"Like Peanut Butter and Jelly": A Qualitative Study of Chiropractic Care and Home Exercise Among Older Adults With Spinal Disability

Investigating Functional Impairment in Chronic Low Back Pain: A Qualitative Study from the Patients and Specialists' Perspectives

Prompt and appropriate treatment of chronic low back pain (cLBP) is of the utmost importance for preventing relevant disability, high burden of disease, and increasing costs for the healthcare system. Recently, the concept of functional impairment has been associated with any type of chronic pain, and mounting attention has been paid to extending the aims of treatment beyond mere pain remission, including restoration of working capacity, everyday functioning, mobility, and quality of life. Nevertheless, a shared definition of functionality is still lacking. Notably, different specialists involved in the treatment of cLBP such as general practitioners, orthopedists, pain therapists, and physiatrists, and patients themselves have different opinions on what "functional impairment" actually means. On these premises, a qualitative interview study was performed to investigate how the concept of "functionality" is interpreted by different specialists involved in the management of cLBP, and by patients. Overall, all different specialists agreed that functionality should be assessed in clinical practice. However, in spite of several instruments available for evaluating functionality, no homogeneity of behavior is observable.

Discrepant Perceptions of Biopsychosocial and Active Care Recommendations Between Doctors of Chiropractic and Midlife and Older Adult Patients: A Descriptive Survey

OBJECTIVE

The purpose of this study was to assess perceptions about the inclusion of biopsychosocial and active care recommendations during chiropractic clinical encounters between doctors of chiropractic (DCs) and their midlife and older adult patients and to identify whether there were any discrepancies between their recollections.

METHODS

This descriptive cross-sectional survey was part of a mixed-methods research project designed to gather information about the role of electronic health interventions for midlife and older adults who use chiropractic care. For this study, a convenience sample of 29 DCs and 48 chiropractic patients aged 50 years and older from 2 metropolitan areas in the United States completed online surveys between December 2020 and May 2021. The survey matched questions about components of chiropractic care discussed by patients and providers over 12 months. We used descriptive statistics to explore congruence in perceptions between groups and qualitative content analysis to describe DC perceptions of working with this population.

RESULTS

Doctors of chiropractic and patients agreed (>90%) that pain management was the top reason midlife and older adults seek chiropractic care, yet differed in their prioritization of maintenance/wellness care, physical function/rehabilitation, and injury treatment as care drivers. While DCs reported frequent discussions about psychosocial recommendations, fewer patients reported talking about treatment goals (51%), self-care (43%), stress reduction (33%), or the impact of psychosocial factors (23%) and beliefs/attitudes (33%) on spinal health. Patients reported varied recollections about discussing activity limitations (2%) and exercise promotion (68%), being taught exercises (48%), or reassessing exercise progress (29%), which differed from higher levels reported by DCs. Qualitative themes from DCs included psychosocial considerations in patient education, importance of exercise/movement, role of chiropractic in lifestyle changes, and reimbursement limitations for older patients.

CONCLUSION

Doctors of chiropractic and their patients reported discrepant perceptions about biopsychosocial and active care recommendations during clinical encounters. Patients reported modest emphasis on exercise promotion and limited discussion on self-care, stress reduction, and psychosocial factors related to spine health compared to the recollections of DCs who reported frequent discussions of these topics.

Mixed methods systematic review of the literature base exploring working alliance in the chiropractic profession

Background

The construct of working alliance has been used to operationalise the patient–clinician relationship. Research evidence from the rehabilitation literature has established an association between the construct and several patient outcomes. The aim of this systematic literature review was to study working alliance in the chiropractic discipline.

Method

This review followed a mixed method systematic review methodology: EBSCO (The Allied and Complementary Medicine Database), EBSCO (MEDLINE), EBSCO PsycINFO, Web of Science Core Collection, Chiro index, and grey literature were searched for quantitative, qualitative, and mixed methods studies on 17th March 2021. Qualitative appraisal was conducted using the Mixed Methods Appraisal Tool, version 2018. The qualitative component was synthesised via thematic synthesis and explored patients’ and chiropractors’ perceptions of the nature and role of working alliance. The quantitative component was synthesised via narrative synthesis to examine how the construct has been measured in research and what its effect on clinical outcomes and patient satisfaction is. The findings were integrated in the discussion section.

Results

Thirty studies were included. The qualitative component found that both patients and chiropractors consider working alliance as a key factor in the treatment journey. The findings illustrated that the construct includes the bond between a patient and a chiropractor which is underpinned by trust and attentiveness to patients’ needs, values and preferences. Qualitative data also suggested that strong working alliance has the potential to improve patients’ adherence to treatment and that it is characterised by ongoing negotiation of expectations about the goals of care and the tasks involved in the treatment plan. The quantitative component highlighted that even though working alliance is relevant to the chiropractic discipline, very few studies have quantitatively measured the construct and its effect.

Conclusion

The findings of this review emphasise the subjective importance of working alliance in the chiropractic clinical encounter. However, there were not enough homogenous studies measuring the effect of working alliance on clinical outcomes and patient satisfaction to conduct a meta-analysis. Future research should focus on evaluating potential direct and mediated effects on patient outcomes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12998-022-00442-4.

Association Between Psychosocial Parameters and Response to Chiropractic Care Among Older Adults With Chronic Low Back Pain: Secondary Analysis of a Randomized Clinical Trial

OBJECTIVES

The purpose of this study was to determine whether baseline self-efficacy, fear of pain with movement (kinesiophobia), or change in either were associated with clinically important improvement in disability among older adults with chronic low back pain after 12 weeks of chiropractic spinal manipulation (CSM) and exercise.

METHODS

This secondary analysis used randomized trial data from community-dwelling adults aged 65 years or older with chronic spinal disability who received non-pharmacological treatment of CSM and exercise. Those with ≥30% reduction in the Oswestry Disability Index (ODI) after 12 weeks of treatment were considered responders to care. Psychosocial measures included the Pain Self-Efficacy Questionnaire (PSEQ) and the Tampa Scale of Kinesiophobia (TSK). Logistic regression-assessed associations were between psychosocial, demographic, and low back predictors and 30% ODI improvement.

RESULTS

There were 176 community-dwelling older adults included in this analysis. Mean age was 71 years, 59.7% were women; 176 (96.7%) had complete data. Baseline disability (ODI = 26.1 ± 9.3) and back pain (5.0 ± 1.9, 0-10 scale) were moderate. Baseline PSEQ reflected higher self-efficacy (47.7 ± 7.8, 0-60 scale) with minimal kinesiophobia (TSK 34.3 ± 5.2, 17-68 scale). Seventy-two (40.9%) achieved 30% reduction in ODI (mean -5.4 ± 7.9) after 12 weeks of treatment. Mean self-efficacy improvement was clinically important (2.5 ± 6.5 points); kinesiophobia (-2.7 ± 4.4 points) and LBP (-1.6 points) also improved. Baseline PSEQ and percent improvement in PSEQ and TSK were associated with response to treatment in univariate regression analyses but not in multiple regression models that included low back predictors. LBP duration >4 years negatively impacted recovery.

CONCLUSIONS

Among this sample of older adults who received chiropractic manipulation and exercise, baseline self-efficacy and improvements in self-efficacy and kinesiophobia were individually associated with clinically important reductions in disability post-intervention, although not in adjusted models when LBP duration was included.