Chiropractic and Pain

This section was compiled by Frank M. Painter, D.C.
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Pain-related Articles

Chronic Neck Pain and Chiropractic
A Chiro.Org article collection

We hope you will enjoy this extensive collection of articles and studies demonstrating the benefits of chiropractic care for chronic neck pain.

Neck and Back Pain in Children
A Chiro.Org article collection

We hope you will enjoy this extensive collection of articles and studies demonstrating the benefits of chiropractic care for spinal pain in children.

Low Back Pain and Chiropractic
A Chiro.Org article collection

We hope you will enjoy this extensive collection of articles and studies demonstrating the benefits of chiropractic care for low back pain.

Radiculopathy and Chiropractic Page
A Chiro.Org article collection

We hope you will enjoy this extensive collection of articles and studies demonstrating the benefits of chiropractic care for radiculopathy.

Cross-Sectional Analysis of Per Capita Supply of Doctors of Chiropractic
and Opioid Use in Younger Medicare Beneficiaries

J Manipulative Physiol Ther. 2016 (Mar 28) [Epub ahead of print] ~ FULL TEXT

In this exploratory analysis, we found a strong inverse correlation between the per-capita supply of DCs and the proportion of younger Medicare beneficiaries who filled opioid prescriptions. Further, we found a strong inverse correlation between the per-capita spending on CMT and the proportion of younger Medicare beneficiaries who filled opioid prescriptions. Based upon our findings, we suggest that Medicare consider promoting a trial of CMT prior to use of conventional medical care for patients with neck or back pain. The rationale for use of CMT prior to medical care is that concurrent medical care might result in opioid prescriptions; however, further study that examines opioid use when CMT and conventional medical care are concurrently provided is warranted.

On The Origin of Atraumatic Neuromusculoskeletal Pain
Chiropractic Journal of Australia 2016 (Jan);   44 (1):   1–8 ~ FULL TEXT

The purpose of this study was to examine the possible origins of non-specific or atraumatic back pain by applying the Gate Theory of pain and current physiologic concepts. I present a theory that accounts for the initiation and potential consequences of neuromusculoskeletal pain incorporating failure of the mechanism of muscle relaxation and resulting in pain and compromise of the lymphatic system. The theory provides an alternative to current theories and hypotheses of the cause and consequences of neuromusculoskeletal pain.

The Effect of Spinal Manipulation on Deep
Experimental Muscle Pain in Healthy Volunteers

Chiropractic & Manual Therapies 2015 (Sep 7);   23:   25 ~ FULL TEXT

The current findings do not support the theory that HVLA-manipulation has a non-specific, reflex-mediated local or generalized analgesic effect on experimentally induced deep muscle pain. This in turn suggests, that any clinical analgesic effect of HVLA-manipulation is likely related to the amelioration of a pre-existing painful problem, such as reduction of biomechanical dysfunction.

Pain Characteristics of Adolescent Spinal Pain
BMC Pediatr. 2015 (Apr 17);   15 (1):   42 ~ FULL TEXT

Adolescents who suffered from pain in more than one spinal area reported higher pain intensity and frequency than those with pain in only one spinal area. Sleep disorders were a significant predictor for pain in more than one spinal area (p < 0.01) as well as a trend for frequent pain (p = 0.06). Adolescents with frequent pain showed impaired balance on one leg standing with closed eyes (p = 0.02).

Spinal Pain in Adolescents: Prevalence, Incidence, and Course:
A School-based Two-year Prospective Cohort Study
in 1,300 Danes Aged 11-13

BMC Musculoskelet Disord. 2014 (May 29);   15:   187 ~ FULL TEXT

Spinal pain is common at the age of 11-15 years, but some have more pain than others. The pain is likely to progress, i.e., to more locations, higher frequency, and higher pain intensity over a two-year period.

Changes in Pain Sensitivity Following Spinal Manipulation:
A Systematic Review and Meta-analysis

J Electromyogr Kinesiol. 2012 (Oct);   22 (5):   752–767 ~ FULL TEXT

Spinal manipulation (SMT) demonstrated a favorable effect over other interventions on increasing PPT. Subgroup analysis showed a significant effect of SMT on increasing mechanical pressure pain threshold (PPT) at the remote sites of stimulus application supporting a potential central nervous system mechanism. Future studies of SMT related hypoalgesia should include multiple experimental stimuli and test at multiple anatomical sites.

The Effect of Spinal Manipulative Therapy on Experimentally
Induced Pain: A Systematic Literature Review

Chiropractic & Manual Therapies 2012 (Aug 10);   20 (1):   26 ~ FULL TEXT

A systematic search was performed for experimental studies on healthy volunteers and people without chronic syndromes, in which the immediate effect of SMT was tested. Articles selected were reviewed blindly by two authors. A summary quality score was calculated to indicate level of manuscript quality. Outcome was considered positive if the pain-reducing effect was statistically significant. Separate evidence tables were constructed with information relevant to each research question. Results were interpreted taking into account their manuscript quality.

Pain in the Three Spinal Regions: The Same Disorder?
Data From a Population-based Sample of 34,902 Danish Adults

Chiropractic & Manual Therapies 2012 (Apr 5);   20:   11 ~ FULL TEXT

In all, 34,902 (74%) twin individuals representative of the general Danish population, aged 20 to 71, participated in a cross-sectional nation-wide survey. Identical questions from the Standardised Nordic Questionnaire for each of the three spinal regions were used for lumbar, mid-back and neck pain respectively: Pain past year, pain ever, radiating pain, and consequences of back pain (care-seeking, reduced physical activities, sick-leave, change of work/work duties and disability pension). The relative prevalence estimates of these variables were compared for the three spinal regions.

Spinal Manipulative Therapy and Its Role in the Prevention,
Treatment and Management of Chronic Pain

J Canadian Chiro Assoc 2012 (Mar);   56 (1):   5–7 ~ FULL TEXT

Chronic pain is a worldwide epidemic. It is characterized as “pain that persists beyond normal tissue healing time” [1] and is physiologically distinct from acute nociceptive pain. The current research estimates the prevalence of chronic pain in the general population to be anywhere from 10–55%, [2] predominantly affecting the adult population. Studies indicate that the prevalence of chronic pain in the over-60 age group is double that for younger adults. [3] Furthermore, over 80% of elderly (over 65) adults suffer from some form of painful chronic joint disease [4] and greater than 85% of the general population will experience some form of chronic myofascial pain during their lifetime. [5]

Pain in Children and Adolescents: Prevalence, Impact on Daily Life,
and Parents' Perception, A School Survey

Scand J Caring Sci. 2011 (Mar);   25 (1):   27–36

Sixty per cent of the children and adolescents reported pain within the previous 3 months. Pain increased with age, where girls aged 16-18 years reported the most pain. Total prevalence of chronic pain was 21%. Children reported impact on social life; inability to pursue hobbies, disturbed sleep, absence from school, and inability to meet friends because of pain. The girls reported significantly more frequently disturbed sleep, loss of appetite, and use of medication, compared to the boys. There was little agreement between parents and children regarding pain.

Consequences of Spinal Pain: Do Age and Gender Matter?
A Danish Cross-sectional Population-based Study of 34,902
Individuals 20-71 Years of Age

BMC Musculoskelet Disord. 2011 (Feb 8);   12:   39 ~ FULL TEXT

Almost two-thirds of individuals with spinal pain did not report any consequence. Generally, consequences due to LBP were more frequently reported than those due to NP or MBP. Regardless of area of complaint, care seeking and reduced physical activities were the most commonly reported consequences, followed by sick-leave, change of work, and disability pension. There was a small mid-life peak for care-seeking and a slow general increase in reduced activities with increasing age. Increasing age was not associated with a higher reporting of sick-leave but the duration of the sick-leave increased somewhat with age. Disability pension due to spinal pain was reported exceedingly rare before the age of 50. Typically, women slightly more often than men reported some kind of consequences due to spinal pain.

Chronic Pain Reconsidered
Pain. 2008 (Aug 31);   138 (2):   267–276 ~ FULL TEXT

Chronic pain has been traditionally defined by pain duration, but this approach has limited empirical support and does not account for chronic pain's multi-dimensionality. This study compared duration-based and prospective approaches to defining chronic pain in terms of their ability to predict future pain course and outcomes for primary care patients with three common pain conditions: back pain (n=971), headache (n=1078), or orofacial pain (n=455).   At baseline, their chronic pain was classified retrospectively based on Pain Days in the prior six months and prospectively with a prognostic Risk Score identifying patients with "possible" or "probable" chronic pain.

Recognizing the Value of Chiropractic for Chronic Pain
Dynamic Chiropractic 2008 (Sep 23);   26 (20):

The guidelines actually recommend manipulation for chronic, persistent low back or neck pain and cervicogenic headache. [2] This is significant because in the past, the guidelines failed to recommend manipulation, even when other treatment strategies (medication, etc.) were rated as less effective.

Immediate Effects on Pressure Pain Threshold Following a Single
Cervical Spine Manipulation in Healthy Subjects

J Orthop Sports Phys Ther. 2007 (Jun);   37 (6):   325–329

The application of a manipulative intervention directed at the posterior joint of the C5-6 vertebral level produced an immediate increase in PPT over the lateral epicondyle of both elbows in healthy subjects. Effect sizes for the HVLA thrust manipulation were large, suggesting a strong effect of unknown clinical importance at this stage, whereas effect sizes for both placebo and control procedures were small, suggesting no significant effect.

Psychosocial Factors and their Role in Chronic Pain:
A Brief Review of Development and Current Status

Chiropractic & Osteopathy 2005 (Apr 27);   13 (1):   6 ~ FULL TEXT

The belief that pain is a direct result of tissue damage has dominated medical thinking since the mid 20th Century. Several schools of psychological thought proffered linear causal models to explain non-physical pain observations such as phantom limb pain and the effects of placebo interventions. Psychological research has focused on identifying those people with acute pain who are at risk of transitioning into chronic and disabling pain, in the hope of producing better outcomes.

Alternatives in Cancer Pain Treatment:
The Application of Chiropractic Care

Semin Oncol Nurs 2005 (Aug);   21 (3):   184–189

The judicial use of chiropractic services in cancer patients appears to offer many economical and effective strategies for reducing the pain and suffering of cancer patients, as well as providing the potential to improve patient health overall. You'll find more articles like this in the Chiropractic And Cancer Page.

Chronic Pain in Persons With Neuromuscular Disease
Clin J Pain 2005 (Jan);   21 (1):   18–26

In this paper, researchers in a medical school rehabilitation department were interested in finding out what treatments were most effective at reducing pain for neuromuscular diseases (like amyotrophic lateral sclerosis and myotonic muscular dystrophies).
Chiropractic scored the highest pain relief rating (7.33 out of 10), scoring higher than the relief provided by either nerve blocks (6.75) or opioid analgesics (6.37). WOW!!!

Qualitative Review of Studies of Manipulation-induced Hypoalgesia
J Manipulative Physiol Ther 2000 (Feb);   23 (2):   134–138

From the early 1990s, there are several reports involving the use of the pressure algometer initially devised by Fischer.[24] Vernon [25] was the first to report the improvement in paraspinal pressure pain threshold (PPT) levels after manipulation. Six tender muscle spots were measured bilaterally in a subject with chronic right-sided neck and scapular pain. The right side muscle values were all significantly lower than those on the left and were lower than the normal cut-off value of 3.5 kg/cm2 established by Fischer. [24] After a cervicoscapular manipulation, PPT levels rose by an average of 45%, whereas the patient's pain score dropped from 6 to 1/10 on a 10-centimeter VAS. In 1992, Vernon et al [12] reported on 9 subjects with chronic neck pain. Baseline PPT values were obtained bilaterally around the painful segment (fixation) for a total of 4 measured sites. Five subjects were randomly assigned to receive a rotary manipulation, and 4 subjects received the same sort of oscillatory mobilization that had been used in the endorphin study. [21] In the group receiving manipulation, PPT levels at 5 minutes after treatment rose at all 4 sites (ie, bilaterally) an average of 45%, whereas in the control group there was no increase. This difference was statistically significant at all 4 points.

Recent Considerations in Nonsteroidal Anti-inflammatory Drug Gastropathy
American Journal of Medicine 1998 (Jul 27);   105 (1B):   31S–38S

Conservative calculations estimate that approximately 107,000 patients are hospitalized annually for nonsteroidal anti-inflammatory drug (NSAID)-related gastrointestinal (GI) complications and at least 16,500 NSAID-related deaths occur each year among arthritis patients alone.
The figures for all NSAID users would be overwhelming, yet the scope of this problem is generally under-appreciated.
   Analysis of these data indicates that:
(1)   osteoarthritis (OA) and rheumatoid arthritis (RA) patients are 2.5—5.5 times more likely than the general population to be hospitalized for NSAID-related GI events;

(2)   the absolute risk for serious NSAID-related GI toxicity remains constant and the cumulative risk increases over time;

(3)   there are no reliable warning signals- >80% of patients with serious GI complications had no prior GI symptoms;

(4)   independent risk factors for serious GI events were age, prednisone use, NSAID dose, disability level, and previous NSAID-induced GI symptoms; and

(5)   antacids and H2 antagonists do not prevent NSAID-induced gastric ulcers, and high-risk NSAID users who take gastro-protective drugs are more likely to have serious GI complications than patients not taking such medications.

Currently, limiting NSAID use is the only way to decrease the risk of NSAID-related GI events.

Cartilage Maintenance in Osteoarthritis: Interaction of Cytokines, NSAID and
Prostaglandins in Articular Cartilage Damage and Repair

J Rheumatol Suppl 1991 (Mar);   28:   30–37

Evidence is presented that animal and human cartilages are sensitive to the action of certain nonsteroidal antiinflammatory drugs (NSAID) in inhibiting the synthesis of cartilage proteoglycan and also diminishing the repair activity of cartilage recovering after IL-1. In OA cartilage, the sensitivity to action of NSAID may depend on the state of the tissue in terms of glycosaminoglycan (GAG) turnover and GAG synthetic activity of the indigenous chondrocytes. Preliminary investigations of the prostaglandin analog misoprostol on the synthetic repair activities of animal and human cartilage in the presence of NSAID are reported.

Pain Has Significant Negative Effects on Health and Workplace Productivity
J Occupational and Environmental Medicine 2005 (Jul);   47 (7):   658–670

Pain is one of the leading causes of both worker absenteeism, in which an employee must take time away from work, and worker "presenteeism," in which an employee's overall effectiveness at work is limited as a result from physical and/or mental health problems. The effect pain can have on both employees and employers continues to increase significantly; by some estimates, common pain conditions now account for more than $62 billion per year in lost productivity.

Treatment Expectancy Affects the Outcome of Cognitive-Behavioral
Interventions in Chronic Pain

Clin J Pain 2005 (Jan);   21 (1):   18–26

Patients' initial beliefs about the success of a given pain treatment are shown to have an important influence on the final treatment outcome. The aims of the paper are to assess determinants of patients' treatment expectancy and to examine the extent to which treatment expectancy predicts the short-term and long-term outcome of cognitive-behavioral treatment of chronic pain.

Pain Costs Employers Billions in Lost Wages for Sick Days
American employers lose billions of dollars each year because pain keeps workers off the job, according to a 1996 survey by Louis Harris & Associates. "Pain is a major cause of absenteeism in the workforce," said Robert Leitman, Executive Vice President, Louis Harris. "In 1995, pain caused 50 million lost work days at a cost to employers of at least $3 billion in wages for employees who called in sick."

In The Opinion of Drug Companies

Pain and Older Americans Survey
One in five Americans over age 60 takes medication to control pain that lasts for six months or more (chronic pain). This represents 18% of Americans in this age group, or 7.5 million people.

Nearly One in Five Seniors Takes Medication for Chronic Pain
Nearly one in five Americans over age 60 regularly takes medication for chronic pain, according to a 1997 survey. The majority of the 7.5 million seniors who take medication for chronic pain say their medications are effective, but one in four suffers from side effects caused by the drugs. Nearly 40 percent say doctors don't discuss possible side effects of pain medication they prescribe, and half say doctors don't warn them about potential drug interactions.

Pain Is Undertreated in Seniors, Experts Say
Safer, more effective therapy could improve the quality of life of older Americans who take pain medication. This conclusion was shared by pain specialists and experts on aging who reviewed findings of a survey released in June 1997 by The National Council on the Aging, Inc. (NCOA). The survey, conducted by Louis Harris & Associates on behalf of NCOA, examined how pain and its treatment affect the lives of the nearly one in five Americans over age 60 who regularly take pain medication for arthritis and other chronic pain conditions.

End of Opinion

1999 National Pain Survey ~ Executive Summary
Approximately 24 percent of Americans, or roughly 48 million people, suffer from chronic pain; 21.6 million Americans, or one in ten (11%) adults, take prescription pain medication regularly to manage chronic pain; Among individuals taking prescription pain medication, the most common types of chronic pain are arthritis (31%), lower back pain (25%), other types of bone/joint pain (17%), muscle pain or stiffness (13%) and fibromyalgia (12%).

Proving the Existance of Chronic Pain
Pain is ultimately a subjective experience. Proving the existence of pain is therefore, not possible. In practice, when a patient reports pain, the patient is believed to have pain. Yet, not all pain is the same. There may be a variety of reasons for reporting pain to a physician---pain, drug seeking, psychological problems, litigation needs---but there is always a reason. The critical issue is how to untangle the other factors from pain, recognizing that these factors may drive pain and pain may drive these factors.

From the Gate to the Neuromatrix
Pain 1999;   Suppl 6 Aug:   S121–126

The gate control theory's most important contribution to understanding pain was its emphasis on central neural mechanisms. The theory forced the medical and biological sciences to accept the brain as an active system that filters, selects and modulates inputs. The dorsal horns, too, were not merely passive transmission stations but sites at which dynamic activities (inhibition, excitation and modulation) occurred. The great challenge ahead of us is to understand brain function.

Neuroanatomy of the Pain System and of the Pathways that Modulate Pain
J Clin Neurophysiol 1997 (Jan);   14 (1):   2–31

We review many of the recent findings concerning mechanisms and pathways for pain and its modulation, emphasizing sensitization and the modulation of nociceptors and of dorsal horn nociceptive neurons.

Substance P Induced by Peripheral Nerve Injury in Primary Afferent
Sensory Neurons and its Effect on Dorsal Column Nucleus Neurons

J Neurosci 1995 (Nov);   15 (11):   7633–7643

These data indicate that the de novo synthesized SP in the lesioned primary afferent neurons may be involved in an augmentation of excitability in the dorsal column-medial lemniscus sensory pathway. This hyperexcitability may play a role in the pathogenesis of abnormal neuropathic sensations following peripheral nerve injury.

Validity of Five Common Manual Neck Pain–provoking Tests
Scand J Rehabil Med 1995 (Sep);   27 (3):   131–136

This study revealed that palpation for pain was the most reproducable and accurate assessment of reported neck pain. They state: "Palpation over the facet joints in the cervical spine was found to be the most appropriate screening test to corroborate the replies in self–reported questionnaires on dysfunctions of the neck."

Interexaminer Reliability of Palpation for Cervical Spine Tenderness
Scand J Rehabil Med 1995 (Sep);   27 (3):   131–136

As with the study above, spinal palpation for tenderness was found to ba a valid examinatioin tool. They stated: "In this population, palpation for cervical spine tenderness is a highly reliable examination tool."

Cartilage Maintenance in Osteoarthritis: Interaction of Cytokines,
NSAID and Prostaglandins in Articular Cartilage Damage and Repair

J Rheumatol Suppl 1991 (Mar);   28:   30–37

The structural integrity of the matrix of human articular cartilage is maintained by a dynamic equilibrium between synthesis and degradation. In osteoarthritis (OA), synthesis may be inhibited by the presence of subnanogram quantities of the cytokine interleukin 1 (IL-1), leading in the longterm to loss of matrix and susceptibility to mechanical damage. IL-1 may also inhibit the potential for repair processes to take place in this cartilage if continued synthesis and secretion of the cytokine occurs. Evidence is presented that animal and human cartilages are sensitive to the action of certain nonsteroidal antiinflammatory drugs (NSAID) in inhibiting the synthesis of cartilage proteoglycan and also diminishing the repair activity of cartilage recovering after IL-1.

Pain ~ Links of Interest

   American Pain Society   (APS)

   International Association for the Study of Pain

   National Headache Foundation

   NIH Consensus Statement on the Use of Acupuncture

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