weeks
after the first invitation. We allowed 30 days for the comment
We posted the draft CPG on the Clinical Compass website
as a PDF, along with a summary of the background and
methodology of the project, as well as the references for all
statements. We provided a user-friendly comment form to
facilitate response. The project coordinator collected responses.
The project director and the SC reviewed and decided
how to respond to each comment. If the comments
resulted in substantive change, the revised statements were
to be recirculated to the Delphi panel to reach consensus.
Literature search and evaluation
First stage search 1:
Systematic reviews. We identified
343 articles (guidelines and systematic reviews/meta-analyses)
through PubMed, Cochrane Database of Systematic Reviews,
reference tracking, and consultation. Figure 1 is the Preferred
Reporting Items for Systematic Reviews and Meta-Analyses
(PRISMA) flow chart for the literature search. After applying
eligibility criteria, three systematic reviews remained. [6, 10, 27]
(Excluded articles are available in Supplementary Data S2.)
We evaluated two of the articles as high
quality [6, 27] and one as unacceptable quality10; we did not use
the unacceptable (low) quality study to support recommendations.
We selected one of the two remaining articles,
the extensive and high-quality systematic review by the
AHRQ on noninvasive nonpharmacological treatment for
chronic pain,  as an appropriate document to serve as the
initial framework for our recommendations. We accepted
AHRQâ€™s overall rating of the quality of evidence for noninvasive,
nonpharmacological interventions as low to moderate
and that "there was no evidence suggesting increased
risk for serious treatment-related harms for any of the interventions,
although data on harms were limited." ,p.ii We
included in our CPG, the five conditions covered in the
AHRQ review, which are among the most common causes
of chronic MSK pain: LBP, neck pain, chronic tension
headache, OA (knee and hip), and fibromyalgia. 
First stage search 2:
Clinical practice guidelines. From
an initial pool of 147 articles, 23 remained after title
screening and 10 remained after abstract/full-text screening.
Table 6 lists these CPGs; all were considered high quality,
either by our rating with AGREE or a published systematic
review of the quality of CPGs on MSK pain using AGREE. 
All the guidelines were single-condition focused: 5 on neck
pain, [16-18, 29, 30] 4 on LBP, [3,1 4, 15, 31] and 1 on headaches associated
with neck pain.  There were none on other types of
chronic MSK pain.
Second stage search.
We did a targeted search of the
published literature from the end date of the AHRQ review
(November 1, 2017) for topics that showed gaps in the
evidence for therapies used commonly in chiropractic
practice. The interventions we performed searches for were
spinal manipulation/manual therapy, transcutaneous electrical
nerve stimulation (TENS) and interferential current,
low-level laser (LLL) therapy, and acupuncture. Table 7
summarizes the articles identified after searching for each
specific modality from a pool of 348 articles. There were a
total of 21 articles: 5 CPGs, [14, 17, 29, 32, 33] 4 RCTS, [34-37] and 12
SRs, [38-49] as shown by condition and therapy in Table 7.
Nine were acceptable quality and 11 were high quality, using
the modified SIGN rating checklists shown in Tables 1-3 or,
for CPGs, the AGREE scale shown in Table 4).
Table 8 summarizes the quality of the evidence from both
the AHRQ review and our targeted search (2018-2019).
Overall, the evidence was favorable, moderate to low.
There were 62 panelists (of 70 invited); 58 were DCs. Ten
DCs were cross-trained: five in acupuncture, three in
physical therapy (Doctor of Physical Therapy [DPT]), two
in medicine (MD), two in nursing (RN), and one in mental
health counseling (MA). Eighteen of the DCs had academic
masterâ€™s degrees. One panelist was an MD and three were
DPTs. Almost all (57) were practitioners with an average
time in practice of 24 years (range 1-48). Sixteen of the
panelists worked in the Veterans Administration (VA) and
one had a referral arrangement with a local VA. Seven
panelists were faculty at chiropractic institutions and seven
were faculty at nonchiropractic institutions. Practitioners
saw an average of 82 patient visits per week (range: 12-250)
and the average estimated proportion of patients with a chief
complaint of chronic (>3 monthsâ€™ duration) MSK pain was
61% (range: 15-100). Panelistsâ€™ locations (58 of 62 responded)
represented 31 states plus 1 from Australia and 1
from Canada as follows: five from CA; four each from IA
and NY; three each from AZ, KS, MI, OH, and TX; two
each from MD, MN, MO, NY, OR, SD, an WA; and one
each from CO, HI, IL IN, MA, MS, MT, NC, ND, PA, RI,
SC, and TN.
On the first Delphi round, a high level of consensus (from
87% to 100% agreement) was reached on all statements. The
panelists had extensive comments, but most were based on
clarifying rather than substantively changing the statements.
The SC made revisions for the purposes of clarification.
We disseminated an invitation for comment very widely
through the Clinical Compass board, chiropractic state and
national organizations, thus reaching the majority of chiropractors
in the United States as well as interested laypeople.
Postings on the organizationâ€™s Facebook page and website
were accessed by 209 different people. We received three
public comments. All were from DC faculty at U.S. chiropractic
colleges; their suggestions were detailed and specific,
primarily recommending clarifications in the wording
of statements. The SC reviewed their comments and made a
number of nonsubstantive changes for clarity in the seed
statements; additional Delphi rounds were therefore not
required. The final statements are found below.
Chronic pain terminology and definitions
Based on the literature, we prefaced the Delphi consensus
process with definitions of key terminology so that panelists
would be "on the same page" as they rated the statements.
Chronic pain terminology
Chronic pain: persistent or recurrent pain lasting
longer than 3 months (ICD-11 definition)5 or pain
present on at least half the days during the past 6
months (National Pain Strategy definition). 
Chronic primary pain: chronic pain in one or more
anatomic locations accompanied by significant emotional
distress or functional disability and that cannot be
better explained by another chronic pain condition. 
High impact chronic pain: chronic pain that causes
enduring restrictions on activities of daily living, work,
social, and/or recreational activities. 
Neuropathic pain is identified using the following
criteria [50, 51]:
Confirmed pain distribution and sensory dysfunction
that are neuroanatomically congruent.
Confirmed history or presence of a relevant disease
or lesion affecting the peripheral or central
A description of burning, shooting, or pricking pain.
Nociceptive pain is identified using the following
Confirmed proportionate mechanical/anatomical
Pain comparable to trauma/pathology and in an
area of injury or dysfunction with/without referral.
Resolution congruent with anticipated tissue
Pain description typically intermittent and sharp
with movement/mechanical aggravation.
Pain involves additional symptoms of inflammation
(e.g., swelling and redness).
Central sensitization is differentiated from neuropathic
and nociceptive pain using these criteria [5, 51, 52]:
When neuropathic pain has been excluded, central sensitization
pain is differentiated from nociceptive pain as follows52:
Pain is out of proportion to the severity of the associated
injury or disease.
Distribution is diffuse and/or variable, not anatomically
congruent with associated injury or disease, with
accompanying allodynia or hyperalgesia.
Patient is hypersensitive to stimuli such as light,
temperature, stress, and emotions.
Other key terminology and abbreviations
Biopsychosocial intervention: a treatment plan that includes
at least one physical component (such as spinal manipulation
or exercise) and at least one psychological/
social component (such as CBT or mindfulness
CIH: Complementary and integrative health care.
CBT: Cognitive behavioral therapy, in which unhelpfulthought or behavioral patterns are challenged by restructuring
thoughts/beliefs and increasing engagement
in meaningful activities.
MTI: Maximum Therapeutic Improvement.
Psychological and mind-body interventions focus on interactions
among the brain, the rest of the body, the mind,
and behavior and the ways in which emotional, mental,
social, spiritual, experiential, and behavioral factors affect
health. Examples are as follows: psychological therapies
such as CBT and mindfulness meditation; physical mind-
body therapies such as tâ€™ai chi; and yoga. 
Red flags are signs or symptoms noted in the history or
clinical examination that suggests the possibility of serious
pathology or illness requiring immediate referral, more extensive
evaluation, or co-management, or present a contraindication
to an aspect of the proposed treatment plan. [55, 56]
Self-care: An active practice that a person can perform
at home independently after being provided with appropriate
SMT: Spinal manipulative therapy: usually practiced by
DC, doctors of osteopathy (DO), or physical therapists (PT).
Recommendations on Best Practices for Chiropractic Management of Patients with Chronic MSK Pain
General considerations for chronic pain management
1. Emphasize the biopsychosocial model. In keeping with
the recommendation of organizations such as the
AHRQ and the International Society for the Study of
Pain (IASP), management of patients with moderate to
severe and/or complicated chronic MSK pain is best
addressed within a biopsychosocial model rather than
the conventional biomedical model. [6, 58]
2. Prioritize self-management and nonpharmacological
approaches. Self-management and nonpharmacological
therapies should be prioritized over pharmacological
approaches whenever possible. [3, 6-8]
a. For patients on prescribed pain medications, comanagement
with a provider of nonpharmacological
approaches may improve outcomes. 
3. Emphasize active interventions. Although passive interventions
are useful in the initial stages of management
to decrease pain, active interventionsâ€”particularly
exercise and self-careâ€”should be introduced as soon as
possible and emphasized in the management plan. 
a. Passive interventions, both conventional medical
approaches (e.g., medication or surgery) and many
nonpharmacological approaches (e.g., acupuncture,
massage, spinal manipulation, and physical
modalities) should be combined with active interventions
and self-care (e.g., exercise, healthy
diet,  meditation, yoga, and other lifestyle changes)
whenever possible to improve outcomes. 
4. Include both physical and mind-body approaches. For
patients reporting moderate to severe chronic pain, a
nonpharmacological approach that includes both a
physical and mind-body component is recommended. 
These may be administered by the primary treating
clinician, or by referral or co-management with an
interdisciplinary team. 
5. Identify the neurophysiological type of pain. In keeping
with recent advances in the understanding of the
physiology of chronic pain, it is important to differentiate
patientsâ€™ chronic pain in terms of its neurophysiology
(neuropathic, nociceptive, and central sensitization), because
this may affect treatment choices. [51, 60, 61]
6. Consider risk stratification, such as the STarT Back
risk assessment tool, for new episodes of pain to inform
shared decisions about treatment approaches.
Patients with low risk of a poor outcome may require a
less intensive approach, while those with higher risk
may require a more intensive approach incorporating
multiple therapies, including psychological. 
Informed consent/risks and benefits
1. Engage the patient in the informed consent process. Informed
consent is a process requiring active communication
between the patient and clinician. Using clear and
understandable terms, the clinician explains the examination
procedures, diagnosis, treatment options (including no
treatment), and their benefits and risks.  The clinician
should ask the patient if he/she has any questions, and answer
them to the patientâ€™s satisfaction. The patient must
understand this information to make an informed decision.  The informed consent discussion and the patientâ€™s
consent to proceed should be recorded in the medical
2. Comply with local regulations. Legal requirements
may differ by geographic location; clinicians should
seek specific advice from local authorities such as their
malpractice carrier or state association. Both the
American Chiropractic Association (ACA) and the
Association of Chiropractic Colleges (ACC) have
guidelines on informed consent. 
3. Maximize patient safety.
a. Nonpharmacological therapies for chronic pain
have fewer associated harms than pharmacological
interventions, particularly when administered by
appropriately trained health professionals. 
b. Carefully assess patients with chronic pain for
possible contraindications to manipulation, particularly
high-velocity, low-amplitude "thrust"
maneuvers (Table 9) and red flags (Table 10). [62-64]
General diagnostic considerations -- history, examination, and imaging
History and physical examination
1. Recognize the effect of psychosocial factors on chronic
pain physiology. Chronic pain physiology may be
differentiated as nociceptive, neuropathic, and/or
central sensitization types. However, pain physiology
can manifest in individuals through interactions with
psychosocial factors. These may be negative, such as
mood or sleep disorders or work-related factors (such
as hostile work environment, job insecurity, and long
work hours [65, 66]) or protective influences such as coping
skills and social support. [4, 67, 68]
2. Take a thorough pain history. A thorough history of
the patientâ€™s pain symptoms, previous and concurrent
treatment, and psychosocial factors is important to
develop an appropriate chiropractic management plan
for patients with chronic pain. Components of the
history include  the following:
a. Assessment of red and yellow flag risk factors.
b. Onset of current pain and perceptions about initial
c. Pain parameters, including type, severity, location,
frequency, and duration.
d. Provocative and relieving factors.
e. Review of systems.
f. Previous treatment and response, including medical,
surgical, and nonpharmacological.
g. History of past, current, or considered self-care
h. History of diagnostic tests with results.
i. Current medications and nutraceuticals.
j. Complicating factors/barriers to recovery, including
social determinants of health
k. Psychological and behavioral health factors (e.g.,
depression, stress, anxiety, and PTSD).
l. Lifestyle factors such as tobacco use, drugs/
alcohol, diet, exercise, and sedentary lifestyle.
3. Consider "yellow flags." Yellow Flags are psychosocial
factors that might predict poorer outcomes or prolonged
recovery time. They relate to issues such as beliefs
about illness and treatment; attitudes and emotional states;
and pain behavior.  Examples include [17, 69] the following:
a. Belief that activity should be avoided.
b. Pain catastrophizing. 
c. Negative attitude/depression.
d. Work-related stress.
e. Lack of social support.
f. Current compensation and claims issues related to
4. Consider referral for co-management. Patients with
psychological factors, which may present an obstacle
to compliance with or success of the management
plan, may benefit by a referral to a psychologist or
behavioral health counselor for further evaluation and/
or a trial of CBT. [71, 72]
5. Conduct an appropriately focused physical examination.
73 Conduct a physical examination informed by
symptoms and health history, including areas/sites of
primary and secondary symptoms. Both function and
pain should be assessed and include a comprehensive
MSK and neuromuscular examination. 
Diagnostic imaging (general considerations and specific recommendations under each condition)
1. Avoid routine use of imaging. Because chronic MSK
pain is often multifactorial and may not originate from
a local source, imaging evidence is rarely capable of
definitively identifying a pain source.73 However,
imaging may be necessary if red flags are present and
should be evaluated on a case-by-case basis after a
thorough history and examination are performed.
General treatment considerations
1. Use validated Patient-Reported Outcome Measures to
assess patient symptoms and characteristics, and to
assess progress over time.  Some Patient-Reported
Outcome Measures appropriate for chronic pain chiropractic
patients are shown in Table 11. [4, 17, 74]
1. Follow an appropriate care pathway. Figure 2 shows
the chiropractic care pathway for a typical adult patient
with chronic MSK pain.
Considerations for frequency and duration of treatment
1. Avoid a "curative model" approach. A "curative
model" approach is not likely to be successful with
chronic pain management. Pain medications are not
expected to "cure" chronic pain, but to make it
more manageable for the patient. Similarly,
nonpharmacological approaches should not be expected
to "cure" chronic pain within a specified
course of treatment, but may need to be included as
part of an individualâ€™s ongoing pain management
plan. [15, 17, 19, 36, 75, 76] (see Table 12 for details of
2. Set appropriate chronic pain management goals. The
goals of chronic pain management are different from
the goals associated with acute care management.
Chronic care goals may include (but are not limited to)
a. Pain control: relief to tolerance.
b. Support or maximize patientâ€™s current level of
c. Reduce/minimize reliance on medication.
d. Maximize patient satisfaction.
e. Maximize patientâ€™s engagement in meaningful/
pleasurable activities to de-emphasize pain
(examples: playing with grandchildren; getting
hair done; or going to the park)77,#
f. Minimize exacerbation frequency and/or severity.
g. Minimize further disability.
h. Minimize lost time on the job.
3. Consider patient-specific goals. Patients with chronic
MSK pain generally fall into one of these categories:
a. Self-management is sufficient using strategies/
procedures such as exercise, ice, heat, and stress
b. Episodic care is necessary to manage pain. Patients
arrange nonpharmacological care on an asneed
basis to support their self-care strategies for
acute flare-ups, 1-12 visits/episode, followed by
c. Scheduled ongoing physician-directed care is
necessary to manage pain. Treatment withdrawal
results in deterioration36 (Fig. 2 and Table 12).
and treatment recommendations
This guideline includes recommendations for best practices
for chiropractic management of some of the most
common chronic MSK pain conditions. These are
(2) neck pain,
(3) tension headache,
(4) knee and hip OA, and
See General Considerations for Chronic Pain Management
section for details of history, examination, and
red and yellow flags. Specific considerations for each
condition are provided below.
1. Chronic LBP
Diagnostic considerations for LBP
1. Develop an evidence-based working diagnosis. Providers
should develop evidence-based working diagnoses
that describe condition characteristics that will
inform a management approach. [67, 68]
2. Consider physiological pain type. Providers are advised
to consider whether the likely dominant cause of
the LBP is neuropathic, nociceptive, and/or due to
central sensitization to determine the most appropriate
management strategies. [4, 5, 51, 67, 68]
1. Avoid routine imaging. Routine imaging is not recommended for patients with nonspecific LBP. [14, 73]
Factors that indicate the need for imaging are15 as
a. Severe and/or progressive neurologic deficits.
b. Suspected anatomical anomaly such as spondylolisthesis.
c. Severe trauma.
d. Other red flags on history or physical examination.
e. Patient shows no improvement after a reasonable course of care.
f. Additional factors vary with location and type of pain.
2. Consider advanced imaging for some cases of radiculopathy. For patients with CLBP accompanied by radiculopathy, magnetic resonance imaging (MRI) or
computed tomography (CT) scans are preferred to plain film radiographs.  Certain conditions that are not detected on physical examination, such as spinal stenosis, may require MRI to be detected. 
1. Consider multiple approaches. Both active and passive, and both physical and mind-body interventions should
be considered in the management plan. The following
are recommended, based on current evidence [6, 14]
a. Physical active interventions:
Yoga/qigong (which may also be considered "mind-body" interventions)
Lifestyle advice to stay active; avoid sitting ; manage weight if obese ; and quit smoking [78, 79]
b. Physical passive interventions:
Transcutaneous electrical nerve stimulation (TENS) or interferential current may be beneficial
as part of a multimodal approach, at the beginning of treatment to assist the patient in becoming or remaining active. [38, 47]
c. Combined active and passive: multidisciplinary rehabilitation d. Psychological/mind-body interventions 
2. Chronic neck pain
Diagnostic considerations for LBP
See General Diagnostic Considerationsâ€”History, Examination, and Imaging section
Consider appropriate circumstances for imaging. According to the American College of Radiology:
1. AP and lateral views of the cervical spine may be appropriate in patients with a history of
(1) chronic neck pain with or without trauma;
(2) malignancy; or
(3) neck surgery. 
2. Diagnostic imaging to identify degeneration is not recommended because it has not been determined to necessarily be a source of pain. 
3. Serial radiographs of the cervical spine are not associated with improved outcomes. [83, 84]
1. Consider multiple approaches. Both active and passive, and both physical and mind-body interventions should be considered in the management plan for maximum therapeutic effect. The following are recommended, based on current evidence. 
a. Physical active interventions [16, 18]:
b. Physical passive interventions:
Spinal manipulation and mobilization [16, 18, 85]
These modalities may be added as part of a multimodal treatment plan, especially at the beginning, to assist the patient in becoming or remaining active:
Transcutaneous nerve stimulation (TENS), traction, ultrasound, and interferential current. [17, 34, 37]
c. Mind-body interventions [16, 18]
3. Chronic tension headache
Diagnostic considerations for tension headache
By definition, tension-type headache (TTH) is one that is
present at least 15 days each month for more than 3 months. It
may be daily and unremitting and may be accompanied by
mild nausea.  TTH is diagnosed by history exclusively, although
a focused examination that includes blood pressure
should also be conducted. Imaging and other special tests are
not indicated unless the history or examination is suggestive
of another condition, which may be the underlying cause. 
1. Consider multiple approaches. Both active and passive, and both physical and mind-body interventions should be considered in the management plan for maximum therapeutic effect. The following are recommended, based on current evidence :
a. Physical active interventions 
b. Physical passive interventions
c. Combined active and passive
d. Mind-body interventions 
4. Knee and hip OA
Diagnostic considerations for knee OA
1. . For knee OA, the diagnosis relies on the history and physical examination findings and is often confirmed with plain radiographs. Laboratory tests are reserved to rule out other diagnoses.  It is more common in older adults and in the obese (body mass index >30). [87, 88]
1. Imaging is not typically required. Imaging is not required for typical presentation of knee OA; however, with chronic knee pain, conventional (plain) radiographs should be utilized before other imaging modalities. Considerations of radiographic views are important for optimizing the detection of knee OA, and specifically, weight bearing and patellofemoral views are recommended. [89, 90]
2. Consider advanced imaging in some cases. For additional diagnoses, soft tissues are best imaged with diagnostic ultrasound or MRI without contrast, and bone by CT scan or MRI.  Radiographic factors for chronic knee pain in which MRI without IV contrast is usually appropriate to include [89, 90]:
a. Negative radiographs
b. Joint effusion
c. Osteochondritis dissecans
d. Loose bodies
e. History of cartilage or meniscal repair
f. Prior osseous injury (i.e., Second fracture and tibial spine avulsion)
1. Consider multiple approaches. Both active and passive,
and both physical and mind-body interventions should
be considered in the management plan. The following
are recommended, based on current evidence :
a. Physical active interventions:
b. Physical passive interventions:
Diagnostic considerations for Hip OA
1. Develop a clinical diagnosis. Hip OA commonly presents as anterior or posterior hip pain, with persistent deep groin pain that is worse with activity.  The American College of Rheumatology supports clinical diagnosis of hip OA when patients have hip pain, increased pain on internal hip rotation, and concurrent morning stiffness lasting <60 min. 
a. Patients may also have coexisting limitation of flexion with flexion less than or equal to 115° and <15° of internal rotation. 
1. First consider plain radiographs. According to the ACR Appropriateness Criteria for chronic hip pain, the first line of imaging should be plain radiographs of the hip and pelvis for most, if not all, cases. For OA of the hip, physical examination and radiographs may be better for diagnosis than MRI and have reasonable sensitivity and specificity. [92, 94]
Diagnostic considerations for Hip OA
2. Consider advanced imaging for signs of cartilage degeneration. MRI is more sensitive than plain radiographs for detecting early signs of cartilage degeneration. MRI with or without contrast may be indicated if the following are suspected and not confirmed with radiographs :
b. Labral tears
c. Pigmented villonodular synovitis or osteochromatosis
d. Arthritis of uncertain type
1. Consider multiple approaches. Both active and passive,
and both physical and mind-body interventions should
be considered in the management plan. The following
are recommended, based on current evidence6
a. Physical active interventions:
b. Physical passive interventions
Diagnostic considerations for fibromyalgia
Fibromyalgia is diagnosed primarily from a history of a
typical cluster of symptomsâ€”widespread chronic pain,
nonrestorative sleep, and fatigue (physical and/or mental)â€”
when other possible causes have been excluded. 
1. Consider multiple approaches. Both active and passive, and both physical and mind-body interventions should be considered in the management plan. The following are recommended, based on current evidence [6, 95, 96]:
a. Physical active interventions:
Exercise (aerobic and strengthening)
Advice on healthy lifestyle 
Education on the condition 
b. Physical passive interventions:
Spinal manipulation 
Myofascial release 
LLL therapy [43, 49]
c. Combined active and passive: multidisciplinary rehabilitation
d. Mind-body interventions, including CBT, mindfulness meditation, yoga, and tâ€™ai chi, qigong
The management of chronic pain has seen a dramatic shift
recently, with nonpharmacological approaches being preferred
to pharmacological, due to the opioid epidemic.
Therefore, the management of chronic pain patients is not
the domain of any one type of provider. In addition, evidence
supports the biopsychosocial approach that includes
not only multifactorial treatment approach but also a strong
emphasis on psychosocial factors, active care, self-care, and
This guideline is meant to emphasize the use of evidencebased
approaches to chronic MSK pain management that
help patients become active as soon as possible and empower
themselves to manage their pain successfully. It also
aims to encourage DCs to work collaboratively with other
providers to provide patients with the optimal resources for
successfully managing their chronic pain.
A limitation in making such recommendations is that some
treatment practices in common use may not have accumulated
the highest quality evidence. However, it is important to
give practitioners as much guidance as possible, using the
best available evidence, as Sackett first described it. 
There are factors that contribute to the relative scarcity of
high-quality evidence for nonpharmacological treatments, particularly manual therapies, for chronic pain. One is that randomized controlled trials of nonpharmacological treatments,
particularly manual therapies, usually assume a curative model.
 For example, RCTs usually test the hypothesis that a course
of spinal manipulative therapy (SMT) will result in long-term
pain reductionâ€”a curativemodelâ€”and if it does not, then SMT
is considered ineffective.  However, chronic MSK pain is not medically managed in that same curative model. Analgesics are
not expected to function like antibioticsâ€”that is, to "cure" pain after a course of treatment.Although some studies are beginning to approach the topic of chronic pain froma management, rather than curative, approach, [36, 75, 99 ]currently, the literature is still scarce on optimal treatment parameters, and future studies are important to conduct.
After our project was completed and we were preparing
this article, AHRQ published a 2020 update9 to their 2018
review,6 which had formed the foundation of our recommendations.
We found that their 2020 update did not substantively
alter our recommendations. The fact that AHRQ
saw fit to produce an update so quickly emphasizes the
importance of the topic of nonpharmacological approaches
to chronic MSK pain.
We sought to secure buy-in from the chiropractic profession
in developing this guideline by forming a large and broad-based
Delphi panel and by disseminating the preliminary recommendations very widely throughout the profession. We hope
that the consensus achieved will facilitate their use in chiropractic practice. We also hope that these evidence-based recommendations for a variety of conservative treatment
approaches to the management of common chronic MSK pain
conditions will foster collaboration between provider groups,
and thereby improve patient outcomes.
The authors thank Cathy Evans for excellence, as usual,
in coordinating the complex consensus process and ensuring
the highest response rate possible. We also thank Sheryl A.
Walters, MLS, for her expertise in the literature search and
Robert Vining, DC, DHs, for his thorough and constructive
review of the seed statements.
The Delphi panelists were an
essential part of the development of these recommendations.
We thank them for so generously donating their time and
expertise to participate:
Wayne Bennett, DC, DABCO; Craig R. Benton, DC; Charles L. Blum, DC; Gina Bonavito-Larragoite, DC, FIAMA; Michael S. Calhoun, DC, DACBSP; Wayne H. Carr, DC, CCSP, DACRB, IFMCP; Jeffrey R. Cates, DC, MS; Matthew C. Cote, DC, MS;
Monica Curruchich, DC, RN-BSN; John Curtin, MSS, DC, FACO; Vincent DeBono, DC; Mark D. Dehen, DC, FICC;
C. Michael DuPriest, PT, DPT, DC, FACO; Paul Ettlinger, DC; James E. Eubanks, MD, DC, MS; Jason T. Evans, DC,
FIACN, DIBCN, ABIME; Andrew Fogg, DC, MS, DACRB; David Folweiler, DC; Vinicius Tiepppo Francio, DC, MD; Margaret M. Freihaut, DC; William P. Gallagher, Jr., DC; Derek Golley, DC, MHA; Stephen D. Graham, PT, DPT, OCS; Jason N. Guben, BSc(N), DC; Renee Hunter, DC, RN; Brian James, MD; Jeffrey M. Johnson, DC; Yasmeen Khan, DC, MS, MA; Robert E. Klein, DC; Rick Louis LaMarche, DC; Lawrence J. Larragoite, DC, FIAMA, CFMP; William Lawson, DC, MSc, FIANM(us); Robert Leach, DC, MS, CHES; Duane T. Lowe, DC; Eric Luke, DC, MS; Ralph C. Magnuson, PT, DPT, Dip. MDT; Hans W. Mohrbeck, DC; Scott A. Mooring, DC, CCSP; Jack A. Moses, Jr, DC; Mark Mulak, DC, MBA, MS, DACRB; Marcus Nynas, DC, FICC; Juli Olson, DC, DACM; Colette Peabody, DC, MS; Mariangela Penna, DC; Roger Kevin Pringle, DC, MEd; David C. Radford, DC, MSc; John Rosa, DC, FACC, FICC; Vern Saboe, Jr, DC, FACO; Mark Sakalauskas, DC; Bruce Scott, DC; Christopher R. Sherman, DC, MPH; Scott M. Siegel, DC; Charles A. Simpson, DC, DABCO; Albert Stabile, Jr, DC, FICC, CPCP; Kevin Stemple, RPT, MBA; James P. Stupak, DC; Lisa Thomson, DC, CFMP, CME; Jason Weber, DC, DACRB; Susan Wenberg, MA, DC; John S. Weyand, DC; Clint Williamson, DC; and Morgan Young, DC.
Author Disclosure Statement
No competing financial interests exist.
A grant from the NCMIC Foundation provided partial funding for the project director, and the Clinical Compass provided funding for the project coordinator.
Address correspondence to:
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Cheryl Hawk, DC, PhD
Texas Chiropractic College
5912 Spencer Highway
Pasadena, TX 77505
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