A Multidisciplinary Integrative Medicine Team in the Treatment of Chronic Low-Back Pain: An Observational Comparative Effectiveness Study

Multidisciplinary integrative care versus chiropractic care for low back pain: a randomized clinical trial

BACKGROUND

Low back pain (LBP) is influenced by interrelated biological, psychological, and social factors, however current back pain management is largely dominated by one-size fits all unimodal treatments. Team based models with multiple provider types from complementary professional disciplines is one way of integrating therapies to address patients' needs more comprehensively.

METHODS

This parallel group randomized clinical trial conducted from May 2007 to August 2010 aimed to evaluate the relative clinical effectiveness of 12 weeks of monodisciplinary chiropractic care (CC), versus multidisciplinary integrative care (IC), for adults with sub-acute and chronic LBP. The primary outcome was pain intensity and secondary outcomes were disability, improvement, medication use, quality of life, satisfaction, frequency of symptoms, missed work or reduced activities days, fear avoidance beliefs, self-efficacy, pain coping strategies and kinesiophobia measured at baseline and 4, 12, 26 and 52 weeks. Linear mixed models were used to analyze outcomes.

RESULTS

201 participants were enrolled. The largest reductions in pain intensity occurred at the end of treatment and were 43% for CC and 47% for IC. The primary analysis found IC to be significantly superior to CC over the 1-year period (P = 0.02). The long-term profile for pain intensity which included data from weeks 4 through 52, showed a significant advantage of 0.5 for IC over CC (95% CI 0.1 to 0.9; P = 0.02; 0 to 10 scale). The short-term profile (weeks 4 to 12) favored IC by 0.4, but was not statistically significant (95% CI - 0.02 to 0.9; P = 0.06). There was also a significant advantage over the long term for IC in some secondary measures (disability, improvement, satisfaction and low back symptom frequency), but not for others (medication use, quality of life, leg symptom frequency, fear avoidance beliefs, self-efficacy, active pain coping, and kinesiophobia). Importantly, no serious adverse events resulted from either of the interventions.

CONCLUSIONS

Participants in the IC group tended to have better outcomes than the CC group, however the magnitude of the group differences was relatively small. Given the resources required to successfully implement multidisciplinary integrative care teams, they may not be worthwhile, compared to monodisciplinary approaches like chiropractic care, for treating LBP. Trial registration NCT00567333.

Cost-effectiveness of Multidisciplinary Interventions for Chronic Low Back Pain: A Narrative Review

OBJECTIVE

Chronic musculoskeletal pain in adults is a global health and economic problem. The aim of this paper was to systematically review and determine what proportion of multidisciplinary approaches to managing chronic musculoskeletal pain are cost-effective.

MATERIALS AND METHODS

The EconLit, Embase, and PubMed electronic databases were searched for randomized and nonrandomized economic evaluation studies of nonpharmaceutical multidisciplinary chronic pain management interventions published from inception through to August 2019.

RESULTS

Seven studies comprising 2095 patients were included. All studies involved diverse multidisciplinary teams in one or more of the study arms. All studies involved chronic (both chronic and subacute) low back pain and were economic evaluations from either a societal or health care perspective. Two of the 3 studies that reported on a multidisciplinary pain intervention compared with nonmultidisciplinary intervention concluded favorable cost-effectiveness based on cost per quality adjusted life years gained, 1 study was not found to be cost-effective. Cost-effectiveness of the multidisciplinary intervention of interest was also not established by another 3-arm study. Two studies compared 2 multidisciplinary interventions; neither of these could definitively declare cost-effectiveness. The remaining study indicated the intervention by a multidisciplinary team was more effective but at a higher cost. None of the included studies used decision models to estimate long-term health outcomes and cost-effectiveness of multidisciplinary programs.

DISCUSSION

There are few studies on the cost-effectiveness of multidisciplinary chronic pain management interventions. This study encourages additional rigorous economic evaluations of multidisciplinary models for chronic pain management. Economic evaluations that enable extrapolating costs and effects of multidisciplinary programs beyond the time horizon of clinical trials may be more informative for clinicians and health administrators.

A Systematic Review of Practiced-Based Research of Complementary and Integrative Health Therapies as Provided for Pain Management in Clinical Settings: Recommendations for the Future and A Call to Action

OBJECTIVE

The goal of this systematic review was to evaluate practice-based, real-world research of individualized complementary and integrative health (CIH) therapies for pain as provided in CIH outpatient clinics.

METHODS

A systematic review was conducted using PubMed, Ovid, Cochrane, Web of Science, Scopus and Embase through Dec 2020. The study was listed in the PROSPERO database (CRD42020159193). Major categories of variables extracted included study details and demographics; interventions; and outcomes.

RESULTS

The literature search yielded 3,316 records with 264 assessed for full text review. Of those, 23 studies (including ∼8,464 patients) were specific to pain conditions as a main outcome. Studies included chiropractic, acupuncture, multimodal individualized intervention/programs, physiotherapy, and anthroposophic medicine therapy. Retention rates ranged from 53% to 91%, with studies offering monetary incentives showing the highest retention. The 0-10 numerical rating scale was the most common pain questionnaire (n = 10, 43% of studies), with an average percent improvement across all studies and timepoints of 32% (range 18-60%).

CONCLUSIONS

Findings from this systematic review of practice-based, real-word research indicate that CIH therapies exert positive effects on various pain outcomes. Although all studies reported beneficial impacts on one or more pain outcomes, the heterogeneous nature of studies limits our overall understanding of CIH as provided in clinical settings. Accordingly, we present numerous recommendations to improve publication reporting and guide future research. Our call to action is future, practice-based CIH research is needed, but should be more expansive and in association with a CIH scientific society with academic and healthcare members.

Try-It-On: Preparing family nurse practitioners to use holistic integrative interventions to reduce opioid prescriptions in chronic pain management

In the United States, more than 130 people die each day from an opioid overdose. Nonopioid chronic pain management options are necessary in primary care. This educational innovation describes a new curriculum to teach future family nurse practitioner (FNP) prescribers holistic integrative interventions to decrease overprescribing of opioids for chronic pain management. The Modeling and Role Modeling theory and Kirkpatrick Evaluation Model guided the development and implementation of the curriculum innovation using a Try-It-On teaching-learning strategy, which focuses on immersion experience. The focus was to teach students to communicate effectively with patients in an effort to increase patient awareness of the pathophysiology of pain, risks of opioid use, and holistic integrative pain management options. Students learned to manage chronic pain within a holistic focus through immersion within integrative modalities, such as yoga, meditation, mindfulness, and guided imagery. Pre and post participation evaluations documented students' increased comfort level managing patients with chronic pain. Students reported they were much more likely to prescribe holistic integrative modalities after completing the Try-It-On learning modules. Holistic integrative interventions are a viable treatment option and/or adjunct treatment for chronic pain management. In conclusion, using the Try-It-On, teaching-learning strategy provided FNP students with the tools needed to prescribe nonopioid holistic integrative interventions to manage chronic pain.

Whole Systems Research Methods in Health Care: A Scoping Review

Objectives: This scoping review evaluates two decades of methodological advances made by “whole systems research” (WSR) pioneers in the fields of traditional, complementary, and integrative medicine (TCIM). Rooted in critiques of the classical randomized controlled trial (RCT)'s suitability for evaluating holistic, complex TCIM interventions, WSR centralizes the principle of “model validity,” representing a “fit” between research design and therapeutic paradigm.

Design: In consultation with field experts, 41 clinical research exemplars were selected for review from across 13 TCIM disciplines, with the aim of mapping the range and methodological characteristics of WSR studies. Using an analytic charting approach, these studies' primary and secondary features are characterized with reference to three focal areas: research method, intervention design, and outcome assessment.

Results: The reviewed WSR exemplars investigate a wide range of multimodal and multicomponent TCIM interventions, typified by wellness-geared, multitarget, and multimorbid therapeutic aims. Most studies include a behavioral focus, at times in multidisciplinary or team-based contexts. Treatments are variously individualized, often with reference to “dual” (biomedical and paradigm-specific) diagnoses. Prospective and retrospective study designs substantially reflect established biomedical research methods. Pragmatic, randomized, open label comparative effectiveness designs with “usual care” comparators are most widely used, at times with factorial treatment arms. Only two studies adopt a double-blind, placebo-controlled RCT format. Some cohort-based controlled trials engage nonrandomized allocation strategies (e.g., matched controls, preference-based assignment, and minimization); other key designs include single-cohort pre–post studies, modified n-of-1 series, case series, case report, and ethnography. Mixed methods designs (i.e., qualitative research and economic evaluations) are evident in about one-third of exemplars. Primary and secondary outcomes are predominantly assessed, at multiple intervals, through patient-reported measures for symptom severity, quality of life/wellness, and/or treatment satisfaction; some studies concurrently evaluate objective outcomes.

Conclusions: Aligned with trends emphasizing “fit-for-purpose” research designs to study the “real-world” effectiveness of complex, personalized clinical interventions, WSR has emerged as a maturing scholarly discipline. The field is distinguished by its patient-centered salutogenic focus and engagement with nonbiomedical diagnostic and treatment frameworks. The rigorous pursuit of model validity may be further advanced by emphasizing complex analytic models, paradigm-specific outcome assessment, inter-rater reliability, and ethnographically informed designs. Policy makers and funders seeking to support best practices in TCIM research may refer to this review as a key resource.

Cost-Effectiveness of a Team-Based Integrative Medicine Approach to the Treatment of Back Pain

OBJECTIVES

To report the results of health economic analyses comparing two treatment approaches for chronic low back pain (CLBP).

DESIGN

Observational prospective cohort study comparing effectiveness and cost-effectiveness of CLBP care provided at an integrative care clinic with that provided in other clinics within the same hospital. CLBP-related medical utilization, function, quality of life, and days of work incapacity were self-reported at baseline, 3, 6, and 12 months.

SETTINGS/LOCATION

Osher Clinical Center (OCC) based at a tertiary academic hospital (Brigham and Women's Hospital [BWH]) and other clinics at BWH.

SUBJECTS

CLBP patients seeking care at OCC or non-OCC BWH clinics.

INTERVENTIONS

Integrative or conventional care for CLBP as prescribed by the treating clinician(s).

OUTCOME MEASURES

Quality-adjusted life years (QALYs) were estimated per treatment approach based on the SF-12. Cost per QALY gained was evaluated using an incremental cost-effectiveness ratio (ICER). ICERs based on CLBP-specific effectiveness measures (Roland Disability Questionnaire [RDQ] and bothersomeness of pain [BOP]) were exploratory outcomes.

RESULTS

Total adjusted annual CLBP-related costs per patient were greater in the OCC versus non-OCC group ($11,526.73 vs. $6,810.63). Between group differences in QALYs were small and ICER estimate of cost per QALY gained was high ($436,676). However, unadjusted mean direct costs per patient decreased over time in the OCC group. Savings in direct costs of $391 (95% confidence interval: -1,078 to 1,861) were observed in the OCC group for the 6- to 12-month period, driven primarily by reduced medication usage. ICERs based on adjusted RDQ and BOP group differences showed cost of $2,073 and $4,203 for a one-point reduction per respective scale.

CONCLUSIONS

When adjusted for baseline differences, self-reported costs were higher in the OCC group with only small effects on QALYs. However, trends toward decreased direct expenditures and medication usage over time warrant further investigation. Future studies evaluating potential benefits of integrative care models for the management of CLBP should employ randomized designs, longer observational periods, and explore multiple metrics of cost-effectiveness.