CHIROPRACTIC AND SPINAL PAIN MANAGEMENT
 
   

Chiropractic and
Spinal Pain Management

This section was compiled by Frank M. Painter, D.C.
Send all comments or additions to:
  Frankp@chiro.org

If there are terms in these articles you don't understand, you can get a definition from the Merriam Webster Medical Dictionary. If you want information about a specific disease, you can access the Merck Manual. You can also search Pub Med for more abstracts on this, or any other health topic.

Jump to: Pain Resources Pain-related Articles Patient Expectations


Chiropractic in an Integrative Health Care Model Pain Links
 
   

Pain-related Resources
 
   

Chiropractors as the Spinal Health Care Experts
A Chiro.Org article collection

Enjoy these learned articles about chiropractors as first-contact Spinal Health Care Experts.

Chronic Neck Pain and Chiropractic
A Chiro.Org article collection

Review this extensive collection of studies detailing how chiropractic and spinal manipulation are effective for the relief of spinal pain.

Pregnancy-related Spinal Pain and Chiropractic
A Chiro.Org article collection

Review this growing collection of studies detailing how effective chiropractic management is for pregancy-related low back and pelvic 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.

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.

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.

Low Back Pain Guidelines from Around the World
A Chiro.Org article collection

A new addition from the American College of Physicians (2017) recommends the use of noninvasive, non-drug treatments for low back pain before resorting to drug therapies, which were found to have limited benefits. One of the non-drug options cited by ACP is spinal manipulation. This section also includes recommendations from the California Industrial Medical Council, the Royal College of General Practitioners, the 1994 AHCPR guides, the "Mercy Conference Document", and the New Zealand "Psychosocial Yellow Flags" Page

Proving the Existance of Chronic Pain
Steven G. Yeomans, DC, FACO, and Jeffrey E. Fitzthum, DC, MD
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.

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).

Interestingly, chiropractic scored with the highest pain relief rating
(7.33 out of 10), scoring higher than the relief provided by either:
  • nerve blocks   (6.75),
  • opioid analgesics   (6.37),
  • Muscle relaxants   (5.78),
  • Massage   (5.48),
  • Acupuncture   (5.29), or
  • Ibuprofen, aspirin   (5.22).   WOW!!!

 
   

Pain-related Articles
 
   
A Unique Series of Medical Guidlines

All 3 of the following guidelines reviewed the medical literature on low back pain and strongly advise medical doctors to first recommend non-pharmacologic therapies, including chiropractic, BEFORE resorting to offering NSAIDs, opiates or other more invasive treatments, for low back (spinal) pain patients.

These recommendations will:

  1. save money,
  2. will increase patient satisfaction,
  3. will improve patient outcomes and
  4. will reduce chronicity.

Guideline for Opioid Therapy and Chronic Noncancer Pain
CMAJ. 2017 (May 8);   189 (18):   E659–E666 ~ FULL TEXT

This new Canadian guideline published today (May 8, 2017) in the Canadian Medical Association Journal (CMAJ) strongly recommends doctors to consider non-pharmacologic therapy, including chiropractic, in preference to opioid therapy for chronic non-cancer pain.   The guideline is the product of an extensive review of evidence involving input from medical, non-medical, regulatory, and patient stakeholders.

Association of Spinal Manipulative Therapy With Clinical Benefit and Harm
for Acute Low Back Pain: Systematic Review and Meta-analysis

JAMA. 2017 (Apr 11);   317 (14):   1451–1460 ~ FULL TEXT

For the second time in as many months, a prominent medical journal has endorsed spinal manipulation for the management of low back pain. [1] On April 11th 2017, JAMA published a systematic review of 26 randomized clinical trials in order to evaluate the safety and effectiveness of spinal manipulation for low back pain.  The authors concluded:   “Among patients with acute low back pain, spinal manipulative therapy was associated with improvements in pain and function with only transient minor musculoskeletal harms.”

Noninvasive Treatments for Acute, Subacute, and Chronic
Low Back Pain: A Clinical Practice Guideline From
the American College of Physicians

Ann Intern Med. 2017 (Apr 4);   166 (7):   514–530 ~ FULL TEXT

Given that most patients with acute or subacute low back pain improve over time regardless of treatment, clinicians and patients should select nonpharmacologic treatment with superficial heat (moderate-quality evidence), massage, acupuncture, or spinal manipulation (low-quality evidence). If pharmacologic treatment is desired, clinicians and patients should select nonsteroidal anti-inflammatory drugs or skeletal muscle relaxants (moderate-quality evidence).   (Grade: strong recommendation).


Elevated Production of Nociceptive CC-chemokines and sE-selectin
in Patients with Low Back Pain and the Effects of Spinal Manipulation:
A Non-randomized Clinical Trial

Clin J Pain. 2017 (Apr 19) [Epub] ~ FULL TEXT

The production of chemotactic cytokines is significantly and protractedly elevated in LBP patients. Changes in chemokine production levels, which might be related to SMT, differ in the acute and chronic LBP patient cohorts.

Provider and Patient Perspectives on Opioids and Alternative Treatments
for Managing Chronic Pain: A Qualitative Study

BMC Fam Pract. 2017 (Mar 24);   17 (1):   164 ~ FULL TEXT

Despite widespread dissatisfaction with opioid medications for pain management, many practical barriers challenged access to other options. Most of the participants' perceived acupuncture and chiropractic (A/C) care as helpful for short term pain relief. We identified that problems with timing, expectations, and plan coverage limited A/C care potential for pain relief treatment.   CONCLUSIONS:   These results suggest that education about realistic expectations for chronic pain management and therapy options, as well as making acupuncture and chiropractic (A/C) care more easily accessible, might lead to more satisfaction for patients and providers, and provide important input to policy makers.

Complementary and Alternative Medicine Use by Children
with Pain in the United States

Acad Pediatr. 2017 (Feb 20).  pii: S1876-2859(17)30063-3

Parents reported that 26.6% of children had pain conditions (e.g. headache, abdominal, musculoskeletal pain) in the past year; of these children, 21.3% used CAM. In contrast only 8.1% of children without pain conditions used CAM (χ2: p<.001). CAM use among children with pain was associated with female sex (adjusted odds ratio (aOR)=1.49, p=0.005), higher income (aOR=1.61, p=0.027), and presence of 4+ comorbidities (aOR=2.01, p=0.013). Among children with pain who used CAM the 2 most commonly used CAM modalities were biologically-based therapies (47.3%) (e.g., special diets and herbal supplements) and manipulative or body-based therapies (46.3%) (e.g., chiropractic and massage).   CONCLUSIONS: CAM is frequently used by children with pain in the USA and many parents report benefits for their child's symptoms.

Non-steroidal Anti-inflammatory Drugs for Spinal Pain:
A Systematic Review and Meta-analysis

Annals of the Rheumatic Diseases 2017 (Feb 2) [Epub ahead of print]

While it is now clear that paracetamol is ineffective for spinal pain, there is not consensus on the efficacy of non-steroidal anti-inflammatory drugs (NSAIDs) for this condition. We performed a systematic review with meta-analysis to determine the efficacy and safety of NSAIDs for spinal pain. We included 35 randomised placebo-controlled trials. NSAIDs reduced pain and disability, but provided clinically unimportant effects over placebo. Six participants (95% CI 4 to 10) needed to be treated with NSAIDs, rather than placebo, for one additional participant to achieve clinically important pain reduction. When looking at different types of spinal pain, outcomes or time points, in only 3 of the 14 analyses were the pooled treatment effects marginally above our threshold for clinical importance. NSAIDs increased the risk of gastrointestinal reactions by 2.5 times (95% CI 1.2 to 5.2), although the median duration of included trials was 7 days.

Regular Use of Medication for Musculoskeletal Pain and Risk of
Long-term Sickness Absence: A Prospective Cohort Study
Among the General Working Population

Eur J Pain. 2017 (Feb);   21 (2):   366–373 ~ FULL TEXT

Regular use of pain medication due to musculoskeletal pain is prospectively associated with long-term sickness absence (LTSA) even when adjusted for pain intensity. This study suggests that use of pain medication can be an important factor to be aware of in the prevention of sickness absence. Thus, regular use of pain medication – and not solely the intensity of pain – can be an early indicator that musculoskeletal pain can lead to serious consequences such as long-term sickness absence.

Combining Pain Therapy with Lifestyle: The Role of Personalized
Nutrition and Nutritional Supplements According to the
SIMPAR Feed Your Destiny Approach

J Pain Res. 2016 (Dec 8);   9:   1179–1189 ~ FULL TEXT

Recently, attention to the lifestyle of patients has been rapidly increasing in the field of pain therapy, particularly with regard to the role of nutrition in pain development and its management. In this review, we summarize the latest findings on the role of nutrition and nutraceuticals, microbiome, obesity, soy, omega-3 fatty acids, and curcumin supplementation as key elements in modulating the efficacy of analgesic treatments, including opioids. These main topics were addressed during the first edition of the Study In Multidisciplinary Pain Research workshop: "FYD (Feed Your Destiny): Fighting Pain", held on April 7, 2016, in Rome, Italy, which was sponsored by a grant from the Italian Ministry of Instruction on "Nutraceuticals and Innovative Pharmacology".

Multidimensional Diagnostic Criteria for Chronic Pain:
Introduction to the ACTTION-American Pain Society
Pain Taxonomy (AAPT)

J Pain. 2016 (Sep);   17 (9 Suppl):   T1–9 ~ FULL TEXT

A variety of approaches have been used to develop diagnostic criteria for chronic pain. The published evidence of the reliability and validity of existing diagnostic criteria is limited, and these criteria have typically not been used in clinical practice. The availability of a widely accepted, consistently applied, and evidence-based taxonomy of diagnostic criteria would improve the quality of clinical research on chronic pain and would be of great value in clinical practice. To address the need for evidence-based diagnostic criteria for the major chronic pain conditions, the Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks (ACTTION) public-private partnership with the US Food and Drug Administration and the American Pain Society (APS) have collaborated on the development of the ACTTION-APS Pain Taxonomy (AAPT).

Whose Pain Is It Anyway? Comparability of Pain Reports
From Children and Their Parents

Chiropractic & Manual Therapies 2016 (Aug 1);   24:   24 ~ FULL TEXT

Percentage agreement between parent and child assessment was around 50% in Sample 1 and 68% in Sample 2. The poor agreement was due to children reporting pain when their parent did not, the reverse very rarely occurred. Pain of greater intensity or longer duration resulted in better agreement between the child and parent. Child age and gender did not influence the likelihood of agreement.

Neural Correlates of Fear of Movement in Patients with
Chronic Low Back Pain vs. Pain-Free Individuals

Front Hum Neurosci. 2016 (Jul 26);   10:   386 ~ FULL TEXT

In the current fMRI study, we applied a novel approach encompassing: (1) video clips of potentially harmful activities for the back as fear of movement (FOM) inducing stimuli; and (2) the assessment of FOM in both, chronic low back pain (cLBP) patients (N = 20) and age- and gender-matched pain-free subjects (N = 20). Derived from the fear avoidance (FA) model, we hypothesized that FOM differentially affects brain regions involved in fear processing in patients with cLBP compared to pain-free individuals due to the recurrent pain and subsequent avoidance behavior.

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

J Manipulative Physiol Ther. 2016 (May);   39 (4):   263–266 ~ 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.

Does Cervical Spine Manipulation Reduce Pain in People With
Degenerative Cervical Radiculopathy? A Systematic Review
of the Evidence, and a Meta-analysis

Clinical Rehabilitation 2016 (Feb);   30 (2):   145–155

Three trials with 502 participants were included. Meta-analysis suggested that cervical spine manipulation (mean difference 1.28, 95% confidence interval 0.80 to 1.75; P < 0.00001; heterogeneity: Chi(2) = 8.57, P = 0.01, I(2) = 77%) improving visual analogue scale for pain showed superior immediate effects compared with cervical computer traction. The overall strength of evidence was judged to be moderate quality. One out of three trials reported the adverse events and none with a small sample size.

Attenuation Effect of Spinal Manipulation on Neuropathic and Postoperative
Pain Through Activating Endogenous Anti-Inflammatory Cytokine
Interleukin 10 in Rat Spinal Cord

J Manipulative Physiol Ther. 2016 (Jan);   39 (1):   42–53 ~ FULL TEXT

After CCD and de-CCD treatments, the animals exhibited behavioral and neurochemical signs of neuropathic pain manifested as mechanical allodynia and thermal hyperalgesia, DRG inflammation, DRG neuron hyperexcitability, induction of c-Fos, and the increased expression of PKCγ in the spinal cord as well as increased level of IL-1β and TNF-α in DRG and the spinal cord. Repetitive Activator-assisted spinal manipulative therapy significantly reduced simulated neuropathic and postoperative pain, inhibited or reversed the neurochemical alterations, and increased the anti-inflammatory IL-10 in the spinal cord.

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).

A Qualitative Study of Changes in Expectations Over Time Among Patients
with Chronic Low Back Pain Seeking Four CAM Therapies

BMC Complement Altern Med. 2015 (Feb 5);   15:   12 ~ FULL TEXT

These findings suggest the value of further research into the potential of the CAM therapeutic process to assist patients in taking control of their health management and wellness. Sointu [58] argues that CAM use is becoming increasingly common because the “discourse of well-being” (9) embedded in CAM interactions (see also [24, 25]) resonates with how people understand their bodies and selves. Our data support the finding that CAM participants report greater awareness of the need for ongoing engagement in their own care, an increased sense of control or empowerment, and motivation to seek effective coping strategies. [ Editorial Comment: These are all things that conventional medicine struggles with.]

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]

Elevated Production of Inflammatory Mediators Including Nociceptive
Chemokines in Patients With Neck Pain: A Cross-Sectional Evaluation

J Manipulative Physiol Ther. 2011 (Oct);   34 (8):   498–505 ~ FULL TEXT

Production of inflammatory mediators was consistently elevated in NP patients in this study, both in vitro and in vivo, and activation of inflammatory pathways was accompanied by up-regulation of CC chemokine synthesis. This suggests that, in NP patients, CC chemokines may be involved in regulation of local inflammatory response through recruitment of immune cells to the inflamed tissue and exert pronociceptive effects.

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.

Pain Management by Primary Care Physicians, Pain Physicians,
Chiropractors, and Acupuncturists: A National Survey

Southern Medical Journal 2010 (Aug);   103 (8):   738–747

Of the chronic pain patients seen for evaluation, the percentages subsequently treated on an ongoing basis range from 51% (PCPs) to 63% (pain physicians). Pain physicians prescribe long-acting opioids such as methadone, antidepressants or anti-convulsants, and other nontraditional analgesics approximately 50–100% more often than PCPs. Twenty-nine percent of PCPs and 16% of pain physicians reported prescribing opioids less often than they deem appropriate because of regulatory oversight concerns. Of the four groups, PCPs are least likely to feel confident in their ability to manage musculoskeletal pain and neuropathic pain, and are least likely to favor mandatory pain education for all PCPs.

Spinal Manipulative Therapy Has an Immediate Effect on Thermal Pain
Sensitivity in People With Low Back Pain: A Randomized Controlled Trial

Phys Ther. 2009 (Dec); 89 (12): 1292–1303

Hypoalgesia to A-delta fiber-mediated pain perception was not observed. Group-dependent hypoalgesia of temporal summation specific to the lumbar innervated region was observed. Pair-wise comparisons indicated significant hypoalgesia in participants who received SMT, but not in those who rode a stationary bicycle or performed low back extension exercises. Psychological factors did not significantly correlate with changes in temporal summation in participants who received SMT.

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.

Efficacy of Selected Complementary and Alternative Medicine
Interventions For Chronic Pain

J Rehabil Res Dev. 2007;   44 (2):   195–222 ~ FULL TEXT

Complementary and alternative medicine (CAM) is a group of diverse medical and healthcare systems, therapies, and products that are not presently considered part of conventional medicine. This article provides an up-to-date review of the efficacy of selected CAM modalities in the management of chronic pain. Findings are presented according to the classification system developed by the National Institutes of Health National Center for Complementary and Alternative Medicine (formerly Office of Alternative Medicine) and are grouped into four domains: biologically based medicine, energy medicine, manipulative and body-based medicine, and mind-body medicine.

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.

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.

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.

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.

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!!!

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.

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.

Clinical Study on Manipulative Treatment of Derangement
of the Atlantoaxial Joint

J Tradit Chin Med 1999 (Dec);   19 (4):   273–278

The derangement of the atlantoaxial joint is one of main cervical sources of dizziness and headache, which were based on the observation on the anatomy of the upper cervical vertebrae, analysis of X-ray film of the atlantoaxial joint, and the manipulative treatment in 35 patients with cervical spondylosis.

Spinal Pain Syndromes:
Nociceptive, Neuropathic, and Psychologic Mechanisms

J Manipulative Physiol Ther 1999 (Sep);   22 (7):   458–472 ~ FULL TEXT

Although the treatment of neuropathic pain is difficult, sufficient evidence in the literature demonstrates that the treatment of nociceptive pain should be multimodal and involve spinal manipulation, muscle lengthening/stretching, trigger point therapy, rehabilitation exercises, electrical modalities, a variety of nutritional factors, and mental/emotional support.

Chronic Spinal Pain Syndromes: A Clinical Pilot Trial Comparing Acupuncture,
A Nonsteroidal Anti-inflammatory Drug, and Spinal Manipulation

J Manipulative Physiol Ther 1999 (Jul);   22 (6):   376–381 ~ FULL TEXT

The consistency of the results provides, in spite of several discussed shortcomings of this pilot study, evidence that in patients with chronic spinal pain syndromes spinal manipulation, if not contraindicated, results in greater improvement than acupuncture and medicine.

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.

1999 National Pain Survey ~ Executive Summary
Ortho-McNeil Pharmaceutical

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%).

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.

Dysafferentation: A Novel Term to Describe the Neuropathophysiological
Effects of Joint Complex Dysfunction. A Look at Likely Mechanisms
of Symptom Generation

J Manipulative Physiol Ther 1998 (May);   21 (4):   267–280 ~ FULL TEXT

Joint complex dysfunction should be included in the differential diagnosis of pain and visceral symptoms because joint complex dysfunction can often generate symptoms which are similar to those produced by true visceral disease.
You may also enjoy this response from another chiropractic researcher.

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.

Chronic Cervical Zygapophysial Joint Pain After Whiplash:
A Placebo–Controlled Prevalence Study

SPINE 1996 (Aug 1);   21 (15):   1737–1744

The prevalence of cervical zygapophysial joint pain after whiplash has been studied by means of comparative local anesthetic blocks. The concern is that such blocks may be compromised by placebo responses and that prevalence estimates based on such blocks may exaggerate the importance of this condition. In this study, sixty-eight consecutive patients referred for chronic neck pain after whiplash were studied. Those who did not experience pain relief together with the patients with dominant neck pain proceeded to undergo placebo-controlled local anesthetic blocks. Two different local anesthetics and a placebo injection of normal saline were administered in random order and under double-blindfolded conditions. A positive diagnosis was made if the patient's pain was completely and reproducibly relieved by each local anesthetic but not by the placebo injection. Overall, the prevalence of cervical zygapophysial joint pain (C2-C3 or below) was 60% (95% confidence interval, 46%, 73%).

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.

Long-term Outcome After Whiplash Injury: A 2-year Follow-up Considering
Features of Injury Mechanism and Somatic, Radiologic, and Psychosocial Findings

Medicine (Baltimore) 1995 (Sep);   74 (5):   281–297

Previous studies, however, focused on somatic symptoms on the one hand or considered only psychological or neuropsychological variables on the other hand, often in loosely defined or selected groups of patients. No study so far has analyzed the long-term outcome in a nonselected group of patients using a clear injury definition considering patient history; somatic, radiologic, and neuropsychological findings; and features of the injury mechanisms assessed soon after trauma and during follow-up. With regard to baseline findings the following significant differences were found (on this cohort): Symptomatic patients were older, had higher incidence of rotated or inclined head position at the time of impact, had higher prevalence of pretraumatic headache, showed higher intensity of initial neck pain and headache, complained of a greater number of symptoms, had a higher incidence of symptoms of radicular deficit and higher average scores on a multiple symptom analysis, and displayed more degenerative signs (osteoarthrosis) on X ray.

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."

The Prevalence of Chronic Cervical Zygapophysial Joint Pain
After Whiplash

Spine Journal 1995 (Jan 1);   20 (1):   20–26

In a significant proportion of patients with whiplash, chronic, refractory neck pain develops. Provisional data suggest many of these patients have zygapophysial joint pain, but the diagnosis has been established by single, uncontrolled diagnostic block. In this study, fifty consecutive, referred patients with chronic neck pain after whiplash injury were studied using double-blind, controlled, diagnostic blocks of the cervical zygapophysial joints. On separate occasions, the joint was blocked with either lignocaine or bupivacaine in random order. A positive diagnosis was made only if both blocks relieved the patient's pain and bupivacaine provided longer relief. In this population, cervical zygapophysial joint pain was the most common source of chronic neck pain after whiplash.

Contribution of Central Neuroplasticity to Pathological Pain:
Review of Clinical and Experimental Evidence

Pain 1993 (Mar);   52 (3):   259–285

Peripheral tissue damage or nerve injury often leads to pathological pain processes, such as spontaneous pain, hyperalgesia and allodynia, that persist for years or decades after all possible tissue healing has occurred. Although peripheral neural mechanisms, such as nociceptor sensitization and neuroma formation, contribute to these pathological pain processes, recent evidence indicates that changes in central neural function may also play a significant role.

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 Costs Employers Billions in Lost Wages for Sick Days
Business and Health Magazine

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
The National Council on the Aging

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
The National Council on the Aging

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
The National Council on the Aging

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

 
   

Patient Expectations of Relief
 
   

A Qualitative Study of Changes in Expectations Over Time Among
Patients with Chronic Low Back Pain Seeking Four CAM Therapies

BMC Complement Altern Med. 2015 (Feb 5);   15:   12 ~ FULL TEXT

Pre-treatment expectations consisted of conjecture about whether or not the CAM therapy could relieve pain and improve participation in meaningful activities. Expectations tended to shift over the course of treatment to be more inclusive of broader lifestyle factors, the need for long-term pain management strategies and attention to long-term quality of life and wellness. Although a shift toward greater acceptance of chronic pain and the need for strategies to keep pain from flaring was observed across participants regardless of therapy, participants varied in their assessments of whether increased awareness of the need for ongoing self-care and maintenance strategies was considered a "positive outcome". Regardless of how participants evaluated the outcome of treatment, participants from all four therapies reported increased awareness, acceptance of the chronic nature of pain, and attention to the need to take responsibility for their own health.

Individual Expectation: An Overlooked, But Pertinent, Factor in the
Treatment of Individuals Experiencing Musculoskeletal Pain

Phys Ther. 2010 (Sep);   90 (9):   1345–1355 ~ FULL TEXT

Physical therapists consider many factors in the treatment of patients with musculoskeletal pain. The current literature suggests expectation is an influential component of clinical outcomes related to musculoskeletal pain for which physical therapists frequently do not account. The purpose of this clinical perspective is to highlight the potential role of expectation in the clinical outcomes associated with the rehabilitation of individuals experiencing musculoskeletal pain. The discussion focuses on the definition and measurement of expectation, the relationship between expectation and outcomes related to musculoskeletal pain conditions, the mechanisms through which expectation may alter musculoskeletal pain conditions, and suggested ways in which clinicians may integrate the current literature regarding expectation into clinical practice.

Expectations for Recovery Important in the Prognosis of Whiplash Injuries
PLoS Med. 2008 (May 13);   5 (5):   e105 ~ FULL TEXT

In conclusion, we suggest early assessment of expectations for recovery to be made, in order to identify people at risk for poor prognosis after WAD. Furthermore, controlled studies on interventions aimed at modifying expectations are warranted. Such studies could be conducted on the population level, similar to the successful media campaign on back pain beliefs, which decreased disability claims, both in terms of incidence and time on benefits. [31, 32] Alternatively interventions targeting persons in the acute phase of an injury should be evaluated. Finally, it is not inconceivable that our findings can be extended to persons with pain conditions other than WAD.

The Influence of Expectation on Spinal Manipulation Induced Hypoalgesia:
An Experimental Study in Normal Subjects

BMC Musculoskelet Disord. 2008 (Feb 11);   9:   19 ~ FULL TEXT

The current study replicates prior findings of c- fiber mediated hypoalgesia in the lower extremity following SMT and this occurred regardless of expectation. A significant increase in pain perception occurred following SMT in the low back of participants receiving negative expectation suggesting a potential influence of expectation on SMT induced hypoalgesia in the body area to which the expectation is directed.

 
   

Chiropractic in an Integrative Health Care Model
 
   

Principles of Integrative Medicine

Creating an integrative medicine model for patient care is about more than randomly choosing between methods of the traditional healthcare system and the alternative medicine sector. Integrative healthcare, to effectively treat chronic pain, combines any and all safe and effective treatment modalities, without regard for whether the modality originated in the allopathic, pharmaceutical or CAM arena.

Chiropractors as the Spinal Health Care Experts
A Chiro.Org article collection

Enjoy these articles about chiropractors as first-contact Spinal Health Care Experts.

Integrated Health Care and Chiropractic
A Chiro.Org article collection

Enjoy these articles about chiropractic integration into HMOs, IPAs and the Veterans program..

An Integrated Approach to Chronic Pain
Dynamic Chiropractic ~ May 2017 ~ FULL TEXT

Findings from a unique Medicaid pilot project in Rhode Island involving high-use Medicaid recipients from two health plans were recently presented to the state's Department of Health, [1] demonstrating stellar outcomes with regard to medication use, ER visits, health care costs and patient satisfaction.   Since 2012, Rhode Island Medicaid "Community of Care" enrollees suffering from chronic pain have participated in an integrated chronic pain program administered by Advanced Medicine Integration. Longtime readers will recall that for nearly two decades, AMI has been coordinating chiropractic and integrated care services in various states to help address the chronic pain epidemic in a community-based, integrated fashion. [2-3]

Integrative Health Care for a Medicaid Population:
Interview with Alan Post, D.C.

Topics in Integrative Health Care 2012;   3 (4) ~ FULL TEXT

In the United States, Medicaid is the government-sponsored health insurance program for people with the lowest incomes and many who are disabled. Medicaid is paid for by a combination of federal and state government funds, with the federal share covering the majority of costs. In the state of Rhode Island, Medicaid initiated in 2012 a pilot program under which management of patients with chronic pain would include the option of chiropractic, acupuncture and massage therapy services. In this interview with Rhode Island chiropractor Alan Post, DC, he describes the specifics of the program and emphasizes its cost-saving potential.   Alan R. Post, DC, is past president of the Chiropractic Society of Rhode Island and the New England Chiropractic Council. He holds a Bachelor of Science in Human Biology and graduated with honors from Logan College of Chiropractic in 1982. At various points in his career, he has served as a state-appointed Medical Examiner for the Rhode Island Workers’ Compensation System, as a member of the Rhode Island Blue Cross Specialty Advisory Board for Chiropractic, the Specialty Advisory Board for the Physician One Health Plan. He currently serves as a member of the Advisory Board at the University of Bridgeport Chiropractic College.

AMI Model Working in Florida: Functional Improvements,
Reduced Utilization Costs by Medicaid Patients

Dynamic Chiropractic ~ April 22, 2008 ~ FULL TEXT

Background:   Alternative Medicine Integration (AMI) originally achieved recognition within the chiropractic community for its unique HMO model that utilized doctors of chiropractic as primary-care physicians (PCPs) and the portal of entry into an integrated health care delivery system, inclusive of hospitals, MDs and MD specialists and outpatient facilities.   Contracted with Blue Cross Blue Shield's HMO-Illinois, AMI's integrated IPA demonstrated excellent clinical and cost outcomes.   These outcomes were published in the June 2007 issue of JMPT and reviewed in the June 4, 2007 issue of DC. [1] In July 2007, AMI received the national endorsement of the Congress of Chiropractic State Associations (COCSA) for its outcomes-based model of chiropractic medical management.

Chiropractors as Primary Care Providers
Dynamic Chiropractic ~ June 4, 2007 ~ FULL TEXT

The latest issue of the Journal of Manipulative and Physiological Therapeutics features an update to Sarnat and Winterstein's 2004 research paper that assessed chiropractors' effectiveness as primary care providers (PCPs).   As with the 2004 report, the latest research concludes that a managed care network with chiropractic gatekeepers saves substantial costs and results in decreased utilization as compared to PCPs using conventional medicine alone.

Clinical Utilization and Cost Outcomes from an Integrative Medicine
Independent Physician Association: An Additional 3-year Update

J Manipulative Physiol Ther 2007 (May);   30 (4):   263–269 ~ FULL TEXT

The initial report (JMPT 2004 (Jun) ; 27 (5): 336–347) analyzed clinical and cost utilization data from the years 1999 to 2002 for an integrative medicine independent physician association (IPA) whose primary care physicians (PCPs) were exclusively doctors of chiropractic.

This report updates the subsequent utilization data from the IPA for the years 2003 to 2005 and includes first-time comparisons in data points among PCPs of different licensures who were oriented toward complementary and alternative medicine (CAM).   The authors found that:

“During the past 7 years, and with a larger population than originally reported, the CAM-oriented PCPs using a nonsurgical/nonpharmaceutical approach demonstrated reductions in both clinical and cost utilization when compared with PCPs using conventional medicine alone.”

The savings?   Clinical and cost utilization based on 70,274 member-months over a 7-year period demonstrated decreases of:

60.2% in-hospital admissions
59.0% less hospital days
62.0% less outpatient surgeries and procedures and
85% less pharmaceutical costs

when compared with conventional medicine IPA performance for the same health maintenance organization product in the same geography and time frame.

Clinical and Cost Outcomes of an Integrative Medicine IPA
J Manipulative Physiol Ther 2004 (Jun) ;   27 (5):   336–347 ~ FULL TEXT

In 1999, a large Chicago HMO began to utilize doctors of chiropractic (DCs) in a primary care provider role. The DCs focused on assessment and evaluation of risk factors and practiced with a non-pharmaceutical/non-surgical approach. Insurance claims and patient surveys were analyzed to compare clinical outcomes, costs and member satisfaction with a normative control group.

During the 4-year study, this integrative medical approach, emphasizing a variety of complimentary and alternative medical (CAM) therapies, resulted in lower patient costs and improved clinical outcomes for patients. The patients who went to DCs as their primary care providers had 43 percent decreases in hospital admissions, 52 percent reductions in pharmaceutical costs and 43 percent fewer outpatient surgeries and procedures.

If you like these results, you will absolutely LOVE the 7-Year Follow-Up!

 
   

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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