JACM

THE JOURNAL OF ALTERNATIVE AND COMPLEMENTARY MEDICINE

Volume 26, Number 10, 2020, pp. 884–901
Mary Ann Liebert, Inc.
DOI: 10.1089/acm.2020.0181

ORIGINAL ARTICLES

Best Practices for Chiropractic Management

of Patients with Chronic Musculoskeletal Pain:
A Clinical Practice Guideline
Cheryl Hawk, DC, PhD,1 Wayne Whalen, DC, BSN,2 Ronald J. Farabaugh, DC,3
Clinton J. Daniels, DC, MS,4 Amy L. Minkalis, DC, MS,5 David N. Taylor, DC,6
Derek Anderson, PhD,4 Kristian Anderson, DC, MS,7 Louis S. Crivelli, DC, MS,8
Morgan Cark, DC,9 Elizabeth Barlow,10 David Paris, DC,11
Richard Sarnat, MD,3 and John Weeks12

Abstract
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. Recommenda-
tions 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 be-
havior 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

1
Texas Chiropractic College, Pasadena, TX, USA.
2
Private Practice, Santee, CA, USA.
3
Advanced Medicine Integration Group, L.P., Columbus, OH, USA.
4
VA Puget Sound Health Care System, Tacoma, WA, USA.
5
Palmer Center for Chiropractic Research, Davenport, IA, USA.
6
Texas Chiropractic College, Pasadena, TX, USA.
7
Private Practice, Grand Forks, ND, USA.
8
Private Practice, Greenbelt, MD, USA.
9
Private Practice, Eureka, CA, USA.
10
Texas Chiropractic College, Pasadena, TX, USA.
11
VA Northern CA Health Care System, Redding, CA, USA.
12
Seattle, WA, USA.
ª Cheryl Hawk et al. 2020; Published by Mary Ann Liebert, Inc. This Open Access article is distributed under the terms of
the Creative Commons License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution,
and reproduction in any medium, provided the original work is properly cited.

884
CHRONIC MUSCULOSKELETAL PAIN GUIDELINE 885

planning and implementation, and concurrent management and referral. Appropriate referral and coman-
agement 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 collabo-
ration between provider groups, and thereby improve patient outcomes.

Keywords: chronic pain, chronic musculoskeletal pain, spinal manipulation, chiropractic, clinical practice guideline

Introduction proaches other than spinal manipulation, or may not directly

employ them with patients. It is important that all health care
P ain 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 2013–2014.1
providers become familiar with evidence-based approaches,
within a biopsychosocial model, to help patients manage
chronic pain. This is important whether the provider directly
At least 70 million U.S. adults have chronic pain.1,2 Opioid employs such approaches, refers the patient to other pro-
use has risen along with the increase in pain prevalence.1 viders who do, or advises the patient on self-care activities.
Visits to health care providers decreased slightly within this In response to the opioid epidemic, nonpharmacological
same time period, perhaps suggesting that people tend to approaches to chronic pain management are expected to
manage pain with medications rather than provider-based become increasingly legitimized.12 Because the public ex-
nonpharmacological approaches.1 pects Doctors of Chiropractics (DCs) to use such therapies
Authoritative groups, including the Agency for Healthcare more than medical physicians do, they may be more likely
Research and Quality (AHRQ) and the American College of to seek out chiropractic practitioners for these therapies.13
Physicians (ACP), have recommended that chronic back pain Thus it is important that DCs become familiar with these
and other chronic musculoskeletal (MSK) pain be treated approaches within the context of the biopsychosocial model.
initially through nonpharmacological approaches.3 Currently, although there are CPGs addressing a chiropractic
Some experts recommend viewing chronic pain as ‘‘a approach to LBP,14,15 neck pain,16,17 and headaches18
disease entity in itself, rather than merely a symptom of separately, there is not a single CPG addressing non-
another condition.’’4 The International Classification of pharmacological approaches to more than one type of MSK
Disease 11 (ICD-11) has created a new category of ‘‘chronic pain as a primary complaint. The purpose of this project
pain,’’ with the following disorders included: (1) chronic was therefore to develop such a guideline.
primary pain, which includes disorders such as fibromyalgia
or back pain, which is not otherwise classified; (2) chronic Methods
cancer pain; (3) chronic post-traumatic and postsurgical
The purpose of the project was to develop an evidence-
pain; (4) chronic neuropathic pain; (5) chronic headache and
based CPG through a broad-based consensus process on best
orofacial pain, which includes temporomandibular joint
practices for chiropractic management of patients with
pain; (6) chronic visceral pain; and (7) chronic MSK pain.5,6
chronic MSK pain.
The AHRQ, Institute of Medicine (IOM), and the Na-
The development of recommendations followed steps
tional Pain Strategy Report6–8 recommend that chronic pain
developed and tested in previous projects15,17,19:
be addressed through the biopsychosocial model, rather than
solely through the conventional biomedical model. This  Establish a Steering Committee (SC) to perform the
includes an emphasis on nonpharmacological and self- core project functions of examining the evidence, de-
management approaches, with pharmacological approaches veloping recommendations based on the best available
being secondary.3,6–8 evidence, and integrating the Delphi panelists’ ratings
The 2018 and 2020 AHRQ systematic reviews recom- and contributions into the recommendations until a
mend noninvasive, nonpharmacological approaches to consensus is reached.
several of the most common chronic MSK pain conditions:  Examine the most current CPGs and/or systematic re-
chronic LBP (CLBP), chronic neck pain, osteoarthritis views related to each aspect of management.
(OA), fibromyalgia, and chronic tension headache.6,9 A  Identify gaps in the CPG(s) and/or systematic reviews
2018 review in the Journal of Family Practice organized that may form barriers to best practices.
its evidence-based recommendations for common chronic  Perform targeted literature searches for the highest
pain conditions by the treatment approach: (1) exercise- available evidence on the gap topics.
based therapies such as yoga and t’ai chi; (2) mind–body  Make recommendations on chiropractic management,
therapies such as Cognitive Behavioral Therapy (CBT) and based on the best available evidence.
mindfulness-based meditation; and (3) complementary  Conduct a Delphi consensus process with a panel of
modalities such as acupuncture and spinal manipulation.10 practitioners, faculty, and researchers experienced in
The purpose of this project was to develop a clinical chronic MSK pain management.
practice guideline (CPG) for chiropractic management of  Gather additional feedback from a public posting of the
chronic MSK pain. The chiropractic profession’s primary consensus statements.15
approach to patient care has traditionally been spinal ma-
Human subject considerations
nipulation, but its scope of practice includes many other
nonpharmacological approaches.11 Like medical physicians, The lead institution’s Institutional Review Board ap-
chiropractors may not be familiar with many of these ap- proved the project before it started. All Delphi panelists
886 HAWK ET AL.

participated voluntarily and without compensation; they Exclusion criteria:

signed an informed consent and agreed to be acknowledged
1. Nonrelevant (e.g., addressed interventions outside the
by name in any publication only if they signed a consent to
scope of U.S. chiropractors or addressed risk factors, but
be acknowledged.
not interventions; did not address chronic MSK pain).
2. Addressed only one type of MSK pain as a primary
Project SC complaint (e.g., only back pain) and/or one type of
Of the 11-member SC, 8 were DCs. All of these have intervention (e.g., only CBT), to have a comprehensive
extensive experience in chiropractic management of chronic seed document to base our recommendations.
MSK pain and/or knowledge of the evidence base on clin- 3. Included in another systematic review.
ical care of MSK pain. All have held or currently hold Search 2 inclusion criteria
leadership positions in chiropractic professional organiza-
tions, education and/or research. Three of the DCs are 1. Guidelines related to spinal manipulation and/or
members of the Scientific Council of the Clinical Compass manual therapy.
(Council on Chiropractic Guidelines and Practice Para- 2. Published 2016–2019.
meters. Three of the DCs work full time at the Veterans 3. English language.
Health Administration (VA); two are full-time faculty at Exclusion criteria:
chiropractic institutions; and one DC is cross-trained as a
registered nurse (RN). The project director is a DC with a 1. Nonrelevant (not CPGs; outside chiropractic scope of
PhD in Preventive Medicine and is also a Certified Health practice or not related to chronic MSK pain).
Education Specialist. One SC member is a medical physi-
cian (MD) with many years of experience with chronic pain
management; one is a psychologist (PhD) who works with Second stage search. First, we drafted preliminary
chronic pain patients in the VA; and one is a representative evidence-based recommendations based on the results of the
for laypeople and also a journal editor with extensive ex- initial search. In cases where recommendations for specific
perience with complementary health care. The SC was re- modalities or procedures were absent due to sparse evidence
sponsible for identifying, reviewing, and evaluating the for procedures commonly used in chiropractic practice
evidence underlying the development of the initial seed (as identified by the current Practice Analysis of Chir-
statements, modifying these statements based on the Delphi opractic11), we did a targeted search of the published literature
panelists’ comments, and writing the final article. from the end date of the source systematic review or guideline
through 2019. We included guidelines, systematic reviews,
Literature search randomized controlled trials, or outcome cohort studies.
The literature search focused on the evidence base for
nonpharmacological, nonsurgical interventions for chronic Evaluation of the quality of the evidence
MSK pain. A health sciences librarian, working with the SC,
conducted the literature search in two stages. The databases We then evaluated the quality of the articles identified in
we searched were Cochrane Database of Systematic Re- our searches. We evaluated CPGs using the Appraisal of
views and PubMed/Medline, because it is unlikely that Guidelines for Research & Evaluation instrument (AGREE)
higher levels of evidence would be found in other databases, Global Rating Scale (Table 1).21 We evaluated systematic
but not in these. The search strategy may be accessed in reviews, RCTs, and cohort studies investigating treatments
Supplementary Data S1. In addition, we used reference using modified SIGN (Scottish Intercollegiate Guideline
tracking and consulted topic experts on the SC to ensure that Network) checklists, which have been used in other studies
relevant articles were not missed. by our team.22–24 The SIGN checklist rates the studies as
‘‘high quality, low risk of bias,’’ ‘‘acceptable quality, mod-
erate risk of bias,’’ ‘‘low quality, high risk of bias,’’ or
First stage search. To identify a ‘‘seed’’ document or ‘‘unacceptable’’ quality. See Tables 2–4 for details of scoring.
documents on which to base development of the initial set of We did not assess the quality of other types of studies, simply
recommendations, we conducted two searches: (1) identify identifying their design and categorizing them as ‘‘lower
the most recent systematic reviews for nonpharmacological level.’’ At least two investigators rated each study and dis-
treatment of chronic MSK pain and (2) identify CPGs spe- cussed differences in ratings until they reached agreement.
cific to manipulation and manual therapy. We restricted the We used the GRADE (Grading of Recommendations
searches to recent literature rather than doing a compre- Assessment, Development, and Evaluation) system to assess
hensive search, since CPGs should be based on the most the overall quality of the evidence.25,* Table 5 summarizes
current literature, and current systematic reviews were ex- GRADE.25 At least two investigators performed the GRADE
pected to cover earlier studies.20 assessment independently. If they disagreed, they discussed
Search 1 inclusion criteria: the assessment and used the majority opinion.
1. Published January 1, 2017, to August 15, 2019.
2. English language.
3. Addressed nondrug, nonsurgical treatment of chronic
MSK pain in adults. *www.essentialevidenceplus.com/product/ebm_loe.cfm?show=
4. Systematic reviews/meta-analyses. grade.
 Table 1. AGREE Global Rating Scale Table 3. Cohort Study Modified SIGN Checklist
Each item is rated on a 1–7 scale from lowest (1) to highest Item Yes/noa
(7) quality; maximum score = 49. Quality assessed as
follows: 1 Addresses an appropriate and clearly focused
 Divide total score by 7 for average score. question.
 High quality: average 6–7; acceptable quality: average 2 Groups are similar, except for factor of interest.
4–5; unacceptable quality: <4 3 Number of people who declined enrollment is
Process of development stated.
1. Rate the overall quality of the guideline development 4 Likelihood that some patients might have the
methods. outcome when enrolled are taken into
 Were the appropriate stakeholders involved in the account in the analysis.
development of the guideline? 5 Attrition in each group stated.
 Was the evidentiary base developed systematically? 6 Dropouts and compliant participants compared
 Were recommendations consistent with the literature by exposure.
Presentation style 7 The outcomes are clearly defined.
2. Rate the overall quality of the guideline presentation. 8 Assessment of outcome is made blind to
 Was the guideline well organized? exposure status.
 Were the recommendations easy to find? 9 The method of assessment of exposure is
reliable.
Completeness of reporting 10 Evidence from other sources is used to
3. Rate the completeness of reporting. demonstrate that the method of outcome
 Was the guideline development process transparent assessment is valid and reliable.
and reproducible? 11 Main potential confounders identified and
 How complete was the information to inform accounted for in design and analysis.
decision-making? 12 Confidence intervals are reported.
Clinical validity Total scoreb
4. Rate the overall quality of the guideline a
recommendations. Rating: ‘‘Yes’’ = 1; ‘‘No’’ or unable to tell from the article = 0.
b
 Are the recommendations clinically sound? Scoring—sum of items as follows: 10–12 = high quality, low risk
 Are the recommendations appropriate for the of bias; 6–9 = acceptable quality, moderate risk of bias; <6 = low
quality, high risk of bias.
intended patients?
Overall assessment
5. Rate the overall quality of this guideline.
6. I would recommend this guideline for use in practice.
7. I would make use of a guideline of this quality in my
professional decisions.
Table 4. Systematic Review/Meta-Analysis
Modified SIGN Checklist
Item Yes/noa
Table 2. Randomized Controlled Trial Modified
SIGN Checklist 1 Research question was clearly defined and
eligibility criteria listed.
Item Yes/noa 2 A comprehensive literature search was
conducted.
1 The study addressed an appropriate and clearly 3 At least two people selected studies.
focused question. 4 At least two people extracted data.
2 Group assignment was randomized. 5 The status of publication was not used as an
3 The sample size was justified by a power inclusion criterion.
calculation. 6 The excluded studies were listed.
4 Investigators were blinded to patients’ group 7 The relevant characteristics of included studies
assignment. were provided.
5 Patients were blinded to group assignment. 8 The quality of included studies was assessed
6 Groups were similar at the start of the trial. and reported.
7 The only difference between groups was the 9 At least two people assessed quality of the
treatment of interest. included studies.
8 Outcomes were measured in a standard, valid, 10 Appropriate methods were used to combine
and reliable way. individual study results.
9 A power calculation was used and required 11 Likelihood of publication bias was assessed
sample size attained. appropriately.
10 An intention to treat analysis was performed. 12 Conflicts of interest were declared.
Total scoreb Total scoreb
a a
Rating: ‘‘Yes’’ = 1; ‘‘No’’ or unable to tell from the article = 0. Rating: ‘‘Yes’’ = 1; ‘‘No’’ or unable to tell from the article = 0.
b b
Scoring—sum of items as follows: 9–10 = high quality, low risk Scoring—sum of items as follows: 10–12 = high quality, low risk
of bias; 6–8 = acceptable quality, moderate risk of bias; <6 = low of bias; 6–9 = acceptable quality, moderate risk of bias; <6 = low
quality, high risk of bias. quality, high risk of bias.

887
888 HAWK ET AL.

Table 5. Rating the Quality of Evidence Using Methodology of the Delphi process
the Grading of Recommendations Assessment,
Development and Evaluation System The process was conducted electronically, through
e-mail. Throughout the process, panelists remained anony-
Level of Quality mous, having been assigned an identification number at the
evidence rating Explanation of quality rating beginning. This was done to avoid possible bias, since all
raters’ comments were shared among the SC and the Delphi
A High High level of confidence in the effects panelists. As in all of our previous consensus processes, we
of the intervention. used the RAND-UCLA methodology.26 This method em-
 Several high-quality studies with
consistent outcomes ploys an ordinal Likert ‘‘appropriateness’’ rating scale in
B Moderate Confidence in the effects of the which ‘‘appropriate’’ indicates that the expected patient
intervention may change with health benefits exceed expected negative effects by a large
future research findings enough margin that the recommended action is worthwhile,
 Only one high-quality study or without considering costs.26 This 1–9 scale is anchored by
 Several lower quality studies 1 = ‘‘highly inappropriate and 9 = ‘‘highly appropriate, with
C Low Confidence in the effects of the ‘‘uncertain’’ placed over the middle of the scale. Panelists had
intervention is very likely to change unlimited space for comments immediately following each
with future research findings statement. They were also instructed to provide citations to
 All studies have severe limitations
support their comments, if possible.
D Very Low Uncertainty about the effects of the
intervention
 Only expert opinion and/or Data management and analysis. The project coordina-
 No research evidence or tor entered the ratings data into an SPSS (v. 25) database,
 Very low-quality evidence and she and the project director computed medians and
percentages of agreement. In keeping with the rigorous
Source: GRADE.103
RAND-UCLA methodology, we set the threshold for con-
sensus 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
Development of seed statements as ‘‘uncertain’’; and 7–9 as ‘‘appropriate’’ (i.e., agreement).
The SC drafted a set of seed statements/concepts en- The project coordinator organized the panelists’ comments
compassing key aspects of the clinical encounter, including by panelist ID, statement number, and rating to facilitate
informed consent, diagnosis, treatment, concurrent care and review. The SC then reviewed the ratings and their ac-
co-management, and/or referral. Based on the literature, in companying deidentified comments. Taking the comments
addition to statements regarding chronic MSK pain in gen- and supporting evidence into account, the SC then revised
eral, we addressed five of the most common chronic MSK the statements that did not reach consensus. The project
pain conditions: LBP, neck pain, knee and hip OA pain, and coordinator provided these revised statements and the dei-
fibromyalgia.6 We cited evidence supporting all statements dentified comments to the Delphi panel for another round of
in the text and provided live links to the full text or abstracts rating.
in the attached reference list, so that during the consensus
process, panelists could conveniently access them to make External review: Public comments
an evidence-informed rating.
Influential organizations such as the AGREE Enterprise
recommend incorporating various means for ensuring
Delphi consensus panel stakeholder involvement into a guideline development pro-
cess. We already involved stakeholders in the SC and the
We sought to recruit a broad-based panel of DCs and
Delphi panel. For additional input, we invited public com-
other health professionals who had experience with man-
ments on the draft CPG after completing the Delphi process.
aging patients with chronic MSK pain, valued scientific
We used several routes to disseminate this invitation:
evidence, and were geographically dispersed throughout the
United States. We focused on the United States because  Clinical Compass e-mailing list through a MailChimp
practice parameters and reimbursement issues vary among e-mail blast; this includes the Clinical Compass Board
countries. We also made it clear to participants that they (comprised United States state chiropractic organizations
must be able to respond in a timely manner to the process, and a number of national chiropractic and academic or-
which was conducted by e-mail. ganizations (about 900 individuals total). It also includes
We recruited Delphi panelists by (1) inviting experts who vendors, whose contacts included interested laypersons.
had participated in our previous consensus projects and (2)  Invitations were sent through the chiropractic organi-
circulating an invitation through the Clinical Compass zation ChiroCongress to its member associations, re-
board, which includes representatives of the Congress of presenting over 35,000 chiropractors.
Chiropractic State Associations, the American Chiropractic  Facebook and LinkedIn through the Clinical Compass
Association, the International Chiropractors Association, page, which is open to both health professionals and
and the Association of Chiropractic Colleges. The SC re- interested laypersons
viewed the resulting volunteers, who submitted both a form  Chiropractic Summit e-mail list; this is a national or-
with their practice characteristics and their CV. ganization of chiropractic groups and individuals.
CHRONIC MUSCULOSKELETAL PAIN GUIDELINE 889

These routes had some overlap, which served to reinforce chronic pain,6 as an appropriate document to serve as the
the message. In addition, a reminder was sent out 2 weeks initial framework for our recommendations. We accepted
after the first invitation. We allowed 30 days for the com- AHRQ’s overall rating of the quality of evidence for non-
ment period. invasive, nonpharmacological interventions as low to mod-
We posted the draft CPG on the Clinical Compass web- erate and that ‘‘there was no evidence suggesting increased
site as a PDF, along with a summary of the background and risk for serious treatment-related harms for any of the in-
methodology of the project, as well as the references for all terventions, although data on harms were limited.’’6,p.ii We
statements. We provided a user-friendly comment form to included in our CPG, the five conditions covered in the
facilitate response. The project coordinator collected re- AHRQ review, which are among the most common causes
sponses. The project director and the SC reviewed and de- of chronic MSK pain: LBP, neck pain, chronic tension
cided how to respond to each comment. If the comments headache, OA (knee and hip), and fibromyalgia.6
resulted in substantive change, the revised statements were
to be recirculated to the Delphi panel to reach consensus. First stage search 2: Clinical practice guidelines. From
an initial pool of 147 articles, 23 remained after title
Results screening and 10 remained after abstract/full-text screening.
Table 6 lists these CPGs; all were considered high quality,
Literature search and evaluation
either by our rating with AGREE or a published systematic
First stage search 1: Systematic reviews. We identified review of the quality of CPGs on MSK pain using AGREE.28
343 articles (guidelines and systematic reviews/meta-analyses) All the guidelines were single-condition focused: 5 on neck
through PubMed, Cochrane Database of Systematic Reviews, pain,16–18,29,30 4 on LBP,3,14,15,31 and 1 on headaches asso-
reference tracking, and consultation. Figure 1 is the Preferred ciated with neck pain.32 There were none on other types of
Reporting Items for Systematic Reviews and Meta-Analyses chronic MSK pain.
(PRISMA) flow chart for the literature search. After applying
eligibility criteria, three systematic reviews remained.6,10,27 Second stage search. We did a targeted search of the
(Excluded articles are available in Supplementary Data S2.) published literature from the end date of the AHRQ review
(November 1, 2017) for topics that showed gaps in the
Evaluation. We evaluated two of the articles as high evidence for therapies used commonly in chiropractic
quality6,27 and one as unacceptable quality10; we did not use practice. The interventions we performed searches for were
the unacceptable (low) quality study to support recom- spinal manipulation/manual therapy, transcutaneous elec-
mendations. We selected one of the two remaining articles, trical nerve stimulation (TENS) and interferential current,
the extensive and high-quality systematic review by the low-level laser (LLL) therapy, and acupuncture. Table 7
AHRQ on noninvasive nonpharmacological treatment for summarizes the articles identified after searching for each

Records identified through Additional records identified

PubMed/Medline (327) and Cochrane through reference tracking
Database of Systematic Reviews (14) and expert recommendations
(n =341) (n=7)

Records after duplicates removed (5)

(n =343)

FIG. 1. PRISMA flow diagram for

Abstracts screened Records excluded first-stage literature search. Excluded
(n =343) Non-relevant or studies listed in Supplementary Data.
addressed single
condition (n =337)*

Full-text articles
assessed for eligibility Records excluded
(n =6) Included in another
systematic review
(n =1)*
Not systematic review
Studies included in (n=2)*
qualitative synthesis
(n =3)
890 HAWK ET AL.

Table 6. Clinical Practice Guidelines That Include Manipulation and Manual Therapies, 2016–2019
Topic First author Year Qualitya
Chronic headache associated with neck pain Cote.32 2019 H
Acute and CLBP Globe15 2016 Hb
Acute and CLBP Bussieres14 2018 H
Acute and CLBP and sciatica National Guideline Center31 2016 H
Acute and CLBP Qaseem3 2017 H
Acute and chronic neck pain Whalen17 2019 H
Acute and chronic neck pain Cote18 2016 Hb
Acute and chronic neck pain Blanpied30 2017 H
Acute and chronic neck pain Bussieres16 2016 H
Acute and chronic neck pain Bier29 2018 H
a
Quality was assessed using the AGREE Global Rating Scale (Table 4).
b
Rating from a published review of CPGs related to musculoskeletal pain.28
CLBP, chronic low-back pain.

specific modality from a pool of 348 articles. There were a master’s degrees. One panelist was an MD and three were
total of 21 articles: 5 CPGs,14,17,29,32,33 4 RCTS,34–37 and 12 DPTs. Almost all (57) were practitioners with an average
SRs,38–49 as shown by condition and therapy in Table 7. time in practice of 24 years (range 1–48). Sixteen of the
Nine were acceptable quality and 11 were high quality, using panelists worked in the Veterans Administration (VA) and
the modified SIGN rating checklists shown in Tables 1–3 or, one had a referral arrangement with a local VA. Seven
for CPGs, the AGREE scale shown in Table 4). panelists were faculty at chiropractic institutions and seven
Table 8 summarizes the quality of the evidence from both were faculty at nonchiropractic institutions. Practitioners
the AHRQ review and our targeted search (2018–2019). saw an average of 82 patient visits per week (range: 12–250)
Overall, the evidence was favorable, moderate to low. and the average estimated proportion of patients with a chief
complaint of chronic (>3 months’ duration) MSK pain was
61% (range: 15–100). Panelists’ locations (58 of 62 re-
Delphi process
sponded) represented 31 states plus 1 from Australia and 1
There were 62 panelists (of 70 invited); 58 were DCs. Ten from Canada as follows: five from CA; four each from IA
DCs were cross-trained: five in acupuncture, three in and NY; three each from AZ, KS, MI, OH, and TX; two
physical therapy (Doctor of Physical Therapy [DPT]), two each from MD, MN, MO, NY, OR, SD, an WA; and one
in medicine (MD), two in nursing (RN), and one in mental each from CO, HI, IL IN, MA, MS, MT, NC, ND, PA, RI,
health counseling (MA). Eighteen of the DCs had academic SC, and TN.

Table 7. Evidence from Targeted Search for Interventions 2018–2019, by Condition

Condition Design First author Quality Primary intervention
LBP CPG Bussieres14 H SM/MT
SR Wu47 H TENS
SR Almeida38 A TENS/IFC
RCT Barone-Gibbs35 A MB/L
RCT Eklund36 H SM
Neck pain CPG Whalen17 H SM/MT
CPG Bier29 H SM/MT
SR Almeida38 A TENS/IFC
RCT Albornoz-Cabello34 H IFC
RCT Yesil37 A TENS/IFC
Headache CPG Cote et al.32 H SM/MT
CPG Steiner33 H Multiple
SR Gu42 H MB/L
Knee OA SR Gong41 A ACU
SR Sun46 A ACU
SR Stausholm45 H LLL
SR Wysynska48 A LLL
SR Anwer39 H MT
Hip OA SR Ceballos-Laita40 H MT
Fibromyalgia SR Kim44 H ACU
SR Yeh49 A LLL
SR Honda43 A LLL/TENS
ACU, acupuncture; LLL, low-level laser therapy; MB/L, mind–body, psychological therapies or lifestyle counseling; MT, manual
therapy; OA, osteoarthritis; SM, spinal manipulation; TENS/IFC, transcutaneous nerve stimulation/interferential current; Multiple = various
nonpharmacological therapies, including those already listed and others.
CHRONIC MUSCULOSKELETAL PAIN GUIDELINE 891

Table 8. Quality of Evidence for Targeted  Neuropathic pain is identified using the following
(Procedure/Topic Specific) Searches criteria50,51:
1. Confirmed pain distribution and sensory dysfunc-
CLBP CNP CTTH KOA HOA FM tion that are neuroanatomically congruent.
SM/MT C B C B C; B C (MT) 2. Confirmed history or presence of a relevant dis-
C (SM) ease or lesion affecting the peripheral or central
TENS/IFC B C B C nervous system.
LLL C B B B 3. A description of burning, shooting, or pricking pain.
ACU C C C B-C; B C  Nociceptive pain is identified using the following
MB/L B-C B C criteria51:
1. Confirmed proportionate mechanical/anatomical
Strength of evidence rated by the AHRQ systematic review is in symptom characteristics.
bold italics. Strength of evidence is otherwise based on rating of
literature published 2018–2019, including clinical practice guide- 2. Pain comparable to trauma/pathology and in an
lines, systematic review/meta-analyses, and randomized controlled area of injury or dysfunction with/without referral.
trials. GRADE classifications: (see Table 5 for details): A = high; 3. Resolution congruent with anticipated tissue
B = moderate; C = low; D = very low. healing time.
ACU, acupuncture; CLBP, chronic low-back pain; CNP, chronic
neck pain; CTTH, chronic tension-type headache; FM, fibromyal- 4. Pain description typically intermittent and sharp
gia; HOA, hip osteoarthritis; KOA, knee osteoarthritis; LLL, low- with movement/mechanical aggravation.
level laser therapy; MB/L, mind–body, psychological therapies and 5. Pain involves additional symptoms of inflamma-
lifestyle counseling; MT, manual therapy; SM/MT, spinal manip- tion (e.g., swelling and redness).
ulation/manual therapy; SM, spinal manipulation; TENS/IFC,  Central sensitization is differentiated from neuro-
transcutaneous nerve stimulation/interferential current.
pathic and nociceptive pain using these criteria5,51,52:
On the first Delphi round, a high level of consensus (from When neuropathic pain has been excluded, central sensiti-
87% to 100% agreement) was reached on all statements. The zation pain is differentiated from nociceptive pain as follows52:
panelists had extensive comments, but most were based on
1. Pain is out of proportion to the severity of the asso-
clarifying rather than substantively changing the statements.
ciated injury or disease.
The SC made revisions for the purposes of clarification.
2. Distribution is diffuse and/or variable, not anatomi-
Public comments cally congruent with associated injury or disease, with
accompanying allodynia or hyperalgesia.
We disseminated an invitation for comment very widely 3. Patient is hypersensitive to stimuli such as light,
through the Clinical Compass board, chiropractic state and temperature, stress, and emotions.
national organizations, thus reaching the majority of chiro-
practors in the United States as well as interested laypeople. Other key terminology and abbreviations
Postings on the organization’s Facebook page and website  Biopsychosocial intervention: a treatment plan that in-
were accessed by 209 different people. We received three cludes at least one physical component (such as spinal ma-
public comments. All were from DC faculty at U.S. chiro- nipulation or exercise) and at least one psychological/
practic colleges; their suggestions were detailed and spe- social component (such as CBT or mindfulness
cific, primarily recommending clarifications in the wording meditation).53
of statements. The SC reviewed their comments and made a  CIH: Complementary and integrative health care.
number of nonsubstantive changes for clarity in the seed  CBT: Cognitive behavioral therapy, in which unhelpful
statements; additional Delphi rounds were therefore not thought or behavioral patterns are challenged by re-
required. The final statements are found below. structuring thoughts/beliefs and increasing engagement
in meaningful activities.
Chronic pain terminology and definitions  MTI: Maximum Therapeutic Improvement.
Based on the literature, we prefaced the Delphi consensus  Psychological and mind–body interventions focus on in-
process with definitions of key terminology so that panelists teractions among the brain, the rest of the body, the mind,
would be ‘‘on the same page’’ as they rated the statements. and behavior and the ways in which emotional, mental,
social, spiritual, experiential, and behavioral factors affect
Chronic pain terminology health. Examples are as follows: psychological therapies
such as CBT and mindfulness meditation; physical mind–
 Chronic pain: persistent or recurrent pain lasting body therapies such as t’ai chi; and yoga.54
longer than 3 months (ICD-11 definition)5 or pain  Red flags are signs or symptoms noted in the history or
present on at least half the days during the past 6 clinical examination that suggests the possibility of serious
months (National Pain Strategy definition).8 pathology or illness requiring immediate referral, more ex-
 Chronic primary pain: chronic pain in one or more tensive evaluation, or co-management, or present a contra-
anatomic locations accompanied by significant emo- indication to an aspect of the proposed treatment plan.55,56
tional distress or functional disability and that cannot be  Self-care: An active practice that a person can perform
better explained by another chronic pain condition.’’5 at home independently after being provided with ap-
 High impact chronic pain: chronic pain that causes propriate instruction.57
enduring restrictions on activities of daily living, work,  SMT: Spinal manipulative therapy: usually practiced by
social, and/or recreational activities.8 DC, doctors of osteopathy (DO), or physical therapists (PT).
892 HAWK ET AL.

Recommendations on Best Practices for Chiropractic understand this information to make an informed deci-
Management of Patients with Chronic MSK Pain sion.15 The informed consent discussion and the patient’s
General considerations for chronic pain management
consent to proceed should be recorded in the medical
record.
1. Emphasize the biopsychosocial model. In keeping with 2. Comply with local regulations. Legal requirements
the recommendation of organizations such as the may differ by geographic location; clinicians should
AHRQ and the International Society for the Study of seek specific advice from local authorities such as their
Pain (IASP), management of patients with moderate to malpractice carrier or state association. Both the
severe and/or complicated chronic MSK pain is best American Chiropractic Association (ACA) and the
addressed within a biopsychosocial model rather than Association of Chiropractic Colleges (ACC) have
the conventional biomedical model.6,58 guidelines on informed consent.17,{
2. Prioritize self-management and nonpharmacological 3. Maximize patient safety.
approaches. Self-management and nonpharmaco- a. Nonpharmacological therapies for chronic pain
logical therapies should be prioritized over pharma- have fewer associated harms than pharmacological
cological approaches whenever possible.3,6–8 interventions, particularly when administered by
a. For patients on prescribed pain medications, co- appropriately trained health professionals.3
management with a provider of nonpharma- b. Carefully assess patients with chronic pain for
cological approaches may improve outcomes.53 possible contraindications to manipulation, par-
3. Emphasize active interventions. Although passive in- ticularly high-velocity, low-amplitude ‘‘thrust’’
terventions are useful in the initial stages of manage- maneuvers (Table 9) and red flags (Table 10).62–64
ment to decrease pain, active interventions—particularly
exercise and self-care—should be introduced as soon as
General diagnostic considerations—history,
possible and emphasized in the management plan.8
examination, and imaging
a. Passive interventions, both conventional medical
approaches (e.g., medication or surgery) and many History and physical examination
nonpharmacological approaches (e.g., acupunc-
ture, massage, spinal manipulation, and physical 1. Recognize the effect of psychosocial factors on chronic
modalities) should be combined with active in- pain physiology. Chronic pain physiology may be
terventions and self-care (e.g., exercise, healthy differentiated as nociceptive, neuropathic, and/or
diet,59 meditation, yoga, and other lifestyle chan- central sensitization types. However, pain physiology
ges) whenever possible to improve outcomes.38 can manifest in individuals through interactions with
4. Include both physical and mind–body approaches. For psychosocial factors. These may be negative, such as
patients reporting moderate to severe chronic pain, a mood or sleep disorders or work-related factors (such
nonpharmacological approach that includes both a as hostile work environment, job insecurity, and long
physical and mind–body component is recommended.53 work hours65,66) or protective influences such as cop-
These may be administered by the primary treating ing skills and social support.4,67,68
clinician, or by referral or co-management with an 2. Take a thorough pain history. A thorough history of
interdisciplinary team.53 the patient’s pain symptoms, previous and concurrent
5. Identify the neurophysiological type of pain. In keep- treatment, and psychosocial factors is important to
ing with recent advances in the understanding of the develop an appropriate chiropractic management plan
physiology of chronic pain, it is important to differenti- for patients with chronic pain. Components of the
ate patients’ chronic pain in terms of its neurophysiology history include17 the following:
(neuropathic, nociceptive, and central sensitization), be- a. Assessment of red and yellow flag risk factors.
cause this may affect treatment choices.51,60,61 b. Onset of current pain and perceptions about initial
6. Consider risk stratification, such as the STarT Back precipitating factors.
risk assessment tool, for new episodes of pain to in- c. Pain parameters, including type, severity, location,
form shared decisions about treatment approaches. frequency, and duration.
Patients with low risk of a poor outcome may require a d. Provocative and relieving factors.
less intensive approach, while those with higher risk e. Review of systems.
may require a more intensive approach incorporating f. Previous treatment and response, including medi-
multiple therapies, including psychological.31 cal, surgical, and nonpharmacological.
g. History of past, current, or considered self-care
strategies.
Informed consent/risks and benefits
h. History of diagnostic tests with results.
1. Engage the patient in the informed consent process. In- i. Current medications and nutraceuticals.
formed consent is a process requiring active communica- j. Complicating factors/barriers to recovery, in-
tion between the patient and clinician. Using clear and cluding social determinants of health{
understandable terms, the clinician explains the examina-
tion procedures, diagnosis, treatment options (including no
treatment), and their benefits and risks.15 The clinician {
www.chirocolleges.org/resources/informed-consent-guideline
{
should ask the patient if he/she has any questions, and an- https://www.healthypeople.gov/2020/topics-objectives/topic/
swer them to the patient’s satisfaction. The patient must social-determinants-of-health
CHRONIC MUSCULOSKELETAL PAIN GUIDELINE 893

Table 9. Possible Contraindications to Spinal or Other Joint Manipulation

or Mobilization Procedures15,100
System Condition
Musculoskeletal  Primary or metastatic bone tumors
 Severe osteoporosis
 Structural instability (such as unstable spondylolisthesis or postsurgical joint instability)
Inflammatory  Osteomyelitis
 Rheumatoid arthritis in the active systemic stage, or locally
if acute inflammation or atlantoaxial instability is present
Neurologic  Progressive or sudden neurologic deficit
 Spinal cord tumors with neurological compromise or requiring medical intervention
Hematologic  Any unstable bleeding disorders, including high-dose anticoagulant therapy
 Unstable aortic aneurysm
Clinician attributes Inadequate physical examination
Inadequate manipulative training
Soft-tissue, instrument-assisted manipulation and low-velocity, low-amplitude mobilization procedures may be considered for
application, as clinically indicated on an individual basis.15,100

k. Psychological and behavioral health factors (e.g., Diagnostic imaging (general considerations and specific
depression, stress, anxiety, and PTSD). recommendations under each condition)
l. Lifestyle factors such as tobacco use, drugs/
1. Avoid routine use of imaging. Because chronic MSK
alcohol, diet, exercise, and sedentary lifestyle.
pain is often multifactorial and may not originate from
3. Consider ‘‘yellow flags.’’ ‘‘Yellow Flags’’ are psychoso-
a local source, imaging evidence is rarely capable of
cial factors that might predict poorer outcomes or pro-
definitively identifying a pain source.73 However,
longed recovery time. They relate to issues such as beliefs
imaging may be necessary if red flags are present and
about illness and treatment; attitudes and emotional states;
should be evaluated on a case-by-case basis after a
and pain behavior.69 Examples include17,69 the following:
thorough history and examination are performed.
a. Belief that activity should be avoided.
b. Pain catastrophizing.70
c. Negative attitude/depression. General treatment considerations
d. Work-related stress. Outcome assessment
e. Lack of social support.
f. Current compensation and claims issues related to 1. Use validated Patient-Reported Outcome Measures to
chronic pain. assess patient symptoms and characteristics, and to
4. Consider referral for co-management. Patients with assess progress over time.4 Some Patient-Reported
psychological factors, which may present an obstacle Outcome Measures appropriate for chronic pain chi-
to compliance with or success of the management ropractic patients are shown in Table 11.4,17,74
plan, may benefit by a referral to a psychologist or Care pathway
behavioral health counselor for further evaluation and/
or a trial of CBT.71,72 1. Follow an appropriate care pathway. Figure 2 shows
5. Conduct an appropriately focused physical examina- the chiropractic care pathway for a typical adult pa-
tion.73 Conduct a physical examination informed by tient with chronic MSK pain.
symptoms and health history, including areas/sites of
Considerations for frequency and duration of treatment
primary and secondary symptoms. Both function and
pain should be assessed and include a comprehensive 1. Avoid a ‘‘curative model’’ approach. A ‘‘curative
MSK and neuromuscular examination.73 model’’ approach is not likely to be successful with

Table 10. Red Flags on History and Examination15,17,55,56

Red flags: History Red flags: Examination6
 Cancer  Abnormal sensory, motor or deep tendon reflexes
 Confusion/altered consciousness  Fever >100F
 Connective tissue disease  Nuchal rigidity
 Osteopenia  Pain pattern unrelated to movements or activities
 Severe nocturnal pain
 Significant trauma or infection
 Unexplained weight loss
 Unexplained/novel neck pain
 Visual or speech disturbances
 Weakness or loss of sensation
 ‘‘Worst headache ever’’ or new headache, unlike any previous
 Table 11. Patient-Reported Outcome Measures for Assessing Chronic Musculoskeletal Pain4
Pain characteristics Functional ability Quality of life Psychological factors
Verbal Rating Scale Patient Specific Functional Medical Outcomes Study Beck Depression Inventory
Numeric Rating Scale Scale (PSFS)17 Short Form Health Patient Health Questionnaire (PHQ9)
Survey (SF-36)
Visual Analog Scale Pain Disability Index Global Well-Being Scale74 Profile of Mood States
Neuropathic Pain Scale Brief Pain Inventory EuroQol Coping Strategies Questionnaire
Central Sensitization PROMIS Global Health PTSD Checklist-Specific Version
Inventory51,61,101 Alcohol/drug dependency:
CAGE-AID102
Tools for assessing specific types of pain (low back, etc.) are shown in those sections Only tools for assessing general chronic pain rather
than those for specific locations (low back, etc.) are shown.

Patient presents with chronic (> 3 mo)

musculoskeletal pain.

Refer
appropriately or No 1
Evaluate: Treatment Yes Red flags present? Yes Refer appropriately
provide self-care benefits outweigh risks? (See Table 10) for management/
instructions. comanagement.
No or appropriately managed

Physical (SMT, soft tissue, exercise) and

psychological/mind-body approach
(see Table 12 for frequency and duration)

Condition No
Consider further No Returned to pre- Yes Discharge with
worsens with
diagnostic testing. episode status?
1 self-care
treatment
2 instructions.
withdrawal?

Yes
Red flags Refer to
or other Yes Consider ongoing care
appropriate 3
conditions outside plan (See Table 12).
provider/facility.
scope or skill set?

No

Other Discontinue care and

treatment options No refer to appropriate
available at this provider/facility for
facility? opinion/management.

Yes

Trial of different
intervention(s)

FIG. 2. Care pathway for chiropractic management of adult patients with chronic musculoskeletal pain.14,16
1
Evaluation and re-evaluation components: History; perform focused examination; imaging if warranted (new trau-
ma/symptoms/red flags); patient-reported outcome measures (PROMs) (Table 11); pain frequency and intensity; functional
ability; quality of life; psychological factors.
2
Attempt treatment withdrawal when patient reaches maximum therapeutic improvement. If improvements deteriorate,
ongoing care may be necessary to maintain functional status. Withdrawal can be tapered or abrupt. Either instruct patient to
return if symptoms recur; or schedule him/her for re-evaluation at regular intervals.
3
To document necessity for ongoing care, record: Response to initial treatment (use valid outcome measures); MTI,
Maximum Therapeutic Benefit; residual activity limitation; patient’s self-care attempts; have alternative treatments been
considered or attempted?

894
CHRONIC MUSCULOSKELETAL PAIN GUIDELINE 895

Table 12. Visit Frequency and Duration of Care for Chiropractic Management of Chronic
(>3 Months) Musculoskeletal Pain15,17
Type of episode No. of treatment visits Duration of care Re-evaluation period
Mild exacerbation 1–6/episode Per episode Beginning and end of episode
Moderate or severe 2–3/week 2–4 weeks Every 2–4 weeks
exacerbation
Scheduled interval for ongoing 1–4/month Ongoing Minimum of every 6 visits, or as
management36,a,b needed to document changes.c
a
Support with documentation of either functional improvement or functional optimization. This may include, but is not limited to the
following: (1) substantial symptom recurrence upon treatment withdrawal, (2) minimization/control of pain, (3) maintenance of function
and ability to perform, (4) minimization of dependence on interventions with greater risk(s) of adverse events, and (5) maintained or
improved work capacity.
b
Three to four visits per month on an ongoing basis only indicated in exceptional circumstance. One to two visits per month may be
necessary if care is supported by a well-documented care
management plan.
c
Document patient’s efforts to comply with self-care recommendations.

chronic pain management. Pain medications are not Condition-specific diagnosis

expected to ‘‘cure’’ chronic pain, but to make it and treatment recommendations
more manageable for the patient. Similarly, This guideline includes recommendations for best prac-
nonpharmacological approaches should not be ex- tices for chiropractic management of some of the most
pected to ‘‘cure’’ chronic pain within a specified common chronic MSK pain conditions. These are (1) LBP,
course of treatment, but may need to be included as (2) neck pain, (3) tension headache, (4) knee and hip OA,
part of an individual’s ongoing pain management and (5) fibromyalgia.6
plan.15,17,19,36,75,76 (see Table 12 for details of See General Considerations for Chronic Pain Man-
‘‘Ongoing Management.’’) agement section for details of history, examination, and
2. Set appropriate chronic pain management goals. The red and yellow flags. Specific considerations for each
goals of chronic pain management are different from condition are provided below.
the goals associated with acute care management.
Chronic care goals may include (but are not limited to) 1. Chronic LBP
the following:
a. Pain control: relief to tolerance.
Diagnostic considerations for LBP
b. Support or maximize patient’s current level of
function/ADLs. 1. Develop an evidence-based working diagnosis. Pro-
c. Reduce/minimize reliance on medication. viders should develop evidence-based working diag-
d. Maximize patient satisfaction. noses that describe condition characteristics that will
e. Maximize patient’s engagement in meaning- inform a management approach.67,68
ful/pleasurable activities to de-emphasize pain 2. Consider physiological pain type. Providers are ad-
(examples: playing with grandchildren; getting vised to consider whether the likely dominant cause of
hair done; or going to the park)77,# the LBP is neuropathic, nociceptive, and/or due to
f. Minimize exacerbation frequency and/or severity. central sensitization to determine the most appropriate
g. Minimize further disability. management strategies.4,5,51,67,68
h. Minimize lost time on the job.
3. Consider patient-specific goals. Patients with chronic Diagnostic imaging
MSK pain generally fall into one of these categories:
a. Self-management is sufficient using strategies/ 1. Avoid routine imaging. Routine imaging is not re-
procedures such as exercise, ice, heat, and stress commended for patients with nonspecific LBP.14,73
reduction. Factors that indicate the need for imaging are15 as
b. Episodic care is necessary to manage pain. Pa- follows:
tients arrange nonpharmacological care on an as- a. Severe and/or progressive neurologic deficits.
need basis to support their self-care strategies for b. Suspected anatomical anomaly such as spondylo-
acute flare-ups, 1–12 visits/episode, followed by listhesis.
release. c. Severe trauma.
c. Scheduled ongoing physician-directed care is d. Other red flags on history or physical examination.
necessary to manage pain. Treatment withdrawal e. Patient shows no improvement after a reasonable
results in deterioration36 (Fig. 2 and Table 12). course of care.
f. Additional factors vary with location and type of
pain.
2. Consider advanced imaging for some cases of radi-
culopathy. For patients with CLBP accompanied by
#
https://www.va.gov/PAINMANAGEMENT/docs/CBT-CP_ radiculopathy, magnetic resonance imaging (MRI) or
Therapist_Manual.pdf computed tomography (CT) scans are preferred to
896 HAWK ET AL.

plain film radiographs.15 Certain conditions that are Exercise combined with manipulation/mobili-
not detected on physical examination, such as spinal zation.
stenosis, may require MRI to be detected.30 b. Physical passive interventions:
 Spinal manipulation and mobilization16,18,85
Interventions  Massage
 Low-level laser
1. Consider multiple approaches. Both active and passive,  Acupuncture
and both physical and mind–body interventions should  These modalities may be added as part of a
be considered in the management plan. The following multimodal treatment plan, especially at the
are recommended, based on current evidence6,14 beginning, to assist the patient in becoming or
a. Physical active interventions: remaining active:
 Exercise  Transcutaneous nerve stimulation (TENS), trac-
 Yoga/qigong (which may also be considered
tion, ultrasound, and interferential current.17,34,37
‘‘mind–body’’ interventions) c. Mind–body interventions16,18
 Lifestyle advice to stay active; avoid sitting35;  Yoga
manage weight if obese78; and quit smoking78,79  qigong
b. Physical passive interventions:
 Spinal manipulation/mobilization 3. Chronic tension headache
 Massage
 Acupuncture Diagnostic considerations for tension headache
 LLL therapy
By definition, tension-type headache (TTH) is one that is
 Transcutaneous electrical nerve stimulation
present at least 15 days each month for more than 3 months. It
(TENS) or interferential current may be bene- may be daily and unremitting and may be accompanied by
ficial as part of a multimodal approach, at the mild nausea.33 TTH is diagnosed by history exclusively, al-
beginning of treatment to assist the patient in though a focused examination that includes blood pressure
becoming or remaining active.38,47 should also be conducted. Imaging and other special tests are
c. Combined active and passive: multidisciplinary not indicated unless the history or examination is suggestive
rehabilitation of another condition, which may be the underlying cause.33
d. Psychological/mind–body interventions80
 CBT Interventions
 Mindfulness-based stress reduction
1. Consider multiple approaches. Both active and pas-
2. Chronic neck pain sive, and both physical and mind–body interventions
should be considered in the management plan for
Diagnostic considerations maximum therapeutic effect. The following are re-
commended, based on current evidence6:
See General Diagnostic Considerations—History, Ex- a. Physical active interventions33
amination, and Imaging section  Reassurance that TTH does not indicate pres-
ence of a disease.
Diagnostic imaging  Advice to avoid triggers.
 Exercise (aerobic).
Consider appropriate circumstances for imaging. Ac- b. Physical passive interventions
cording to the American College of Radiology:  Spinal manipulation6,32
 Acupuncture6,33
1. AP and lateral views of the cervical spine may be
 Cold packs or menthol gels33
appropriate in patients with a history of (1) chronic
neck pain with or without trauma; (2) malignancy; or c. Combined active and passive
(3) neck surgery.81 d. Mind–body interventions33
 CBT
2. Diagnostic imaging to identify degeneration is not
 Relaxation therapy
recommended because it has not been determined to
 Biofeedback
necessarily be a source of pain.82
 Mindfulness Meditation42
3. Serial radiographs of the cervical spine are not asso-
ciated with improved outcomes.83,84 4. Knee and hip OA
Knee OA
Interventions
Diagnostic considerations for knee OA
1. Consider multiple approaches. Both active and pas-
sive, and both physical and mind–body interventions 1. Rely first on history and physical examination. For
should be considered in the management plan for knee OA, the diagnosis relies on the history and
maximum therapeutic effect. The following are re- physical examination findings and is often confirmed
commended, based on current evidence.6 with plain radiographs. Laboratory tests are reserved to
a. Physical active interventions16,18: rule out other diagnoses.86 It is more common in older
 Exercise (range of motion and strengthening). adults and in the obese (body mass index >30).87,88
CHRONIC MUSCULOSKELETAL PAIN GUIDELINE 897

Diagnostic imaging 2. Consider advanced imaging for signs of cartilage de-

generation. MRI is more sensitive than plain radiographs
1. Imaging is not typically required. Imaging is not re- for detecting early signs of cartilage degeneration.
quired for typical presentation of knee OA; however, MRI with or without contrast may be indicated if
with chronic knee pain, conventional (plain) radio- the following are suspected and not confirmed with
graphs should be utilized before other imaging mo- radiographs92:
dalities. Considerations of radiographic views are a. Impingement
important for optimizing the detection of knee OA, b. Labral tears
and specifically, weight bearing and patellofemoral c. Pigmented villonodular synovitis or osteochro-
views are recommended.89,90 matosis
2. Consider advanced imaging in some cases. For addi- d. Arthritis of uncertain type
tional diagnoses, soft tissues are best imaged with di- e. Infection
agnostic ultrasound or MRI without contrast, and bone
by CT scan or MRI.89 Radiographic factors for chronic Interventions
knee pain in which MRI without IV contrast is usually
appropriate to include89,90: 1. Consider multiple approaches. Both active and passive,
a. Negative radiographs and both physical and mind–body interventions should
b. Joint effusion be considered in the management plan. The following
c. Osteochondritis dissecans are recommended, based on current evidence6
d. Loose bodies a. Physical active interventions:
 Exercise
e. History of cartilage or meniscal repair
f. Prior osseous injury (i.e., Second fracture and b. Physical passive interventions
 Manual therapy40
tibial spine avulsion)
5. Fibromyalgia
Interventions
Diagnostic considerations for fibromyalgia
1. Consider multiple approaches. Both active and passive,
and both physical and mind–body interventions should Fibromyalgia is diagnosed primarily from a history of a
be considered in the management plan. The following typical cluster of symptoms—widespread chronic pain,
are recommended, based on current evidence6: nonrestorative sleep, and fatigue (physical and/or mental)—
a. Physical active interventions: when other possible causes have been excluded.95
 Exercise
b. Physical passive interventions: Interventions
 Manual therapy39 1. Consider multiple approaches. Both active and passive,
 Ultrasound and both physical and mind–body interventions should
 Acupuncture, using ‘‘high dose’’ (greater treat- be considered in the management plan. The following
ment frequency, at least 3 · week)41,46 are recommended, based on current evidence6,95,96:
 LLL therapy45,48 a. Physical active interventions:
 Exercise (aerobic and strengthening)
Hip OA  Advice on healthy lifestyle95
 Education on the condition95
Diagnostic considerations for Hip OA b. Physical passive interventions:
1. Develop a clinical diagnosis. Hip OA commonly  Spinal manipulation97
presents as anterior or posterior hip pain, with persis-  Myofascial release97
tent deep groin pain that is worse with activity.91 The  Acupuncture44
American College of Rheumatology supports clinical  LLL therapy43,49
diagnosis of hip OA when patients have hip pain, in- c. Combined active and passive: multidisciplinary
creased pain on internal hip rotation, and concurrent rehabilitation
morning stiffness lasting <60 min.92 d. Mind–body interventions, including CBT, mind-
a. Patients may also have coexisting limitation of fulness meditation, yoga, and t’ai chi, qigong
flexion with flexion less than or equal to 115 and
<15 of internal rotation.93 Discussion
The management of chronic pain has seen a dramatic shift
Diagnostic imaging
recently, with nonpharmacological approaches being pre-
1. First consider plain radiographs. According to the ferred to pharmacological, due to the opioid epidemic.
ACR Appropriateness Criteria for chronic hip pain, Therefore, the management of chronic pain patients is not
the first line of imaging should be plain radiographs of the domain of any one type of provider. In addition, evi-
the hip and pelvis for most, if not all, cases. For OA of dence supports the biopsychosocial approach that includes
the hip, physical examination and radiographs may be not only multifactorial treatment approach but also a strong
better for diagnosis than MRI and have reasonable emphasis on psychosocial factors, active care, self-care, and
sensitivity and specificity.92,94 patient empowerment.
898 HAWK ET AL.

This guideline is meant to emphasize the use of evidence- Monica Curruchich, DC, RN-BSN; John Curtin, MSS, DC,
based approaches to chronic MSK pain management that FACO; Vincent DeBono, DC; Mark D. Dehen, DC, FICC;
help patients become active as soon as possible and em- C. Michael DuPriest, PT, DPT, DC, FACO; Paul Ettlinger,
power themselves to manage their pain successfully. It also DC; James E. Eubanks, MD, DC, MS; Jason T. Evans, DC,
aims to encourage DCs to work collaboratively with other FIACN, DIBCN, ABIME; Andrew Fogg, DC, MS, DACRB;
providers to provide patients with the optimal resources for David Folweiler, DC; Vinicius Tiepppo Francio, DC, MD;
successfully managing their chronic pain. Margaret M. Freihaut, DC; William P. Gallagher, Jr., DC;
A limitation in making such recommendations is that some Derek Golley, DC, MHA; Stephen D. Graham, PT, DPT,
treatment practices in common use may not have accumu- OCS; Jason N. Guben, BSc(N), DC; Renee Hunter, DC, RN;
lated the highest quality evidence. However, it is important to Brian James, MD; Jeffrey M. Johnson, DC; Yasmeen Khan,
give practitioners as much guidance as possible, using the DC, MS, MA; Robert E. Klein, DC; Rick Louis LaMarche,
best available evidence, as Sackett first described it.98 DC; Lawrence J. Larragoite, DC, FIAMA, CFMP; William
There are factors that contribute to the relative scarcity of Lawson, DC, MSc, FIANM(us); Robert Leach, DC, MS,
high-quality evidence for nonpharmacological treatments, par- CHES; Duane T. Lowe, DC; Eric Luke, DC, MS; Ralph C.
ticularly manual therapies, for chronic pain. One is that ran- Magnuson, PT, DPT, Dip. MDT; Hans W. Mohrbeck, DC;
domized controlled trials of nonpharmacological treatments, Scott A. Mooring, DC, CCSP; Jack A. Moses, Jr, DC; Mark
particularly manual therapies, usually assume a curative mod- Mulak, DC, MBA, MS, DACRB; Marcus Nynas, DC, FICC;
el.75 For example, RCTs usually test the hypothesis that a course Juli Olson, DC, DACM; Colette Peabody, DC, MS; Mar-
of spinal manipulative therapy (SMT) will result in long-term iangela Penna, DC; Roger Kevin Pringle, DC, MEd; David C.
pain reduction—a curative model—and if it does not, then SMT Radford, DC, MSc; John Rosa, DC, FACC, FICC; Vern Sa-
is considered ineffective.75 However, chronic MSK pain is not boe, Jr, DC, FACO; Mark Sakalauskas, DC; Bruce Scott, DC;
medically managed in that same curative model. Analgesics are Christopher R. Sherman, DC, MPH; Scott M. Siegel, DC;
not expected to function like antibiotics—that is, to ‘‘cure’’ pain Charles A. Simpson, DC, DABCO; Albert Stabile, Jr,
after a course of treatment. Although some studies are beginning DC, FICC, CPCP; Kevin Stemple, RPT, MBA; James
to approach the topic of chronic pain from a management, rather P. Stupak, DC; Lisa Thomson, DC, CFMP, CME; Jason
than curative, approach,36,75,99 currently, the literature is still Weber, DC, DACRB; Susan Wenberg, MA, DC; John S.
scarce on optimal treatment parameters, and future studies are Weyand, DC; Clint Williamson, DC; and Morgan Young, DC.
important to conduct.
After our project was completed and we were preparing
Author Disclosure Statement
this article, AHRQ published a 2020 update9 to their 2018
review,6 which had formed the foundation of our recom- No competing financial interests exist.
mendations. We found that their 2020 update did not sub-
stantively alter our recommendations. The fact that AHRQ
Funding Information
saw fit to produce an update so quickly emphasizes the
importance of the topic of nonpharmacological approaches A grant from the NCMIC Foundation provided partial
to chronic MSK pain. funding for the project director, and the Clinical Compass
We sought to secure buy-in from the chiropractic profession provided funding for the project coordinator.
in developing this guideline by forming a large and broad-based
Delphi panel and by disseminating the preliminary recom- Supplementary Material
mendations very widely throughout the profession. We hope Supplementary Data S1
that the consensus achieved will facilitate their use in chiro- Supplementary Data S2
practic practice. We also hope that these evidence-based rec-
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