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Aspinall SL, Nim C, Hartvigsen J, Cook CE, Skillgate E, Vogel S, Hohenschurz-Schmidt D, Underwood M, Rubinstein SM. Waste not, want not: call to action for spinal manipulative therapy researchers. Chiropr Man Therap 2024; 32:16. [PMID: 38745213 PMCID: PMC11092111 DOI: 10.1186/s12998-024-00539-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2024] [Accepted: 05/01/2024] [Indexed: 05/16/2024] Open
Abstract
BACKGROUND Research waste is defined as research outcomes with no or minimal societal benefits. It is a widespread problem in the healthcare field. Four primary sources of research waste have been defined: (1) irrelevant or low priority research questions, (2) poor design or methodology, (3) lack of publication, and (4) biased or inadequate reporting. This commentary, which was developed by a multidisciplinary group of researchers with spinal manipulative therapy (SMT) research expertise, discusses waste in SMT research and provides suggestions to improve future research. MAIN TEXT This commentary examines common sources of waste in SMT research, focusing on design and methodological issues, by drawing on prior research and examples from clinical and mechanistic SMT studies. Clinical research is dominated by small studies and studies with a high risk of bias. This problem is compounded by systematic reviews that pool heterogenous data from varying populations, settings, and application of SMT. Research focusing on the mechanisms of SMT often fails to address the clinical relevance of mechanisms, relies on very short follow-up periods, and has inadequate control for contextual factors. CONCLUSIONS This call to action is directed to researchers in the field of SMT. It is critical that the SMT research community act to improve the way research is designed, conducted, and disseminated. We present specific key action points and resources, which should enhance the quality and usefulness of future SMT research.
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Affiliation(s)
| | - Casper Nim
- Medical Research Unit, Spine Centre of Southern Denmark, University Hospital of Southern Denmark, Middelfart, Denmark
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
- Center for Muscle and Joint Health, Department of Sport Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark
| | - Jan Hartvigsen
- Center for Muscle and Joint Health, Department of Sport Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark
- Chiropractic Knowledge Hub, Odense, Denmark
| | - Chad E Cook
- Department of Orthopaedics, Department of Population Health Sciences, Duke Clinical Research Institute, Duke University, Durham, NC, USA
| | - Eva Skillgate
- Department of Health Promotion Science, Sophiahemmet University, Stockholm, Sweden
- Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
- Naprapathögskolan, Scandinavian College of Naprapathic Manual Medicine, Stockholm, Sweden
| | - Steven Vogel
- Research Centre, University College of Osteopathy, London, UK
| | - David Hohenschurz-Schmidt
- Research Centre, University College of Osteopathy, London, UK
- Pain Research, Department of Surgery & Cancer, Imperial College London, London, UK
| | - Martin Underwood
- Warwick Clinical Trials Unit, Warwick Medical School, Coventry, UK
- University Hospitals of Coventry and Warwickshire, Coventry, UK
| | - Sidney M Rubinstein
- Department of Health Sciences, Faculty of Science and Amsterdam Movement Science Research Institute, Vrije Universiteit, Amsterdam, the Netherlands
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Courtney RE, Schadegg MJ, Bolton R, Smith S, Harden SM. Using a Whole Health Approach to Build Biopsychosocial-Spiritual Personal Health Plans for Veterans with Chronic Pain. Pain Manag Nurs 2024; 25:69-74. [PMID: 37839983 DOI: 10.1016/j.pmn.2023.09.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 09/08/2023] [Accepted: 09/18/2023] [Indexed: 10/17/2023]
Abstract
Chronic pain affects over 50 million Americans per year and costs society billions of dollars annually. It is widely accepted that the biomedical model is outdated and research on the biopsychosocial model of chronic pain has increased in recent years, concurrent with investigations into self-management of chronic pain. The Veterans Health Administration (VHA) has incorporated both of these approaches into their Whole Health System. This work describes the VHA Whole Health System, reviews the literature on alignment between the Whole Health System's Circle of Health and chronic pain, and explains how the VHA Whole Health model may be used as a method for organizing self-management strategies within a personal health plan in the context of chronic pain. Given the infusion of nurses throughout the healthcare system, nurses are in a unique position to champion this biopsychosocial-spiritual approach to care.
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Affiliation(s)
- Rena E Courtney
- PREVAIL Center for Chronic Pain, Salem, VA Health Care System, Salem, Virginia; Virginia Tech Carilion School of Medicine, Salem, Virginia.
| | - Mary J Schadegg
- NYU Grossman School of Medicine/NYU Langone Health, New York, New York
| | - Rendelle Bolton
- Center for Healthcare Organization and Implementation Research, Bedford VA Health Care System, Bedford, Massachusetts
| | - Stephanie Smith
- PREVAIL Center for Chronic Pain, Salem, VA Health Care System, Salem, Virginia
| | - Samantha M Harden
- Virginia Tech Carilion School of Medicine, Salem, Virginia; Virginia Tech, Blacksburg, Virginia
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Does MB, Adams SR, Kline-Simon AH, Marino C, Charvat-Aguilar N, Weisner CM, Rubinstein AL, Ghadiali M, Cowan P, Young-Wolff KC, Campbell CI. A patient activation intervention in primary care for patients with chronic pain on long term opioid therapy: results from a randomized control trial. BMC Health Serv Res 2024; 24:112. [PMID: 38254073 PMCID: PMC10802020 DOI: 10.1186/s12913-024-10558-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 01/03/2024] [Indexed: 01/24/2024] Open
Abstract
BACKGROUND Given significant risks associated with long-term prescription opioid use, there is a need for non-pharmacological interventions for treating chronic pain. Activating patients to manage chronic pain has the potential to improve health outcomes. The ACTIVATE study was designed to evaluate the effectiveness of a 4-session patient activation intervention in primary care for patients on long-term opioid therapy. METHODS The two-arm, pragmatic, randomized trial was conducted in two primary care clinics in an integrated health system from June 2015-August 2018. Consenting participants were randomized to the intervention (n = 189) or usual care (n = 187). Participants completed online and interviewer-administered surveys at baseline, 6- and 12- months follow-up. Prescription opioid use was extracted from the EHR. The primary outcome was patient activation assessed by the Patient Activation Measure (PAM). Secondary outcomes included mood, function, overall health, non-pharmacologic pain management strategies, and patient portal use. We conducted a repeated measure analysis and reported between-group differences at 12 months. RESULTS At 12 months, the intervention and usual care arms had similar PAM scores. However, compared to usual care at 12 months, the intervention arm demonstrated: less moderate/severe depression (odds ratio [OR] = 0.40, 95%CI 0.18-0.87); higher overall health (OR = 3.14, 95%CI 1.64-6.01); greater use of the patient portal's health/wellness resources (OR = 2.50, 95%CI 1.42-4.40) and lab/immunization history (OR = 2.70, 95%CI 1.29-5.65); and greater use of meditation (OR = 2.72; 95%CI 1.61-4.58) and exercise/physical therapy (OR = 2.24, 95%CI 1.29-3.88). At 12 months, the intervention arm had a higher physical health measure (mean difference 1.63; 95%CI: 0.27-2.98). CONCLUSION This trial evaluated the effectiveness of a primary care intervention in improving patient activation and patient-reported outcomes among adults with chronic pain on long-term opioid therapy. Despite a lack of improvement in patient activation, a brief intervention in primary care can improve outcomes such as depression, overall health, non-pharmacologic pain management, and engagement with the health system. TRIAL REGISTRATION The study was registered on 10/27/14 on ClinicalTrials.gov (NCT02290223).
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Affiliation(s)
- Monique B Does
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA, 94612-2403, USA.
| | - Sara R Adams
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA, 94612-2403, USA
| | - Andrea H Kline-Simon
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA, 94612-2403, USA
| | - Catherine Marino
- Physical Medicine and Rehabilitation, Kaiser Permanente Northern California, Santa Clara, CA, USA
| | - Nancy Charvat-Aguilar
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA, 94612-2403, USA
| | - Constance M Weisner
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA, 94612-2403, USA
- Department of Psychiatry, University of California, San Francisco, CA, USA
| | - Andrea L Rubinstein
- Department of Pain Medicine, The Permanente Medical Group, Santa Rosa, CA, USA
| | - Murtuza Ghadiali
- Addiction Medicine and Recovery Services, The Permanente Medical Group, San Francisco, CA, USA
| | - Penney Cowan
- American Chronic Pain Association, Rocklin, CA, USA
| | - Kelly C Young-Wolff
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA, 94612-2403, USA
- Department of Psychiatry, University of California, San Francisco, CA, USA
| | - Cynthia I Campbell
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA, 94612-2403, USA
- Department of Psychiatry, University of California, San Francisco, CA, USA
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4
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Goldsmith ES, Koffel E, Ackland PE, Hill J, Landsteiner A, Miller W, Stroebel B, Ullman K, Wilt TJ, Duan-Porter WD. Evaluation of Implementation Strategies for Cognitive Behavioral Therapy (CBT), Acceptance and Commitment Therapy (ACT), and Mindfulness-Based Stress Reduction (MBSR): a Systematic Review. J Gen Intern Med 2023; 38:2782-2791. [PMID: 37012538 PMCID: PMC10069727 DOI: 10.1007/s11606-023-08140-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Accepted: 03/06/2023] [Indexed: 04/05/2023]
Abstract
BACKGROUND Improving access to evidence-based psychotherapies (EBPs) is a Veterans Health Administration (VHA) priority. Cognitive behavioral therapy (CBT), acceptance and commitment therapy (ACT), and mindfulness-based stress reduction (MBSR) are effective for chronic pain and several mental health conditions. We synthesized evidence on implementation strategies to increase EBP access and use. METHODS We searched MEDLINE, Embase, PsycINFO, and CINAHL from inception until March 2021 for articles on EBP implementation within integrated health systems to treat chronic pain or chronic mental health conditions. Reviewers independently screened articles, extracted results, coded qualitative findings, and rated quality using modified criteria from Newcastle-Ottawa (quantitative results) or Critical Appraisal Skills Programme (qualitative results). We categorized implementation strategies using the Expert Recommendations for Implementing Change (ERIC) framework and classified outcomes using RE-AIM domains (Reach, Effectiveness, Adoption, Implementation, Maintenance). RESULTS Twelve articles (reporting results from 10 studies) evaluated CBT (k = 11) and ACT (k = 1) implementation strategies in large integrated healthcare systems. No studies evaluated MBSR implementation. Eight articles evaluated strategies within VHA. Six articles reported on national VHA EBP implementation programs; all involved training/education, facilitation, and audit/feedback. CBT and ACT implementation demonstrated moderate to large improvements in patient symptoms and quality of life. Trainings increased mental health provider self-efficacy in delivering EBPs, improved provider EBP perceptions, and increased provider EBP use during programs, but had unclear impacts on Reach. It was unclear whether external facilitation added benefit. Provider EBP maintenance was modest; barriers included competing professional time demands and patient barriers. DISCUSSION Multi-faceted CBT and ACT implementation programs increased provider EBP Adoption but had unclear impacts on Reach. Future implementation efforts should further evaluate Reach, Adoption, and Maintenance; assess the added value of external facilitation; and consider strategies targeting patient barriers. Future work should use implementation frameworks to guide evaluations of barriers and facilitators, processes of change, and outcomes. REGISTRATION PROSPERO registration number CRD42021252038.
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Affiliation(s)
- Elizabeth S Goldsmith
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, One Veterans Dr, Minneapolis, MN, USA.
- University of Minnesota Medical School, Minneapolis, MN, USA.
| | - Erin Koffel
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, One Veterans Dr, Minneapolis, MN, USA
| | - Princess E Ackland
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, One Veterans Dr, Minneapolis, MN, USA
- University of Minnesota Medical School, Minneapolis, MN, USA
| | - Jessica Hill
- Department of Clinical Psychology, Binghamton University, Binghamton, NY, USA
| | - Adrienne Landsteiner
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, One Veterans Dr, Minneapolis, MN, USA
| | - Wendy Miller
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, One Veterans Dr, Minneapolis, MN, USA
- University of Minnesota Medical School, Minneapolis, MN, USA
| | - Benjamin Stroebel
- Department of Dermatology, University of California - San Francisco School of Medicine, San Francisco, CA, USA
| | - Kristen Ullman
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, One Veterans Dr, Minneapolis, MN, USA
| | - Timothy J Wilt
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, One Veterans Dr, Minneapolis, MN, USA
- University of Minnesota Medical School, Minneapolis, MN, USA
- School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Wei Denise Duan-Porter
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, One Veterans Dr, Minneapolis, MN, USA
- University of Minnesota Medical School, Minneapolis, MN, USA
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Roseen EJ, Pinheiro A, Lemaster CM, Plumb D, Wang S, Elwy AR, Streeter CC, Lynch S, Groessl E, Sherman KJ, Weinberg J, Saper RB. Yoga Versus Education for Veterans with Chronic Low Back Pain: a Randomized Controlled Trial. J Gen Intern Med 2023; 38:2113-2122. [PMID: 36650329 PMCID: PMC10361953 DOI: 10.1007/s11606-023-08037-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Accepted: 12/30/2022] [Indexed: 01/19/2023]
Abstract
BACKGROUND Yoga is effective for chronic low back pain (cLBP) in civilians but understudied among Veterans. OBJECTIVE Determine whether yoga is more effective than an educational book for improving disability and pain among Veterans with cLBP. DESIGN, SETTING, AND PARTICIPANTS Veterans diagnosed with cLBP at a VA medical center enrolled in a randomized controlled trial from March to December of 2015. INTERVENTIONS Twelve weekly hatha yoga classes or education using The Back Pain Helpbook. MEASURES Co-primary outcomes were changes from baseline at 12 weeks in back-related disability on the modified Roland Morris Disability Questionnaire and pain on the Defense & Veterans Pain Rating Scale. Secondary outcomes were global improvement, patient satisfaction, pain medication use, and post-traumatic stress symptoms. An intention-to-treat approach was used in primary analyses. RESULTS One hundred twenty Veterans (mean age, 55.5 [SD = 16.9]; 11 [9%] women; mean number of chronic conditions, 5.5) were randomized to yoga (n = 62) and education (n = 58). At 12 weeks, reductions in back-related disability in yoga (mean difference [MD] = - 3.50, 95% CI: - 5.03, - 1.97) were not significantly different than education (MD = - 2.55, 95% CI: - 4.10, - 0.99; between-group difference: - 0.95 [95% CI: - 3.14, 1.23], p = 0.39). For pain, there was no significant difference between yoga (MD = - 1.01, 95% CI: - 1.67, - 0.35) and education (MD = - 0.81, 95% CI: - 1.36, - 0.27; between-group difference: - 0.20, 95% CI: - 1.06, 0.66, p = 0.65). More yoga than education participants reported being very much or extremely improved (39% vs 19%, OR = 3.71, 95% CI: 1.37, 10.02, p = 0.01) and very satisfied with treatment (60% vs 31%, OR = 4.28, 95% CI: 1.70, 10.77, p = 0.002). No differences in pain medication use or post-traumatic stress symptoms were observed at 12 weeks. No serious adverse events were reported in either group. CONCLUSION Twelve weekly yoga classes were not more effective than an education intervention for improving pain or disability outcomes among mostly older male Veterans with cLBP and multiple comorbid health conditions. CLINICALTRIALS GOV IDENTIFIER NCT02224183.
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Affiliation(s)
- Eric J. Roseen
- Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine and Boston Medical Center, Boston University Medical Campus, 801 Massachusetts Ave, Second Floor, Boston, MA 02131 USA
- Department of Physical Medicine and Rehabilitation and New England Geriatric Research Education and Clinical Center, VA Boston Healthcare System, Boston, MA USA
| | - Adlin Pinheiro
- Department of Biostatistics, Boston University School of Public Health, Boston, MA USA
| | - Chelsey M. Lemaster
- Department of Family Medicine, Boston University School of Medicine and Boston Medical Center, Boston, MA USA
- Department of Surgery, University of Arizona College of Medicine, Tucson, AZ USA
| | - Dorothy Plumb
- Department of Family Medicine, Boston University School of Medicine and Boston Medical Center, Boston, MA USA
| | - Shihwe Wang
- Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA USA
| | - A. Rani Elwy
- Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA USA
- Department of Psychiatry and Human Behavior, Warren Alpert Medical School of Brown University, Providence, RI USA
| | - Chris C. Streeter
- Department of Psychiatry and Neurology, Boston University School of Medicine, Boston, MA USA
- Department of Psychiatry, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA USA
| | | | - Erik Groessl
- Herbert Wertheim School of Public Health, University of California San Diego and VA San Diego Health Care System, San Diego, CA USA
| | - Karen J. Sherman
- Kaiser Permanente Washington Health Research Institute, Seattle WA and Department of Epidemiology, University of Washington, Seattle, WA USA
| | - Janice Weinberg
- Department of Biostatistics, Boston University School of Public Health, Boston, MA USA
| | - Robert B. Saper
- Department of Wellness and Preventive Medicine, Cleveland Clinic, Cleveland, OH USA
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Haun JN, Fowler CA, Venkatachalam HH, Saenger MS, Alman AC, Smith BM, Schneider T, Benzinger R, Stroupe K, French DD. Empower Veterans Program (EVP): a chronic pain management program demonstrates positive outcomes among veterans. BMC Health Serv Res 2023; 23:431. [PMID: 37138319 PMCID: PMC10155644 DOI: 10.1186/s12913-023-09327-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Accepted: 03/22/2023] [Indexed: 05/05/2023] Open
Abstract
BACKGROUND Chronic pain is a highly prevalent health condition among veterans. Traditional pharmacological interventions present unique challenges for chronic pain management including prescription opioid addiction and overdose. In alignment with the 2016 Comprehensive Addiction and Recovery Act and VA's Stepped Care Model to meet veterans' pain management needs, the Offices of Rural Health and Pain Management, Opioid Safety, and Prescription Drug Monitoring Program (PMOP) funded an enterprise-wide initiative to implement a Step 3 integrated tele-pain program: Empower Veterans Program (EVP). EVP provides veterans with chronic pain self-care skills using a whole health driven approach to pain management. OBJECTIVES The Comprehensive Addiction and Recovery Act prompted the strategic approach to offer non-pharmacological options to meet veterans' pain management needs. EVP, a 10-week interdisciplinary group medical appointment, leverages Acceptance and Commitment Therapy, Mindful Movement, and Whole Health to provide veterans with chronic pain self-care skills. This evaluation was conducted to describe participant characteristics, graduation, and satisfaction rates; and assess pre-post patient-reported outcomes (PRO) associated with EVP participation. METHODS A sample of 639 veterans enrolled in EVP between May, 2015 and December, 2017 provided data to conduct descriptive analyses to assess participant demographics, graduation, and satisfaction rates. PRO data were analyzed using a within-participants pre-post design, and linear mixed-effects models were used to examine pre-post changes in PRO. RESULTS Of 639 participants, 444 (69.48%) graduated EVP. Participant median program satisfaction rating was 8.41 (Interquartile Range: 8.20-9.20). Results indicate pre-post EVP improvements (Bonferroni-adjusted p < .003) in the three primary pain outcomes (intensity, interference, catastrophizing), and 12 of 17 secondary outcomes, including physical, psychological, health-related quality of life (HRQoL), acceptance, and mindfulness measures. DISCUSSION Data suggest that EVP has significant positive outcomes in pain, psychological, physical, HRQoL, acceptance, and mindfulness measures for veterans with chronic pain through non-pharmacological means. Future evaluations of intervention dosing effect and long-term effectiveness of the program is needed.
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Grants
- OMAT ID# 16403,16404, 16405, 16489, 16490 U.S. Department of Veterans Affairs
- OMAT ID# 16403,16404, 16405, 16489, 16490 U.S. Department of Veterans Affairs
- OMAT ID# 16403,16404, 16405, 16489, 16490 U.S. Department of Veterans Affairs
- OMAT ID# 16403,16404, 16405, 16489, 16490 U.S. Department of Veterans Affairs
- OMAT ID# 16403,16404, 16405, 16489, 16490 U.S. Department of Veterans Affairs
- OMAT ID# 16403,16404, 16405, 16489, 16490 U.S. Department of Veterans Affairs
- OMAT ID# 16403,16404, 16405, 16489, 16490 U.S. Department of Veterans Affairs
- OMAT ID# 16403,16404, 16405, 16489, 16490 U.S. Department of Veterans Affairs
- OMAT ID# 16403,16404, 16405, 16489, 16490 U.S. Department of Veterans Affairs
- OMAT ID# 16403,16404, 16405, 16489, 16490 U.S. Department of Veterans Affairs
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Affiliation(s)
- Jolie N Haun
- Research and Development Service, James A. Haley Veterans' Hospital, 8900 Grand Oak Circle, Tampa, FL, 33637, USA
- Division of Epidemiology, Department of Internal Medicine, University of Utah, 295 Chipeta Way, Salt Lake City, UT, 84132, USA
| | - Christopher A Fowler
- Research and Development Service, James A. Haley Veterans' Hospital, 8900 Grand Oak Circle, Tampa, FL, 33637, USA.
- Department of Psychiatry and Behavioral Neurosciences, University of South Florida, 3515 E. Fletcher Ave, Tampa, FL, 33613, USA.
| | - Hari H Venkatachalam
- Research and Development Service, James A. Haley Veterans' Hospital, 8900 Grand Oak Circle, Tampa, FL, 33637, USA
| | - Michael S Saenger
- Anesthesia Service Line, Atlanta Veterans Administration Health Care System, 1670 Clairmont Rd, Decatur, GA, 30033, USA
- Division of Internal Medicine, School of Medicine, Emory University, 201 Dowman Dr, Atlanta, GA, 30322, USA
| | - Amy C Alman
- Research and Development Service, James A. Haley Veterans' Hospital, 8900 Grand Oak Circle, Tampa, FL, 33637, USA
- Division of Epidemiology, Department of Internal Medicine, University of Utah, 295 Chipeta Way, Salt Lake City, UT, 84132, USA
| | - Bridget M Smith
- Department of Veterans Affairs, Center of Innovation for Complex Chronic Healthcare, Edward Hines, Jr. VA Hospital, 5000 South 5th Ave, Hines, IL, 60141, USA
| | - Tali Schneider
- Research and Development Service, James A. Haley Veterans' Hospital, 8900 Grand Oak Circle, Tampa, FL, 33637, USA
| | - Rachel Benzinger
- Research and Development Service, James A. Haley Veterans' Hospital, 8900 Grand Oak Circle, Tampa, FL, 33637, USA
| | - Kevin Stroupe
- Department of Veterans Affairs, Center of Innovation for Complex Chronic Healthcare, Edward Hines, Jr. VA Hospital, 5000 South 5th Ave, Hines, IL, 60141, USA
| | - Dustin D French
- Department of Veterans Affairs, Center of Innovation for Complex Chronic Healthcare, Edward Hines, Jr. VA Hospital, 5000 South 5th Ave, Hines, IL, 60141, USA
- Center for Health Services and Outcomes Research, Feinberg School of Medicine, Northwestern University, 633 N. St. Clair St. Suite 2000, Chicago, IL, 60611, USA
- Departments of Ophthalmology and Medical Social Sciences, Feinberg School of Medicine, Northwestern University, 645 N. Michigan Ave. Suite 440, Chicago, IL, 60611, USA
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7
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Goldsmith ES, Miller WA, Koffel E, Ullman K, Landsteiner A, Stroebel B, Hill J, Ackland PE, Wilt TJ, Duan-Porter W. Barriers and facilitators of evidence-based psychotherapies for chronic pain in adults: A systematic review. THE JOURNAL OF PAIN 2023; 24:742-769. [PMID: 36934826 DOI: 10.1016/j.jpain.2023.02.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 02/20/2023] [Accepted: 02/24/2023] [Indexed: 03/21/2023]
Abstract
Cognitive behavioral therapy (CBT), acceptance and commitment therapy (ACT), and mindfulness-based stress reduction (MBSR) have demonstrated effectiveness for improving outcomes in chronic pain. These evidence-based psychotherapies (EBPs) remain underutilized in clinical practice, however. To identify research gaps and next steps for improving uptake of EBPs, we conducted a systematic review of patient-, provider-, and system-level barriers and facilitators of their use for chronic pain. We searched MEDLINE, Embase, PsycINFO, and CINAHL databases databases from inception through September 2022. Prespecified eligibility criteria included outpatient treatment of adults with chronic pain; examination of barriers and facilitators and/or evaluation of implementation strategies; conducted in the United States (US), United Kingdom (UK), Ireland, Canada or Australia; and publication in English. Two reviewers independently assessed eligibility and rated quality. We conducted a qualitative synthesis of results using a best-fit framework approach building upon domains of the Consolidated Framework for Implementation Research (CFIR). We identified 34 eligible studies (33 moderate or high quality), most (n=28) of which addressed patient-level factors. Shared barriers across EBPs included variable patient buy-in to therapy rationale and competing responsibilities for patients; shared facilitators included positive group or patient-therapist dynamics. Most studies examining ACT and all examining MBSR assessed only group formats. No studies compared barriers, facilitators, or implementation strategies of group CBT to individual CBT, or of telehealth to in-person EBPs. Conceptual mismatches of patient knowledge and beliefs with therapy principles were largely analyzed qualitatively, and studies did not explore how these mismatches were addressed to support engagement. Future research on EBPs for chronic pain in real-world practice settings is needed to explore provider and system-level barriers and facilitators, heterogeneity of effects and uptake, and both effects and uptake of EBPs delivered in various formats, including group vs. individual therapy and telehealth or asynchronous digital approaches. Perspective This systematic review synthesizes evidence on barriers and facilitators to uptake of cognitive behavioral therapy, acceptance and commitment therapy, and mindfulness-based stress reduction for chronic pain. Findings can guide future implementation work to increase availability and use of evidence-based psychotherapies for treatment of chronic pain. Registration: PROSPERO number CRD42021252038.
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Affiliation(s)
- Elizabeth S Goldsmith
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA; Department of Medicine, University of Minnesota Medical School, Minneapolis, MN, USA.
| | - Wendy A Miller
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA; Department of Medicine, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Erin Koffel
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA
| | - Kristen Ullman
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA; Veterans Affairs Evidence Synthesis Program, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA
| | - Adrienne Landsteiner
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA; Veterans Affairs Evidence Synthesis Program, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA
| | - Benjamin Stroebel
- Department of Dermatology, University of California - San Francisco School of Medicine, San Francisco, CA, USA
| | - Jessica Hill
- Department of Clinical Psychology, Binghamton University, Binghamton, NY, USA
| | - Princess E Ackland
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA; Department of Medicine, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Timothy J Wilt
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA; Department of Medicine, University of Minnesota Medical School, Minneapolis, MN, USA; Veterans Affairs Evidence Synthesis Program, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA; Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis, MN, USA
| | - Wei Duan-Porter
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA; Department of Medicine, University of Minnesota Medical School, Minneapolis, MN, USA; Veterans Affairs Evidence Synthesis Program, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA
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8
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Hadlandsmyth K, Driscoll MA, Mares JG, Au V, Miell KR, Lund BC. Rurality impacts pain care for female veterans similarly to male veterans. J Rural Health 2023; 39:313-319. [PMID: 35170073 DOI: 10.1111/jrh.12646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
PURPOSE Rural disparities exist in access to multidisciplinary pain care with higher rates of opioid prescribing in rural regions. Among Veterans, who have prevalent rates of chronic pain, women often evidence complex presentations, multiple comorbidities, and dissatisfaction with care. This study investigates the impact of rurality on pain care for women specifically, and whether this varies from the impact of rurality for men. METHODS A cohort of Veterans with chronic pain in 2018 was built utilizing VA administrative data. Variables of interest included: demographic, comorbidities, medications, and health care utilization for chronic pain. FINDINGS The cohort included 2,261,030 Veterans; 11% (n = 248,977) were women. Significantly fewer women (7%) compared to men (10.7%) received long-term opioids (adjusted OR = 0.77, 95% CI: 0.75-0.78). Men, relative to women, were also more likely to receive gabapentinoids and nonsteroidal ant-inflammatory drugs, whereas women, relative to men, were more likely to receive muscle relaxants and duloxetine. Women were more likely to receive most psychiatric medications. Rural women received more primary care visits compared to urban women (adjusted OR = 1.19, 95% CI: 1.15-1.22), but fewer women's clinic visits (a subset of primary care visits: adjusted OR = 0.69, 95% CI:0.67-0.71) and fewer pain specialty care visits (physical therapy, pain clinic, and mental health visits with pain codes). Rural effects did not vary substantially between women and men. CONCLUSIONS Rural-dwelling Veterans received more pain and psychiatric medications compared to urban Veterans and fewer specialty care visits. Rural Veterans may benefit from increased access to specialty chronic pain care.
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Affiliation(s)
- Katherine Hadlandsmyth
- Office of Rural Health, Veterans Rural Health Resource Center, Iowa City VA Health Care System, Iowa City, Iowa, USA
- Center for Access and Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, Iowa, USA
- Department of Anesthesia, University of Iowa, Carver College of Medicine, Iowa City, Iowa, USA
| | - Mary A Driscoll
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut, USA
- Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut, USA
| | - Jasmine G Mares
- Department of Anesthesia, University of Iowa, Carver College of Medicine, Iowa City, Iowa, USA
| | - Vanessa Au
- Office of Rural Health, Veterans Rural Health Resource Center, Iowa City VA Health Care System, Iowa City, Iowa, USA
- Center for Access and Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, Iowa, USA
| | - Kelly Richardson Miell
- Office of Rural Health, Veterans Rural Health Resource Center, Iowa City VA Health Care System, Iowa City, Iowa, USA
- Center for Access and Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, Iowa, USA
| | - Brian C Lund
- Office of Rural Health, Veterans Rural Health Resource Center, Iowa City VA Health Care System, Iowa City, Iowa, USA
- Center for Access and Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, Iowa, USA
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9
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Braverman MT, Volmar KM, Govier DJ. "The Pain Doesn't Have to Control You." A Qualitative Evaluation of Three Pain Clinics Teaching Nonopioid Pain Management Strategies. Am J Health Promot 2023; 37:210-221. [PMID: 36053192 DOI: 10.1177/08901171221119799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
PURPOSE To explore factors related to effectiveness of nonpharmacological treatment for opioid-dependent patients suffering with chronic pain. APPROACH A qualitative study incorporating individual interviews and focus group interviews. SETTING 3 rural Oregon nonopioid pain management clinics. INTERVENTION A 10-week nonpharmacological educational program incorporating cognitive-behavioral therapy, movement therapy, mindfulness, and other skills. PARTICIPANTS AND METHODS Across sites, we conducted 9 individual interviews with clinic staff and 3 focus group interviews with 34 patients who had participated in the course. Thematic analysis was used to identify themes within and across respondent groups. RESULTS Analysis revealed 4 primary themes: program goals; program benefits; characteristics of patients who benefit from the program; coordination of clinic experiences with other care. Several primary findings can be highlighted. The clinics focused on improving patients' quality of life, while opioid use reduction was a potential secondary benefit, driven by patients. Major program benefits included enhanced pain self-management skills, patients' greater assertiveness in communications with healthcare providers, and, in numerous cases, opioid use reduction. Participants were unanimous that predisposition toward active self-management of one's pain was an essential factor for positive outcomes. Patients reported considerable variability in providers' understanding of their clinic participation. CONCLUSION Nonpharmacological approaches for treating chronic pain can be effective for many patients. Clinics teaching these approaches should be more fully integrated into the healthcare system.
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Affiliation(s)
- Marc T Braverman
- School of Social and Behavioral Health Sciences, 2694Oregon State University, Corvallis, OR, USA
| | - Karen M Volmar
- Department of Health Policy and Management, 41474University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Diana J Govier
- VA HSR&D Center to Improve Veteran Involvement in Care, Portland, OR, USA
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10
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Mares JG, Lund BC, Adamowicz JL, Burgess DJ, Rothmiller SJ, Hadlandsmyth K. Differences in chronic pain care receipt among veterans from differing racialized groups and the impact of rural versus urban residence. J Rural Health 2023. [PMID: 36695646 DOI: 10.1111/jrh.12744] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
PURPOSE The current study aimed to identify differences in Veterans Affairs (VA) chronic pain care for Black, Asian, and Hispanic Americans, compared to non-Hispanic White Americans, and examine the intersection of race and rurality. METHODS Using national administrative data, all veterans who presented to the VA for chronic pain in 2018 were included. Demographic and comorbidity variables were built from 2018 data and health care utilization variables from 2019 data. Multivariate log-binomial regression models examined differences between racialized groups, and interactions with rural/urban residence, for each health care utilization variable. FINDINGS The full cohort included 2,135,216 veterans with chronic pain. There were no differences between racialized groups in pain-related primary care visits. Black Americans were less likely to receive pain clinic visits (aRR = 0.87, CI: 0.86-0.88). Rurality further decreased the likelihood of Black Americans visiting a pain clinic. Black, Hispanic, and Asian Americans were more likely to receive pain-related physical therapy visits relative to White Americans. Black and Hispanic Americans were more likely to present to emergency/urgent care for chronic pain. While there were no differences in pain-related primary care visits, the decreased likelihood of pain clinic visits and increased use of emergency department/urgent care among Black Americans could indicate inadequate management of chronic pain. CONCLUSIONS Tailored strategies are needed to provide equitable care that meets the needs of patients from racialized groups while accounting for systemic and cultural factors.
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Affiliation(s)
- Jasmine G Mares
- Office of Rural Health, Veterans Rural Resource Center, Iowa City VA Health Care System, Iowa City, Iowa, USA.,Department of Anesthesia, Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA
| | - Brian C Lund
- Office of Rural Health, Veterans Rural Resource Center, Iowa City VA Health Care System, Iowa City, Iowa, USA.,Center for Comprehensive Access and Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, Iowa, USA.,Department of Epidemiology, College of Public Health, University of Iowa, Iowa City, Iowa, USA
| | - Jenna L Adamowicz
- Office of Rural Health, Veterans Rural Resource Center, Iowa City VA Health Care System, Iowa City, Iowa, USA.,Department of Psychological & Brain Sciences, University of Iowa, Iowa City, Iowa, USA
| | - Diana J Burgess
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA.,Center for Care Delivery and Outcomes Research, Veterans Affairs Medical Center, Minneapolis, Minnesota, USA
| | - Shamira J Rothmiller
- Office of Rural Health, Veterans Rural Resource Center, Iowa City VA Health Care System, Iowa City, Iowa, USA.,Center for Comprehensive Access and Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, Iowa, USA.,Department of Counselor Education, University of Iowa, Iowa City, Iowa, USA
| | - Katherine Hadlandsmyth
- Office of Rural Health, Veterans Rural Resource Center, Iowa City VA Health Care System, Iowa City, Iowa, USA.,Department of Anesthesia, Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA.,Center for Comprehensive Access and Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, Iowa, USA
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11
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Pratscher SD, Sibille KT, Fillingim RB. Conscious connected breathing with breath retention intervention in adults with chronic low back pain: protocol for a randomized controlled pilot study. Pilot Feasibility Stud 2023; 9:15. [PMID: 36694217 PMCID: PMC9872326 DOI: 10.1186/s40814-023-01247-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 01/16/2023] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Chronic pain is a major source of human suffering, and chronic low back pain (cLBP) is among the most prevalent, costly, and disabling of pain conditions. Due to the significant personal and societal burden and the complex and recurring nature of cLBP, self-management approaches that can be practiced at home are highly relevant to develop and test. The respiratory system is one of the most integrated systems of the body, and breathing is bidirectionally related with stress, emotion, and pain. Thus, the widespread physiological and psychological impact of breathing practices and breathwork interventions hold substantial promise as possible self-management strategies for chronic pain. The primary aim of the current randomized pilot study is to test the feasibility and acceptability of a conscious connected breathing with breath retention intervention compared to a sham control condition. METHODS The rationale and procedures for testing a 5-day conscious connected breathing with breath retention intervention, compared to a deep breathing sham control intervention, in 24 adults (18-65 years) with cLBP is described. Both interventions will be delivered using standardized audio recordings and practiced over 5 days (two times in-person and three times at-home), and both are described as Breathing and Attention Training to reduce possible expectancy and placebo effects common in pain research. The primary outcomes for this study are feasibility and acceptability. Feasibility will be evaluated by determining rates of participant recruitment, adherence, retention, and study assessment completion, and acceptability will be evaluated by assessing participants' satisfaction and helpfulness of the intervention. We will also measure other clinical pain, psychological, behavioral, and physiological variables that are planned to be included in a follow-up randomized controlled trial. DISCUSSION This will be the first study to examine the effects of a conscious connected breathing with breath retention intervention for individuals with chronic pain. The successful completion of this smaller-scale pilot study will provide data regarding the feasibility and acceptability to conduct a subsequent trial testing the efficacy of this breathing self-management practice for adults with cLBP. TRIAL REGISTRATION Clinicaltrials.gov, identifier NCT04740710 . Registered on 5 February 2021.
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Affiliation(s)
- Steven D Pratscher
- Department of Community Dentistry and Behavioral Science, University of Florida, Gainesville, FL, USA.
- Pain Research and Intervention Center of Excellence, University of Florida, Gainesville, FL, USA.
| | - Kimberly T Sibille
- Pain Research and Intervention Center of Excellence, University of Florida, Gainesville, FL, USA
- Department of Physical Medicine & Rehabilitation, University of Florida, Gainesville, FL, USA
| | - Roger B Fillingim
- Department of Community Dentistry and Behavioral Science, University of Florida, Gainesville, FL, USA
- Pain Research and Intervention Center of Excellence, University of Florida, Gainesville, FL, USA
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12
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Annaswamy TM, Bahirat K, Raval G, Chung YY, Pham T, Prabhakaran B. Clinical feasibility and preliminary outcomes of a novel mixed reality system to manage phantom pain: a pilot study. Pilot Feasibility Stud 2022; 8:232. [PMID: 36273191 PMCID: PMC9588245 DOI: 10.1186/s40814-022-01187-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 10/13/2022] [Indexed: 11/12/2022] Open
Abstract
Background To assess the clinical feasibility of a virtual mirror therapy system in a pilot sample of patients with phantom pain. Methods Our Mixed reality system for Managing Phantom Pain (Mr. MAPP) mirrors the preserved limb to visualize the amputated limb virtually and perform exercises. Seven patients with limb loss and phantom pain agreed to participate and received the system for 1-month home use. Outcome measures were collected at baseline and 1 month. Results Four (of seven recruited) participants completed the study, which was temporarily suspended due to COVID-19 restrictions. At 1 month, in-game data showed a positive trend, but pain scores showed no clear trends. Functioning scores improved for 1 participant. Conclusions Mr. MAPP is feasible and has the potential to improve pain and function in patients with phantom pain. Trial registration Clinical Trials Registration, NCT04529083 Supplementary Information The online version contains supplementary material available at 10.1186/s40814-022-01187-w.
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Affiliation(s)
- Thiru M Annaswamy
- Department of Physical Medicine & Rehabilitation, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA. .,Penn State Health Rehabilitation Hospital, Hummelstown, PA, USA.
| | | | - Gargi Raval
- Physical Medicine & Rehabilitation Service, VA North Texas Health Care System, Dallas, USA
| | - Yu Yen Chung
- Department of Computer Science, UT Dallas, Dallas, TX, USA
| | - Tri Pham
- UT Southwestern Medical School, Dallas, TX, USA
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13
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Williams RM, Day MA, Ehde DM, Turner AP, Ciol MA, Gertz KJ, Patterson D, Hakimian S, Suri P, Jensen MP. Effects of hypnosis vs mindfulness meditation vs education on chronic pain intensity and secondary outcomes in veterans: a randomized clinical trial. Pain 2022; 163:1905-1918. [PMID: 35082248 PMCID: PMC11089905 DOI: 10.1097/j.pain.0000000000002586] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 12/21/2021] [Indexed: 11/27/2022]
Abstract
ABSTRACT Effective, rigorously evaluated nonpharmacological treatments for chronic pain are needed. This study compared the effectiveness of training in hypnosis (HYP) and mindfulness meditation (MM) with an active education control (ED). Veterans (N = 328) were randomly assigned to 8 manualized, group-based, in-person sessions of HYP (n = 110), MM (n = 108), or ED (n = 110). Primary (average pain intensity [API]) and secondary outcomes were assessed at pretreatment, posttreatment, and 3 and 6 months posttreatment. Treatment effects were evaluated using linear regression, a generalized estimating equation approach, or a Fisher exact test, depending on the variable. There were no significant omnibus between-group differences in pretreatment to posttreatment change in API; however, pretreatment to posttreatment improvements in API and several secondary variables were seen for participants in all 3 conditions. Participation in MM resulted in greater decreases in API and pain interference at 6 months posttreatment relative to ED. Participation in HYP resulted in greater decreases in API, pain interference, and depressive symptoms at 3 and 6 months posttreatment compared with ED. No significant differences on outcomes between HYP and MM were detected at any time point. This study suggests that all 3 interventions provide posttreatment benefits on a range of outcomes, but the benefits of HYP and MM continue beyond the end of treatment, while the improvements associated with ED dissipate over time. Future research is needed to determine whether the between-group differences that emerged posttreatment are reliable, whether there are benefits of combining treatments, and to explore moderating and mediating factors.
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Affiliation(s)
- Rhonda M. Williams
- VA Puget Sound Health Care System, Seattle, Washington
- University of Washington School of Medicine, Department of Rehabilitation Medicine Seattle, Washington
| | - Melissa A. Day
- University of Washington School of Medicine, Department of Rehabilitation Medicine Seattle, Washington
- University of Queensland, School of Psychology, Australia
| | - Dawn M. Ehde
- University of Washington School of Medicine, Department of Rehabilitation Medicine Seattle, Washington
| | - Aaron P. Turner
- VA Puget Sound Health Care System, Seattle, Washington
- University of Washington School of Medicine, Department of Rehabilitation Medicine Seattle, Washington
| | - Marcia A. Ciol
- University of Washington School of Medicine, Department of Rehabilitation Medicine Seattle, Washington
| | - Kevin J. Gertz
- University of Washington School of Medicine, Department of Rehabilitation Medicine Seattle, Washington
| | - David Patterson
- University of Washington School of Medicine, Department of Rehabilitation Medicine Seattle, Washington
| | - Shahin Hakimian
- Department of Neurology, University of Washington, Seattle, Washington
| | - Pradeep Suri
- VA Puget Sound Health Care System, Seattle, Washington
- University of Washington School of Medicine, Department of Rehabilitation Medicine Seattle, Washington
- University of Washington Clinical Learning, Evidence and Research (CLEAR) Center, Seattle, Washington
| | - Mark P. Jensen
- University of Washington School of Medicine, Department of Rehabilitation Medicine Seattle, Washington
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14
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Paskins Z, Farmer CE, Manning F, Andersson DA, Barlow T, Bishop FL, Brown CA, Clark A, Clark EM, Dulake D, Gulati M, Le Maitre CL, Jones RK, Loughlin J, Mason DJ, McCarron M, Millar NL, Pandit H, Peat G, Richardson SM, Salt EJ, Taylor EJ, Troeberg L, Wilcox RK, Wise E, Wilkinson C, Watt FE. Research priorities to reduce the impact of musculoskeletal disorders: a priority setting exercise with the child health and nutrition research initiative method. THE LANCET. RHEUMATOLOGY 2022; 4:e635-e645. [PMID: 36275038 PMCID: PMC9584828 DOI: 10.1016/s2665-9913(22)00136-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Involving research users in setting priorities for research is essential to ensure the outcomes are patient-centred and maximise its value and impact. The Musculoskeletal Disorders Research Advisory Group Versus Arthritis led a research priority setting exercise across musculoskeletal disorders. The Child Health and Nutrition Research Initiative (CHNRI) method of setting research priorities with a range of stakeholders was used, involving four stages and two surveys, to: (1) gather research uncertainties, (2) consolidate these, (3) score uncertainties against importance and impact, and (4) analyse scoring for prioritisation. 213 people responded to the first survey and 285 people to the second, representing clinicians, researchers, and people with musculoskeletal disorders. Key priorities included developing and testing new treatments, better treatment targeting, early diagnosis, prevention, and better understanding and management of pain, with an emphasis on understanding underpinning mechanisms. We present a call to action to researchers and funders to target these priorities.
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Affiliation(s)
- Zoe Paskins
- Primary Care Centre Versus Arthritis, Keele University, Keele, UK
| | | | - Fay Manning
- School of Medicine, Keele University, Keele, UK
- College of Medicine and Health, University of Exeter, Exeter, UK
| | - David A Andersson
- Wolfson CARD, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Tim Barlow
- Department of Orthopaedics, Wrightington Hospital, Wigan, UK
| | | | | | | | - Emma M Clark
- Bristol Medical School, University of Bristol, UK
| | | | - Malvika Gulati
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | | | - Richard K Jones
- Centre for Health Sciences Research, University of Salford, Manchester, UK
| | - John Loughlin
- Biosciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | | | - Maura McCarron
- Department of Rheumatology, Belfast Health and Social Care Trust, Belfast, UK
| | - Neil L Millar
- Institute of Infection, Immunity and Inflammation, College of Medicine, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - Hemant Pandit
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
| | - George Peat
- Primary Care Centre Versus Arthritis, Keele University, Keele, UK
| | - Stephen M Richardson
- Division of Cell Matrix Biology and Regenerative Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UK
| | - Emma J Salt
- Primary Care Centre Versus Arthritis, Keele University, Keele, UK
- University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | | | - Linda Troeberg
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Ruth K Wilcox
- Institute of Medical and Biological Engineering, University of Leeds, Leeds, UK
| | - Elspeth Wise
- Talbot Medical Centre, South Shields & Primary Care Rheumatology and Musculoskeletal Medicine Society, South Shields, UK
| | | | - Fiona E Watt
- Department of Immunology and Inflammation, Imperial College London, London, UK
- Correspondence to: Dr Fiona E Watt, Department of Immunology and Inflammation, Hammersmith Campus, Imperial College London, London W12 0NN, UK
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15
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Salsbury SA, Twist E, Wallace RB, Vining RD, Goertz CM, Long CR. Care Outcomes for Chiropractic Outpatient Veterans (COCOV): a qualitative study with veteran stakeholders from a pilot trial of multimodal chiropractic care. Pilot Feasibility Stud 2022; 8:6. [PMID: 35031072 PMCID: PMC8759237 DOI: 10.1186/s40814-021-00962-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 12/13/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Low back pain (LBP) is common among military veterans seeking treatment in Department of Veterans Affairs (VA) healthcare facilities. As chiropractic services within VA expand, well-designed pragmatic trials and implementation studies are needed to assess clinical effectiveness and program uptake. This study evaluated veteran stakeholder perceptions of the feasibility and acceptability of care delivery and research processes in a pilot trial of multimodal chiropractic care for chronic LBP. METHODS The qualitative study was completed within a mixed-method, single-arm, pragmatic, pilot clinical trial of chiropractic care for LBP conducted in VA chiropractic clinics. Study coordinators completed semi-structured, in person or telephone interviews with veterans near the end of the 10-week trial. Interviews were audiorecorded and transcribed verbatim. Qualitative content analysis using a directed approach explored salient themes related to trial implementation and delivery of chiropractic services. RESULTS Of 40 participants, 24 completed interviews (60% response; 67% male gender; mean age 51.7 years). Overall, participants considered the trial protocol and procedures feasible and reported that the chiropractic care and recruitment methods were acceptable. Findings were organized into 4 domains, 10 themes, and 21 subthemes. Chiropractic service delivery domain encompassed 3 themes/8 subthemes: scheduling process (limited clinic hours, scheduling future appointments, attendance barriers); treatment frequency (treatment sufficient for LBP complaint, more/less frequent treatments); and chiropractic clinic considerations (hire more chiropractors, including female chiropractors; chiropractic clinic environment; patient-centered treatment visits). Outcome measures domain comprised 3 themes/4 subthemes: questionnaire burden (low burden vs. time-consuming or repetitive); relevance (items relevant for LBP study); and timing and individualization of measures (questionnaire timing relative to symptoms, personalized approach to outcomes measures). The online data collection domain included 2 themes/4 subthemes: user concerns (little difficulty vs. form challenges, required computer skills); and technology issues (computer/internet access, junk mail). Clinical trial planning domain included 2 themes/5 subthemes: participant recruitment (altruistic service by veterans, awareness of chiropractic availability, financial compensation); and communication methods (preferences, potential barriers). CONCLUSIONS This qualitative study highlighted veteran stakeholders' perceptions of VA-based chiropractic services and offered important suggestions for conducting a full-scale, veteran-focused, randomized trial of multimodal chiropractic care for chronic LBP in this clinical setting. TRIAL REGISTRATION ClinicalTrials.gov NCT03254719.
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Affiliation(s)
- Stacie A. Salsbury
- Palmer Center for Chiropractic Research, Palmer College of Chiropractic, 741 Brady Street, Davenport, Iowa 52803 USA
| | - Elissa Twist
- Palmer Center for Chiropractic Research, Palmer College of Chiropractic, 741 Brady Street, Davenport, Iowa 52803 USA
| | - Robert B. Wallace
- Department of Epidemiology, College of Public Health, The University of Iowa, S422 CPHB, 145 N. Riverside Drive, Iowa City, Iowa 52242 USA
| | - Robert D. Vining
- Palmer Center for Chiropractic Research, Palmer College of Chiropractic, 741 Brady Street, Davenport, Iowa 52803 USA
| | - Christine M. Goertz
- Department of Orthopaedic Surgery, Duke University School of Medicine, 200 Morris Street, Durham, North Carolina 27701 USA
| | - Cynthia R. Long
- Palmer Center for Chiropractic Research, Palmer College of Chiropractic, 741 Brady Street, Davenport, Iowa 52803 USA
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16
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Sellinger JJ, Martino S, Lazar C, Mattocks K, Rando K, Serowik K, Ablondi K, Fenton B, Gilstad-Hayden K, Brummett B, Holtzheimer PE, Higgins D, Reznik TE, Semiatin AM, Stapley T, Ngo T, Rosen MI. The acceptability and feasibility of screening, brief intervention, and referral to treatment for pain management among new England veterans with chronic pain: A pilot study. Pain Pract 2022; 22:28-38. [PMID: 33934499 PMCID: PMC9084457 DOI: 10.1111/papr.13023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 04/09/2021] [Accepted: 04/23/2021] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Musculoskeletal disorders often lead to chronic pain in Veterans. Chronic pain puts sufferers at risk for substance misuse, and early intervention is needed for both conditions. This pilot study tested the feasibility and acceptability of a Screening, Brief Intervention, and Referral to Treatment for Pain Management intervention (SBIRT-PM) to help engage Veterans seeking disability compensation for painful musculoskeletal disorders in multimodal pain treatment and to reduce risky substance use, when indicated. METHODS This pilot study enrolled 40 Veterans from 8 medical centers across New England in up to 4 sessions of telephone-based counseling using a motivational interviewing framework. Counseling provided education about, and facilitated engagement in, multimodal pain treatments. Study eligibility required Veterans be engaged in no more than 2 Veteran Affairs (VA) pain treatment modalities, and study participation involved a 12-week postassessment and semistructured interview about the counseling process. RESULTS Majorities of enrolled Veterans screened positive for comorbid depression and problematic substance use. Regarding the offered counseling, 80% of participants engaged in at least one session, with a mean of 3 sessions completed. Ninety percent of participants completed the postassessment. Numerically, most measures improved slightly from baseline to week 12. In semistructured interviews, participants described satisfaction with learning about new pain care services, obtaining assistance connecting to services, and receiving support from their counselors. DISCUSSION It was feasible to deliver SBIRT-PM to Veterans across New England to promote engagement in multimodal pain treatment and to track study outcomes over 12 weeks. Preliminary results suggest SBIRT-PM was well-received and has promise for the targeted outcomes.
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Affiliation(s)
- John J Sellinger
- VA Connecticut Healthcare System, West Haven, Connecticut, USA
- Yale University School of Medicine, New Haven, Connecticut, USA
| | - Steve Martino
- VA Connecticut Healthcare System, West Haven, Connecticut, USA
- Yale University School of Medicine, New Haven, Connecticut, USA
| | - Christina Lazar
- VA Connecticut Healthcare System, West Haven, Connecticut, USA
- Yale University School of Medicine, New Haven, Connecticut, USA
| | - Kristin Mattocks
- VA Central Western Massachusetts Healthcare System, Leeds, Massachusetts, USA
- University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Kenneth Rando
- VA Connecticut Healthcare System, West Haven, Connecticut, USA
- Yale University School of Medicine, New Haven, Connecticut, USA
| | - Kristin Serowik
- VA Connecticut Healthcare System, West Haven, Connecticut, USA
- Yale University School of Medicine, New Haven, Connecticut, USA
| | - Karen Ablondi
- VA Connecticut Healthcare System, West Haven, Connecticut, USA
- Yale University School of Medicine, New Haven, Connecticut, USA
| | - Brenda Fenton
- VA Connecticut Healthcare System, West Haven, Connecticut, USA
- Yale University School of Medicine, New Haven, Connecticut, USA
| | | | - Bradley Brummett
- VA Central Western Massachusetts Healthcare System, Leeds, Massachusetts, USA
| | - Paul E Holtzheimer
- White River Junction VA Medical Center, White River Junction, Vermont, USA
- Dartmouth School of Medicine, Hanover, New Hampshire, USA
| | - Diana Higgins
- VA Boston Healthcare System, Boston, Massachusetts, USA
- Boston University School of Medicine, Boston, Massachusetts, USA
| | - Thomas E Reznik
- Providence VA Medical Center, Providence, Rhode Island, USA
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | | | | | - Tu Ngo
- Bedford VA Medical Center, Bedford, Massachusetts, USA
| | - Marc I Rosen
- VA Connecticut Healthcare System, West Haven, Connecticut, USA
- Yale University School of Medicine, New Haven, Connecticut, USA
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17
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Burgess DJ, Vallone D, Bair MJ, Matthias MS, Taylor BC, Taylor SL. Shifting the National Consciousness about Pain Treatment: The Critical Need for a National Public Education Campaign. THE JOURNAL OF PAIN 2021; 22:1129-1133. [PMID: 33945848 DOI: 10.1016/j.jpain.2021.03.156] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 03/13/2021] [Accepted: 03/28/2021] [Indexed: 10/21/2022]
Abstract
The failure of past practices and policies related to opioid prescribing for chronic pain has led federal agencies and professional organizations to recommend multimodal approaches that prioritize evidence-based nonpharmacological pain treatments (NPTs). These multimodal approaches, which include both traditional and complementary/integrative approaches, hold great promise for reducing the burden of chronic pain and reducing opioid use. Unfortunately, NPT approaches are underutilized due to a daunting array of interrelated barriers including the public's attitudes and beliefs about chronic pain and its treatment. Given the dual crises of chronic pain and opioid use, there is a critical need for a national public health campaign on chronic pain and its treatment to help educate the American public about NPT pain management options, while countering the misleading messages promulgated by the pharmaceutical industry, including but not limited to messages promoting the broad use of prescription opioids and minimizing its risks. Despite these dual crises of chronic pain and opioid use in the U.S., there has never been a concerted effort to broadly educate the American public about these issues and NPT pain management options.
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Affiliation(s)
- Diana J Burgess
- VA HSR&D Center for Care Delivery and Outcomes Research, Minneapolis VA Medical Center, Minneapolis, Minnesota; University of Minnesota Medical School Minneapolis, Minnesota.
| | - Donna Vallone
- Schroeder Institute, Truth Initiative, Washington, DC; Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; College of Global Public Health, New York University, New York, NY
| | - Matthew J Bair
- Center for Health Information and Communication, Indianapolis VA Medical Center, Indianapolis, IN; Regenstrief Institute, Indianapolis, IN; Indiana University School of Medicine, Indianapolis, IN
| | - Marianne S Matthias
- Center for Health Information and Communication, Indianapolis VA Medical Center, Indianapolis, IN; Regenstrief Institute, Indianapolis, IN; Indiana University School of Medicine, Indianapolis, IN
| | - Brent C Taylor
- VA HSR&D Center for Care Delivery and Outcomes Research, Minneapolis VA Medical Center, Minneapolis, Minnesota; University of Minnesota Medical School Minneapolis, Minnesota
| | - Stephanie L Taylor
- Center for the Study of Healthcare Innovation, Implementation and Policy, Greater Los Angeles VA Healthcare System, Los Angeles, California; Departments of Medicine and Health Policy and Management, UCLA, Los Angeles; California
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18
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Nicosia FM, Gibson CJ, Purcell N, Zamora K, Tighe J, Seal KH. Women Veterans' Experiences with Integrated, Biopsychosocial Pain Care: A Qualitative Study. PAIN MEDICINE 2021; 22:1954-1961. [PMID: 33547797 DOI: 10.1093/pm/pnaa481] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVES Biopsychosocial, integrated pain care models are increasingly implemented in the Veterans Health Administration to improve chronic pain care and reduce opioid-related risks, but little is known about how well these models address women veterans' needs. DESIGN Qualitative, interview-based study. SETTING San Francisco VA Health Care System Integrated Pain Team (IPT), an interdisciplinary team that provides short-term, personalized chronic pain care emphasizing functional goals and active self-management. SUBJECTS Women with chronic pain who completed ≥3 IPT sessions. METHODS Semistructured phone interviews focused on overall experience with IPT, perceived effectiveness of IPT care, pain care preferences, and suggested changes for improving gender-sensitive pain care. We used a rapid approach to qualitative thematic analysis to analyze interviews. RESULTS Fourteen women veterans (mean age 51 years; range 33-67 years) completed interviews. Interviews revealed several factors impacting women veterans' experiences: 1) an overall preference for receiving both primary and IPT care in gender-specific settings, 2) varying levels of confidence that IPT could adequately address gender-specific pain issues, 3) barriers to participating in pain groups, and 4) barriers to IPT self-management recommendations due to caregiving responsibilities. CONCLUSIONS Women veterans reported varied experiences with IPT. Recommendations to improve gender-sensitive pain care include increased provider training; increased knowledge of and sensitivity to women's health concerns; and improved accommodations for prior trauma, family and work obligations, and geographic barriers. To better meet the needs of women veterans with chronic pain, integrated pain care models must be informed by an understanding of gender-specific needs, challenges, and preferences.
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Affiliation(s)
- Francesca M Nicosia
- San Francisco VA Health Care System, San Francisco, California.,Institute for Health and Aging, University of California San Francisco, San Francisco, California
| | - Carolyn J Gibson
- San Francisco VA Health Care System, San Francisco, California.,Department of Psychiatry, University of California San Francisco, San Francisco, California
| | - Natalie Purcell
- San Francisco VA Health Care System, San Francisco, California.,Institute for Health and Aging, University of California San Francisco, San Francisco, California.,Department of Social and Behavioral Sciences, University of California San Francisco, San Francisco, California
| | - Kara Zamora
- San Francisco VA Health Care System, San Francisco, California.,Department of Anthropology, History, and Social Medicine, University of California San Francisco, San Francisco, California
| | - Jennifer Tighe
- San Francisco VA Health Care System, San Francisco, California
| | - Karen H Seal
- San Francisco VA Health Care System, San Francisco, California.,Department of Psychiatry, University of California San Francisco, San Francisco, California.,Department of Anthropology, History, and Social Medicine, University of California San Francisco, San Francisco, California.,Department of Medicine, University of California San Francisco, San Francisco, California, USA
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19
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Glynn LH, Chen JA, Dawson TC, Gelman H, Zeliadt SB. Bringing chronic-pain care to rural veterans: A telehealth pilot program description. Psychol Serv 2021; 18:310-318. [PMID: 31944817 PMCID: PMC7927421 DOI: 10.1037/ser0000408] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Opioid-related harms disproportionately affect rural communities. Recent research-based policy changes have called for reductions in opioid prescribing and substitution of safe and effective alternatives to opioids for treating chronic pain, but such alternatives are often difficult to access in rural areas. Telehealth services can help address this disparity by bringing evidence-based, biopsychosocial chronic-pain services to rural and underserved patients with chronic pain. This article describes a 2-year pilot project for delivering chronic-pain care by pain specialists from central hubs at Veterans Health Administration (VA) medical centers to spokes at VA community-based outpatient clinics (CBOCs). The VA Puget Sound Pain Telehealth pilot program offered pain education classes, cognitive-behavioral therapy groups, opioid-safety education, and acupuncture education. The program delivered 501 encounters to patients from 1 hub to 4 CBOC spoke sites from 2016 to 2018, and supported training, administration, equipment acquisition, and grant-writing. The quality-improvement project was rolled out using existing local resources. We present initial findings about the patients who utilized Pain Telehealth, share lessons learned, and discuss future directions for expansion. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
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Affiliation(s)
| | | | | | - Hannah Gelman
- Denver-Seattle Center of Innovation (COIN) for Veteran-Centered Value-Driven Care
| | - Steven B Zeliadt
- Denver-Seattle Center of Innovation (COIN) for Veteran-Centered Value-Driven Care
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20
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Fritz JM, Davis AF, Burgess DJ, Coleman B, Cook C, Farrokhi S, Goertz C, Heapy A, Lisi AJ, McGeary DD, Rhon DI, Taylor SL, Zeliadt S, Kerns RD. Pivoting to virtual delivery for managing chronic pain with nonpharmacological treatments: implications for pragmatic research. Pain 2021; 162:1591-1596. [PMID: 33156148 PMCID: PMC8089114 DOI: 10.1097/j.pain.0000000000002139] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 10/28/2020] [Indexed: 11/27/2022]
Affiliation(s)
- Julie M Fritz
- Department of Physical Therapy and Athletic Training, University of Utah, Salt Lake City, UT, United States
| | - Alison F Davis
- Pain Management Collaboratory, Department of Psychiatry (dept. affiliation for Dr. Davis) Yale University School of Medicine, New Haven, CT, United States
| | - Diana J Burgess
- VA HSR&D Center for Care Delivery and Outcomes Research, Minneapolis VA Medical Center, Minneapolis, MN, United States. Dr. Burgess is now with Department of Medicine (dept. affiliation for Dr. Burgess) University of Minnesota Medical School, Minneapolis, MN, United States
| | - Brian Coleman
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, Pain Management Collaboratory Coordinating Center, Yale School of Medicine, New Haven, CT, United States
| | - Chad Cook
- Doctor of Physical Therapy Division, Duke University School of Medicine, Durham, NC, United States
| | - Shawn Farrokhi
- DoD-VA Extremity and Amputation Center of Excellence, Department of Physical and Occupational Therapy, Naval Medical Center, San Diego, CA, United States
| | - Christine Goertz
- Department of Orthopaedics, Duke University School of Medicine, and Core Faculty Member, Duke-Margolis Center for Health Policy, Durham, NC, United States
| | - Alicia Heapy
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, United States. Dr. Heapy is now with VA Connecticut Healthcare System Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, Health Services Research and Development Center of Innovation, West Haven/Yale School of Medicine, New Haven, CT, United States
| | - Anthony J Lisi
- Department of Veterans Affairs, and Associate Research Scientist, Yale Center for Medical Informatics, Yale University School of Medicine, New Haven, CT, United States
| | - Donald D McGeary
- Departments of Rehabilitation Medicine and Psychiatry (Dept. affiliation for Dr. McGeary) University of Texas Health, San Antonio, TX, United States
| | - Daniel I Rhon
- Brooke Army Medical Center and Uniformed Services University of the Health Sciences, Bethesda, MD, United States
| | - Stephanie L Taylor
- VA HSR&D, VA Greater Los Angeles Healthcare System, Los Angeles, CA, United States. Dr. McGeary is now with Departments of Medicine and Health Policy and Management, UCLA, Los Angeles, CA, United States
| | - Steven Zeliadt
- Veterans Administration Puget Sound Health Care System, Department of Health Services, University of Washington, Seattle, WA, United States
| | - Robert D Kerns
- Departments of Psychiatry, Neurology, and Psychology, Yale University, New Haven, CT, United States. Dr. Kerns is now with VA Connecticut Healthcare System Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, West Haven, CT, United States
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21
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Bowen E, Nayfe R, Milburn N, Mayo H, Reid MC, Fraenkel L, Weiner D, Halm EA, Makris UE. Do Decision Aids Benefit Patients with Chronic Musculoskeletal Pain? A Systematic Review. PAIN MEDICINE 2021; 21:951-969. [PMID: 31880805 DOI: 10.1093/pm/pnz280] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To review the effect of patient decision aids for adults making treatment decisions regarding the management of chronic musculoskeletal pain. METHODS We performed a systematic review of randomized controlled trials of adults using patient decision aids to make treatment decisions for chronic musculoskeletal pain in the outpatient setting. RESULTS Of 477 records screened, 17 met the inclusion criteria. Chronic musculoskeletal pain conditions included osteoarthritis of the hip, knee, or trapeziometacarpal joint and back pain. Thirteen studies evaluated the use of a decision aid for deciding between surgical and nonsurgical management. The remaining four studies evaluated decision aids for nonsurgical treatment options. Outcomes included decision quality, pain, function, and surgery utilization. The effects of decision aids on decision-making outcomes were mixed. Comparing decision aids with usual care, all five studies that examined knowledge scores found improvement in patient knowledge. None of the four studies that evaluated satisfaction with the decision-making process found a difference with use of a decision aid. There was limited and inconsistent data on other decision-related outcomes. Of the eight studies that evaluated surgery utilization, seven found no difference in surgery rates with use of a decision aid. Five studies made comparisons between different types of decision aids, and there was no clearly superior format. CONCLUSIONS Decision aids may improve patients' knowledge about treatment options for chronic musculoskeletal pain but largely did not impact other outcomes. Future efforts should focus on improving the effectiveness of decision aids and incorporating nonpharmacologic and nonsurgical management options.
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Affiliation(s)
- Emily Bowen
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas
| | - Rabih Nayfe
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas
| | - Nathaniel Milburn
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas
| | - Helen Mayo
- Health Sciences Digital Library and Learning Center, UT Southwestern Medical Center, Dallas, Texas
| | - M C Reid
- Division of Geriatrics and Palliative Medicine, Weill Cornell Medicine, Cornell University, New York, New York
| | - Liana Fraenkel
- Yale University School of Medicine, New Haven, Connecticut
| | - Debra Weiner
- Geriatric Research, Education and Clinical Center, Veterans Administration Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,Department of Medicine, Psychiatry, Anesthesiology and Clinical & Translational Science, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Ethan A Halm
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas
| | - Una E Makris
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas.,Department of Medicine, VA North Texas Health Care System, Dallas, Texas, USA
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22
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Kerns RD, Brandt CA. NIH-DOD-VA Pain Management Collaboratory: Pragmatic Clinical Trials of Nonpharmacological Approaches for Management of Pain and Co-occurring Conditions in Veteran and Military Health Systems: Introduction. PAIN MEDICINE 2021; 21:S1-S4. [PMID: 33313722 DOI: 10.1093/pm/pnaa358] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Robert D Kerns
- Departments of Psychiatry, Neurology, and Psychology, Yale University, New Haven, Connecticut
| | - Cynthia A Brandt
- Department of Emergency Medicine and Yale Center for Medical Informatics, Yale University School of Medicine, New Haven, Connecticut.,Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, New Haven, Connecticut, USA
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23
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Coleman BC, Goulet JL, Higgins DM, Bathulapalli H, Kawecki T, Ruser CB, Bastian LA, Martino S, Piette JD, Edmond SN, Heapy AA. ICD-10 Coding of Musculoskeletal Conditions in the Veterans Health Administration. PAIN MEDICINE 2021; 22:2597-2603. [PMID: 33944953 DOI: 10.1093/pm/pnab161] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
OBJECTIVE We describe the most frequently used musculoskeletal diagnoses in Veterans Health Administration (VHA) care. We report the number of visits and patients associated with common musculoskeletal ICD-10 codes and compare trends across primary and specialty care settings. DESIGN Secondary analysis of a longitudinal cohort study. SUBJECTS Veterans included in the Musculoskeletal Diagnosis Cohort with a musculoskeletal diagnosis from October 1, 2015 through September 30, 2017. METHODS We obtained counts and proportions of all musculoskeletal diagnosis codes used and the number of unique patients with each musculoskeletal diagnosis. Diagnosis use was compared between primary and specialty care settings. RESULTS Of over 6,400 possible ICD-10 M-codes describing "Diseases of the Musculoskeletal System and Connective Tissue", 5,723 codes were used at least once. The most frequently used ICD-10 M-code was "Low Back Pain" (18.3%) followed by "Cervicalgia" (3.6%). Collectively, the 100 most frequently used codes accounted for 80% of M-coded visit diagnoses, and 95% of patients had at least one of these diagnoses. The most common diagnoses (spinal pain, joint pain, osteoarthritis) were used similarly in primary and specialty care settings. CONCLUSION A diverse sample of all available musculoskeletal diagnosis codes were used; however, less than 2% of all possible codes accounted for 80% of the diagnoses used. This trend was consistent across primary and specialty care settings. The most frequently used diagnosis codes describe the types of musculoskeletal conditions, among a large pool of potential diagnoses, that prompt veterans to present to VHA for musculoskeletal care.
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Affiliation(s)
- Brian C Coleman
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, CT.,Yale School of Medicine, Yale University, New Haven, CT
| | - Joseph L Goulet
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, CT.,Yale School of Medicine, Yale University, New Haven, CT
| | - Diana M Higgins
- Anesthesiology, Critical Care, and Pain Medicine Service, VA Boston Healthcare System, Boston, MA.,Boston University School of Medicine, Boston, MA
| | - Harini Bathulapalli
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, CT.,Yale School of Medicine, Yale University, New Haven, CT
| | - Todd Kawecki
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, CT.,Yale School of Medicine, Yale University, New Haven, CT
| | - Christopher B Ruser
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, CT.,Yale School of Medicine, Yale University, New Haven, CT
| | - Lori A Bastian
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, CT.,Yale School of Medicine, Yale University, New Haven, CT
| | - Steve Martino
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, CT.,Yale School of Medicine, Yale University, New Haven, CT
| | - John D Piette
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI.,University of Michigan School of Public Health, Ann Arbor, MI
| | - Sara N Edmond
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, CT.,Yale School of Medicine, Yale University, New Haven, CT
| | - Alicia A Heapy
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, CT.,Yale School of Medicine, Yale University, New Haven, CT
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24
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Cupler ZA, Daniels CJ, Anderson DR, Anderson MT, Napuli JG, Tritt ME. Suicide prevention, public health, and the chiropractic profession: a call to action. Chiropr Man Therap 2021; 29:14. [PMID: 33853629 PMCID: PMC8048297 DOI: 10.1186/s12998-021-00372-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 03/26/2021] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Suicide is a major public health concern that has wide-reaching implications on individuals, families, and society. Efforts to respond to a public health concern as a portal-of-entry provider can reduce morbidity and mortality of patients. The objective of this commentary is a call to action to initiate dialogue regarding suicide prevention and the role the chiropractic profession may play. DISCUSSION This public health burden requires doctors of chiropractic to realize current strengths and recognize contemporaneous deficiencies in clinical, research, and policy environments. With this better understanding, only then can the chiropractic profession strive to enhance knowledge and promote clinical acumen to target and mitigate suicide risk to better serve the public. CONCLUSION We implore the profession to transition from bystander to actively engaged in the culture of suicide prevention beholden to all aspects of the biopsychosocial healthcare model. The chiropractic profession's participation in suicide prevention improves the health and wellness of one's community while also impacting the broader public health arena.
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Affiliation(s)
- Zachary A Cupler
- Butler VA Health Care System, Butler, PA, USA.
- Institute for Clinical Research Education, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
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25
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Zeliadt SB, Coggeshall S, Gelman H, Shin MH, Elwy AR, Bokhour BG, Taylor SL. Assessing the Relative Effectiveness of Combining Self-Care with Practitioner-Delivered Complementary and Integrative Health Therapies to Improve Pain in a Pragmatic Trial. PAIN MEDICINE 2020; 21:S100-S109. [PMID: 33313736 DOI: 10.1093/pm/pnaa349] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Many health care systems are beginning to encourage patients to use complementary and integrative health (CIH) therapies for pain management. Many clinicians have anecdotally reported that patients combining self-care CIH therapies with practitioner-delivered therapies report larger health improvements than do patients using practitioner-delivered or self-care CIH therapies alone. However, we are unaware of any trials in this area. DESIGN The APPROACH Study (Assessing Pain, Patient-Reported Outcomes and Complementary and Integrative Health) assesses the value of veterans participating in practitioner-delivered CIH therapies alone or self-care CIH therapies alone compared with the combination of self-care and practitioner-delivered care. The study is being conducted in 18 Veterans Health Administration sites that received funding as part of the Comprehensive Addiction and Recovery Act to expand availability of CIH therapies. Practitioner-delivered therapies under study include chiropractic care, acupuncture, and therapeutic massage, and self-care therapies include tai chi/qi gong, yoga, and meditation. The primary outcome will be improvement on the Brief Pain Inventory 6 months after initiation of CIH as compared with baseline scores. Patients will enter treatment groups on the basis of the care they receive because randomizing patients to specific CIH therapies would require withholding therapies routinely offered at VA. We will address selection bias and confounding by using sites' variations in business practices and other encouragements to receive different types of CIH therapies as a surrogate for direct randomization by using instrumental variable econometrics methods. SUMMARY Real-world evidence about the value of combining self-care and practitioner-delivered CIH therapies from this pragmatic trial will help guide the VA and other health care systems in offering specific nonpharmacological approaches to manage patients' chronic pain.
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Affiliation(s)
- Steven B Zeliadt
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington.,Department of Health Services, School of Public Health, University of Washington, Seattle, Washington
| | - Scott Coggeshall
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington
| | - Hannah Gelman
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington
| | - Marlena H Shin
- Center for Healthcare Organization & Implementation Research, VA Boston Health Care System, Boston, Massachusetts
| | - A Rani Elwy
- Center for Healthcare Organization & Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, Massachusetts.,Department of Psychiatry and Human Behavior, Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - Barbara G Bokhour
- Center for Healthcare Organization & Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, Massachusetts.,Department of Population and Quantitative Health Sciences, Division of Preventive and Behavioral Health, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Stephanie L Taylor
- Center for the Study of Healthcare Innovation, Implementation and Policy, Greater Los Angeles VA Health Care System, Los Angeles, California.,School of Medicine, Department of Health Policy and Management, UCLA School of Public Health, Los Angeles, California, USA
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26
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Purcell N, Becker WC, Zamora KA, McGrath SL, Hagedorn HJ, Fabian ER, McCamish N, Seal KH. Tailored to Fit: How an Implementation Framework Can Support Pragmatic Pain Care Trial Adaptation for Diverse Veterans Affairs Clinical Settings. Med Care 2020; 58 Suppl 2 9S:S80-S87. [PMID: 32826776 PMCID: PMC7444583 DOI: 10.1097/mlr.0000000000001376] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Veterans Affairs (VA) has rolled out a holistic, multicomponent Whole Health care model nationwide, yet no pragmatic trials have been conducted in real-world clinical settings to compare its effectiveness against other evidence-based approaches for chronic pain management in veterans. OBJECTIVES We describe the adaptation of the first large pragmatic randomized controlled trial of the Whole Health model for chronic pain care for diverse VA clinical settings. RESEARCH DESIGN Informed by the Promoting Action on Research Implementation in Health Systems implementation framework, we conducted qualitative semistructured interviews to obtain feedback on trial design from VA leadership, frontline clinicians, and veterans with chronic pain at 5 VA enrollment sites. Next, we convened in-person evidence-based quality improvement (EBQI) meetings with study stakeholders (including frontline clinicians and administrators) at each site to discuss study design; review interview themes; and identify site-specific barriers, facilitators, and approaches to implementation. Ethnographic observations from EBQI meetings provided additional insight into implementation strategies. SUBJECTS Seventy-four veteran and VA staff stakeholders were interviewed; 71 stakeholders participated in EBQI meetings. RESULTS At each site, unique clinical contexts and varying resources for Whole Health and pain care delivery affected plans for trial implementation. We present examples of local adaptations that emerged through the formative evaluation process to facilitate implementation and yield a more pragmatic trial design. CONCLUSIONS A systematic formative evaluation can facilitate engagement and buy-in of study stakeholders. Locally tailored pragmatic implementation strategies may improve the likelihood of successful trial execution as well as future implementation of evidence-based pain care approaches in real-world clinical settings.
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Affiliation(s)
- Natalie Purcell
- San Francisco VA Health Care System (San Francisco, CA)
- University of California, San Francisco (San Francisco, CA)
| | - William C. Becker
- VA Connecticut Healthcare System (West Haven, CT)
- Yale School of Medicine (New Haven, CT)
| | - Kara A. Zamora
- San Francisco VA Health Care System (San Francisco, CA)
- University of California, San Francisco (San Francisco, CA)
| | | | - Hildi J. Hagedorn
- Minneapolis VA Health Care System (Minneapolis, MN)
- University of Minneapolis (Minneapolis, MN)
| | - Eva R. Fabian
- San Francisco VA Health Care System (San Francisco, CA)
| | | | - Karen H. Seal
- San Francisco VA Health Care System (San Francisco, CA)
- University of California, San Francisco (San Francisco, CA)
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Yoga Practice Among Veterans With and Without Chronic Pain: A Mixed Methods Study. Med Care 2020; 58 Suppl 2 9S:S133-S141. [PMID: 32826783 DOI: 10.1097/mlr.0000000000001331] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The primary aim of this study was to examine differences in yoga practice between persons with and without chronic pain. Secondarily, we describe use of the Essential Properties of Yoga Questionnaire, Short Form (EPYQ-SF) for self-report. DESIGN Participants were members of an existing cohort of veterans who completed a 2015-2016 survey focused on pain and nonpharmacological health practices. Cohort members who reported yoga in the past year [n=174 (9.4%) of 1850] were eligible for the present study, which used multiple-contact mixed-mode survey methodology to collect data on yoga practices. The EPYQ-SF was used to assess properties and context of yoga practice. Practice patterns were compared for participants with and without chronic pain. To explore potential reasons for reported yoga practice patterns, focused semistructured interviews were conducted with a subset of participants. RESULTS Of 174 participants contacted, 141 (82%) returned the yoga questionnaire and 110 (78% of respondents) were still practicing yoga. Among yoga practitioners, 41 (37%) had chronic pain. Practitioners with chronic pain reported gentler (2.8 vs. 3.1, 5-point scale) and less active (2.9 vs. 3.3) yoga practice than those without. Those with chronic pain attended yoga studios less frequently and reported shorter yoga practices than those without. Most yoga practice was self-directed and at home. CONCLUSIONS Differences in yoga practice of persons with and without chronic pain have implications for implementation of yoga interventions for chronic pain. Future interventions should focus on alternative individual delivery formats or addressing barriers to group practice among people with chronic pain.
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28
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Coleman BC, Fodeh S, Lisi AJ, Goulet JL, Corcoran KL, Bathulapalli H, Brandt CA. Exploring supervised machine learning approaches to predicting Veterans Health Administration chiropractic service utilization. Chiropr Man Therap 2020; 28:47. [PMID: 32680545 PMCID: PMC7368704 DOI: 10.1186/s12998-020-00335-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 07/02/2020] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Chronic spinal pain conditions affect millions of US adults and carry a high healthcare cost burden, both direct and indirect. Conservative interventions for spinal pain conditions, including chiropractic care, have been associated with lower healthcare costs and improvements in pain status in different clinical populations, including veterans. Little is currently known about predicting healthcare service utilization in the domain of conservative interventions for spinal pain conditions, including the frequency of use of chiropractic services. The purpose of this retrospective cohort study was to explore the use of supervised machine learning approaches to predicting one-year chiropractic service utilization by veterans receiving VA chiropractic care. METHODS We included 19,946 veterans who entered the Musculoskeletal Diagnosis Cohort between October 1, 2003 and September 30, 2013 and utilized VA chiropractic services within one year of cohort entry. The primary outcome was one-year chiropractic service utilization following index chiropractic visit, split into quartiles represented by the following classes: 1 visit, 2 to 3 visits, 4 to 6 visits, and 7 or greater visits. We compared the performance of four multiclass classification algorithms (gradient boosted classifier, stochastic gradient descent classifier, support vector classifier, and artificial neural network) in predicting visit quartile using 158 sociodemographic and clinical features. RESULTS The selected algorithms demonstrated poor prediction capabilities. Subset accuracy was 42.1% for the gradient boosted classifier, 38.6% for the stochastic gradient descent classifier, 41.4% for the support vector classifier, and 40.3% for the artificial neural network. The micro-averaged area under the precision-recall curve for each one-versus-rest classifier was 0.43 for the gradient boosted classifier, 0.38 for the stochastic gradient descent classifier, 0.43 for the support vector classifier, and 0.42 for the artificial neural network. Performance of each model yielded only a small positive shift in prediction probability (approximately 15%) compared to naïve classification. CONCLUSIONS Using supervised machine learning to predict chiropractic service utilization remains challenging, with only a small shift in predictive probability over naïve classification and limited clinical utility. Future work should examine mechanisms to improve model performance.
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Affiliation(s)
- Brian C Coleman
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, 11-ACSL-G, 950 Campbell Avenue, West Haven, CT, 06516, USA.
- Yale School of Medicine, Yale University, New Haven, CT, USA.
| | - Samah Fodeh
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, 11-ACSL-G, 950 Campbell Avenue, West Haven, CT, 06516, USA
- Yale School of Medicine, Yale University, New Haven, CT, USA
| | - Anthony J Lisi
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, 11-ACSL-G, 950 Campbell Avenue, West Haven, CT, 06516, USA
- Yale School of Medicine, Yale University, New Haven, CT, USA
| | - Joseph L Goulet
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, 11-ACSL-G, 950 Campbell Avenue, West Haven, CT, 06516, USA
- Yale School of Medicine, Yale University, New Haven, CT, USA
| | - Kelsey L Corcoran
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, 11-ACSL-G, 950 Campbell Avenue, West Haven, CT, 06516, USA
- Yale School of Medicine, Yale University, New Haven, CT, USA
| | - Harini Bathulapalli
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, 11-ACSL-G, 950 Campbell Avenue, West Haven, CT, 06516, USA
- Yale School of Medicine, Yale University, New Haven, CT, USA
| | - Cynthia A Brandt
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, 11-ACSL-G, 950 Campbell Avenue, West Haven, CT, 06516, USA
- Yale School of Medicine, Yale University, New Haven, CT, USA
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Daniels CJ, Gliedt JA, Suri P, Bednarz EM, Lisi AJ. Management of patients with prior lumbar fusion: a cross-sectional survey of Veterans Affairs chiropractors' attitudes, beliefs, and practices. Chiropr Man Therap 2020; 28:29. [PMID: 32552863 PMCID: PMC7304138 DOI: 10.1186/s12998-020-00322-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Accepted: 05/12/2020] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Little is known about the preferred treatment strategies of chiropractors in managing low back pain patients with prior lumbar fusions. There are several case reports which describe chiropractic care following surgical intervention, but there are no cohort or experimental studies published. Therefore, we sought to examine self-reported management approaches and practice patterns related to the management of patients with prior surgical lumbar fusion, among United States Veterans Affairs (VA) chiropractors. METHODS An electronic survey was administered nationwide to all chiropractors providing clinical care within VA. Questions were informed by a prior survey and piloted on a sample of chiropractors external to VA. Statistical analysis included respondent background information, and quantitative analysis of chiropractic referral patterns and practices. This survey collect information on 1) provider demographics, 2) VA referral patterns, and 3) attitudes, beliefs, practices and interventions utilized by VA chiropractors to manage patients with a history of surgical lumbar fusion. RESULTS The survey response rate was 46.3% (62/134). The respondents were broadly representative of VA chiropractic providers in age, gender, and years in practice. The majority of respondents (90.3%) reported seeing at least 1 post-fusion patient in the past month. The most common therapeutic approaches utilized by VA chiropractors were healthy lifestyle advice (94.9%), pain education (89.8%), exercise prescription (88.1%), stretching (66.1%) and soft tissue manual therapies (62.7%). A relatively smaller proportion described always or frequently incorporating lumbar (16.9%), thoracic (57.6%) or pelvic (39.0%) spinal manipulation. CONCLUSION This survey provides preliminary data on VA chiropractic services in the management of patients with prior lumbar fusion. These patients are often seen by VA chiropractors, and our findings support the need for further study to advance understanding of interventions utilized by chiropractors in this patient population.
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Affiliation(s)
- Clinton J Daniels
- Rehabilitation Care Services, VA Puget Sound Health Care System, 9600 Veterans Drive, Tacoma, WA, 98493, USA.
| | - Jordan A Gliedt
- Department of Neurosurgery, Medical College of Wisconsin, 9200 W. Wisconsin Ave., Milwaukee, WI, 53226, USA
| | - Pradeep Suri
- Rehabilitation Care Services, VA Puget Sound Health Care System, 9600 Veterans Drive, Tacoma, WA, 98493, USA.,Seattle Epidemiologic Research and Information Center, VA Puget Sound Health Care System, 1660 S Columbian Way, Seattle, WA, 98108, USA.,Department of Rehabilitation Medicine, University of Washington, 325 9th Ave, Seattle, WA, 98104, USA
| | - Edward M Bednarz
- Rehabilitation Care Services, VA Puget Sound Health Care System, 9600 Veterans Drive, Tacoma, WA, 98493, USA
| | - Anthony J Lisi
- Chiropractic Service Chief, VA Connecticut Health Care System, 950 Campbell Ave, West Haven, CT, 06516, USA
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Factors Associated With Posttraumatic Stress Disorder Among Veterans of Recent Wars Receiving Veterans Affairs Chiropractic Care. J Manipulative Physiol Ther 2020; 43:753-759. [PMID: 32534740 DOI: 10.1016/j.jmpt.2019.10.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Revised: 08/16/2019] [Accepted: 10/22/2019] [Indexed: 11/22/2022]
Abstract
OBJECTIVES Post-traumatic stress disorder (PTSD) is thought to complicate pain management outcomes, which is consistent with the impact of other psychosocial factors in the biopsychosocial model of pain. This study aimed to identify patient sociodemographic and clinical characteristics associated with PTSD prevalence among veterans of Operations Enduring Freedom/Iraqi Freedom/New Dawn (OEF/OIF/OND) who received Veterans Affairs (VA) chiropractic care. METHODS A cross-sectional analysis of electronic health record data from a national cohort study of OEF/OIF/OND veterans with at least 1 visit to a VA chiropractic clinic from 2001 to 2014 was performed. The primary outcome measure was a prior PTSD diagnosis. Variables including sex, race, age, body mass index, pain intensity, alcohol and substance use disorders, and smoking status were examined in association with PTSD diagnosis using logistic regression. RESULTS We identified 14,025 OEF/OIF/OND veterans with at least 1 VA chiropractic visit, with a mean age of 38 years and 54.2% having a diagnosis of PTSD. Male sex (adjusted odds ratio [OR] = 1.23, 95% CI = 1.11-1.37), younger age (OR = 0.99, CI = 0.98-0.99), moderate-to-severe pain intensity (numerical rating scale ≥ 4) (OR = 1.72, CI = 1.59-1.87), body mass index ≥ 30 (OR = 1.34, CI = 1.24-1.45), current smoking (OR = 1.32, CI = 1.20-1.44), and having an alcohol or substance use disorder (OR = 4.51, CI = 4.01-5.08) were significantly associated with a higher likelihood of PTSD diagnosis. CONCLUSION Post-traumatic stress disorder is a common comorbidity among OEF/OIF/OND veterans receiving VA chiropractic care and is significantly associated with several patient characteristics. Recognition of these factors is important for the appropriate diagnosis and management of veterans with PTSD seeking chiropractic treatment for pain conditions.
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Williams RM, Ehde DM, Day M, Turner AP, Hakimian S, Gertz K, Ciol M, McCall A, Kincaid C, Pettet MW, Patterson D, Suri P, Jensen MP. The chronic pain skills study: Protocol for a randomized controlled trial comparing hypnosis, mindfulness meditation and pain education in Veterans. Contemp Clin Trials 2020; 90:105935. [PMID: 31926321 PMCID: PMC7072005 DOI: 10.1016/j.cct.2020.105935] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Revised: 12/23/2019] [Accepted: 01/06/2020] [Indexed: 01/19/2023]
Abstract
OBJECTIVES To describe the protocol of a randomized controlled trial to evaluate the effectiveness and mechanisms of three behavioral interventions. METHODS Participants will include up to 343 Veterans with chronic pain due to a broad range of etiologies, randomly assigned to one of three 8-week manualized in-person group treatments: (1) Hypnosis (HYP), (2) Mindfulness Meditation (MM), or (3) Education Control (EDU). PROJECTED OUTCOMES The primary aim of the study is to compare the effectiveness of HYP and MM to EDU on average pain intensity measured pre- and post-treatment. Additional study aims will explore the effectiveness of HYP and MM compared to EDU on secondary outcomes (i.e., pain interference, sleep, depression, anxiety and PTSD), and the maintenance of effects at 3- and 6-months post-treatment. Participants will have electroencephalogram (EEG) assessments at pre- and post-treatment to determine if the power of specific brain oscillations moderate the effectiveness of HYP and MM (Study Aim 2) and examine brain oscillations as possible mediators of treatment effects (exploratory aim). Additional planned exploratory analyses will be performed to identify possible treatment mediators (i.e., pain acceptance, catastrophizing, mindfulness) and moderators (e.g., hypnotizability, treatment expectations, pain type, cognitive function). SETTING The study treatments will be administered at a large Veterans Affairs Medical Center in the northwest United States. The treatments will be integrated within clinical infrastructure and delivered by licensed and credentialed health care professionals.
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Affiliation(s)
- Rhonda M Williams
- VA Puget Sound Health Care System, 1660 S. Columbian Way, RCS-117, Seattle, WA 98108, United States of America; University of Washington School of Medicine, Department of Rehabilitation Medicine, Ninth & Jefferson Building, Box 359612, Seattle, WA 98104, United States of America.
| | - Dawn M Ehde
- University of Washington School of Medicine, Department of Rehabilitation Medicine, Ninth & Jefferson Building, Box 359612, Seattle, WA 98104, United States of America
| | - Melissa Day
- The University of Queensland, School of Psychology, Faculty of Health & Behavioral Sciences, St. Lucia Campus, Brisbane, QLD 4072, Australia
| | - Aaron P Turner
- VA Puget Sound Health Care System, 1660 S. Columbian Way, RCS-117, Seattle, WA 98108, United States of America; University of Washington School of Medicine, Department of Rehabilitation Medicine, Ninth & Jefferson Building, Box 359612, Seattle, WA 98104, United States of America
| | - Shahin Hakimian
- University of Washington School of Medicine, Department of Neurology, Harborview Medical Center, 325 Ninth Ave, Box 359745, Seattle, WA 98104, United States of America
| | - Kevin Gertz
- University of Washington School of Medicine, Department of Rehabilitation Medicine, Ninth & Jefferson Building, Box 359612, Seattle, WA 98104, United States of America
| | - Marcia Ciol
- University of Washington School of Medicine, Department of Rehabilitation Medicine, Ninth & Jefferson Building, Box 359612, Seattle, WA 98104, United States of America
| | - Alisha McCall
- VA Puget Sound Health Care System, 1660 S. Columbian Way, RCS-117, Seattle, WA 98108, United States of America
| | - Carrie Kincaid
- VA Puget Sound Health Care System, 1660 S. Columbian Way, RCS-117, Seattle, WA 98108, United States of America
| | - Mark W Pettet
- University of Washington, Integrated Brain Imaging Center, Department of Radiology, 1959 NE Pacific St., Box 357115, Seattle, WA 98195, United States of America
| | - David Patterson
- University of Washington School of Medicine, Department of Rehabilitation Medicine, Ninth & Jefferson Building, Box 359612, Seattle, WA 98104, United States of America
| | - Pradeep Suri
- VA Puget Sound Health Care System, 1660 S. Columbian Way, RCS-117, Seattle, WA 98108, United States of America; University of Washington School of Medicine, Department of Rehabilitation Medicine, Ninth & Jefferson Building, Box 359612, Seattle, WA 98104, United States of America
| | - Mark P Jensen
- University of Washington School of Medicine, Department of Rehabilitation Medicine, Ninth & Jefferson Building, Box 359612, Seattle, WA 98104, United States of America
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Abraham TH, Deen TL, Hamilton M, True G, O'Neil MT, Blanchard J, Uddo M. Analyzing free-text survey responses: An accessible strategy for developing patient-centered programs and program evaluation. EVALUATION AND PROGRAM PLANNING 2020; 78:101733. [PMID: 31675509 DOI: 10.1016/j.evalprogplan.2019.101733] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Revised: 08/11/2019] [Accepted: 10/17/2019] [Indexed: 06/10/2023]
Abstract
Despite widespread availability of yoga in the Veterans Health Administration (VA), it remains unclear how to best evaluate yoga programs. This is particularly problematic for programs aimed at veterans with mental health concerns, as evaluation typically focuses narrowly upon mental health symptom severity, even though program participants may have other health-related priorities. We analyzed responses to free-text questions on 237 surveys completed by veterans with mental health concerns enrolled in a yoga program at six VA clinics in Louisiana to characterize veteran participants' experiences with yoga. Qualitative analysis resulted in 15 domains reflecting veterans' individual health-related values and priorities. We use results to illustrate the potential for analysis of free-text responses to reveal valuable insights into patient experiences, demonstrating how these data can inform patient-centered program evaluation. The approach we present is more accessible to those responsible for decision-making about local programs than conventional methods of analyzing qualitive evaluation data.
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Affiliation(s)
- Traci H Abraham
- Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Affairs Healthcare System, 2200 Fort Roots Drive, Building 58, North Little Rock, AR 72114-1706, United States; Department of Psychiatry, University of Arkansas for Medical Sciences, 4301 West Markham Street, Little Rock, AR 72205, United States; VA South Central Mental Illness Research, Education and Clinical Center, 2200 Fort Roots Drive, Building 58, North Little Rock, AR 72114-1706, United States.
| | - Tisha L Deen
- Central Arkansas Veterans Healthcare System, Eugene J. Towbin Healthcare Center, 2200 Fort Roots Drive, North Little Rock, AR 72114-1706, United States
| | - Michelle Hamilton
- Southeast Louisiana Veterans Health Care System, 2400 Canal Street, New Orleans, LA 70119, United States
| | - Gala True
- South Central Mental Illness Research, Education and Clinical Center, Southeast Louisiana Veterans Health Care System, 2400 Canal Street, New Orleans, LA 70119, United States; Tulane University School of Medicine, 1430 Tulane Avenue, New Orleans, LA 70112, United States
| | | | | | - Madeline Uddo
- South Central Mental Illness Research, Education and Clinical Center, Southeast Louisiana Veterans Health Care System, 2400 Canal Street, New Orleans, LA 70119, United States
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Higgins DM, LaChappelle KM, Serowik KL, Driscoll MA, Lee A, Heapy AA. Predictors of Participation in a Nonpharmacological Intervention for Chronic Back Pain. PAIN MEDICINE 2019; 19:S76-S83. [PMID: 30753730 DOI: 10.1093/pm/pny077] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Objective Cognitive behavioral therapy for chronic pain (CBT-CP) has been identified as an evidence-based adjunct or alternative to opioid pain care. However, little is known about which patients participate in CBT-CP. This study examined predictors of enrollment in a noninferiority trial of in-person vs technology-based CBT-CP for patients with chronic back pain. Setting A single Veterans Health Affairs (VHA) medical center. Subjects Veterans with chronic back pain. Design and Methods For eligible participants (N = 290), individual factors (demographics, distance from a VHA medical center, pain intensity, receipt of opioid prescription, and recruitment method) collected at trial screening were examined to identify predictors of enrollment (i.e., signed consent form). Of those who enrolled, duration of participation in the treatment portion of the study was examined. Results Among eligible patients, 54% declined enrollment due to lack of interest. Regression analyses revealed that patients not in receipt of an opioid were more likely to enroll. The probability of being in the trial long enough to receive a "dose" of treatment (3 visits or more) was 0.76 (0.04). Conclusions Overall, enrollment rates were low. However, most patients who enrolled in the study (102 of 134 signed consent) were retained and received a treatment dose. Patients not receiving opioids were more likely to enroll, suggesting that patients who are prescribed opioids, an important group for treatment outreach, are likely underengaged. Identifying predictors of enrollment in CBT-CP may help increase recruitment efficiency and assist in targeting patients who may benefit but are not currently interested in treatment.
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Affiliation(s)
- Diana M Higgins
- Anesthesiology, Critical Care, and Pain Medicine/Research Service, VA Boston Healthcare System, Boston, Massachusetts.,Department of Psychiatry, School of Medicine, Boston University, Boston, Massachusetts
| | - Kathryn M LaChappelle
- VA Connecticut Healthcare System, Pain Research, Informatics, Multimorbidities, and Education (PRIME) Health Services Research and Development Center of Innovation, West Haven, Connecticut
| | - Kristin L Serowik
- Anesthesiology, Critical Care, and Pain Medicine/Research Service, VA Boston Healthcare System, Boston, Massachusetts
| | - Mary A Driscoll
- VA Connecticut Healthcare System, Pain Research, Informatics, Multimorbidities, and Education (PRIME) Health Services Research and Development Center of Innovation, West Haven, Connecticut.,Department of Psychiatry, School of Medicine, Yale University, New Haven, Connecticut, USA
| | - Allison Lee
- VA Connecticut Healthcare System, Pain Research, Informatics, Multimorbidities, and Education (PRIME) Health Services Research and Development Center of Innovation, West Haven, Connecticut
| | - Alicia A Heapy
- VA Connecticut Healthcare System, Pain Research, Informatics, Multimorbidities, and Education (PRIME) Health Services Research and Development Center of Innovation, West Haven, Connecticut.,Department of Psychiatry, School of Medicine, Yale University, New Haven, Connecticut, USA
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Purcell N, Zamora K, Gibson C, Tighe J, Chang J, Grasso J, Seal KH. Patient Experiences With Integrated Pain Care: A Qualitative Evaluation of One VA's Biopsychosocial Approach to Chronic Pain Treatment and Opioid Safety. Glob Adv Health Med 2019; 8:2164956119838845. [PMID: 31041143 PMCID: PMC6480990 DOI: 10.1177/2164956119838845] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Accepted: 02/27/2019] [Indexed: 01/08/2023] Open
Abstract
Background Mounting concern about the risks and limited effectiveness of opioid therapy for chronic pain has spurred the implementation of novel integrated biopsychosocial pain care models in health-care systems like the Department of Veterans Affairs (VA). However, little is known about patient experiences with these new care models. Objective We conducted a qualitative study to examine patient experiences with a pain care model currently being disseminated at the VA: interdisciplinary, integrated pain teams (IPTs) embedded in primary care. Method We interviewed 41 veterans who received care from VA’s first IPT to learn how working with the team impacted their pain care and quality of life. We asked about their overall experience with IPT, what worked and did not work for them, and what changes they would recommend to improve IPT care. Results The interviews revealed a wide spectrum of patient experiences and varying perspectives on the extent to which the new model improved their pain and quality of life. Thematic analysis shed light on factors impacting patients’ experiences, including pretreatment goals and expectations as well as attitudes toward opioids and nonpharmacological treatments. Conclusion We discuss the implications of our findings for national efforts to implement biopsychosocial pain care, and we offer recommendations to promote patient-centered implementation.
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Affiliation(s)
- Natalie Purcell
- San Francisco VA Health Care System, San Francisco, California.,University of California, San Francisco, San Francisco, California
| | - Kara Zamora
- San Francisco VA Health Care System, San Francisco, California.,University of California, San Francisco, San Francisco, California
| | - Carolyn Gibson
- San Francisco VA Health Care System, San Francisco, California.,University of California, San Francisco, San Francisco, California
| | - Jennifer Tighe
- San Francisco VA Health Care System, San Francisco, California
| | - Jamie Chang
- San Francisco VA Health Care System, San Francisco, California.,Santa Clara University, Santa Clara, California
| | - Joseph Grasso
- San Francisco VA Health Care System, San Francisco, California
| | - Karen H Seal
- San Francisco VA Health Care System, San Francisco, California.,University of California, San Francisco, San Francisco, California
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Affiliation(s)
- Robert D Kerns
- Departments of Psychiatry, Neurology and Psychology, Yale University, New Haven, CT, USA
| | - Erin E Krebs
- University of Minnesota Medical School, Minneapolis, MN, USA
| | - David Atkins
- Office of Research and Development, Department of Veterans Affairs (10P9H), 810 Vermont Ave NW, Washington DC, 20420, USA.
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