Maiers, Michele J.

Background:  Low back pain (LBP) is a prevalent and costly condition in the United States. Evidence suggests there is no one treatment which is best for all patients, but instead several viable treatment options. Additionally, multidisciplinary management of LBP may be more effective than monodisciplinary care. An integrative model that includes both complementary and alternative medicine (CAM) and conventional therapies, while also incorporating patient choice, has yet to be tested for chronic LBP. The primary aim of this study is to determine the relative clinical effectiveness of 1) monodisciplinary chiropractic care and 2) multidisciplinary integrative care in 200 adults with non-acute LBP, in both the short-term (after 12 weeks) and long-term (after 52 weeks). The primary outcome measure is patient-rated back pain. Secondary aims compare the treatment approaches in terms of frequency of symptoms, low back disability, fear avoidance, self-efficacy, general health status, improvement, satisfaction, work loss, medication use, lumbar dynamic motion, and torso muscle endurance. Patients’ and providers’ perceptions of treatment will be described using qualitative methods, and cost-effectiveness and cost utility will be assessed.

 Methods and Design: This paper describes the design of a randomized clinical trial (RCT), with cost-effectiveness and qualitative studies conducted alongside the RCT. Two hundred participants ages 18 and older are being recruited and randomized to one of two 12-week treatment interventions. Patient-rated outcome measures are collected via self-report questionnaires at baseline, and at 4, 12, 26, and 52 weeks post-randomization. Objective outcome measures are assessed at baseline and 12 weeks by examiners blinded to treatment assignment. Health care cost data is collected by self-report questionnaires and treatment records during the intervention phase and by monthly phone interviews thereafter. Qualitative interviews, using a semi-structured format, are conducted with patients at the end of the 12-week treatment period and also with providers at the end of the trial.

 Discussion: This mixed-methods randomized clinical trial assesses clinical effectiveness, cost-effectiveness, and patients’ and providers’ perceptions of care, in treating non-acute LBP through evidence-based individualized care delivered by monodisciplinary or multidisciplinary care teams.

Background: For the treatment of chronic back pain, it has been theorized that integrative care plans can lead to
better outcomes than those achieved by monodisciplinary care alone, especially when using a collaborative,
interdisciplinary, and non-hierarchical team approach. This paper describes the use of a care pathway designed to
guide treatment by an integrative group of providers within a randomized controlled trial.

Methods: A clinical care pathway was used by a multidisciplinary group of providers, which included
acupuncturists, chiropractors, cognitive behavioral therapists, exercise therapists, massage therapists and primary
care physicians. Treatment recommendations were based on an evidence-informed practice model, and reached
by group consensus. Research study participants were empowered to select one of the treatment
recommendations proposed by the integrative group. Common principles and benchmarks were established to
guide treatment management throughout the study.

Results: Thirteen providers representing 5 healthcare professions collaborated to provide integrative care to study
participants. On average, 3 to 4 treatment plans, each consisting of 2 to 3 modalities, were recommended to study
participants. Exercise, massage, and acupuncture were both most commonly recommended by the team and
selected by study participants. Changes to care commonly incorporated cognitive behavioral therapy into
treatment plans.

Conclusion: This clinical care pathway was a useful tool for the consistent application of evidence-based care for
low back pain in the context of an integrative setting.

The purpose of this study was to assess the relative efficacy of supervised exercise, spinal manipulation, and home exercise for the treatment of CLBP.  A total of 301 individuals were included in this trial. For all three treatment groups, outcomes improved during the 12 weeks of treatment. Those who received supervised trunk exercise were most satisfied with care and experienced the greatest gains in trunk muscle endurance and strength, but they did not significantly differ from those receiving chiropractic spinal manipulation or home exercise in terms of pain and other patient-rated individual outcomes, in both the short- and long-term.  For CLBP, supervised exercise was significantly better than chiropractic spinal manipulation and home exercise in terms of satisfaction with treatment and trunk muscle endurance and strength. Although the short- and long-term differences between groups in patient-rated pain, disability, improvement, general health status, and medication use consistently favored the supervised exercise group, the differences were relatively small and not statistically significant for these individual outcomes.

The overall objective of our educational program is to facilitate evidence informed practice (EIP) among CAM practitioners. Through the practice of EIP, we aim to educate research-literate Content on integrative healthcare and complementary and alternative medicine is being taught in hundreds of educational programs across the country. Nursing, medical, osteopathic, chiropractic, acupuncture, naturopathic, and other programs are finding creative and innovative ways to include these approaches in new models of education and practice. 

Neck pain is a common global health care complaint with considerable social and economic impact. Systematic reviews have found exercise therapy (ET) to be effective for neck pain, either alone or in combination with spinal manipulation. However, it is unclear to what extent spinal manipulation adds to supervised exercise or how supervised high-dose exercise compares with low-dose home exercise.

The NCCAM-funded R25 project has provided the impetus for meaningful culture change at Northwestern Health Sciences University (NWHSU) which, over the long term, can affect the professional culture of our CAM constituents. Benefiting from a unique collaboration with the University of Minnesota Center for Spirituality and Healing, we are making substantial progress in developing our CAM professionals' research-related skill sets so that they may truly learn and practice in evidence informed ways.

Global Perceived Effect (GPE) is a commonly used outcome measure for musculoskeletal conditions like neck pain; however, little is known regarding the factors patients take into account when determining their GPE. The overall objective of this work was to describe the thematic variables, which comprise the GPE from the patient's perspective.

Objective: To explore perceptions of spinal manipulative therapy and exercise among adults aged 65 years and older with chronic neck pain.

Design: Mixed methods study embedded within a randomized clinical trial.

Subjects/Patients: Interviews were conducted with 222 of 241 randomized clinical trial participants. They had a mean age of 72. 2 years and they had neck pain of moderate severity and of 6 years mean duration.
Methods: Semi-structured interviews were conducted at the completion of the 12 week intervention phase, during which participants received spinal manipulative therapy and exercise interventions. Interviews explored determinants of satisfaction with care, whether or not therapy was worthwhile, and what was liked and disliked about treatment. Interviews were recorded and transcribed; content analysis was used to identify themes within responses.

Results: Participants placed high value on their relationships with health care team members, supervision, individualized care, and the exercises and information provided as treatment. Change in symptoms did not figure as prominently as social and process-related themes. Perceptions of age, activities, and co-morbidities influenced some seniors’ expectations of treatment results, and comorbidities impacted perceptions of their ability to participate in active care.

Conclusion: Relationship dynamics should be leveraged in clinical encounters to enhance patient satisfaction and perceived value of care.

Objectives: To describe the process for selecting and training chiropractic opinion leaders (OLs) and best practice collaborators (BPCs) to increase the uptake of best practice. Methods: In Phase 1, OLs were identified using a cross-sectional survey among Canadian chiropractic stakeholders. A 10-member committee ranked nominees. Top-ranked nominees were invited to a training workshop. In Phase 2, a national e-survey was administered to 7200 Canadian chiropractors to identify.