Prevalence and Characteristics of Chronic Spinal Pain Patients
with Different Hopes (Treatment Goals) for Ongoing Chiropractic Care

This section is compiled by Frank M. Painter, D.C.
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FROM:   J Alternative and Complementary Medicine 2019 (Oct 1);   25 (10):   1015–1025 ~ FULL TEXT


Patricia M. Herman, ND, PhD, Sarah E. Edgington, MA, Gery W. Ryan, PhD, and Ian D. Coulter, PhD

RAND Corporation,
Santa Monica, CA.

Objectives:   The treatment goals of patients successfully using ongoing provider-based care for chronic spinal pain can help inform health policy related to this care.

Design:   Multinomial logistical hierarchical linear models were used to examine the characteristics of patients with different treatment goals for their ongoing care.

Settings/Location:   Observational data from a large national sample of patients from 125 chiropractic clinics clustered in 6 U.S. regions.

Subjects:   Patients with nonwork-injury-related nonspecific chronic low-back pain (CLBP) and chronic neck pain (CNP).

Interventions:   All were receiving ongoing chiropractic care.

Outcome measures:   Primary outcomes were patient endorsement of one of four goals for their treatment. Explanatory variables included pain characteristics, pain beliefs, goals for mobility/flexibility, demographics, and other psychological variables.

Results:   Across our sample of 1614 patients (885 with CLBP and 729 with CNP) just under one-third endorsed a treatment goal of having their pain go away permanently (cure). The rest had goals of preventing their pain from coming back (22% CLBP, 16% CNP); preventing their pain from getting worse (14% CLBP, 12% CNP); or temporarily relieving their pain (31% CLBP, 41% CNP). In univariate analysis across these goals, patients differed significantly on almost all variables. In the multinomial logistic models, a goal of cure was associated with shorter pain duration and more belief in a medical cure; a goal of preventing pain from coming back was associated with lower pain levels; and those with goals of preventing their pain from getting worse or temporarily relieving pain were similar, including in having their pain longer.

Conclusions:   Although much of health policy follows a curative model, the majority of these CLBP and CNP patients have goals of pain management (using ongoing care) rather than "cure" (care with a specific end) for their chiropractic care. This information could be useful in crafting policy for patients facing provider-based nonpharmacologic care for chronic pain.

KEYWORDS:   chiropractic care; chronic low-back pain; chronic neck pain; goals of treatment; ongoing care

From the Full-Text Article:


Over 40% of adults in the U.S. experience chronic pain, [1] often chronic spinal (back and neck) pain, [1–3] and these patients have lived with this pain for years to decades on average. [4–8] This pain is also associated with substantial comorbidity, 9 and is expensive to the health care system [10] and to employers. [11]

Although most with chronic spinal pain use medications, a substantial minority have used provider-based therapies (e.g., chiropractic, physical therapy). [9, 12] Lately several provider-based nonpharmacologic approaches (e.g., multidisciplinary rehabilitation, acupuncture, cognitive behavioral therapy, spinal manipulation) have been shown to be effective [13–20] and are now recommended as first-line treatments in clinical practice guidelines for chronic back pain. [21, 22]

Unfortunately, the ongoing provision of provider-based care for chronic spinal pain is not well addressed in health and payer policies. [23–25] Coverage is not available for all recommended nonpharmacologic therapies, and where coverage is available, patients face a variety of barriers, including high out-of-pocket expenses and other (e.g., travel, missed work) costs for every visit, visit limits, and prior authorization requirements. [24]

Given the chronic (i.e., long term) nature of chronic lowback pain (CLBP) and chronic neck pain (CNP), patient demand for some type of ongoing care, and the substantial out-of-pocket and other costs patients face in seeing these providers, policy makers could benefit from data on patients who are currently using ongoing provider-based care to manage their pain. One important component to understanding these patients’ use is to examine what they hope to get from their treatment—that is, are they looking for a ‘‘cure’’ (complete and permanent elimination of their pain, which would then end their need for treatment) or some type of management of their symptoms, which would require ongoing care. Cure is often assumed to be the goal of medical intervention and many health care policies are based on a curative model. [26, 27] On the other hand, chronic pain patients may be more interested in chronic pain management, 19 support care, [28] or maintenance care. [28, 29] This study takes advantage of data from a large sample of patients using ongoing chiropractic care for their CLBP and CNP to examine the prevalence and characteristics of patients with different goals for their care.

Materials and Methods


This study uses observational longitudinal self-report data collected from a large sample of patients in the United States using chiropractic care to treat their nonspecific CLBP and/or CNP. [4] The overall project under which these data were collected, [30, 31] and the data collection methods [32, 33] and general patient characteristics (i.e., an average duration of pain of 14 years and average time in chiropractic care of 11 years) [4] are described elsewhere. However, in brief, data were collected from October 2016 to January 2017 and used a multistage systematic stratified sampling over four levels: regions/states, metropolitan areas, chiropractic providers/ clinics, and patients. The regions and metropolitan areas were: Dallas, Texas; Minneapolis, Minnesota; Portland, Oregon; San Diego, California; Tampa, Florida; and Seneca Falls/Upstate, New York. Our goal was to recruit 20 chiropractors (clinics) per region and to gather data from 7 CLBP and 7 CNP patients per clinic.

Each clinic was provided with a short prescreening questionnaire on an iPad to offer to all patients visiting the clinic during the next 4 weeks. Patients who met prescreening criteria and provided an e-mail address were invited to the study and sent a longer screening questionnaire to establish eligibility (i.e., that they had CLBP and/or CNP defined as pain for at least 3 months before seeing the chiropractor and/or self-report of chronicity). Eligible patients provided informed consent, answered additional questions, and then were sent a series of seven additional questionnaires over the next 3 months. Participants received online gift cards for every step of participation and those who completed all questionnaires received a total of $200. This study uses a subset of the data collected from the screening and baseline questionnaires.


In this study we describe patients’ goals for ongoing care and examine the relationship between these goals and a variety of patient characteristics. Patient goals were elicited in the baseline survey using an item asking for those with only CLBP or with both CLBP and CNP, where their CLBP was worse (hereafter referred to as those with CLBP): Which of the following best describes what you hope to get from your chiropractor regarding your low-back pain? This question had four response categories, and respondents were asked to choose one: Prevent low-back pain from coming back or prevent reinjury; Prevent low-back pain from getting worse; Ease low-back pain or make low-back pain go away temporarily; and Make low-back pain go away permanently (cure). Those with only CNP or who said their CNP was worse (hereafter referred to as those with CNP) received the same question with similar response options but asking about neck pain.

We hypothesized that patients’ characteristics would differ by their goals for care. For example, patients who had their pain for less time may be more likely to believe that their pain will go away completely and to have a goal of cure. The characteristics examined included characteristics of their pain, beliefs about their pain, goals/hopes for their mobility and flexibility, demographics, and psychological variables. Characteristics of pain include baseline pain levels (pain numerical rating scale or NRS [34]) and function using the 10-item Neck Disability Index (NDI) [35] for those with CNP and the 10-item Oswestry Disability Index (ODI) [36] for those with CLBP. These measures are recommended for use in their respective populations and have substantial literature on their validity and reliability (pain NRS [37–41]; NDI [42–45]; ODI [46–48]). We also included whether a respondent had both CLBP and CNP (associated with worse outcomes49) and their reported years of pain at baseline (a potential justification for ongoing care [19]).

The dataset also included several measures of patients’ beliefs about their pain. Patients reported what their pain level would be on a 0–10 scale if they did not see their chiropractor, and whether they believed their pain was chronic. Patients also reported their level of agreement (strongly disagree to strongly agree) with statements about chronic pain, including that it will never go away, it is important to understand what causes my pain, and it is unsafe for someone with my condition to be physically active (a measure of fear avoidance [19, 50, 51]). We also measured three subscales of the 30-item version of the Survey of Pain Attitudes (SOPA-30): Perceived control over pain, appropriateness of medications, and belief in a medical cure and the responsibility of providers to find that cure. [52, 53] We used averages of 0 = very untrue to 4 = very true with scores >2 (2 = neither true nor untrue) indicating statements that are true for the respondent.

Because there has been a movement at least within providers to focus on function rather than pain, [54] all respondents were also asked to choose from four options for what they hope to get from their chiropractor regarding mobility and flexibility. These options somewhat paralleled those asked regarding pain, including one representing cure: I expect complete return to original mobility and flexibility. We included age, gender, and education as possible predictors of treatment goals since studies have found that older patients respond less favorably to treatment, [6, 55, 56] and age may be a justification for ongoing care. [19] CLBP outcomes have also been at times found to be associated with higher (Bachelor’s degree or higher) education. [57, 58]

Finally, we hypothesized that certain psychological traits and states could predict patients’ treatment goals. Selfefficacy for pain management (PSE) used the 5-item subscale of the Chronic Pain Self-Efficacy Scale [59] and averages of responses from 1 = very uncertain to 10 = very certain as to ability to accomplish each. Expectations (can effect outcomes, [60, 61] are related to hopes/treatment goals [62, 63] and are one justification for ongoing care [19]) used two items from the Credibility/Expectancy Questionnaire: how successful your chiropractor will be in reducing your pain (very or extremely successful vs. not at all), and how much improvement in pain do you expect over the next 3 months (a lot or quite a bit of improvement vs. some to no improvement). [64] Worry and anxiety are associated with worse outcomes, [51, 65] and may be related to treatment goals. We included how often patients endorsed this statement as true: I worry all the time about whether pain will end (all the time to not at all). Those who are depressed have worse outcomes, [50, 65] and may be justified to receive ongoing care. [19]

Depression was measured using the 4-item Patient-Reported Outcomes Measurement Information System-29 v2.0 depression scale for mild depression or above (scores >52.5). [66, 67] Finally, there is growing evidence that pain catastrophizing is associated with outcomes, [60, 68–70] and may affect patients’ goals for treatment. We measured catastrophizing using the sum of 0–4 scores from three items asking how often these statements are true: I worry all the time about whether the pain will end, I think the pain is never going to get any better, there is nothing I can do to reduce the intensity of the pain.

Variables for clinic (chiropractor) and region (state and metropolitan area) were used to determine whether there were differences in patients’ treatment goals by chiropractor or region.


We first presented averages and frequencies by treatment goal for the variables considered as potential predictors and examined differences by endorsed goal using one-way analysis of variance and χ2 tests, respectively.

We used multinomial logistical hierarchical linear modeling (HLM, aka multilevel modeling or mixed models [71–73]) for our analyses to account for the potential clustering of patients within clinics and regions. We set the group with the treatment goal of cure as the base outcome. Therefore, our estimated coefficients indicate the relative risks of those with each of the other treatment goal compared with those with the goal of cure.

We first ran unconditional (no predictor variables) HLM models to determine whether patients’ goals were clustered by region and/or by chiropractor/clinic. We used the Bayesian Information Criterion (BIC) fit statistic (smallest value) to choose the best unconditional model in terms of clustering variable. [74] We then added the proposed predictor variables (pain characteristics, pain beliefs, mobility/flexibility goals, demographics and psychological variables) that were found to differ significantly ( p < 0.05) across treatment goals for either condition in our univariate analyses to the best unconditional HLM to see which variables best predicted patient treatment goals.

All analyses were performed using Stata 15.1. This study was approved by the RAND Human Subjects Protection Committee.


Of the 2024 chiropractic patients with CLBP and CNP who completed the baseline survey, [4] 1,708 had nonspecific chronic low back or neck pain, and 1,614 (94.5%) of these had sufficient data to be included in our analyses — 885 with nonspecific CLBP and 729 with nonspecific CNP. Tables 1 and 2 show the means and frequencies of each of our predictor variables by treatment goals for those with CLBP and CNP, respectively. As can be seen, patients endorsing each treatment goal differed by almost all these variables for both the CLBP and CNP samples.

Table 3 shows the results of the unconditional models. As can be seen from the variance attributed to region and clinic that neither variable explained a significant proportion of the overall variance seen in the data—that is, goals did not vary by clinic and region. Since the models without clustering had the best (lowest) BIC values, our full models did not cluster by clinic or region.

Tables 4 and 5 show the results of the full models for CLBP and CNP and including all the predictor variables that were found to be significantly different across treatment goal groups for at least one condition in our univariate analyses (Tables 1 and 2). As can be seen, when we control for all variables fewer show significant differences across groups.

Compared with those with other treatment goals, patients with a goal of cure tended to be less likely to believe their pain would never go away, and more likely to believe it is important to understand the cause of their pain, to have a goal for their mobility and flexibility of a return to original levels, and to believe in a medical cure and the responsibility of providers to find that cure. They also have had their pain for a shorter period of time than those with other treatment goals. Nevertheless, roughly half of this group has had their pain for at least 5 years and a third for 10 years or more implying that their goal of cure has been elusive.

The rest (majority) of the patients in our sample had goals relating to different types of pain management. One group endorsed the goal of preventing their pain from coming back or preventing reinjury; a goal which implies that they had accepted where they were and did not want their previous pain levels to return. This group did have significantly lower pain levels than those with other goals. Another group, the smallest group (12%–14% of the samples), endorsed the goal of preventing their pain from getting worse. A related goal of learning how to ensure their mobility and flexibility did not get worse was 7–12 times more likely in this group than in those with a goal of cure. The last group is the largest for CNP (41%) and equally as large as those with a goal of cure (31%) for CLBP. They endorse a goal for treatment of easing their pain or temporarily relieving it. In many ways this group is similar to those with the goal of preventing their pain from getting worse, but that similarity can differ by condition. For example, those with CNP over 5 years were three to four times more likely to have either of these goals than a goal of cure, but those with longer-term CLBP were only more likely to have a goal of easing their pain.


Patients using chiropractic care for their CLBP and CNP have different treatment goals for that care. Just under onethird of those with either type of pain report a goal of having their pain go away permanently, a goal we called ‘‘cure.’’ Given the average amount of time these patients have lived with their pain (14 years [4]) this low focus on cure should not be surprising. The majority, on the other hand, report other goals related to the management of their symptoms. Many health care and payer policies and clinical trial protocols for provider-based therapies are geared toward cure. That is, it will take X number of treatments and then you should be done—that is, be cured. Care beyond the initial course of treatment can require documentation of continued improvement. [19, 75–78] Others have argued that continued care would require clinical deterioration with treatment withdrawal. [19, 28] However, given these patients’ managementrelated goals, either requirement may be counter to the role of medicine to relieve suffering and even unethical. We may need to find and support some ongoing care system that better matches these chronic spinal pain patients’ goals for their care.

Given low average pain levels (3–4 on a 0–10 scale), and low disability (minimal to moderate for back [36] and mild for neck [44]), and given patient estimates that their pain would be twice as high if they did not see their chiropractor, it could be said that these patients are all to some extent managing their pain, and fairly well, with ongoing chiropractic care. Another study of these same patients showed that they generally hold steady at these pain and disability levels for the next 3 months. [79] Given this, continuous improvement may not be a reasonable criterion for continued care. Several studies have found pain management self-efficacy goes up with treatment (with a mind–body program in older adults with CLBP, [80] with acupuncture and Alexander technique for CNP, [81] and with interdisciplinary pain management for a variety of pain conditions [82]). Our scores for the PSE (7– 8 on a 1–10 scale) are higher than all pretreatment scores in these studies but are well in line with their post-treatment scores. This would be expected since our sample has all been under treatment, often for years. These high PSE scores are also in line with average scores tending toward truth (i.e., >2) for their having control over their pain.

Various authors have used different names for ongoing chiropractic pain management. One term, maintenance care, has been particularly vilified as a negative form of ongoing care. The concern here seems to be that patients return for ongoing chiropractic care because of clinician dependence, lowered self-efficacy, or heightened fear. [19, 83] It is true that some patients in our sample worry about their pain to a moderate to great degree, but the percentage with this level of worry was low (between 12% and 25%), and as discussed above, their level of pain management self-efficacy was generally high.

There also seems to be some variation in how maintenance care is defined. It has been defined variously as elective care given at regular intervals designed to maintain maximum health and promote optimal function, [28] long-term care that includes ongoing patient health education, [84] and care for a patient that did not report a specific complaint. [85] One group of chiropractors in Denmark has done the most work on the concept of maintenance care. They define it as care for nonacute patients with the purpose of preventing recurrence of episodic conditions and/or maintaining a desired level of function. [86, 87] Under this definition at least two of our groups (i.e., with goals of preventing their pain from getting worse or preventing their pain from coming back) might be experiencing maintenance care.

Another term, support care, has been used to describe necessary care for patients who have reached maximum therapeutic benefit (their improvement has plateaued), but for whom therapeutic withdrawal has led to deterioration and failure to sustain previous therapeutic gains. [28] It is fairly clear that the patients in this sample have reached a plateau in their improvement. [79] However, it is unclear whether therapeutic withdrawal, years of lived experience that included various withdrawals, or their chiropractor was the source of their estimates of what their pain would be if they did not see their chiropractor. They definitely believe that their previous therapeutic gains would deteriorate without continued care, so these patients could also be considered to be receiving support care.

This study benefits from extensive data collected from a large sample of patients with chronic nonspecific spinal pain. However, it is not without limitations. We offered patients the four options for treatment goals used in this study. We did allow respondents to write in an ‘‘other’’ goal. However, only two each in the CLBP and CNP samples did, and these patients were excluded from our analysis sample. Nevertheless, patients may have stated their treatment goals differently. It would have also been interesting to know how long they held these goals and whether they were salient during their treatment decisions. Given the concern that patients utilize ongoing chiropractic care due to reasons such as clinician dependence or coercion for provider financial gain, it would have been helpful to have a measure of whether patients’ responses were based on what they were told by their chiropractor versus their lived experience. Nevertheless, their having lived with their pain condition for an average of 14 years [4] gives weight to responses based on lived experience.


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.

Author Disclosure Statement

No competing financial interests exist.

Funding Information

The data for this study was collected under a grant funded by the National Center for Complementary and Integrative Health Grant No. 1U19AT007912-01. The analyses of these data in this study was funded by National Chiropractic Mutual Insurance Company Foundation.


  1. Tsang A, Von Korff M, Lee S, et al.
    Common chronic pain conditions in developed and developing countries:
    Gender and age differences and comorbidity with depressionanxiety disorders.
    J Pain 2008;9:883–891.

  2. Institute of Medicine.
    Relieving Pain in America: A Blueprint for Transforming Prevention,
    Care, Education, and Research

    Washington, DC: The National Academies Press, 2011.

  3. Johannes CB, Le TK, Zhou X, et al.
    The prevalence of chronic pain in United States adults: Results of an Internetbased survey.
    J Pain 2010;11:1230–1239.

  4. Herman P, Hilton L, Sorbero ME, et al
    Characteristics of Chiropractic Patients Being Treated for Chronic Low Back and Neck Pain
    J Manipulative Physiol Ther. 2018; 41: 445–455

  5. Knauer SR, Freburger JK, Carey TS.
    Chronic low back pain among older adults: A population-based perspective.
    J Aging Health 2010;22:1213–1234.

  6. Verkerk K, Luijsterburg P, Heymans M, et al.
    Prognosis and course of pain in patients with chronic non-specific low back pain:
    A 1-year follow-up cohort study.
    Eur J Pain 2015;19:1101–1110.

  7. Evans, R, Bronfort, G, Nelson, B, and Goldsmith, CH.
    Two-year Follow-up of a Randomized Clinical Trial of Spinal Manipulation and
    Two Types of Exercise for Patients With Chronic Neck Pain

    Spine (Phila Pa 1976). 2002 (Nov 1); 27 (21): 2383–2389

  8. Niemisto L, Lahtinen-Suopanki T, Rissanen P, Lindgren K-A, Sarna S, Hurri H.
    A Randomized Trial of Combined Manipulation, Stabilizing Exercises,
    and Physician Consultation Compared to Physician Consultation Alone
    for Chronic Low Back Pain

    Spine (Phila Pa 1976) 2003 (Oct 1); 28 (19): 2185–2191

  9. Gore M, Sadosky A, Stacey BR, Tai KS, Leslie D.
    The Burden of Chronic Low Back Pain: Clinical Comorbidities, Treatment Patterns,
    and Health Care Costs in Usual Care Settings

    Spine (Phila Pa 1976). 2012 (May 15); 37 (11): E668–677

  10. Martin BI. Deyo R. Mirza SK, et al.
    Expenditures and Health Status Among Adults With Back and Neck Problems
    JAMA 2008 (Feb 13); 299 (6): 656–664

  11. Stewart WF, Ricci JA, Chee E, Morganstein D, Lipton R.
    Lost Productive Time and Cost Due to Common Pain Conditions in the US Workforce
    JAMA 2003 (Nov 12); 290 (18): 2443–2454

  12. Ivanova JI, Birnbaum HG, Schiller M, et al.
    Real-world practice patterns, health-care utilization, and costs in patients with low back pain:
    The long road to guidelineconcordant care.
    Spine J 2011;11:622–632.

  13. Cramer H, Lauche R, Haller H, Dobos G.
    A systematic review and meta-analysis of yoga for low back pain.
    Clin J Pain 2013;29:450–460.

  14. Furlan AD, Giraldo M, Baskwill A, et al.
    Massage for lowback pain.
    Cochrane Database Syst Rev 2015;9:CD001929.

  15. Henschke N, Ostelo R, van Tulder MW, et al.
    Behavioural treatment for chronic low-back pain.
    Cochrane Database Syst Rev 2010;7:CD002014.

  16. Kamper SJ, Apeldoorn A, Chiarotto A, et al.
    Multidisciplinary biopsychosocial rehabilitation for chronic low back pain:
    Cochrane systematic review and meta-analysis.
    BMJ 2015;350:h444.

  17. Vickers AJ, Cronin AM, Maschino AC, et al.
    Acupuncture for Chronic Pain: Individual Patient Data Meta-analysis
    Archives of Internal Medicine 2012 (Oct 22); 172 (19): 1444–1453

  18. Chou R, Atlas SJ, Stanos SP, Rosenquist RW.
    Nonsurgical Interventional Therapies for Low Back Pain:
    A Review of the Evidence for an American Pain Society
    Clinical Practice Guideline

    Spine (Phila Pa 1976). 2009 (May 1); 34 (10): 1078–1093

  19. Farabaugh RJ, Dehen MD, Hawk C.
    Management of Chronic Spine-Related Conditions:
    Consensus Recommendations of a Multidisciplinary Panel

    J Manipulative Physiol Ther 2010 (Sep); 33 (7): 484–492

  20. Skelly AC, Chou R, Dettori JR, et al.
    Noninvasive Nonpharmacological Treatment for Chronic Pain:
    A Systematic Review

    Comparative Effectiveness Review no. 209
    Agency for Healthcare Research and Quality (US), Rockville (MD) (2018)

  21. Qaseem A, Wilt TJ, McLean RM, Forciea MA;
    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

  22. The Diagnosis and Treatment of Low Back Pain Work Group.
    VA/DoD Clinical Practice Guideline for Diagnosis and Treatment of Low Back Pain
    Washington, DC: The Office of Quality, Safety and Value, VA, &
    Office of Evidence Based Practice, U.S. Army MedicalCommand, 2017, Version 2.0.

  23. Goertz CM, George SZ.
    Insurer Coverage of Nonpharmacological Treatments for Low Back Pain-Time for a Change
    JAMA Netw Open. 2018 (Oct 5);   1 (6):   e183037

  24. Heyward J , Jones CM , Compton WM , et al .
    Coverage of Nonpharmacologic Treatments for Low Back Pain Among US Public and Private Insurer
    JAMA Network Open 2018 (Oct 5); 1 (6): e183044

  25. Schatman ME.
    The role of the health insurance industry in perpetuating suboptimal pain management.
    Pain Med 2011; 12:415–426.

  26. Gonen JS.
    Neither prevention nor cure: Managed care for women with chronic conditions.
    Womens Health Issues 1999;9:68S–78S.

  27. Bishai D, Paina L, Li Q, et al.
    Advancing the application of systems thinking in health: Why cure crowds out prevention.
    Health Res Policy Syst 2014;12:28.

  28. Anderson-Peacock, E, Blouin, JS, Bryans, R et al.
    Chiropractic Clinical Practice Guideline: Evidence-based
    Treatment of Adult Neck Pain Not Due to Whiplash

    J Canadian Chiro Assoc 2005 (Sep); 49 (3): 158–209

  29. Sandnes KF, Bjornstad C, Leboeuf-Yde C, Hestbaek L:
    The Nordic Maintenance Care Program - Time Intervals Between Treatments of Patients
    With Low Back Pain: How Close and Who Decides?

    Chiropractic & Osteopathy 2010 (Mar 8);   18:   5

  30. Coulter, ID, Herman, PM, Ryan, GW, Hays, RD, Hilton, LG, and Whitley, MD.
    Researching the Appropriateness of Care in the Complementary and Integrative Health Professions: Part 1
    J Manipulative Physiol Ther. 2018 (Nov);   41 (9):   800–806

  31. Coulter ID, Herman PM, Ryan GW, et al.
    The challenge of determining appropriate care in the era of patient-centered care and rising health care costs.
    J Health Serv Res Policy 2019;24:201–206.

  32. Whitley, MD, Coulter, ID, Ryan, GW, Hays, RD, Sherbourne, C, and Herman, PM.
    Researching the Appropriateness of Care in the Complementary and Integrative Health Professions Part 3:
    Designing Instruments With Patient Input

    J Manipulative Physiol Ther. 2019 (Jun);   42 (5):   307–318

  33. Coulter, ID, Aliyev, G, Whitley, MD et al.
    Researching the Appropriateness of Care in the Complementary and Integrative Health Professions Part 4:
    Putting Practice Back Into Evidence-based Practice by Recruiting Clinics and Patients

    J Manipulative Physiol Ther. 2019 (Jun);   42 (5):   319–326

  34. Huskisson E.
    Measurement of pain.
    Lancet 1974;304: 1127–1131.

  35. Vernon H, Mior S.
    The Neck Disability Index: A Study of Reliability and Validity
    J Manipulative Physiol Ther 1991 (Sep); 14 (7): 409–415

  36. Fairbank J, Couper J, Davies J, O’Brien J.
    The Oswestry low back pain disability questionnaire.
    Physiotherapy 1980; 66:271–273.

  37. Bijur PE, Latimer CT, Gallagher EJ.
    Validation of a verbally administered numerical rating scale of acute pain for use
    in the emergency department.
    Acad Emerg Med 2003; 10:390–392.

  38. Childs JD, Piva SR, Fritz JM.
    Responsiveness of the numeric pain rating scale in patients with low back pain.
    Spine (Phila Pa 1976) 2005;30:1331.

  39. Downie W, Leatham P, Rhind V, et al.
    Studies with pain rating scales.
    Ann Rheum Dis 1978;37:378–381.

  40. Paice JA, Cohen FL.
    Validity of a verbally administered numeric rating scale to measure cancer pain intensity.
    Cancer Nurs 1997;20:88–93.

  41. Salaffi F, Stancati A, Silvestri CA, et al.
    Minimal clinically important changes in chronic musculoskeletal pain intensity measured on
    a numerical rating scale.
    Eur J Pain 2004; 8:283–291.

  42. Cleland JA, Fritz JM, Whitman JM, Palmer JA.
    The reliability and construct validity of the Neck Disability Index and patient specific
    functional scale in patients with cervical radiculopathy.
    Spine (Phila Pa 1976) 2006;31:598–602.

  43. McCarthy MJ, Grevitt MP, Silcocks P, Hobbs G.
    The Reliability of the Vernon and Mior Neck Disability Index, and its Validity
    Compared With the Short Form-36 Health Survey Questionnaire

    European Spine Journal 2007 (Dec); 16 (12): 2111–2117

  44. Vernon H.
    The Neck Disability Index: State-of-the-Art, 1991-2008
    J Manipulative Physiol Ther 2008 (Sep); 31 (7): 491–502

  45. Wheeler AH, Goolkasian P, Baird AC, Darden BV.
    Development of the Neck Pain and Disability Scale: Item analysis, face, and criterion-related validity.
    Spine (Phila Pa 1976) 1999;24:1290.

  46. Gronblad M, Hupli M, Wennerstrand P, et al.
    Intercorrelation and test-retest reliability of the pain disability index (PDI) and the Oswestry disability
    questionnaire (ODQ) and their correlation with pain intensity in low back pain patients.
    Clin J Pain 1993;9:189–195.

  47. Fisher K, Johnston M.
    Validation of the Oswestry low back pain disability questionnaire, its sensitivity as a measure of
    change following treatment and its relationship with other aspects of the chronic pain experience.
    Physiother Theory Pract 1997;13:67–80.

  48. Davidson M, Keating JL.
    A Comparison of Five Low Back Disability Questionnaires:
    Reliability and Responsiveness

    Physical Therapy 2002 (Jan); 82 (1): 8–24

  49. Schellingerhout JM, Verhagen AP, Heymans MW, et al.
    Which subgroups of patients with non-specific neck pain are more likely to benefit from spinal manipulation
    therapy, physiotherapy, or usual care?
    Pain 2008;139:670–680.

  50. Moffett JAK, Carr J, Howarth E.
    High fear-avoiders of physical activity benefit from an exercise program for patients with back pain.
    Spine (Phila Pa 1976) 2004;29:1167–1172.

  51. Jensen OK, Nielsen CV, Stengaard-Pedersen K.
    One-year prognosis in sick-listed low back pain patients with and without radiculopathy.
    Prognostic factors influencing pain and disability.
    Spine J 2010;10:659–675.

  52. Jensen MP, Karoly P, Huger R.
    The development and preliminary validation of an instrument to assess patients’ attitudes toward pain.
    J Psychosom Res 1987;31:393–400.

  53. Tait RC, Chibnall JT.
    Development of a brief version of the Survey of Pain Attitudes.
    Pain 1997;70:229–235.

  54. Henry SG, Bell RA, Fenton JJ, Kravitz RL.
    Goals of chronic pain management: Do patients and primary care physicians agree and does it matter?
    Clin J Pain 2017;33: 955–961.

  55. Cook CE, Learman KE, O’Halloran BJ, et al.
    Which prognostic factors for low back pain are generic predictors of outcome across a range of recovery domains?
    Phys Ther 2013;93:32–40.

  56. Underwood M, Morton V, Farrin A, Team UBT.
    Do baseline characteristics predict response to treatment for low back pain?
    Secondary analysis of the UK BEAM dataset [ISRCTN32683578].
    Rheumatology 2007;46:1297–1302.

  57. Niemisto L, Sarna S, Lahtinen-Suopanki T, et al.
    Predictive factors for 1-year outcome of chronic low back pain following manipulation,
    stabilizing exercises, and physician consultation or physician consultation alone.
    J Rehabil Med 2004;36:104–109.

  58. Dionne C, Von Korff M, Koepsell T, et al.
    Formal education and back pain: A review.
    J Epidemiol Community Health 2001;55:455–468.

  59. Anderson KO, Dowds BN, Pelletz RE, et al.
    Development and initial validation of a scale to measure selfefficacy beliefs in patients with chronic pain.
    Pain 1995; 63:77–83.

  60. Smeets R, Beelen S, Goossens M, et al.
    Chapter 7: Treatment expectancy and credibility are associated with the outcome of both physical and
    cognitive-behavioral treatment in chronic low back pain. In: Smeets R, ed.
    Active Rehabilitation for Chronic Low Back Pain: Cognitive-Behavioral, Physical, or Both?
    Eindhoven: Maastricht University, 2008:138–160.

  61. Eaves ER, Sherman KJ, Ritenbaugh C, Hsu C, Nichter M, Turner JA, et al.
    A Qualitative Study of Changes in Expectations Over Time Among Patients with
    Chronic Low Back Pain Seeking Four CAM Therapies

    BMC Complement Altern Med. 2015 (Feb 5); 15: 12

  62. Hsu C, Sherman KJ, Eaves ER, et al.
    New perspectives on patient expectations of treatment outcomes: Results from qualitative interviews
    with patients seeking complementary and alternative medicine treatments for chronic low back pain.
    BMC Complement Altern Med 2014;14:276.

  63. Eaves ER, Ritenbaugh C, Nichter M, et al.
    Modes of hoping: Understanding hope and expectation in the context of a clinical trial of
    complementary and alternative medicine for chronic pain.
    Explore (NY) 2014;10:225–232.

  64. Devilly GJ, Borkovec TD.
    Psychometric properties of the credibility/expectancy questionnaire.
    J Behav Ther Exp Psychiatry 2000;31:73–86.

  65. Smeets RJ, Maher CG, Nicholas MK, et al.
    Do psychological characteristics predict response to exercise and advice for subacute low back pain?
    Arthritis Care Res (Hoboken) 2009;61:1202–1209.

  66. Health Measures.
    PROMIS Adult Profile Scoring Manual.
    Evanston, IL: Northwestern University, 2019.

  67. Amtmann D, Kim J, Chung H, et al.
    Comparing CESD-10, PHQ-9, and PROMIS depression instruments in individuals with multiple sclerosis.
    Rehabil Psychol 2014;59:220.

  68. Hill JC, Lewis M, Sim J, et al.
    Predictors of poor outcome in patients with neck pain treated by physical therapy.
    Clin J Pain 2007;23:683–690.

  69. Smeets RJ, Vlaeyen JW, Kester AD, Knottnerus JA.
    Reduction of pain catastrophizing mediates the outcome of both physical and
    cognitive-behavioral treatment in chronic low back pain.
    J Pain 2006;7:261–271.

  70. van der Windt DA, Kuijpers T, Jellema P, et al.
    Do psychological factors predict outcome in both low-back pain and shoulder pain?
    Ann Rheum Dis 2007;66:313–319.

  71. Heo M, Faith MS, Mott JW, et al.
    Hierarchical linear models for the development of growth curves:
    An example with body mass index in overweight/obese adults.
    Stat Med 2003;22:1911–1942.

  72. Raudenbush SW, Bryk AS.
    Hierarchical Linear Models: Applications and Data Analysis Methods. 2nd ed.
    Thousand Oaks, CA: Sage Publications, 2002.

  73. Singer JD.
    Using SAS PROC MIXED to fit multilevel models, hierarchical models, and individual growth curve models.
    J Educ Behav Stat 1998;24:323–355.

  74. Whittaker TA, Furlow CF.
    The comparison of model selection criteria when selecting among competing hierarchical linear models.
    J Mod Appl Stat Methods 2009;8:15.

  75. Colorado Division of Workers’ Compensation.
    Low Back Pain Medical Treatment Guidelines
    Denver, CO: Colorado Division of Workers’ Compensation, 2014: 112.

  76. Colorado Division of Workers’ Compensation.
    Cervical Spine Injury Medical Treatment Guidelines
    Denver, CO: Colorado Division of Workers’ Compensation, 2014:96.

  77. Globe, G, Farabaugh, RJ, Hawk, C et al.
    Clinical Practice Guideline: Chiropractic Care for Low Back Pain
    J Manipulative Physiol Ther. 2016 (Jan); 39 (1): 1–22

  78. Globe GA, Morris CE, Whalen WM, et al.
    Chiropractic management of low back disorders: Report from a consensus process.
    J Manipulative Physiol Ther 2008;31: 651–658.

  79. Hays RD, Spritzer KL, Sherbourne CD, Ryan GW, Coulter ID.
    Group and Individual-level Change on Health-related Quality of Life
    in Chiropractic Patients With Chronic Low Back or Neck Pain

    Spine (Phila Pa 1976) 2019 (May 1);   44 (9):   647–651

  80. Morone NE, Greco CM, Moore CG, et al.
    A mind-body program for older adults with chronic low back pain: A randomized clinical trial.
    JAMA Intern Med 2016;176: 329–337.

  81. MacPherson H.
    Alexander technique lessons or acupuncture sessions for persons with chronic neck pain.
    Ann Intern Med 2016;164:376.

  82. Gagnon CM, Scholten P, Atchison J.
    Multidimensional patient impression of change following interdisciplinary pain management.
    Pain Pract 2018;18:997–1010.

  83. Gliedt JA, Schneider MJ, Evans MW, King J, Eubanks JE.
    The Biopsychosocial Model and Chiropractic: A Commentary with Recommendations
    for the Chiropractic Profession

    Chiropractic & Manual Therapies 2017 (Jun 7); 25: 16

  84. Jamison JR.
    Health Information and Promotion in Chiropractic Clinics
    J Manipulative Physiol Ther. 2002 (May);   25 (4):   240–245

  85. Stevens G, Campeanu M, Sorrento AT, et al.
    Retrospective demographic analysis of patients seeking care at a free university chiropractic clinic.
    J Chiropr Med 2016; 15:19–26.

  86. Myburgh C, Brandborg-Olsen D, Albert H, Hestbaek L.
    The Nordic Maintenance Care Program: What Is Maintenance Care?
    Interview Based Survey of Danish Chiropractors

    Chiropractic & Manual Therapies 2013 (Aug 20); 21: 27

  87. Hansen SF, Laursen ALS, Jensen TS, Leboeuf-Yde C, L H.
    The Nordic Maintenance Care Program: What Are the Indications For Maintenance Care
    In Patients With Low Back Pain? A Survey of the Members of the
    Danish Chiropractors' Association

    Chiropractic & Osteopathy 2010 (Sep 1); 18: 25




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