Study Offers an Integrative Care Pathway That Includes Chiropractic

Chiropractic Integrated Care Pathway for Low Back Pain in Veterans: Results of a Delphi Consensus Process

Anthony J. Lisi, DC; Stacie A. Salsbury, PhD, RN; Cheryl Hawk, DC, PhD; Robert D. Vining, DC

Robert B. Wallace, MD, MSc; Richard Branson, DC; Cynthia R. Long, PhD; Lucille Burgo-Black, MD, FACP; and Christine M. Goertz, DC, PhDb

Journal of Manipulative and Physiological Therapeutics Volume 41, Number 2

Objective: The purpose of this study was to develop an integrated care pathway for doctors of chiropractic, primary care providers, and mental health professionals who manage veterans with low back pain, with or without mental health comorbidity, within Department of Veterans Affairs health care facilities.

Methods: The research method used was a consensus process. A multidisciplinary investigative team reviewed clinical guidelines and Veterans Affairs pain and mental health initiatives to develop seed statements and care algorithms to guide chiropractic management and collaborative care of veterans with low back pain. A 5-member advisory committee approved initial recommendations. Veterans Affairs-based panelists (n = 58) evaluated the pathway via e-mail using a modified RAND/UCLA methodology. Consensus was defined as agreement by 80% of panelists.

Results: The modified Delphi process was conducted in July to December 2016. Most (93%) seed statements achieved consensus during the first round, with all statements reaching consensus after 2 rounds. The final care pathway addressed the topics of informed consent, clinical evaluation including history and examination, screening for red flags, documentation, diagnostic imaging, patient-reported outcomes, adverse event reporting, chiropractic treatment frequency and duration standards, tailored approaches to chiropractic care in veteran populations, and clinical presentation of common mental health conditions. Care algorithms outlined chiropractic case management and interprofessional collaboration and referrals between doctors of chiropractic and primary care and mental health providers.

Conclusion: This study offers an integrative care pathway that includes chiropractic care for veterans with low back pain.


Of the 5.7 million patients served annually in Department of Veterans Affairs (VA) facilities, more than half experience chronic pain.1 Much of the chronic pain reported by veterans is musculoskeletal (MSK) pain,2-8 with around 25% consistently reporting low back pain (LBP).7 The prevalence of severe pain is more common in veterans with LBP than in nonveterans.9 Coincident with MSK pain, many veterans are diagnosed with mental health conditions, such as depression, anxiety, posttraumatic stress disorder (PTSD), and substance use disorders. Veterans with MSK pain and mental health comorbidity use more VA health care services than veterans without these conditions, including primary care, medical specialty, chronic pain, and behavioral health services.

The widely accepted biopsychosocial model postulates that physical disease, mental health or illness, and social factors interact and contribute to the patient’s overall suffering and experience of chronic pain. Clinical practice guidelines (CPGs) and systematic reviews recommend that clinicians incorporate biopsychosocial approaches into the management of patients with LBP, including effective non-pharmacological therapies such as patient education, activity/exercise, yoga, massage, acupuncture, and spinal manipulation. However, few strategies exist to integrate these complementary therapies with conventional approaches to pain management, and little evidence is available to guide collaborative management among musculoskeletal specialists, primary care providers, and mental health professionals, all of whom are often involved in the management of patients with LBP.

The Department of Veterans Affairs expanded its delivery of non-pharmacological treatment offerings for LBP when, in 2004, it began providing chiropractic services, including spinal manipulation, both on site at select VA facilities and through purchased care arrangements with private sector providers. Previous work indicates that the use of VA chiropractic services has grown substantially since its inception, as currently upward of 46,000 veterans are being served, and that doctors of chiropractic (DCs) working in VA manage LBP through the delivery of evidence-based, non-pharmacological services. Although the use of chiropractic care in VA has expanded, few data exist to inform optimal models of access to and delivery of chiropractic care, in VA or elsewhere.

The implementation of chiropractic services in VA presents a novel opportunity to explore strategies to improve collaborative case management for patients with LBP, including those with mental health comorbidity. One aim of our research project, Collaborative Care for Veterans with Spine Pain and Mental Health Conditions, was to develop a consensus-based, chiropractic integrated care pathway to guide clinical decision making and improve communication and referral processes between DCs, primary care providers, and mental health professionals who manage veterans with LBP in VA healthcare facilities. Care pathways are health care tools designed to support evidence-based practices, clinical decision making, and the organization of care processes for providers treating patients with well-defined health conditions, such as those with LBP.

The purpose of this study was to develop a consensus-based, integrated care pathway for DCs, primary care providers, and mental health professionals who manage veterans with LBP, with or without mental health comorbidity, within VA health care facilities.


This article offers an integrated care pathway for chiropractic management of veterans with LBP, with or without mental health comorbidity. The pathway was developed by VA-based DCs, primary care providers, mental health professionals, and clinical experts in the field of veterans’ health. The pathway provides a reasonable approach to multidisciplinary care for veterans with acute and chronic LBP.

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