Welcome back to the Spine IQ Back Blog! Last week we discussed the new Academy of Orthopedic Physical Therapy clinical practice guidelines for low back pain.1 This week, we wanted to discuss the most recent chiropractic management clinical practice guideline.2 As we have discussed many times on Spine IQ’s Back Blog, clinical practice guidelines are important because research shows they lead to better outcomes for patients at a more cost-effective option.3 Additionally, there is ample amount of evidence that supports the type of treatments that conservative spine clinicians deliver as first-line or adjunct for musculoskeletal pain.4 Below we discuss the chiropractic guideline recommendations and highlight the similarities and differences between the physical therapy and chiropractic clinical practice guidelines.

Recommendations for Chiropractic management of chronic pain

Note: Chronic pain was defined as “persistent to recurrent pain lasting longer than 3 months or pain present on at least half the days during the past 6 months.”

  • emphasize the biopsychosocial model
    • recognize the potential for psychosocial factors to influence chronic pain
  • screen for yellow flags (e.g., belief that activity should be avoided, pain catastrophizing, depression, lack of social support)
  • prioritize self-management
  • co-manage patients who are taking prescribed pain medications
  • emphasize active interventions
  • provide passive interventions (e.g., acupuncture and spinal manipulation) combined with active interventions or self-management advice
  • provide physical and mind-body approaches or co-manage with practitioner experienced in this treatment (e.g., mindfulness coach)
  • Identify if pain is neuropathic, nociceptive, or central sensitization
  • Use risk stratification tools (e.g., STarT Back risk assessment)
  • Provide informed consent of assessment results, diagnosis, and treatment options that include possibility of no treatment
  • Follow the scope of practice of their state/province
  • Avoid use of imaging unless “red flags” are present
  • Screen for red flags:
    • Abnormal neurological findings
    • Fever >100 degrees
    • Pain unrelated to movement
  • Emphasize patient safety
    • Possible contraindications to spinal manipulation:
      • Metastatic bone tumors
      • Severe osteoporosis
      • Osteomyelitis
      • Progressive neurological deficit
    • Use validated patient-reported outcome measures
      • Visual analog scale, patient specific functional scale, brief pain inventory, and EuroQol PROMIS global health
    • Avoid curative model and provide care to reduce suffering
      • Set patient centered chronic pain management goals (e.g., maximize activity/function and patient satisfaction)


As you will notice, this chiropractic clinical practice guideline has more in-depth recommendations then the Academy of Orthopedic Physical Therapy’s clinical practice guideline. This is likely because the physical therapy guideline focused on interventions that could be delivered by physical therapists, meanwhile the chiropractic guideline considered all aspects of the patient-clinician interaction. In terms of interventions, both guidelines provide very similar recommendations. Emphasizing non-pharmacological care is a common recommendation in most if not all musculoskeletal pain clinical practice guidelines because such care tends to be safer and equally or more effective as pharmacological management.4,5 It is important to remember that  while clinical practice guidelines are not meant to be prescriptive, clinicians should consider these recommendations when providing care and using shared decision making to discuss with the patient the best treatment plan for them based on their unique experience and preference, the clinician’s expertise, and clinical practice guideline recommendations.


  1. George SZ, Fritz JM, Silfies SP, et al. Interventions for the Management of Acute and Chronic Low Back Pain: Revision 2021. J Orthop Sports Phys Ther. 2021;51(11):CPG1-CPG60. doi:10.2519/jospt.2021.0304
  2. Hawk C, Whalen W, Farabaugh RJ, et al. Best Practices for Chiropractic Management of Patients with Chronic Musculoskeletal Pain: A Clinical Practice Guideline. J Altern Complement Med. Published online October 8, 2020. doi:10.1089/acm.2020.0181
  3. Fritz JM, Cleland JA, Brennan GP. Does adherence to the guideline recommendation for active treatments improve the quality of care for patients with acute low back pain delivered by physical therapists? Med Care. 2007;45(10):973-980. doi:10.1097/MLR.0b013e318070c6cd
  4. Lin I, Wiles L, Waller R, et al. What does best practice care for musculoskeletal pain look like? Eleven consistent recommendations from high-quality clinical practice guidelines: systematic review. Br J Sports Med. 2020;54(2):79-86. doi:10.1136/bjsports-2018-099878
  5. Qaseem A, Wilt TJ, McLean RM, Forciea MA, Clinical Guidelines Committee of the American College of Physicians. Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2017;166(7):514-530. doi:10.7326/M16-2367