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. Recommendations were made for nonpharmacological treatments, including acupuncture, spinal manipulation/mobilization, and other manual therapy; modalities such as low-level laser and interferential current; exercise, including yoga; mind–body interventions, including mindfulness meditation and cognitive behavior therapy; and lifestyle modifications such as diet and tobacco cessation. Recommendations covered many aspects of the clinical encounter, from informed consent through diagnosis, assessment, treatment planning and implementation, and concurrent management and referral. Appropriate referral and comanagement were emphasized.Conclusions: These evidence-based recommendations for a variety of conservative treatment approaches to the management of common chronic MSK pain conditions may advance consistency of care, foster collaboration between provider groups, and thereby improve patient outcomes.
Highlights
Pain prevalence has increased among United States adults by 25% from 1998 to 2014, according to a 2019 report, with 41% reporting pain in the period 2013–2014.1 At least 70 million U.S adults have chronic pain.[1,2]
RCTs, and cohort studies investigating treatments using modified SIGN (Scottish Intercollegiate Guideline Network) checklists, which have been used in other studies by our team.[22,23,24]
We focused on the United States because practice parameters and reimbursement issues vary among countries
Summary
Pain prevalence has increased among United States adults by 25% from 1998 to 2014, according to a 2019 report, with 41% reporting pain in the period 2013–2014.1 At least 70 million U.S adults have chronic pain.[1,2] Opioid use has risen along with the increase in pain prevalence.[1]. Authoritative groups, including the Agency for Healthcare Research and Quality (AHRQ) and the American College of Physicians (ACP), have recommended that chronic back pain and other chronic musculoskeletal (MSK) pain be treated initially through nonpharmacological approaches.[3]. The AHRQ, Institute of Medicine (IOM), and the National Pain Strategy Report[6,7,8] recommend that chronic pain be addressed through the biopsychosocial model, rather than solely through the conventional biomedical model. This includes an emphasis on nonpharmacological and selfmanagement approaches, with pharmacological approaches being secondary.[3,6,7,8]
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