Chronic pain is widespread and increasing, affecting 100 million Americans, and costs the nation an estimated $635 billion annually in combined healthcare cost and lost productivity.1 Non-specific low back pain (LBP), particularly among those 65 years and older, is the fifth most common healthcare complaint and reason for seeking healthcare intervention.2
Current evidence, however, suggests that treatment of chronic pain that is focused on unimodal options -pharmacological or non-pharmacological- is inadequate. Also inadequate is physician and public awareness and education about pain and its management.3 Consequently, despite treatment, recurrence of pain episodes is common, and as many as 7% of patients with unresolved persistent back pain develop chronic pain.4
The escalating social and economic burden of managing chronic pain in America has resulted in the recent publication of the National Pain Strategy (NPS), an effort initiated by the Institute of Medicine and coordinated by the United States Department of Health and Human Service (HHS).5
The NPS outlines specific actions to reduce pain prevalence and to improve its treatment. Informed by scientific evidence, the NPS attempts to transform the approach to the prevention and management of pain.
Improving access to safe and effective care for people suffering from pain has been identified as a public health priority. “Chronic pain is a significant public health problem, affecting millions of Americans and incurring significant economic costs to our society,”said Karen B. DeSalvo, MD, MPH, the HHS acting assistant secretary for health , adding that “This report identifies the key steps we can take to improve how we prevent, assess and treat pain in this country.”
Linda Porter, PhD, director at the NIH’s Office of Pain Policy and co-chair of the Interagency Pain Research Coordinating Committee working group that developed the report added “We need to ensure that people with pain get appropriate care and that means defining how we can best manage pain care in this country.”
The NPS recognizes that a pain management care strategy that integrates complementary and alternative medicine with conventional therapies and modeled on individualized patient choice has a place in addressing the chronic pain epidemic in America. The strategy places emphasis on a multidisciplinary team-based biopsychosocial model of care, empowering patients to make treatment decisions by improving their knowledge of, and access to available treatment options.
This requires improved patient and professional education regarding the myths, misconceptions and perceived stigma surrounding chronic pain and its management. One of the key goals of the NPS is the establishment of initiatives that can help reduce the over-reliance on prescription opioid medications for the management of chronic pain.
The NPS specifically calls for more evidence-based research, especially to address the paucity of research focused on patient-centered integrative models of care for chronic pain. To that effect, several studies and study protocols have been completed or are in development to compare or assess the benefits of various pain treatment modalities, including chiropractic, complementary medicine, pharmacological and integrative care.
These studies have contributed to the gradual shift seen in recent years for the treatment of chronic back pain, from a mono- to a multi-disciplinary approach that integrates complementary and alternative treatment modalities (CAM) to the traditional chiropractic and pharmacological treatment options.
There is ample evidence to support an integrated CAM and conventional medical therapy over a single treatment modality for the management of chronic LBP.8-10 Other studies indicate that an individualized patient-centered, coordinated, team-based care improves outcomes for patients with LBP.
Although many of these studies lack the robustness of a large-scale well-designed randomized controlled trial (RCT), a study published in 2010 by Westrom and colleagues employed a mixed-methods RCT design to assess the clinical- and cost-effectiveness of a mono-disciplinary chiropractic care versus an individualized multi-disciplinary integrative care of adult patients with LBP.
The study randomized 200 patients to 12 weeks of mono-disciplinary chiropractic care or multi-disciplinary integrative care (which included chiropractic, cognitive behavioral therapy [CBT], massage therapy, medication, self-care education, and traditional Chinese medicine).
The clinical care pathway consisted in an individualized assessment of patient response to treatment against a pre-specified benchmark of target improvement. Failure to meet the expected treatment outcome necessitated consensus agreement on change in protocol by the multidisciplinary team of practitioners (including acupuncturists, chiropractors, cognitive behavioral therapists, exercise therapists, massage therapists and primary care physicians).
The study found that on average, practitioners arrived at a consensus to recommend 3 to 4 treatment plans, each consisting of 2 to 3 modalities.14 Exercise therapy, massage therapy and acupuncture were the most recommended, and study participant selected treatment modality.
Patients to whom these non-pharmacological treatment approaches were recommended showed preference for exercise therapy (95%), while CBT gathered 49% of votes; massage therapy, acupuncture and self-care education were chosen by 55%, 69% and 77% of patients, respectively.
Although medication therapy alone or in combination with other treatment modalities was offered the least by practitioners, all participants to whom it was presented as an option selected it. The study indicates that clinical care pathway is a useful approach to evidence-based management of chronic back pain and suggests that chronic back pain can be managed with minimum medication therapy.
Individualized chronic pain care is more appropriate than a “one-size-fits-all” approach, and involving patients in the selection of their treatment may positively affect outcomes. This, in combination with safer prescribing practices should result in improved pain care.
Summary and Clinical Applicability
The application of clinical care pathway for individualized, multidisciplinary and integrative care is a chronic pain management approach that aligns with the NPS.
While more robust RCTs are needed to provide additional support for integrating complementary and alternative treatment modalities to the traditional chiropractic and pharmacological treatment options for the management of chronic pain, efforts are needed to equip practitioners and patients with the tools and information they need to make informed, patient-centered treatment decisions.
- Gaskin DJ, Richard P. The economic costs of pain in the United States. J Pain. 2012;13(8):715-724
- Health, United States, 2014. Centers for Disease Control and Prevention. Trend Tables. Available at: http://www.cdc.gov/nchs/data/hus/2014/046.pdf. Accessed September 9, 2016.
- Partners Against pain. Chronic Pain Is Often Inadequately Treated. Available at: http://www.partnersagainstpain.com/hcp/pain-management-education/chronic-pain-inadequate-treatment/. Accessed September 9, 2016.
- Speed C. Low back pain. BMJ. 2004;328(7448):1119-1121.
- National Pain Strategy. US Department of Health and Human Services. Published March 2016. Available at: https://iprcc.nih.gov/docs/HHSNational_Pain_Strategy.pdf. Accessed September 9, 2016.
- The Interagency Pain Research Coordinating Committee. National Pain Strategy. National Institutes of Health. Published online March 18, 2016. Available at: https://iprcc.nih.gov/National_Pain_Strategy/NPS_Main.htm. Accessed September 9, 2016.
- Stuber KJ, Langweiler M, Mior S, McCarthy PW. Assessing patient-centered care in patients with chronic health conditions attending chiropractic practice: protocol for a mixed-methods study. Chiropr Man Therap. 2016;24:15.
- Hu XY, Chen NN, Chai QY, et al. Integrative treatment for low back pain: An exploratory systematic review and meta-analysis of randomized controlled trials. Chin J Integr Med. 2015 Oct 26. [Epub ahead of print]
- Sit RW, Wong W, Law SW, Wu JC. Integrative Western and Traditional Chinese Medicine service model for low back pain. Int J Clin Pharmacol Ther. 2016;54(7):539-543.
- Kizhakkeveettil A, Rose K, Kadar GE. Integrative therapies for low back pain that include complementary and alternative medicine care: a systematic review. Glob Adv Health Med. 2014;3(5):49-64.
- Eisenberg DM, Buring JE, Hrbek AL, et al. A model of integrative care for low-back pain. J Altern Complement Med. 2012;18(4):354-362.
- O’Connor BB, Eisenberg DM, Buring JE, et al. Within-team Patterns of Communication and Referral in Multimodal Treatment of Chronic Low Back Pain Patients by an Integrative Care Team. Glob Adv Health Med. 2015;4(2):36-45.
- Westrom KK, Maiers MJ, Evans RL, Bronfort G. Individualized chiropractic and integrative care for low back pain: the design of a randomized clinical trial using a mixed-methods approach. Trials. 2010;11:24.
- Maiers MJ, Westrom KK, Legendre CG, Bronfort G. Integrative care for the management of low back pain: use of a clinical care pathway. BMC Health Serv Res. 2010;10:298.
- Press Release. Centers for Disease Control and Prevention. Tuesday, March 15, 2016. CDC Releases Guideline for Prescribing Opioids for Chronic Pain. Available at: http://www.cdc.gov/media/releases/2016/p0315-prescribing-opioids-guidelines.html. Accessed September 9, 2016.