The objective of this paper, as stated by its authors, was to develop an evidence-based clinical practice guideline (CPG) through a broad-based consensus process on best practices for chiropractic management of patients with chronic musculoskeletal (MSK) pain.

Using systematic reviews identified in an initial literature search, a steering committee of experts in research and management of patients with chronic MSK pain drafted a set of recommendations. Additional supportive literature was identified to supplement gaps in the evidence base. A multidisciplinary panel of experienced practitioners and educators rated the recommendations through a formal Delphi consensus process using the RAND Corporation/University of California, Los Angeles, methodology.

The Delphi process was conducted January–February 2020. The 62-member Delphi panel reached consensus on chiropractic management of five common chronic MSK pain conditions:

• low-back pain (LBP),
• neck pain,
• tension headache,
• osteoarthritis (knee and hip),
• fibromyalgia.

Recommendations were made for non-pharmacological treatments, including:

• acupuncture,
• spinal manipulation/mobilization,
• other manual therapy;
• low-level laser (LLL);
• interferential current;
• exercise, including yoga;
• mind–body interventions, including mindfulness meditation and cognitive behavior therapy (CBT);
• lifestyle modifications such as diet and tobacco cessation.

Recommendations covered many aspects of the clinical encounter, from informed consent through diagnosis, assessment, treatment planning and implementation, and concurrent management and referral. Appropriate referral and comanagement were emphasized.

Therapeutic recommendations for low back pain:

• Consider multiple approaches. Both active and passive, and both physical and mind–body interventions should be considered in the management plan. The following are recommended, based on current evidence.
• Exercise
• Yoga/qigong (which may also be considered “mind–body” interventions)
• Lifestyle advice to stay active; avoid sitting; manage weight if obese; and quit smoking
• Spinal manipulation/mobilization
• Massage
• Acupuncture
• LLL therapy
• Transcutaneous electrical nerve stimulation (TENS) or interferential current may be beneficial as part of a multimodal approach, at the beginning of treatment to assist the patient in becoming or remaining active.
• Combined active and passive: multidisciplinary rehabilitation
• CBT
• Mindfulness-based stress reduction

Therapeutic recommendations for neck pain:

• Consider multiple approaches. Both active and passive, and both physical and mind–body interventions should be considered in the management plan for maximum therapeutic effect. The following are recommended, based on current evidence.
• Exercise (range of motion and strengthening).
• Exercise combined with manipulation/mobilization.
• Spinal manipulation and mobilization
• Massage
• Low-level laser
• Acupuncture
• These modalities may be added as part of a multimodal treatment plan, especially at the beginning, to assist the patient in becoming or remaining active:
• Transcutaneous nerve stimulation (TENS), traction, ultrasound, and interferential current.
• Yoga
• Qigong

Therapeutic recommendations for tension headache:

• Consider multiple approaches. Both active and passive, and both physical and mind–body interventions should be considered in the management plan for maximum therapeutic effect. The following are recommended, based on current evidence:
• Reassurance that TTH does not indicate presence of a disease.
• Advice to avoid triggers.
• Exercise (aerobic).
• Spinal manipulation
• Acupuncture
• Cold packs or menthol gels
• Combined active and passive
• CBT
• Relaxation therapy
• Biofeedback
• Mindfulness Meditation

Therapeutic recommendations for knee osteoarthritis:

• Consider multiple approaches. Both active and passive, and both physical and mind–body interventions should be considered in the management plan. The following are recommended, based on current evidence:
• Exercise
• Manual therapy
• Ultrasound
• Acupuncture, using “high dose” (greater treatment frequency, at least 3 × week)
• LLL therapy

Therapeutic recommendations for hip osteoarthritis:

• Consider multiple approaches. Both active and passive, and both physical and mind–body interventions should be considered in the management plan. The following are recommended, based on current evidence⁶
• Exercise
• Manual therapy

Therapeutic recommendations for fibromyagia:

• Consider multiple approaches. Both active and passive, and both physical and mind–body interventions should be considered in the management plan. The following are recommended, based on current evidence:
• Exercise (aerobic and strengthening)
• Advice on healthy lifestyle
• Education on the condition
• Spinal manipulation
• Myofascial release
• Acupuncture
• LLL therapy
• multidisciplinary rehabilitation
• CBT
• mindfulness meditation
• yoga
• Tai chi,
• Qigong

The authors concluded that these evidence-based recommendations for a variety of conservative treatment approaches to the management of common chronic MSK pain conditions may advance consistency of care, foster collaboration between provider groups, and thereby improve patient outcomes.

This paper is an excellent example of a pseudo-scientific process resulting in unreliable outcomes.

• The Delphi process was conducted some 4 years ago
• Because of the truly weird inclusion criteria, the findings are based essentially on just 3 systematic reviews.
• Anyone who has ever tried to conduct a consensus excercise knows that the outcome will almost entirely depend on who is chosen to sit on the panel. So, all you have to do to obtain pro-chiro recommendations is to select a few pro-chiro ‘experts’ who then write the recommendations!
• A “best practices for chiropractic management” may sound reasonable but, looking at the therapeutic recommendation, one easily realizes that the authors cast their nets so wide that the result has little to do with what differentiates chiropractic from Physiotherapists or osteopaths.

It is therefore not surprising that the recommendations are laughably unreliable: can, for instance, anyone explain to me why “advice on healthy lifestyle and education on the condition” are recommended for fibromyalgia but not for any other condition?

This paper is, in my view, chiropractic pseudo-science at its most ridiculous!

All it really does is it tries to legitimise all sorts of therapies as part of the chiropractic toolbox. My advice to patients is to:

• consult a physio if you need exercise therapy or LLL or manual therapy or ultrasound or interferential current or TENS or cold packs or massage;
• consult a clinical psychologist if you need CBT, or mindfulness, biofeedback;
• consult a doctor if you want rehab or education or lifestyle advice or reassurance;
• etc. etc.

And please avoid chiropractors who pretend they can do all of the above, while merely wanting to manipulate your neck.