14 I Summer 2019 www.anjc.info Current research supports a multi- modal approach to the treatment of chronic low back pain. It is exciting to observe the research supporting spinal manipulation for both acute and chronic low back pain. Furthermore, the failure of opioids in addressing long-term management of chronic pain has underscored chiropractic’s position that treatment needs to address the underlying cause with the goal to restore homeostasis. Essentially the multimodal approach to care is chiropractic’s Five Pillars of Health: Diet, Exercise, Rest, Emotional/ Spiritual Wellbeing and a Fully Functioning Nervous System, free from interference. As with any condition, the starting point is an accurate diagnosis. A comprehensive history, examination and functional assessment is essential. Be sure to review any previous imaging and labs and consider if additional or new studies are needed. For long-standing patients, re-examine them thoroughly and thoughtfully, as you would your new or returning patients. As part of your initial intake are Outcome Assessment Tools (OAT). This is essential for the chronic pain patient since it may be the only evidence of progress or based on ADL’s. For the low back patient, the most common choices are the Oswestry, Back Bournemouth and Roland-Morris. The Back Bour- nemouth and Roland-Morris incorporate questions which will help you find and monitor psychological overtones in the patient’s pain management. A func- tional rating scale can also be helpful. Regardless of the OAT you choose, use it every 30-60 days. Psychological overtones in the chronic pain patient are real, can be significant, and at times serious obstacles to healing. If the patient has identified with their pain and is having difficulty accepting that they can take control of their pain with lifestyle changes, then perhaps cognitive behavioral therapy (CBT) is needed. Often performed in a group setting, CBT has been shown to be beneficial for chronic pain sufferers. Start building your referral team of CBT providers as part of your “pain recovery” network. While pharmaceuticals work great for pain control, they are dangerous and lethal. From opioids to NSAIDs, pharmaceuticals for chronic pain control is falling out of favor with the general population. However, nutraceuticals are beneficial and have significantly lower risk. While the chronic low back pain patient may need a comprehensive nutritional workup, there are a few established protocols that you can use safely. First, consider the anti-inflammatory protocols recommended by Dr. David Seaman. Stop the grains, beans, sugar, seed oils and hydrogenated fats while ramping up the consumption of vegetables, fruit, fish and poultry. Add an omega-3 fatty acid supplement, anti-inflammatory herbs (curcumin, boswelia, ginger, rosemary) to really shift the body into a less inflamed state. Hit this hard and strict for three weeks and have the patient complete the OAT again. When it works, it is a home run. However, the patient must be diligent and serious on the diet for three weeks to see if chronic low-grade inflammation is an issue in their low back pain. The list of potential nutraceuticals for pain is extensive and beyond the scope of this article. For example, CBD is very vogue currently while joint formulas that contain glucosamine and chondroitin, MSN, white willow bark (salicylic acid), cat’s claw, bromelain, systemic enzymes and papain have been used favorably for pain control for perhaps generations. As we discuss lifestyle changes in the chronic back pain patient, research has shown a lack of high quality sleep is related to fibromyalgia. In fact, sleep allows the body to heal, recover and rebalance. Inadequate quality or quantity of sleep will increase inflamma- tion, weight gain, and prevent the body from restoring homeostasis. Again, proper sleep hygiene and nutraceutical intervention for sleep is the topic for another article. Legislative Update LEGAL Q&A ANJC Scholarship CHIRO ASSIST TECHNIQUE Council OUR HEALTH REHAB Council By Dr. Donald C. DeFabio Chair, ANJC Physical Rehabilitation and Performance Council Chronic Low Back Pain: A Multimodal Approach [ CONTINUED ON PAGE 17 ]