Chronic Primary Pain of the Spine: an Integrative Perspective Part 2


The purpose of this review is to provide a follow-up discussion to a companion article reviewing current models of low back and neck pain, focused on chronic and disabling primary pain of the spine. While the preceding article addresses risk factors, etiology, pathophysiology, and differential diagnosis of low back and neck pain, this article discusses the best available research regarding current management strategies for chronic primary pain of the spine and expands upon ways to improve these strategies. A review of the English medical literature was performed using search terms “chronic primary pain,” “low back pain,” OR “neck pain” AND “management,” “treatment,” “prevention,” or “biopsychosocial.” Additional searches were made using Google Scholar and PubMed search engines through April 18, 2020. The authors reviewed and identified 136 relevant articles to be used in this discussion. While certain elements of societal and legislative infrastructure hinder optimized implementation of evidence-based care, clinical research and updated practice guidelines advocate for the safe and cost-effective nonpharmacological interventions typically offered by chiropractors, physical therapies, and other manual therapists as first-line care. The authors expand upon these therapies individually to determine their relevance and contextual purpose. A framework for an integrative perspective, adopting concepts from biopsychosocial and behavioral models, is called to action to provide an improved understanding of the nature of chronic primary pain and to aid in patient-centered clinical decision-making.

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Fig. 1

Availability of Data and Materials

Not applicable.



Nonsteroidal antiinflammatories


Therapeutic alliance


Functional magnetic resonance imaging


Clinical practice guideline


Neck pain and associated disorders


STarT Back screening tool


Örebro Musculoskeletal Pain Screening Questionnaire


Cognitive behavioral therapy


Acceptance and commitment therapy


Mindfulness-based stress reduction


Cognitive behavioral therapy for chronic pain


Veterans affairs


Spinal manipulation/mobilization technique


Vagal nerve stimulation


Parasympathetic nervous system


Auricular branch of the vagus nerve


Nucleus tractus solitarius


Tumor necrosis factor


Cooperative pain education and self-management


Chronic pain self-management program


Progressive muscle relaxation


Mindfulness meditation


Sympathetic nervous system




Deep slow breathing


Cognitive behavioral therapy for insomnia


International Classification of Disease 11th edition


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NWK was a major contributor in concept development. TJW, CLB, NAH, and NWK performed the literature search, analyzed results, and drafted, revised, and approved the final manuscript. TJW was a major contributor in writing the manuscript.

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Correspondence to Timothy J. Williamson.

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Williamson, T.J., Bolles, C.L., Hedges, N.A. et al. Chronic Primary Pain of the Spine: an Integrative Perspective Part 2. SN Compr. Clin. Med. 3, 473–489 (2021).

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  • Chronic pain
  • Spine
  • Low back pain
  • Neck pain
  • Management
  • Biopsychosocial