A new paradigm for musculoskeletal pain care: moving beyond structural impairments. Conclusion of a chiropractic and manual therapies thematic series

Julie M. Fritz; Alice Kongsted

doi:10.1186/s12998-023-00484-2

Table 1

Summary of the paper included in the thematic series

Authors / Title Methods Aim Authors’ Conclusion
Belton J, Birkinshaw H, Pincus T.
Patient-centered consultations for persons with musculoskeletal conditions [4].
Personal account of a patient and narrative discussion This article is structured in a way that reflects this collaboration [between the healthcare professional and patient], showcasing the importance of acknowledging lived experience, the sharing of information, and the dynamic interactions that shape a consultation, in combination with supporting scientific evidence. This article has discussed several recommendations for clinicians to use in consultations for chronic pain… Ultimately, shared uncertainty between healthcare professionals and patients is the beginning of a journey together exploring the path of pain management. Accompanied by listening, validation, empathy and reassurance, a willingness to explore the paths together and accept the uncertainty of the journey is key to moving forward with chronic pain, for both healthcare professionals and people with pain.

Bronfort G, Maiers M, Schulz C, Leininger B, Westrom K, Angstman G, Evans R.
Multidisciplinary integrative care versus chiropractic care for low back pain: a randomized clinical trial [8].
Randomized clinical trial The purpose of this manuscript is to report the primary and secondary clinical outcomes of a randomized trial of mono-disciplinary chiropractic care, versus multidisciplinary integrative care for sub-acute and chronic low back pain. Low back pain patients who received integrative care by a multidisciplinary integrative care team tended to have better outcomes than those who received chiropractic care. However, given the relatively small magnitude of between group differences and the extensive resources required to successfully manage and implement, the team based integrative care might not be worthwhile. More efficient models for addressing biopsychosocial care for low back pain should be explored with greater emphasis on addressing the full spectrum of related psychosocial mechanisms and ensuring equitable access for all.

Innes S, Goncalves G, Leboeuf-Yde C.
Who are the chiropractic students favouring a limitless scope of practice? Exploring the relation-ship with personality, magical thinking, and academic achievement [9].
Cross-sectional survey of chiropractic students The aim of our study was to explore whether there are any factors that help explain the adoption of views on chiropractic conservatism (ChiroCon) in an evidence-based chiropractic education environment and its association with an increased likelihood of using SMT for conditions without an evidence-base (e.g., non-MSK). To prevent a mismatch between students and learning institutions we recommend that both those colleges that favor the old conservative approach of a limitless scope of practice or other types of magical approaches and institutions with a modern, MSK-only approach should screen for magical thinking to include or exclude potential students according to their requirements. Finally, the findings of this study explained less than 30% of the total variance, and this means that other factors are at play in determining clinical decisions that will require further investigation.

Ivanova D, Bishop FL, Newell D, Field J, Wals M.
Mixed methods systematic review of the literature base exploring working alliance in the chiropractic profession [5].
Mixed methods systematic review This mixed methods systematic review aimed to synthesise qualitative and quantitative evidence to study the nature and the role of working alliance within chiropractic consultations. Strong working alliance (WA) requires ongoing negotiation of treatment goals and expectations alongside collaboration on a mutually agreed upon treatment plan. These processes of negotiation and collaboration are facilitated by, and may in turn strengthen, interpersonal bonds involving trust and mutual respect. Bordin’s formulation of WA has the potential to improve our understanding of chiropractor–patient relationships by providing a conceptual framework for thinking about the nature of the therapeutic relationship and how it can impact clinical outcomes through psychosocial pathways. Further primary research is needed to establish the nature, appropriate measurement, and consequences of WA in chiropractic care.

Joern L, Kongsted A, Thomassen L, Hartvigsen J, Ravn S.
Pain cognitions and impact of low back pain after participation in a self-management program: a qualitative study [2].
Qualitative interviews with GLA:D® participants The objective of this study was to gain insights into the possible shifts in the understanding of LBP and the sense of being able to manage pain among patients participating in the GLA:D® Back program. Our results suggest that that the impact of having participated in the program relate to how the content of the program resonated with the individual patient’s experiences and prior understanding of LBP. Not all patients changed their understanding or came to internalise new under-standings during a 10-weeks program, however the results support existing evidence that an improved understanding of what LBP may translate into people being less negatively affected. Awareness of the ways individuals’ understanding of LBP interact with behaviour and physical activities appear central for providing adaptive professional support and meeting the individual needs.

Saragiotto BT, Sandal LF, Hartvigsen J.
Can you be a manual therapist without using your hands? [6]
Commentary This commentary discusses the use of telehealth by manual therapists. Access to online information,. is everywhere and will continue to grow, making it the most powerful vehicle to spread information, including health information and potentially healthcare for individuals. We suggest that practitioners of manual medicine make telehealth part of their clinical toolbox where it makes sense and where there is evidence that it is beneficial for people who seek their care.

Sherriff B, Clark C, Killingback C, Newell D.
Impact of contextual factors on patient outcomes following conservative low back pain treatment: systematic review [7].
Systematic review This systematic review therefore aims to examine interventions which potentially modify known context factors (CFs) during conservative LBP care… to investigate their impact on patients’ pain intensity and physical functioning outcomes. Delineating the influence and role of CFs in usual care rehabilitation settings may assist in identifying which of these CFs demonstrates potential clinical utility and ethical approaches to rehabilitation. In conclusion, this systematic review has demonstrated preliminary evidence to indicate explicitly leveraging CFs augments conservative LBP treatment. It identified CFs reducing pain intensity and improving physical functioning outcomes and extracted specific strategies with prospective clinical utility. The heterogeneity of interventions suggests modifying more than one CF may be more impactful. In essence, the practitioner’s therapeutic potency lies in their capacity to simultaneously provide physical, cognitive, and emotional care to influence the patient’s mindset and consequently their physiology.

Svendsen MJ, Nicholl BI, Mair FS, Wood K, Rasmussen CDN, Stochkendahl MJ.
One size does not fit all: Participants’ experiences of the selfBACK app to support self-manage-ment of low back pain—a qualitative interview study [3].
Qualitative interviews with selfBACK participants In this paper, we qualitatively explore the implementation of selfBACK on (i) factors influencing embedding, integrating, and sustaining engagement with the selfBACK app, and (ii) the self-perceived effects, acceptability, and satisfaction with the selfBACK app. We identified a number of key factors involved in embedding, integrating and sustaining engagement with the selfBACK app. Participants were generally satisfied with the selfBACK app and many experienced positive effects. The high prevalence of LBP globally coupled with the advantages of providing help through an app offers opportunities to help countless people dealing with LBP in daily managing their pain. A range of factors should be considered to facilitate implementation of self-management of LBP or similar pain conditions. These findings should help inform development of future pain/LBP self-management apps.

Authors / Title	Methods	Aim	Authors’ Conclusion
Belton J, Birkinshaw H, Pincus T. Patient-centered consultations for persons with musculoskeletal conditions [4].	Personal account of a patient and narrative discussion	This article is structured in a way that reflects this collaboration [between the healthcare professional and patient], showcasing the importance of acknowledging lived experience, the sharing of information, and the dynamic interactions that shape a consultation, in combination with supporting scientific evidence.	This article has discussed several recommendations for clinicians to use in consultations for chronic pain… Ultimately, shared uncertainty between healthcare professionals and patients is the beginning of a journey together exploring the path of pain management. Accompanied by listening, validation, empathy and reassurance, a willingness to explore the paths together and accept the uncertainty of the journey is key to moving forward with chronic pain, for both healthcare professionals and people with pain.

Bronfort G, Maiers M, Schulz C, Leininger B, Westrom K, Angstman G, Evans R. Multidisciplinary integrative care versus chiropractic care for low back pain: a randomized clinical trial [8].	Randomized clinical trial	The purpose of this manuscript is to report the primary and secondary clinical outcomes of a randomized trial of mono-disciplinary chiropractic care, versus multidisciplinary integrative care for sub-acute and chronic low back pain.	Low back pain patients who received integrative care by a multidisciplinary integrative care team tended to have better outcomes than those who received chiropractic care. However, given the relatively small magnitude of between group differences and the extensive resources required to successfully manage and implement, the team based integrative care might not be worthwhile. More efficient models for addressing biopsychosocial care for low back pain should be explored with greater emphasis on addressing the full spectrum of related psychosocial mechanisms and ensuring equitable access for all.

Innes S, Goncalves G, Leboeuf-Yde C. Who are the chiropractic students favouring a limitless scope of practice? Exploring the relation-ship with personality, magical thinking, and academic achievement [9].	Cross-sectional survey of chiropractic students	The aim of our study was to explore whether there are any factors that help explain the adoption of views on chiropractic conservatism (ChiroCon) in an evidence-based chiropractic education environment and its association with an increased likelihood of using SMT for conditions without an evidence-base (e.g., non-MSK).	To prevent a mismatch between students and learning institutions we recommend that both those colleges that favor the old conservative approach of a limitless scope of practice or other types of magical approaches and institutions with a modern, MSK-only approach should screen for magical thinking to include or exclude potential students according to their requirements. Finally, the findings of this study explained less than 30% of the total variance, and this means that other factors are at play in determining clinical decisions that will require further investigation.

Ivanova D, Bishop FL, Newell D, Field J, Wals M. Mixed methods systematic review of the literature base exploring working alliance in the chiropractic profession [5].	Mixed methods systematic review	This mixed methods systematic review aimed to synthesise qualitative and quantitative evidence to study the nature and the role of working alliance within chiropractic consultations.	Strong working alliance (WA) requires ongoing negotiation of treatment goals and expectations alongside collaboration on a mutually agreed upon treatment plan. These processes of negotiation and collaboration are facilitated by, and may in turn strengthen, interpersonal bonds involving trust and mutual respect. Bordin’s formulation of WA has the potential to improve our understanding of chiropractor–patient relationships by providing a conceptual framework for thinking about the nature of the therapeutic relationship and how it can impact clinical outcomes through psychosocial pathways. Further primary research is needed to establish the nature, appropriate measurement, and consequences of WA in chiropractic care.

Joern L, Kongsted A, Thomassen L, Hartvigsen J, Ravn S. Pain cognitions and impact of low back pain after participation in a self-management program: a qualitative study [2].	Qualitative interviews with GLA:D® participants	The objective of this study was to gain insights into the possible shifts in the understanding of LBP and the sense of being able to manage pain among patients participating in the GLA:D® Back program.	Our results suggest that that the impact of having participated in the program relate to how the content of the program resonated with the individual patient’s experiences and prior understanding of LBP. Not all patients changed their understanding or came to internalise new under-standings during a 10-weeks program, however the results support existing evidence that an improved understanding of what LBP may translate into people being less negatively affected. Awareness of the ways individuals’ understanding of LBP interact with behaviour and physical activities appear central for providing adaptive professional support and meeting the individual needs.

Saragiotto BT, Sandal LF, Hartvigsen J. Can you be a manual therapist without using your hands? [6]	Commentary	This commentary discusses the use of telehealth by manual therapists.	Access to online information,. is everywhere and will continue to grow, making it the most powerful vehicle to spread information, including health information and potentially healthcare for individuals. We suggest that practitioners of manual medicine make telehealth part of their clinical toolbox where it makes sense and where there is evidence that it is beneficial for people who seek their care.

Sherriff B, Clark C, Killingback C, Newell D. Impact of contextual factors on patient outcomes following conservative low back pain treatment: systematic review [7].	Systematic review	This systematic review therefore aims to examine interventions which potentially modify known context factors (CFs) during conservative LBP care… to investigate their impact on patients’ pain intensity and physical functioning outcomes. Delineating the influence and role of CFs in usual care rehabilitation settings may assist in identifying which of these CFs demonstrates potential clinical utility and ethical approaches to rehabilitation.	In conclusion, this systematic review has demonstrated preliminary evidence to indicate explicitly leveraging CFs augments conservative LBP treatment. It identified CFs reducing pain intensity and improving physical functioning outcomes and extracted specific strategies with prospective clinical utility. The heterogeneity of interventions suggests modifying more than one CF may be more impactful. In essence, the practitioner’s therapeutic potency lies in their capacity to simultaneously provide physical, cognitive, and emotional care to influence the patient’s mindset and consequently their physiology.

Svendsen MJ, Nicholl BI, Mair FS, Wood K, Rasmussen CDN, Stochkendahl MJ. One size does not fit all: Participants’ experiences of the selfBACK app to support self-manage-ment of low back pain—a qualitative interview study [3].	Qualitative interviews with selfBACK participants	In this paper, we qualitatively explore the implementation of selfBACK on (i) factors influencing embedding, integrating, and sustaining engagement with the selfBACK app, and (ii) the self-perceived effects, acceptability, and satisfaction with the selfBACK app.	We identified a number of key factors involved in embedding, integrating and sustaining engagement with the selfBACK app. Participants were generally satisfied with the selfBACK app and many experienced positive effects. The high prevalence of LBP globally coupled with the advantages of providing help through an app offers opportunities to help countless people dealing with LBP in daily managing their pain. A range of factors should be considered to facilitate implementation of self-management of LBP or similar pain conditions. These findings should help inform development of future pain/LBP self-management apps.