J Alternative and Complementary Medicine 2019 (Aug 27) [Epub] ~ FULL TEXT
Patricia M. Herman, ND, PhD, Sarah E. Edgington, MA, Gery W. Ryan, PhD, and Ian D. Coulter, PhD
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,  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  and
to employers. 
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. 
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,  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.  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)  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 ) and function
using the 10-item Neck Disability Index (NDI)  for those
with CNP and the 10-item Oswestry Disability Index
(ODI)  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 ).
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,  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.  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  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 ) 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).  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. 
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
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.  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
Of the 2024 chiropractic patients with CLBP and CNP
who completed the baseline survey,  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 ) 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
Given low average pain levels (3–4 on a 0–10 scale), and
low disability (minimal to moderate for back  and mild for
neck ), 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.  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,  with acupuncture and Alexander technique
for CNP,  and with interdisciplinary pain management
for a variety of pain conditions ). 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,  long-term
care that includes ongoing patient health education,  and
care for a patient that did not report a specific complaint. 
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.  It is fairly
clear that the patients in this sample have reached a plateau
in their improvement.  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  gives weight to responses based on
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.
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.
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