It is not uncommon for patients to seek chiropractic care as a non-pharmacologic option to manage chronic pain. However, these patients can present unique challenges. Chronic pain often involves multiple mechanisms such as neuropathic, inflammatory, musculoskeletal, or central sensitization. Imaging and lab tests do not always correlate with reported pain levels. Chronic pain patients may be frustrated, depressed, anxious, and/or catastrophizing. They may have unrealistic expectations that their pain can be eliminated, when a more reasonable expectation may be to improve function, coping, and quality of life.

Understanding the Complexity of Chronic Pain 
Complex regional pain syndrome (CRPS) is one of the more difficult chronic pain conditions to manage. It typically develops after an injury or surgery and is characterized by severe, persistent pain that is disproportionate to the initial trauma. CRPS may involve sensory, motor, autonomic, and trophic changes, and can significantly impact a patient’s physical and emotional well-being. Because of its complexity, CRPS often requires a multidisciplinary approach, including chiropractic care as part of a broader treatment plan. Chiropractors should be especially mindful of the patient’s sensitivity and potential for flare-ups, and tailor treatment accordingly.

Initial Evaluation and Documentation
Prior to providing chiropractic treatment to the patient, it is important to obtain and document a thorough patient history, including:

• Past medical history
• Social history
• Family medical history
• History of the patient’s current condition
• Any treatment they have received in the past or are currently receiving for their chronic pain

Then perform and document a thorough physical examination. Screen the patient for red flags that might contraindicate chiropractic treatment, require a referral, or require modifications of chiropractic treatment.

Treatment Planning and Goal Setting
Discuss your findings with the patient and determine the patient’s goals for treatment. When creating a treatment plan, consider the whole patient. Collaborate with the patient to develop a chiropractic plan of care to address realistic goals.

Informed Consent and Communication
Be sure to obtain the patient’s informed consent for chiropractic treatment. This should include:

• The specific treatment that will be performed
• The location of the treatment
• The risks and benefits of the treatment
• Treatment alternatives and the risks and benefits of those alternatives

It is important to document all discussions with the patient, including:

• Informed consent discussions
• Realistic expectations for treatment
• Patient education and instructions
• Patient questions and your answers
• Any other communications
• Your rationale for treatment decisions
• Follow-up discussions and post-treatment conversations

Multidisciplinary Care and Collaboration
Chronic pain is rarely just a physical problem. Often there are psychological, social, and functional issues contributing to the patient’s chronic pain for which multidisciplinary care can be utilized.
If the patient is currently receiving treatment from other providers, collaborate with those providers to develop a coordinated, multidisciplinary plan of care. This helps to avoid conflicting advice, builds trust with your patient, and can improve patient satisfaction.

If the patient is not currently receiving treatment from other providers, consider collaborating with other specialists such as physical therapists, occupational therapists, psychologists, cognitive-behavioral therapists, etc. to achieve a more holistic approach.

When multiple providers are involved, it is important that all communicate with each other so that everyone is aware of:

• The treatment the patient is receiving
• The patient’s progress (or lack of progress)
• The current multidisciplinary plan of care

If there is a question or concern about another provider’s treatment, contact that provider to discuss and resolve any issues to avoid providing the patient with conflicting advice. All communications to or from other healthcare providers should be documented in the patient’s record.

Reassessment and Risk Management
Periodically reassess the patient to determine if the patient is responding to your treatment. If the patient is not responding as expected, consider modifying the treatment plan or referring the patient. Document your rationale for continuing or modifying your plan of treatment and for any referrals or diagnostic testing.

While it is important to help manage the patient’s pain, it is also important to protect yourself. Your documentation in the patient’s record should reflect that you:

• Provided the standard of care
• Gave careful thought to your treatment decisions
• Treated the patient with care and concern
• Collaborated with other healthcare professionals

Having this documentation can reduce your risk of being named in a malpractice lawsuit. In the event you are sued, your documentation will be your best defense.

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Disclaimer: “OUM” and “OUM Chiropractor Program” do not refer to a legal entity or insurance company but to a program or symbol of a program underwritten, insured, and administered by ProAssurance Insurance Company of America. The information contained on the OUM Chiropractor Blog does not establish a standard of care, nor does it constitute legal advice. The information is for general informational purposes only. We encourage all blog visitors to consult with their personal attorneys for legal advice, as specific legal requirements may vary from state to state. Links or references to organizations, websites, or other information is for reference use only and do not constitute the rendering of legal, financial, or other professional advice or recommendations. In the event any of the information presented conflicts with the terms and conditions of any policy of insurance offered by ProAssurance Insurance Company of America, the terms and conditions of the actual policy will apply. All information contained on the blog is subject to change.