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Traditional chiropractic training has primarily focused on the mechanical aspects of pathology. Evidence-based chiropractors routinely seek to answer questions like:

  • Which anatomical tissue is irritated?
  • What habits and postures caused or perpetuated the dysfunction?
  • What physical treatments and recommendations are most appropriate?

While mechanically-based assessment is essential, sometimes examining the non-mechanical issues is equally important. Many experts believe that biopsychosocial aspects of pain, particularly chronic pain, will become significantly higher areas of focus for neuromusculoskeletal providers.

 This blog includes three valuable patient education tools that you can download, plus a video interview with Dr. Anthony Nicholson – a practicing chiropractic clinician and leading expert on chronic pain neuroscience.

Chronic pain is pain that occurs

on at least half the days

for six months or more.

NIH- National Pain Strategy

In recent years, countless studies have concluded that how a patient’s brain processes physical stress is a strong prognosticator for recovery…or non-recovery.


 “Among those with LBP, good health in terms of mental- and self-rated health, few pain sites, as well as good psychosocial working conditions seem to indicate a lower risk for work disability.” (1)

BMC Musculoskeletal Disorders. December 2019


 “A large proportion of LBP patients seeking primary health care reported poor outcomes 6 months after consultation. Patients who report chronic LBP and maladaptive psychosocial factors have a significant increase in the risk of poor outcome.” (2)

Plos one. March 2020

To learn more about biopsychosocial management of pain, ChiroUp recently connected with a leading expert on chronic pain neuroscience. In the following interview, Dr. Anthony Nicholson explains some of the key considerations for identifying and managing chronic pain patients.

Interview Outline

0:49     The burden of chronic pain
1:34     The definition and etiology of chronic pain
3:44     Identifying normal vs. unhealthy pain presentations
8:18     Examples of “Yellow Flags”
12:42   Practical interventions for chronic pain
19:48   Chronic pain resources

Learn more about the resources Dr. Nicholson mentioned:
Pain Neuroscience Educational Program: Mastering the First Two Consultations
University of Bridgeport/ CDI Advanced Online Clinical Training


Recognition is the first step toward resolving chronic pain. During the consult, be sure to listen for attitudes and interpretations that sound like Unhealthy Beliefs. Think of them as the “U” in your OPPQRSTU.

Additionally, there are several assessment tools to help identify unhealthy beliefs or interpretations about pain and recovery:

  • Fear-avoidance (assessed via FABQ)
  • Catastrophizing (assessed via PCS)
  • Kinesiophobia (assessed via TSK-11)
  • Passive coping/ Reliance on passive care (assessed via CAPQ)
  • Excessive stress (assessed via PSS)
  • Anxiety (assessed via STAI, PASS-20, GAD-7)
  • PTSD (assessed via PC-PTSD-5, SPRINT)
  • Depression (assessed via PHQ-9)
  • Workplace fears (assessed via FABQ-W)
  • Central sensitization (assessed via CSI)

Pro Tip: ChiroUp subscribers can access any of the yellow flag assessments from their forms library under Clinical/ Impairment Questionnaires. Whenever you’re looking for something specific, try the search bar at the top – if you can’t find it, give our support team a call (844) 462-4476.

Unfortunately, the majority of chiropractors do not code and bill for the treatment of chronic pain. Hence, the insurance data would suggest that chiropractors do not treat chronic pain patients. Providers could consider including the following ICD codes for chronic pain patients:

G89.4              Chronic pain syndrome           Available from: https://icdlist.com/icd-10/G89.4
G89.21            Chronic pain, post-traumatic  Available from: https://icdlist.com/icd-10/G89.21


Evidence-based chiropractors can employ several tools to manage chronic pain patients:

1. Manual Therapy & Exercise Have a Positive Effect.

A recent Archives of Physical Medicine and Rehabilitation review found that manual therapy is an effective tool for reducing unhealthy beliefs about pain:

“The present systematic review highlights the potential effectiveness of conservative interventions [manual therapy, exercise, and multi-disciplinary interventions] to reduce kinesiophobia and fear-avoidance beliefs in individuals with chronic low back pain.” (3)

2. Regularly Scheduled Supportive Care May Help.*

New data concluded that chronic LBP patients, particularly those with unhealthy coping strategies, may benefit from supportive care:

“This study demonstrated that, among dysfunctional patients, maintenance care reduced the number of days of activity-limiting LBP in each new episode and people enjoyed more pain-free weeks.  It is therefore more likely that maintenance care has a psychological effect in the group that has worst coping strategies and struggle to manage their pain, whereby meeting and interacting with the clinician reduces the severity of the pain experience.” (4)

*However, this study also concluded that maintenance care did not have a positive effect on those with healthy coping strategies. And, ongoing maintenance care is a double-edged sword that can create dependent patients who feel the need to rely on passive care.

 So, before we celebrate the merit of passive maintenance care, we should also consider practical ways to create more self-empowered patients.

3. Knowledge is Power

Multiple studies have shown that patient education is essential for resolving chronic pain.

“Individuals … receiving pain education reported lower pain intensity and higher expectations of recovery than their counterparts. (5) 

“Education, as part of multi-disciplinary programs, is likely to improve self-management and self-efficacy in people with chronic pain of any etiology.” (6)

I challenge every evidence-based chiropractor (including myself) to consider what you are doing (or not currently doing) in your clinic to better educate your patients. There is no better time than now to implement new procedures to ensure optimal patient education & compliance. ChiroUp subscribers have access to several chronic pain resources and many other tools to educate & empower patients to play a more active role in their recovery.

If you would like to learn more about how ChiroUp can streamline patient education in your office, visit our website today. We offer a free 14-day trial where you can use all of our platform resources, including the patient education tools mentioned in this blog. The time to check us out is NOW, and I think you’re going to like what you see.

ChiroUp would like to extend a thank you to ChiroUp advisor Dr. James Lehman for review and content contributions; and Dr. Anthony Nicholson for sharing his interview and tireless provider education about this evolving topic.

  1. Mather L, Ropponen A, Mittendorfer-Rutz E, Narusyte J, Svedberg P. Health, work and demographic factors associated with a lower risk of work disability and unemployment in employees with lower back, neck and shoulder pain. BMC Musculoskeletal Disorders. 2019 Dec;20(1):1-0. Link
  2. Cruz EB, Canhão H, Fernandes R, Caeiro C, Branco JC, Rodrigues AM, Pimentel-Santos F, Gomes LA, Paiva S, Pinto I, Moniz R. Prognostic indicators for poor outcomes in low back pain patients consulted in primary care. Plos one. 2020 Mar 27;15(3):e0229265. Link
  3. Martinez-Calderon J, Flores-Cortes M, Morales-Asencio JM, Luque-Suarez A. Conservative Interventions Reduce Fear in Individuals With Chronic Low Back Pain: A Systematic Review. Archives of physical medicine and rehabilitation. 2020 Feb 1;101(2):329-58. Link
  4. Eklund, A., Hagberg, J., Jensen, I. et al. The Nordic maintenance care program: maintenance care reduces the number of days with pain in acute episodes and increases the length of pain free periods for dysfunctional patients with recurrent and persistent low back pain – a secondary analysis of a pragmatic randomized controlled trial. Chiropr Man Therap 28, 19 (2020). Link
  5. Mittinty MM, Vanlint S, Stocks N, Mittinty MN, Moseley GL. Exploring effect of pain education on chronic pain patients’ expectation of recovery and pain intensity. Scandinavian journal of pain. 2018 Apr 25;18(2):211-9. Link
  6. Joypaul S, Kelly F, McMillan SS, King MA. Multi-disciplinary interventions for chronic pain involving education: A systematic review. PloS one. 2019;14(10). Link

About the Author

Dr. Tim Bertelsman

Dr. Tim Bertelsman


Dr. Tim Bertelsman graduated with honors from Logan College of Chiropractic and has been practicing in Belleville, IL since 1992. He has lectured nationally on various clinical and business topics and has been published extensively. He has served in several leadership positions within the Illinois Chiropractic Society and currently serves as past president of the executive board.

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