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The purpose of this study was to explore older adults' illness representations, their beliefs about health, and their coping perceptions of chronic spinal disability.This qualitative descriptive study used structured interviews that were completed during a randomized trial of non-pharmacological management of spine-related disability with chiropractic spinal manipulative therapy and exercise. Dual coders conducted a descriptive thematic analysis of 50 randomly selected transcripts supported by qualitative data management software. The Common-Sense Model provided an organizing framework for coding and interpretation.Fifty participants (34 women, median age: 68 years) described 4 illness representations, 4 coping styles, and 6 coping strategies for their management of spinal disability. Illness representations formed a continuum of little-to-no health impact to bothersome symptoms to heightened symptom intensity to unmanaged pain and/or disability. Most participants adopted either self-care or self-management coping styles, but some used healthcare-seeking or fear avoidance with worsening symptoms or interference with employment or preferred activities. Participants mentioned 6 coping strategies for spinal disability. Distraction included position changes, hobbies, and supportive relationships. Limitation focused on rest and/or relaxation, restricted movements, and activity modifications. Prevention enhanced self-care knowledge, posture and/or ergonomics, nutrition, and stress management. Movement emphasized stretching, home exercise and/or walking, and exercise therapy. Palliation augmented patient comfort through the use of heat and/or ice, over-the-counter medicine, and spinal manipulation. Avoidance strategies included missing employment, stopping house and/or yard work, and prescription medication.The community-dwelling older adults in this study offered varied illness representations of their chronic spinal disability. Most participants combined and personalized coping strategies to minimize pain and symptom impact; thus, representations may influence the coping styles adopted by older persons to manage their spinal conditions. A quote from a participant that pain was "a thought in the back of my mind" suggests the presence of cognitive and emotional processes that may influence individual perceptions and feelings about their spinal symptoms or conditions. These findings suggest that there may be a broader role for spine care clinicians to include teaching older people about self-management strategies to better cope with spinal disabilities.

The public health contribution of various health care professions is shaped by their education and areas of expertise. Growing recognition of musculoskeletal pain as a top driver of health care expenses and of back pain as the leading cause of years lived with disability suggest a greater public health role for the chiropractic profession in the United States and globally. There is little consensus on the depth or breadth of public health competencies within doctor of chiropractic programs that would optimize public health awareness and advocacy by chiropractic practitioners. Building on public health competencies published by other health care professions, an iterative consensus building process with chiropractic professional and educational leaders was used to generate a core set of public health competencies for the chiropractic profession. Sixteen competencies in four domains were developed and agreed to as necessary for chiropractors to more fully support the public health of the communities they serve and are being incorporated across chiropractic academic entities.

Different techniques used to analyze and reduce accelerometer data may impact its interpretation. To determine which variables were impacted by changing analysis parameters, the authors performed a secondary analysis of data gained from a clinical trial conducted on older adults (aged ≥65 years; M = 71.1 and SD = 5.3; n = 100) with neck and back disabilities and compared the effects of two different cut- point sets (Matthews and Freedson sets) commonly used to analyze older adult accelerometry data. The Matthews set was found to assign significantly greater moderate-to-vigorous physical activity per day than the Freedson set in all comparisons. This suggests that, if moderate-to-vigorous physical activity per unit time is a primary outcome measure, the choice of which analysis method is used should be carefully considered. Further results from analyses of dependent variables, time in moderate-to-vigorous physical activity bouts of >10 min/day, mean bout length, and number of bouts per day are discussed.

The purpose of this cross-sectional study was to compare functional limitations and comorbidity prevalence between older adult users and nonusers of chiropractic and osteopathic (DC/DO) manipulation to inform provider training.We conducted a secondary analysis of the 2012 National Health Interview Survey data. Adults age 65 or older who responded to the survey were included. Descriptive statistics are reported for adults who used DC/DO manipulation (vs nonusers) regarding function, comorbidities, musculoskeletal complaints, and medical services. Weighted percentages were derived using SAS and compared with χThe DC/DO users were more often female, overweight or obese, and of white race than nonusers. More DC/DO users reported arthritis (55.3% vs 47.0%,0.01) or asthma (15.0% vs 10.0%, P.01) than nonusers; hypertension (61.9% vs 55.5%, P = .02) and diabetes (20.3% vs 15.7%, P = .02) were more prevalent in nonusers; and other comorbidities were comparable. The DC/DO users reported more joint pain/stiffness (55.7% vs 44.8%), chronic pain (19.8% vs 14.2%), low back pain (27.8% vs 18.4%), low back with leg pain (18.8% vs 10.6%), and neck pain (24.2% vs 13.1%) than nonusers (all P.01). Functional limitations affected two-thirds overall, but DC/DO users reported more difficulties stooping and bending; other limitations were comparable. One in 9 reported activities of daily living or instrumental activities of daily living limitations; nonusers were more affected. Surgery was more common among DC/DO users (26.1% vs 19.3%,0.01); emergency room visits were comparable.Differences existed between older adult manipulation users and nonusers, especially surgical utilization, musculoskeletal complaints, and comorbidities; functional differences were modest. Our findings highlight areas for provider training and awareness regarding comorbidity burden and management needs in older patients who may simultaneously use manipulation and medical care for musculoskeletal complaints.

Objective A mixed methods, randomized controlled trial comparing short- and long-term chiropractic care and exercise therapy for spinal disability in older adults found no between-group differences in the primary outcome. However, those who received long-term management reported greater improvement in neck pain, self-efficacy, function, and balance. This nested qualitative study explored participants' perceptions of the benefits and drawbacks of chiropractic and exercise for spine-related outcomes, with an emphasis on understanding what makes treatment for spine-related problems worthwhile. Methods Of 171 individual interviews conducted after completing study treatment, 50 participants (25 per treatment group) were randomly selected for this analysis. Qualitative descriptive analysis included dual coding of verbatim transcripts by two investigators, further distilled into a consensus-derived codebook of themes and organized using NVIVO software. Results Participants described trial interventions as complimentary to one another for spine-related disability. Chiropractic care was viewed as improving spinal pain and controlling symptoms, while exercise therapy was noted for its long-term impact on self-efficacy and self-management. These older adults considered changes in pain, a global sense of improvement, and improved biomechanical function as making treatment worthwhile. Conclusion Older adults valued non-pharmacological treatment options that aided them in controlling spine-related symptoms, while empowering them to maintain clinical benefit gained after a course of chiropractic spinal manipulation and exercise. The complimentary nature of provider-delivered and active care modalities may be an important consideration when developing care plans. This study underscores the importance of understanding participants' values and experiences when interpreting study results and applying them to practice.

The World Federation of Chiropractic supports the involvement of chiropractors in public health initiatives, particularly as it relates to musculoskeletal health. Three topics within public health have been identified that call for a renewed professional focus. These include healthy ageing; opioid misuse; and women’s, children’s, and adolescents’ health. The World Federation of Chiropractic aims to enable chiropractors to proactively participate in health promotion and prevention activities in these areas, through information dissemination and coordinated partnerships. Importantly, this work will align the chiropractic profession with the priorities of the World Health Organization. Successful engagement will support the role of chiropractors as valued partners within the broader healthcare system and contribute to the health and wellbeing of the communities they serve.

Objectives Transgender individuals commonly experience barriers to quality health care and may suffer from unique musculoskeletal complaints. Although these needs are often inadequately addressed within the health care system, they could be attended to by the chiropractic community. This narrative review describes best practices for delivering culturally sensitive care to transgender patients within the context of chiropractic offices. Methods A literature search generated peer-reviewed material on culturally competent care of the transgender community. Google Scholar and trans-health RSS feeds on social media were also searched to find relevant gray literature. Information pertinent to a chiropractic practice was identified and summarized. Results Contemporary definitions of transgender, gender identity, and sexual orientation provide a framework for culturally sensitive language and clinic culture. Small changes in record keeping and office procedures can contribute to a more inclusive environment for transgender patients and improve a chiropractor's ability to collect important health history information. Special considerations during a musculoskeletal examination may be necessary to properly account for medical and nonmedical practices transgender patients may use to express their gender. Chiropractors should be aware of health care and social and advocacy resources for transgender individuals and recommend them to patients who may need additional support. Conclusions Small yet intentional modifications within the health care encounter can enable chiropractors to improve the health and well-being of transgender individuals and communities.

Background Low back pain (LBP) is a common disabling condition in older adults which often limits physical function and diminishes quality of life. Two clinical trials in older adults have shown spinal manipulative therapy (SMT) results in similar or small improvements relative to medical care; however, the effectiveness of adding SMT or rehabilitative exercise to home exercise is unclear. Methods We conducted a randomized clinical trial assessing the comparative effectiveness of adding SMT or supervised rehabilitative exercise to home exercise in adults 65 or older with sub-acute or chronic LBP. Treatments were provided over 12-weeks and self-report outcomes were collected at 4, 12, 26, and 52 weeks. The primary outcome was pain severity. Secondary outcomes included back disability, health status, medication use, satisfaction with care, and global improvement. Linear mixed models were used to analyze outcomes. The primary analysis included longitudinal outcomes in the short (week 4–12) and long-term (week 4–52). An omnibus test assessing differences across all groups over the year was used to control for multiplicity. Secondary analyses included outcomes at each time point and responder analyses. This study was funded by the US Department of Health and Human Services, Health Resources and Services Administration. Results 241 participants were randomized and 230 (95%) provided complete primary outcome data. The primary analysis showed group differences in pain over the one-year were small and not statistically significant. Pain severity was reduced by 30 to 40% after treatment in all 3 groups with the largest difference (eight percentage points) favoring SMT and home exercise over home exercise alone. Group differences at other time points ranged from 0 to 6 percentage points with no consistent pattern favoring one treatment. One-year post-treatment pain reductions diminished in all three groups. Secondary self-report outcomes followed a similar pattern with no important group differences, except satisfaction with care, where the two combination groups were consistently superior to home exercise alone. Conclusions Adding spinal manipulation or supervised rehabilitative exercise to home exercise alone does not appear to improve pain or disability in the short- or long-term for older adults with chronic low back pain, but did enhance satisfaction with care. Trial registration NCT00269321.

The future of any profession is in the hands of its students and early career practitioners. The Millennial generation of chiropractors embody attributes that are uniquely suited to the evolving landscape of 21L’avenir de toute profession est entre les mains des étudiants et des praticiens en début de carrière. Les chiropraticiens de la génération du millénaire possèdent des qualités particulièrement adaptées au secteur des soins de santé du 21e siècle, qui est en constante évolution. La mondialisation et les progrès rapides de la technologie rendent nécessaire l’adoption d’autres styles de communication, d’autres attitudes à l’égard de la diversité, d’un autre type d’engagement professionnel et peut-être ce qui importe le plus, d’autres idéaux pour l’avenir. Les chiropraticiens du millénaire ont une vision claire de l’avenir de cette profession et sont équipés pour matérialiser cet idéal.

The goals of this study were to identify self-reported differences in function, comorbidities, and medical service utilization among adults who reported using chiropractic and/or osteopathic manipulation in the 2012 National Health Interview Survey, and to compare these between older and younger adults.We conducted a descriptive study of adults aged 18 or older who were included in the 2012 National Health Interview Survey and the Alternative Medicine Questionnaire. We included those who reported using chiropractic and/or osteopathic manipulation in the past 12 months. Responses were analyzed using SAS software. Weighted estimates were reported as percentages of chiropractic/osteopathic users overall and by age group (65 years vs ≥65 years).Among the 8.5% of US adults who reported receiving manipulation, 97.6% saw chiropractors. Most adults were under age 65 (83.7%), female (56.6%), and white (85.1%). Except for sitting tolerance, functional limitations were significantly higher among older manipulation users compared with younger manipulation users (all P.001). Older (vs younger) chiropractic/osteopathic users more often reported functional limitations (65.7% vs 37.2%), had difficulty walking without equipment (14.7% vs 2.8%), found it very difficult or were unable to walk one-quarter mile (15.7% vs 3.8%) or climb 10 steps (11.4% vs 2.5%), and needed help with instrumental activities of daily living (6.9% vs 2.0%). Comorbidities differed by age: cardiovascular events/conditions, cancer, diabetes, and arthritis were more common among older adults, and headaches, neck pain, and depression were more frequent in younger adults. Similar proportions of older and younger adults had emergency room visits (23.0% vs 21.7%); older adults reported more surgeries (26.1% vs 15.4%).Notable differences exist in functional limitations and comorbidities between older and younger chiropractic and osteopathic manipulation users. This information could inform clinical practice, education, and policy.

To describe the process for selecting and training chiropractic opinion leaders (OLs) and best practice collaborators (BPCs) to increase the uptake of best practice.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 additional OLs and BPCs. Recommended names were screened by OLs and final selection made by consensus. Webinars were utilized to train BPCs to engage peers in best practices, and facilitate guideline dissemination.In Phase 1, 21 OLs were selected from 80 nominees. Sixteen attended a training workshop. In Phase 2, 486 chiropractors recommended 1126 potential BPCs, of which 133 were invited to participate and 112 accepted.OLs and BPCs were identified across Canada to enhance the uptake of research among chiropractors.Décrire le processus permettant de choisir et former les leaders d’opinion (LO) et collaborateurs des pratiques d’exemplaire (CPE) en chiropratique dans le but de favoriser l’adoption des pratiques d’excellence.Lors de la première phase, on a désigné les LO au moyen d’une enquête transversale parmi les intervenants canadiens de la chiropratique. Un comité composé de dix membres a classé les candidats. Les candidats les mieux classés ont été invités à un atelier de formation. Lors de la deuxième phase, 7 200 chiropraticiens canadiens se sont soumis à une enquête nationale en ligne visant à désigner d’autres LO et CPE. Les noms recommandés ont été présélectionnés par les LO et le choix final s’est fait d’un commun accord. On s’est servi de webinaires pour former les LO à encourager leurs pairs à adopter des pratiques d’excellence et faciliter la diffusion des lignes directrices.Lors de la première phase, on a choisi 21 LO parmi 80 candidats. Seize d’entre eux ont assisté à un atelier de formation. Lors de la deuxième phase, 486 chiropraticiens ont recommandé 1 126 LO potentiels, parmi lesquels 133 ont été invités à participer et 112 ont accepté.On a désigné des LO et CPE à l’échelle du pays pour favoriser l’adoption de la recherche parmi les chiropraticiens.

This project assessed the nature of collaboration between complementary and alternative medicine (CAM) and traditional, research-intensive (TRI) institutions among the nine National Center of Complementary and Alternative Medicine (NCCAM)-funded Research Education Partnership Project Awards (R25 grant program). A blinded 43-question, IRB-approved survey was administered to primary investigators from 19 awarded CAM and TRI institutions. Quantitative data were analyzed descriptively. Short-answer questions were assessed qualitatively. The survey was completed by 84.2 % of the sample. Their collaborations included faculty exchanges, TRI institution seminars and mentorship of CAM faculty and students in research, joint development of courses and evidence-based practice (EBP) resources, and two-way consulting (TRI-CAM and vice versa). The collaborations were characterized as mutually respectful and personally rewarding, being collective efforts, instilling confidence in each others’ work, having open communication, resulting in mutual learning, and leading to subsequent collaborations. The most important success included training and collaboration among faculty (n = 9), developing EBP knowledge and educational materials (n = 7), improving research infrastructure and collaboration opportunities (n = 6), and cultural change toward EBP (n = 5). The greatest progress included providing educational and research opportunities for students and faculty. The primary challenges were related to time constraints of faculty. Over 70 % of respondents believed that the TRI institution influenced culture change in CAM faculty, and 30 % of TRI institutions reported that the R25 collaboration led to culture change at their own institutions. The responses indicated the CAM-TRI collaborations provided important benefits to both types of institutions, laying the groundwork for continued partnerships and collaboration.

PURPOSE: 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.METHODS: This was a mixed-methods study in which qualitative data were collected within a randomized clinical trial assessing exercise and manual therapy for chronic neck pain. A consecutive sample of 106 patients who completed the trial intervention took part in semi-structured interviews querying the meaning of GPE. Quantitative measures were collected through self-report questionnaires. Interview transcripts were analyzed using content analysis to identify themes, which were then quantified to assess potential relationships.RESULTS: A model of GPE for chronic neck pain emerged comprised of five main themes: neck symptoms (cited by 85 %), biomechanical performance (38 %), activities of daily living (31 %), self-efficacy (10 %), and need for other treatment (6 %). Influencing factors included those contributing to GPE: treatment process (64 %), biomechanical performance (51 %), self-efficacy (16 %), and the nature of the condition (8 %). Factors, which detracted from GPE or prevented recovery included perceived nature of condition (58 %), required daily activities (10 %), lack of diagnosis (5 %), and history of failed treatment (5 %).CONCLUSIONS: GPE appears to capture chronic neck pain patient perceptions of change in different domains important to their individual pain experiences that may not be captured by other outcome instruments. Thus, GPE is a suitable patient-oriented outcome that can complement other measures in research and clinical practice. Importantly, many chronic neck pain patients believe it impossible to reach complete recovery because of a perceived intractable aspect of their neck condition; this has important implications regarding long-term disability and health-seeking behaviors.

Background Patient perceptions may influence the effectiveness and utilization of healthcare interventions, particularly for complex health conditions such as sciatica or back-related leg pain (BRLP). Objectives To explore BRLP patients' perceptions of spinal manipulative therapy (SMT) and home exercise with advice (HEA). Design Qualitative study in a controlled clinical trial. Method Semi-structured interviews conducted after 12 weeks of treatment asked participants about satisfaction with care and whether treatment was worthwhile. An interdisciplinary research team conducted content analysis using qualitative data analysis software to identify and summarize themes. Results Of 192 trial participants, 174 (91%) completed interviews (66% female, age 57.0 ± 11.5 years). Participants identified interactions with providers and staff, perceived treatment effects, and information as key contributors to both their satisfaction and the worthwhile nature of treatment. HEA was liked for its convenience and ability to foster an exercise habit. SMT was liked for specific aspects of the modality (e.g. manipulation, stretching) and provider competency. Most participants reported no dislikes for SMT or HEA, but some noted the dose/time commitment for SMT and discipline of HEA as least liked aspects of the interventions. Conclusions The quality of patient–provider interactions, perceived treatment effects, and information sharing influenced BRLP patients' satisfaction with care. Qualitative research describing patients' preferences can facilitate translation of study findings into practice and allow clinicians to tailor treatments to facilitate compliance and satisfaction with care.

Randomized controlled trial using mixed methods.To evaluate the relative effectiveness of high-dose supervised exercise with and without spinal manipulation and low-dose home exercise for chronic neck pain.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.Two hundred and seventy patients with chronic neck pain were studied at an outpatient clinic. Patients were randomly assigned one of the following interventions: (1) high-dose supervised strengthening exercise with spinal manipulation (exercise therapy combined with spinal manipulation therapy [ET + SMT]), (2) high-dose supervised strengthening exercise (ET) alone, or (3) low-dose home exercise and advice (HEA). The primary outcome was patient-rated pain at baseline and at 4, 12, 26, and 52 weeks. Secondary measures were disability, health status, global perceived effect, medication use, and satisfaction.At 12 weeks, there was a significant difference in patient-rated pain between ET + SMT and HEA (1.3 points, P0.001) and ET and HEA (1.1 points, P = 0.001). Although there were smaller group differences in patient-rated pain at 52 weeks (ET + SMT vs. HEA, 0.2 points, P0.05; ET vs. HEA, 0.3 points, P0.05), linear mixed model analyses incorporating all time points yielded a significant advantage for the 2 supervised exercise groups (ET + SMT vs. HEA, P = 0.03; ET vs. HEA, P = 0.02). Similar results were observed for global perceived effect and satisfaction.Supervised strengthening exercise with and without spinal manipulation performed similarly, yielding better outcomes than home exercise particularly in the short term. Various stakeholders' perspectives should be considered carefully when making recommendations regarding these therapies, taking into account side effects, preferences, and costs.

There is a growing need for students and practitioners of Traditional Chinese Medicine to gain experience with standardized data collection, patient outcomes measurement, and practice-based research. The purpose of this paper is to describe the development of a process for standardized data collection that could eventually be adopted for clinical, research, and quality assurance purposes.The setting for this study was an acupuncture and Oriental medicine teaching clinic in Bloomington, Minnesota.Four (4) aspects of data collection were assessed and improved, including intake and post-treatment questionnaires, follow-up with patients, integration of data collection into clinic flow, and commitment of resources to the project.The outcomes measures were data collection and missing data rates, burden on patients and clinic staff, and efficiency of data entry.Revision to the data collection process resulted in decreased burden to patients and staff, more detailed and aggressive follow-up protocols, enhanced training for clinic staff, and increased personnel and data-related resources.The systematic collection of descriptive and clinical characteristics can be accomplished in a teaching clinic with thoughtful attention paid to data collection protocols, dedicated resources, and the involvement of all relevant personnel.

Spinal manipulative therapy (SMT) and exercise have demonstrated effectiveness for neck pain (NP). Adverse events (AE) reporting in trials, particularly among elderly participants, is inconsistent and challenges informed clinical decision making. This paper provides a detailed report of AE experienced by elderly participants in a randomized comparative effectiveness trial of SMT and exercise for chronic NP. AE data, consistent with CONSORT recommendations, were collected on elderly participants who received 12 weeks of SMT with home exercise, supervised plus home exercise, or home exercise alone. Standardized questions were asked at each treatment; participants were additionally encouraged to report AE as they occurred. Qualitative interviews documented participants' experiences with AE. Descriptive statistics and content analysis were used to categorize and report these data. Compliance was high among the 241 randomized participants. Non-serious AE were reported by 130/194 participants. AE were reported by three times as many participants in supervised plus home exercise, and nearly twice as many as in SMT with home exercise, as in home exercise alone. The majority of AE were musculoskeletal in nature; several participants associated AE with specific exercises. One incapacitating AE occurred when a participant fell during supervised exercise session and fractured their arm. One serious adverse event of unknown relationship occurred to an individual who died from an aneurysm while at home. Eight serious, non-related AE also occurred. Musculoskeletal AE were common among elderly participants receiving SMT and exercise interventions for NP. As such, they should be expected and discussed when developing care plans.

Objective To assess the feasibility of recruiting sciatica patients and to evaluate their compliance in preparation for a full-scale randomized clinical trial. We also aimed to determine the responsiveness of key outcome measures. Methods Thirty-two subjects were randomly assigned to spinal manipulation (n=11), epidural steroid injections (n=11), or self-care education (n=10). No between-group comparisons were planned because of the small sample size. Results At week 12 (the end of the treatment phase), the outcome measures indicating the most improvement/change were the Oswestry disability score (mean, 22.9; SD, 19.9; effect size [ES], 1.8), leg pain severity (mean, 2.9; SD, 1.7; ES, 1.7), and if the symptoms were bothersome (mean, 25.2; SD, 16.0; ES, 1.6). Twenty-four patients were either “very satisfied” or “completely satisfied,” and 22 of 32 patients reported 75% or 100% improvement. After 52 weeks, the outcome measure showing the most improvement/change was leg pain severity (mean, 2.3; SD, 2.6; ES, 1.35), followed by the Oswestry disability score (mean, 15.6; SD, 20; ES, 1.2) and if symptoms were bothersome (mean, 18.1; SD, 22.6; ES, 1.1). Eighteen patients were either “very satisfied” or “completely satisfied,” and 15 of 32 patients reported 75% or 100% improvement. Conclusions The results of this pilot study suggest that it is feasible to recruit subacute and chronic sciatica patients and to obtain their compliance for a full-scale randomized clinical.

Background Little is known about the issues low back pain patients take into account when deciding their satisfaction with care, the importance placed on such satisfaction, or the factors they consider when assessing their overall improvement. Objective The purpose of this study was to explore these issues and to assess the feasibility of implementing qualitative research methods within a clinical trial. Methods Study participants were volunteers taking part in a randomized clinical pilot study comparing nonsurgical treatments for sciatica. Face-to-face interviews were conducted, transcribed, and analyzed using content analysis. Results All 31 individuals who participated in the pilot study were interviewed. When asked which issues they considered when deciding their satisfaction with care, the most frequently identified themes were change in pain, personnel, and the treatment experience. When assessing their overall improvement, all participants considered whether their pain had changed. In response to the question asking participants which outcomes they considered to be most important, severity of pain and quality of life were most commonly cited. Conclusion This study demonstrated that a “mixed methods” approach using qualitative research methods within a clinical trial is not only feasible but can provide interesting and useful information for trial interpretation and future study design. By providing insight to the multidimensional nature of patients' beliefs and perceptions, this technique may not only shape but also redefine the focus of patient-oriented research and health care for low back pain conditions.

Background context Neck pain, common among the elderly population, has considerable implications on health and quality of life. Evidence supports the use of spinal manipulative therapy (SMT) and exercise to treat neck pain; however, no studies to date have evaluated the effectiveness of these therapies specifically in seniors. Purpose To assess the relative effectiveness of SMT and supervised rehabilitative exercise, both in combination with and compared to home exercise (HE) alone for neck pain in individuals ages 65 years or older. Study design/setting Randomized clinical trial. Patient sample Individuals 65 years of age or older with a primary complaint of mechanical neck pain, rated ≥3 (0–10) for 12 weeks or longer in duration. Outcome measures Patient self-report outcomes were collected at baseline and 4, 12, 26, and 52 weeks after randomization. The primary outcome was pain, measured by an 11-box numerical rating scale. Secondary outcomes included disability (Neck Disability Index), general health status (Medical Outcomes Study Short Form-36), satisfaction (7-point scale), improvement (9-point scale), and medication use (days per week). Methods This study was funded by the US Department of Health and Human Services, Health Resources and Services Administration. Linear mixed model analyses were used for comparisons at individual time points and for short- and long-term analyses. Blinded evaluations of objective outcomes were performed at baseline and 12 weeks. Adverse event data were collected at each treatment visit. Results A total of 241 participants were randomized, with 95% reporting primary outcome data at all time points. After 12 weeks of treatment, the SMT with home exercise group demonstrated a 10% greater decrease in pain compared with the HE-alone group, and 5% change over supervised plus home exercise. A decrease in pain favoring supervised plus HE over HE alone did not reach statistical significance. Compared with the HE group, both combination groups reported greater improvement at week 12 and more satisfaction at all time points. Multivariate longitudinal analysis incorporating primary and secondary patient-rated outcomes showed that the SMT with HE group was superior to the HE-alone group in both the short- and long-term. No serious adverse events were observed as a result of the study treatments. Conclusions SMT with HE resulted in greater pain reduction after 12 weeks of treatment compared with both supervised plus HE and HE alone. Supervised exercise sessions added little benefit to the HE-alone program.

Purpose 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 development and implementation of a care pathway designed to guide treatment by an integrative group of providers within a randomized controlled trial.

The NIH National Center for Complementary and Alternative Medicine (NCCAM) has funded two rounds of R25 education grants. The first set of R25 grants were awarded to conventional schools and focused on integrating CAM content into health professions education programs. Grants were awarded to medical and nursing schools predominantly, with one grant going to the American Medical Student Association and one grant being awarded to an institution integrating CAM into nursing, medicine and pharmacy. The second round of R25 grants were awarded to CAM institutions and focused on introducing evidence-based practice into curricula of CAM schools including schools of chiropractic, naturopathic, and acupuncture and Oriental medicine. Although not an explicit objective of the grant program, one of the most significant and enduring outcomes reported by investigators has been culture change. This article describes individual and organizational culture changes that occurred at Northwestern Health Sciences University.

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. Trial registration ClinicalTrials.gov NCT00567333

Background context Several conservative therapies have been shown to be beneficial in the treatment of chronic low back pain (CLBP), including different forms of exercise and spinal manipulative therapy (SMT). The efficacy of less time-consuming and less costly self-care interventions, for example, home exercise, remains inconclusive in CLBP populations. Purpose The purpose of this study was to assess the relative efficacy of supervised exercise, spinal manipulation, and home exercise for the treatment of CLBP. Study design/setting An observer-blinded and mixed-method randomized clinical trial conducted in a university research clinic in Bloomington, MN, USA. Patient sample Individuals, 18 to 65 years of age, who had a primary complaint of mechanical LBP of at least 6-week duration with or without radiating pain to the lower extremity were included in this trial. Outcome measures Patient-rated outcomes were pain, disability, general health status, medication use, global improvement, and satisfaction. Trunk muscle endurance and strength were assessed by blinded examiners, and qualitative interviews were performed at the end of the 12-week treatment phase. Methods This prospective randomized clinical trial examined the short- (12 weeks) and long-term (52 weeks) relative efficacy of high-dose, supervised low-tech trunk exercise, chiropractic SMT, and a short course of home exercise and self-care advice for the treatment of LBP of at least 6-week duration. The study was approved by local institutional review boards. Results 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. Conclusions 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.

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. Trial registration ClinicalTrials.gov NCT00567333

The purpose of this study was to describe patients who seek treatment at an acupuncture and Oriental medicine teaching clinic in the United States, and to systematically measure and describe patients' responses after treatment using a prospective study design.This is a prospective survey of clinic patients at intake and one month following the initial treatment. SETTINGS AND LOCATION: Data were collected in an acupuncture and Oriental medicine teaching clinic located in Bloomington, Minnesota.Of 661 new patients who met eligibility criteria, 485 consented to participate.Patients were administered two self-report questionnaires: one prior to their initial treatment, and a second sent by mail one month later.Data collected at intake included demographics such as age, gender, race, ethnicity, education, and employment, as well as main presenting complaint and chronicity. Patients were also asked at intake whether they had consulted with another health care provider, if they were under continued care, and if they had previous experience with Traditional Chinese Medicine (TCM) treatment. Outcome measures included severity, improvement, and satisfaction. Patients were additionally asked if they continued with TCM care for their presenting condition.Demographics of patients presenting to this teaching clinic were similar to those reported in other outpatient TCM settings. The majority of patients had no previous experience with TCM, and a large percentage was referred by students. Pain was the most common presenting condition, followed closely by wellness care. One month following treatment, most patients reported improvement and satisfaction with care.Standardized data collection and follow-up resulted in a description of patients and outcomes in an acupuncture and Oriental medicine teaching clinic, which can be used for research, educational, quality assurance, and marketing purposes.

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. This column spotlights such innovations in integrative healthcare and CAM education and presents readers with specific educational interventions they can adapt into new or ongoing educational efforts at their institution or programs. We invite readers to submit brief descriptions of efforts in their institutions that reflect the creativity, diversity, and interdisciplinary nature of the field. Please submit to Dr Sierpina at vssierpi@utmb.edu or Dr Kreitzer at kreit003@umn.edu. Submissions should be no more than 500 to 1500 words. Please include any Web site or other resource that is relevant, as well as contact information.

Background Low back pain (LBP) and neck pain (NP) are common conditions in old age, leading to impaired functional ability and decreased independence. Manual and exercise therapies are common and effective therapies for the general LBP and NP populations. However, these treatments have not been adequately researched in older LBP and NP sufferers. The primary aim of these studies is to assess the relative clinical effectiveness of 1) manual treatment plus home exercise, 2) supervised rehabilitative exercise plus home exercise, and 3) home exercise alone, in terms of patient-rated pain, for senior LBP and NP patients. Secondary aims are to compare the three treatment approaches in regards to patient-rated disability, general health status, satisfaction, improvement and medication use, as well as objective outcomes of spinal motion, trunk strength and endurance, and functional ability. Cost-effectiveness and cost-utility will also be assessed. Finally, using qualitative methods, older LBP and NP patient's perceptions of treatment will be explored and described. Methods/Design This paper describes the design of two multi-methods clinical studies focusing on elderly patients with non-acute LBP and NP. Each study includes a randomized clinical trial (RCT), a cost-effectiveness study alongside the RCT, and a qualitative study. Four hundred and eighty participants (240 per study), ages 65 and older, will be recruited and randomized to one of three, 12-week treatment programs. Patient-rated outcome measures are collected via self-report questionnaires at baseline and at 4, 12, 26, and 52 weeks post-randomization. Objective outcomes are assessed by examiners masked to treatment assignment at baseline and 12 weeks. Health care cost data is collected through standardized clinician forms, monthly phone interviews, and self-report questionnaires throughout the study. Qualitative interviews using a semi-structured format are conducted at the end of the 12 week treatment period. Discussion To our knowledge, these are the first randomized clinical trials to comprehensively address clinical effectiveness, cost-effectiveness, and patients' perceptions of commonly used treatments for elderly LBP and NP sufferers. Trial Registration NCT00269321 and NCT00269308

Purpose Neck pain (NP) is a common condition in old age, leading to impaired functional ability and decreased independence. Spinal manipulation and exercise are common and effective treatments for the general NP population; however, their effectiveness among seniors is unknown. The primary aim of this randomized clinical trail was to assess the relative shortand long-term clinical effectiveness of spinal manipulative therapy (SMT) and supervised rehabilitative exercise (SRE), both in combination with and compared to home exercise (HE) alone, in NP patients 65 years and older.

Purpose Evidence to date suggests there is no one treatment approach which is clearly superior for low back pain (LBP). It is plausible that combining treatments with small to moderate effect sizes will improve patient outcomes. Additional benefit might also be achieved by individualizing treatment plans according to patient presentation, for example, by addressing psychosocial factors. Our objective was to assess the relative clinical effectiveness of: 1) mono-disciplinary chiropractic care versus 2) multi-disciplinary integrative care for LBP, within the context of defined clinical care pathways.

BACKGROUND: Back and neck disability are frequent in older adults resulting in loss of function and independence. Exercise therapy and manual therapy, like spinal manipulative therapy (SMT), have evidence of short and intermediate term effectiveness for spinal disability in the general population and growing evidence in older adults. For older populations experiencing chronic spinal conditions, long term management may be more appropriate to maintain improvement and minimize the impact of future exacerbations. Research is limited comparing short courses of treatment to long term management of spinal disability. The primary aim is to compare the relative effectiveness of 12 weeks versus 36 weeks of SMT and supervised rehabilitative exercise (SRE) in older adults with back and neck disability.METHODS/DESIGN: Randomized, mixed-methods, comparative effectiveness trial conducted at a university-affiliated research clinic in the Minneapolis/St. Paul, Minnesota metropolitan area.PARTICIPANTS: Independently ambulatory community dwelling adults ≥ 65 years of age with back and neck disability of minimum 12 weeks duration (n = 200).INTERVENTIONS: 12 weeks SMT + SRE or 36 weeks SMT + SRE.RANDOMIZATION: Blocked 1:1 allocation; computer generated scheme, concealed in sequentially numbered, opaque, sealed envelopes.BLINDING: Functional outcome examiners are blinded to treatment allocation; physical nature of the treatments prevents blinding of participants and providers to treatment assignment.PRIMARY ENDPOINT: 36 weeks post-randomization.DATA COLLECTION: Self-report questionnaires administered at 2 baseline visits and 4, 12, 24, 36, 52, and 78 weeks post-randomization. Primary outcomes include back and neck disability, measured by the Oswestry Disability Index and Neck Disability Index. Secondary outcomes include pain, general health status, improvement, self-efficacy, kinesiophobia, satisfaction, and medication use. Functional outcome assessment occurs at baseline and week 37 for hand grip strength, short physical performance battery, and accelerometry. Individual qualitative interviews are conducted when treatment ends. Data on expectations, falls, side effects, and adverse events are systematically collected.PRIMARY ANALYSIS: Linear mixed-model method for repeated measures to test for between-group differences with baseline values as covariates.DISCUSSION: Treatments that address the management of spinal disability in older adults may have far reaching implications for patient outcomes, clinical guidelines, and healthcare policy.TRIAL REGISTRY: www.ClinicalTrials.gov; Identifier: NCT01057706.