Best Practices for Chiropractic Management of Patients with Chronic Musculoskeletal Pain: A Clinical Practice Guideline

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.

Keywords: chiropractic; chronic musculoskeletal pain; chronic pain; clinical practice guideline; spinal manipulation.

FIG. 1.

PRISMA flow diagram for first-stage literature search. Excluded studies listed in Supplementary Data.

FIG. 2.

Care pathway for chiropractic management of adult patients with chronic musculoskeletal pain.^,Evaluation and re-evaluation components: History; perform focused examination; imaging if warranted (new trauma/symptoms/red flags); patient-reported outcome measures (PROMs) (Table 11); pain frequency and intensity; functional ability; quality of life; psychological factors. 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. 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?