Patient-professional partnerships and chronic back pain self-management: a qualitative systematic review and synthesis

Contexts, behavioural mechanisms and outcomes to optimise therapeutic exercise prescription for persistent low back pain: a realist review

OBJECTIVE

Therapeutic exercises are a core treatment for low back pain (LBP), but it is uncertain how rehabilitative exercise facilitates change in outcomes. Realist reviews explore how the context (C) of certain settings or populations and underlying mechanisms (M) create intended or unintended outcomes (O). Our objective was to explore and understand the behavioural mechanisms by which therapeutic exercise creates change in outcomes of adherence, engagement and clinical outcomes for patients with LBP.

METHODS

This was a realist review reported following the Realist and Meta-narrative Evidence Syntheses: Evolving Standards guidance. We developed initial programme theories, modified with input from a steering group (experts, n=5), stakeholder group (patients and clinicians, n=10) and a scoping search of the published literature (n=37). Subsequently, an information specialist designed and undertook an iterative search strategy, and we refined and tested CMO configurations.

RESULTS

Of 522 initial papers identified, 75 papers were included to modify and test CMO configurations. We found that the patient-clinician therapeutic consultation builds a foundation of trust and was associated with improved adherence, engagement and clinical outcomes, and that individualised exercise prescription increases motivation to adhere to exercise and thus also impacts clinical outcomes. Provision of support such as timely follow-up and supervision can further facilitate motivation and confidence to improve adherence to therapeutic exercises for LBP.

CONCLUSIONS

Engagement in and adherence to therapeutic exercises for LBP, as well as clinical outcomes, may be optimised using mechanisms of trust, motivation and confidence. These CMO configurations provide a deeper understanding of ways to optimise exercise prescription for patients with LBP.

Application of "Partnership Care Model" in chronically ill adults and children: A systematic review and dose-response meta-analysis of randomized controlled trials

BACKGROUND

"Partnership Care Model (PCM)", which is the first partnership conceptual framework founded on the Iranian culture to control chronic diseases, has been recently used in different fields of nursing research with no levels of valid evidence to support its application. Therefore, this systematic review and meta-analysis sought to clarify the impacts of interventions developed based on PCM on quality of life (QoL), sleep quality, anxiety, and depression among adults and children with chronic diseases.

METHODS

International data sources (e.g., PubMed, Web of Science, Scopus) and national databases (e.g., SID, MagIran, IranDoc, IRCT) were searched from 2001 to September 23, 2023, to find Randomized Controlled Trials (RCTs) on PCM-driven interventions for the experimental groups versus no intervention or standard care groups. The studies' methodological quality and evidence quality were rated utilizing the Cochrane risk of bias instruction and the Grading of Recommendations Assessment, Development, and Evaluation (GRADE). Data were pooled by a random-effects approach employing STATA (vers. 11.2).

RESULT

Eighteen RCTs, reported in 22 publications, were qualified. The PCM compared to the standard care significantly improved the QoL among both adults (10 effect sizes [ESs], mean difference [MD]: 3.17, P < 0.001) and children (4 ESs, MD: 4.45, P < 0.001). Likewise, the intervention enhanced adults' sleep quality (3 ESs, MD: 7.15, P < 0.001). The anxiety of adults and children was also significantly lower in the PCM group (4 ESs, MD: -4.52, P = 0.001; 2 ESs, MD: -4.04, P < 0.001, respectively). However, regarding depression, a significant effect of PCM was found only among children (3 ESs, MD: -7.99, P = 0.011). The methodological quality of the studies and the evidence quality were undesirable.

CONCLUSION

The PCM had a promising influence on the caring of adults and children suffering from chronic diseases. However, additional high-quality RCTs are needed to generate a higher quality of evidence concerning the clinical benefits of the PCM.

PROSPERO NO

CRD42021253790.

Exploring mHealth applications for self-management of chronic low back pain: A survey of features and benefits

The adoption of Mobile Health (mHealth) for self-management is growing. mHealth solutions are commonly used in public healthcare and health services, where they are appreciated for their ease of use, broad reach, and wide acceptance. Chronic Low Back Pain (CLBP) is one of the most common health problems and a leading cause of disability. As such, it imposes a tremendous burden on patients and society. Studies have proposed that mHealth self-management solutions, such as mobile applications, can supplement traditional care methods and benefit patients, particularly in self-managing CLBP easier. To this end, the number of available mobile applications for CLBP has increased. This paper i) provides an overview of scientific studies on mobile applications for CLBP management from three different viewpoints: researchers, health professionals, and patients, ii) uncovers the application features that were seen as beneficial in the studies, and iii) contrasts the currently available applications for CLBP in Google Play Store and Apple App Store against the discovered features. The findings show that "Personalization and customization" is the most significant feature as it is beneficial from stakeholders' viewpoint and is represented by most applications. In contrast, "Gamification" and "Artificial intelligence" are the least significant features, indicating a lack of attention from application creators and researchers in this area.

'I can feel myself coming out of the rut': a brief intervention for supporting behaviour change is acceptable to patients with chronic musculoskeletal conditions

AIM

To a) understand the perceptions and experiences of patients with musculoskeletal (MSK) conditions in relation to their physiotherapy care and their acceptability of 'Making Every Contact Count Healthy Conversation Skills' (MECC HCS) as a brief intervention within this care and, b) explore the mechanisms through which MECC HCS might facilitate behaviour change and enhance self-management in patients with MSK conditions.

METHODS

This study adopted an exploratory qualitative design, in which individual, semi-structured interviews with participants were conducted. Eight participants were interviewed. Five had been engaging with physiotherapists trained in and delivering MECC HCS within their routine physiotherapy appointments and three had been engaging with physiotherapists who had not received this training and were instead delivering usual care. MECC HCS is a person-centred approach to behaviour change that aims to empower individuals to take control of their health behaviours by building self-efficacy. The MECC HCS training programme helps healthcare professionals to develop skills in i) using 'open discovery' questions to explore context and allow patients to identify barriers and generate solutions; ii) listening more than giving information/ making suggestions; iii) reflecting on practice and iv) supporting Specific, Measurable, Action-oriented, Realistic, Timed, Evaluated, Reviewed (SMARTER) goal setting.

RESULTS

Those who had engaged with MECC HCS trained physiotherapists found their physiotherapy care highly acceptable and felt that their physiotherapist listened to them, tried to understand their context and world, and helped them plan for change. These individuals experienced increases in self-efficacy and motivation for self-managing their MSK conditions. A need for continued support following physiotherapy treatment was, however, emphasised for long-term self-management.

CONCLUSIONS

MECC HCS is highly acceptable to patients with MSK conditions and pain and may successfully facilitate health-promoting behaviour change and enhance self-management. Providing opportunities to join support groups following physiotherapy treatment may promote long-term self-management and provide social and emotional benefits for individuals. The positive findings of this small qualitative study warrant further investigation on the differences in experiences and outcomes between patients engaging with MECC HCS physiotherapists and those receiving treatment as usual during routine physiotherapy care.

User perspectives on systematic data collection regarding back pain managed in general practice - a qualitative study

BACKGROUND

Back pain is a main driver of disability and the most prevalent reason why people in Demark visit a general practitioner (GP). However, little is known about back pain management in primary care. For new strategies to be sustainable and to accommodate the recommendations for evidence-based practice, patients' perspectives are paramount to complement clinical expertise and research evidence. This study aimed to identify recommendations for systematic data collection in a nationwide cohort regarding the management of back pain in general practice from the perspectives of GPs and patients.

METHOD

We applied an adapted exploratory sequential design using focus groups and individual interviews. Seven GPs and ten patients with back pain participated, and four focus groups and seventeen individual interviews were conducted. Data were analyzed using abductive reasoning.

RESULTS

Both GPs and patients with back pain found that 1) recruitment to a cohort should take place through the GPs, 2) the heterogeneity of patients with back pain and their need for individualized treatment and care should be considered, and 3) data from the cohort should feed into a flowchart or guideline to illustrate a generic patient pathway and visually assist both the patient and GP to obtain an overview and, thus, structure the patient pathway.

CONCLUSION

GPs and patients with back pain both considered the nationwide cohort with the overall aim to investigate back pain management as being extremely relevant in relation to improve t the patient pathway. User perspectives should be explored and integrated into health care interventions.

Implementation of Online Behavior Modification Techniques in the Management of Chronic Musculoskeletal Pain: A Systematic Review and Meta-Analysis

Purpose: The main aim of this systematic review and meta-analysis (MA) was to assess the effectiveness of online behavior modification techniques (e-BMT) in the management of chronic musculoskeletal pain. Methods: We conducted a search of Medline (PubMed), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Web of Science, APA PsychInfo, and Psychological and Behavioral Collections, from inception to the 30 August 2021. The main outcome measures were pain intensity, pain interference, kinesiophobia, pain catastrophizing and self-efficacy. The statistical analysis was conducted using RStudio software. To compare the outcomes reported by the studies, we calculated the standardized mean difference (SMD) over time and the corresponding 95% confidence interval (CI) for the continuous variables. Results: Regarding pain intensity (vs. usual care/waiting list), we found a statistically significant trivial effect size in favor of e-BMT (n = 5337; SMD = −0.17; 95% CI −0.26, −0.09). With regard to pain intensity (vs. in-person BMT) we found a statistically significant small effect size in favor of in-person BMT (n = 486; SMD = 0.21; 95%CI 0.15, 0.27). With respect to pain interference (vs. usual care/waiting list) a statistically significant small effect size of e-BMT was found (n = 1642; SMD = −0.24; 95%CI −0.44, −0.05). Finally, the same results were found in kinesiophobia, catastrophizing, and self-efficacy (vs. usual care/waiting list) where we found a statistically significant small effect size in favor of e-BMT. Conclusions: e-BMT seems to be an effective option for the management of patients with musculoskeletal conditions although it does not appear superior to in-person BMT in terms of improving pain intensity.

A Healing Journey with Chronic Pain: A Meta-Ethnography Synthesizing 195 Qualitative Studies

Objective

There is a large body of research exploring what it means for a person to live with chronic pain. However, existing research does not help us understand what it means to recover. We aimed to identify qualitative research that explored the experience of living with chronic pain published since 2012 and to understand the process of recovery.

Design

A synthesis of qualitative research using meta-ethnography.

Methods

We used the seven stages of meta-ethnography. We systematically searched for qualitative research, published since 2012, that explored adults’ experiences of living with, and being treated for, chronic pain. We used constant comparison to distill the essence of ideas into themes and developed a conceptual model.

Results

We screened 1,328 titles and included 195 studies. Our conceptual model indicates that validation and reconnection can empower a person with chronic pain to embark on a journey of healing. To embark on this journey requires commitment, energy, and support.

Conclusions

The innovation of our study is to conceptualize healing as an ongoing and iterating journey rather than a destination. Health interventions for chronic pain would usefully focus on validating pain through meaningful and acceptable explanations; validating patients by listening to and valuing their stories; encouraging patients to connect with a meaningful sense of self, to be kind to themselves, and to explore new possibilities for the future; and facilitating safe reconnection with the social world. This could make a real difference to people living with chronic pain who are on their own healing journeys.

Patients' perceptions with musculoskeletal disorders regarding their experience with healthcare providers and health services: an overview of reviews

Objectives

This overview of reviews aimed to identify (1) aspects of the patient experience when seeking care for musculoskeletal disorders from healthcare providers and the healthcare system, and (2) which mechanisms are used to measure aspects of the patient experience.

Data sources

Four databases were searched from inception to December 20th, 2019.

Review methods

Systematic or scoping reviews examining patient experience in seeking care for musculoskeletal from healthcare providers and the healthcare system were included. Independent authors screened and selected studies, extracted data, and assessed the methodological quality of the reviews. Patient experience concepts were compiled into five themes from a perspective of a) relational and b) functional aspects. A list of mechanisms used to capture the patient experience was also collected.

Results

Thirty reviews were included (18 systematic and 12 scoping reviews). Relational aspects were reported in 29 reviews and functional aspects in 25 reviews. For relational aspects, the most prevalent themes were “information needs” (education and explanation on diseases, symptoms, and self-management strategies) and “understanding patient expectations” (respect and empathy). For functional aspects, the most prevalent themes were patient’s “physical and environmental needs,” (cleanliness, safety, and accessibility of clinics), and “trusted expertise,” (healthcare providers’ competence and clinical skills to provide holistic care). Interviews were the most frequent mechanism identified to collect patient experience.

Conclusions

Measuring patient experience provides direct insights about the patient’s perspectives and may help to promote better patient-centered health services and increase the quality of care. Areas of improvement identified were interpersonal skills of healthcare providers and logistics of health delivery, which may lead to a more desirable patient-perceived experience and thus better overall healthcare outcomes.

Trial registration

Systematic review registration: PROSPERO (CRD42019136500).

Mind the Gaps: A Qualitative Study Combining Patients' and Nurses' Reflections on Pain Care

Chronic noncancer pain is a serious health problem, one that is often associated with physical debility and emotional suffering. Although chronic noncancer pain is one of the primary reasons that people seek medical care, a significant body of evidence indicates that chronic pain is underdiagnosed and undertreated. There is a consensus among professional stakeholders in pain care that there is a need to strengthen quality, capacity, and competence in pain management at all levels of health care. Thus, there is a need for more in-depth knowledge of both the recipients and the providers of pain care, and qualitative studies can contribute to this. The aim is to explore and combine the perspectives of patients receiving pain care and registered nurses providing care at pain clinics. A multimethod design was based on two qualitative studies consisting of semistructured interviews with patients receiving pain care (N = 10) and nurses providing pain care at pain clinics (N = 10). Qualitative content analysis was applied to interpret and abstract their experiences. The themes developed from triangulation revealed significant gaps between ideal pain care and actual practice: "Dissonance in reflections on personalized care," "A corresponding need for improved information flow in all levels," and "A corresponding need for improved structure in pain care." We suggest a stronger commitment to efficient information flow and person-centered communication to facilitate the patient involvement and self-management. In addition, more resources, education, and training are necessary to enable nurses and other professionals to act upon guidelines and ensure effective pain care.

Primary care patients' use of conventional and complementary medicine for chronic low back pain

Purpose

To investigate among primary care patients and their physicians in western Switzerland the prevalence of use, perceived usefulness, and communication about common treatments for chronic or recurrent low back pain (crLBP) including complementary medicine (CM).

Patients and methods

A cross-sectional cluster observational study involving 499 crLBP patients visiting 45 primary care physicians (PCPs) was conducted from November 1, 2015, to May 31, 2016. Patients and primary care physicians completed questionnaires about lifetime use and usefulness of 30 crLBP therapies. We conducted multivariate analyses of factors associated with therapy use, including sociodemographic variables, pain duration, insurance coverage, and primary care physicians’ characteristics.

Results

The five most frequent modalities used at least once by patients were physiotherapy (81.8%), osteopathic treatment (63.4%), exercise therapy (53.4%), opioids (52.5%), and therapeutic massage (50.8%). For their PCPs, the five most useful therapies were physiotherapy, osteopathic treatment, yoga, meditation, and manual therapy. In multivariate analysis, the use of physiotherapy was significantly associated with longer pain duration; osteopathic treatment was associated with age under 75 years, female gender, higher education, and CM insurance coverage. Exercise therapy was associated with non-smoking and longer pain duration. Smokers were more likely and patients of PCPs with CM training were less likely to have used opioids. During their lifetime, 86.6% of the participants had used at least one CM therapy to manage their crLBP, with a mean of 3.3 (SD=2.9) therapies used per participant; 46.1% of participants reported that their PCP did not enquire about CM use. Among CM users, 64.7% informed their PCP about it.

Conclusion

Patients with crLBP use a variety of treatments, including self-prescribed and unreimbursed therapies, most frequently physiotherapy and osteopathy. The results suggest that PCPs should systematically discuss with their patients the treatments they tried to manage crLBP, including CM.

Living life precariously with rheumatoid arthritis - a mega-ethnography of nine qualitative evidence syntheses

Background

Rheumatoid arthritis is an autoimmune disease that causes joint inflammation. It affects around 400,000 people in the UK and 1 million adults in the USA. Given the appropriate treatment, many can have relatively few symptoms. It is therefore important to understand what it is like to live with rheumatoid arthritis and gain insight into peoples’ decisions about utilising healthcare. The aims of this study were: (1) to bring together qualitative evidence syntheses that explore patients’ experience of living with rheumatoid arthritis and (2) develop a conceptual understanding of what it is like to live with rheumatoid arthritis.

Methods

We used the methods of mega-ethnography. The innovation of mega-ethnography is to use conceptual findings from qualitative evidence syntheses as primary data. We searched four bibliographic databases from inception until September 2018 to identify qualitative evidence syntheses that explored patients’ experience of rheumatoid arthritis.

Results

We identified 373 qualitative evidence syntheses, removed 179 duplicates and screened 194 full text studies. We identified 42 qualitative evidence syntheses that explored the experience of pain or arthritis and 9 of these explored the experience of rheumatoid arthritis. We abstracted ideas into 10 conceptual categories: (1) rheumatoid arthritis is in control of my body (2) rheumatoid arthritis alters reciprocity; (3) rheumatoid arthritis is an emotional challenge; (4) rheumatoid arthritis disrupts my present and future self; (5) the challenge of balancing personal and work life; (6) I am trying to make sense of what is happening; (7) rheumatoid arthritis is variable and unpredictable; (8) rheumatoid arthritis is invisible; (9) I need a positive experience of healthcare, and (10) I need to reframe the situation. We developed a conceptual model underpinned by living life precariously with rheumatoid arthritis.

Conclusions

This is the second mega-ethnography, or synthesis of qualitative evidence syntheses using the methods of meta-ethnography. Future research should consider the proliferation of qualitative evidence synthesis in order to avoid duplication of research effort. Our model for rheumatoid arthritis has some important clinical implications that might be transferable to other musculoskeletal conditions.

Electronic supplementary material

The online version of this article (10.1186/s41927-018-0049-0) contains supplementary material, which is available to authorized users.

Living with chronic pain: Patients' experiences with healthcare services in Norway

AIM

To explore the experiences with healthcare received by people living with chronic nonmalignant pain in Norway.

DESIGN

A descriptive and explorative qualitative design.

METHODS

A total of 18 individual semistructured interviews was conducted in 2015. Qualitative content analysis was applied.

RESULTS

The findings revealed challenges related to a multifaceted pain condition. Participants described interactions with a supportive health care where being listened to, believed in and experiencing mutual trust were emphasized. When interactions with healthcare professionals made the participants feel insignificant, they found it difficult to express their needs, which seemed to reinforce practical difficulties and unfulfilled expectations and make them lose hope in their recovery. This implies the importance of a holistic understanding of and support for more person-centred practice to accommodate patients' expectations and expressed needs. Here, the nurses have an essential role in having a positive impact on future healthcare services.

The Management of Chronic Back Pain in Primary Care Settings: Exploring Perceived Facilitators and Barriers to the Development of Patient-Professional Partnerships

Supporting patients in forming partnerships with health professionals is the key of effective self-management. This study aimed to explore the nature of patient-professional partnerships and its related factors that create facilitators and barriers to patients' self-management ability. A constructivist grounded theory approach was undertaken. Three main themes emerged: interaction and communication, integrated care, and service and system. A theoretical model was generated that posits effective communication, individualized integrated care, and high-quality service as key influences on the successful development of patient-professional partnerships and patients' ability to self-manage. Giving attention to these factors helps understand the development, implementation, mechanisms, and evaluation of building a patient-professional partnership and maximizes the opportunities for patient self-management of chronic pain. Future research and practice are needed to move beyond a simplistic focus on health outcomes to address the complex links between partnerships and treatment delivery processes, and interventions, effects, and patients' context.

Applying GRADE-CERQual to qualitative evidence synthesis findings-paper 7: understanding the potential impacts of dissemination bias

BACKGROUND

The GRADE-CERQual (Confidence in Evidence from Reviews of Qualitative research) approach has been developed by the GRADE (Grading of Recommendations Assessment, Development and Evaluation) Working Group. The approach has been developed to support the use of findings from qualitative evidence syntheses in decision-making, including guideline development and policy formulation. CERQual includes four components for assessing how much confidence to place in findings from reviews of qualitative research (also referred to as qualitative evidence syntheses): (1) methodological limitations, (2) coherence, (3) adequacy of data and (4) relevance. This paper is part of a series providing guidance on how to apply CERQual and focuses on a probable fifth component, dissemination bias. Given its exploratory nature, we are not yet able to provide guidance on applying this potential component of the CERQual approach. Instead, we focus on how dissemination bias might be conceptualised in the context of qualitative research and the potential impact dissemination bias might have on an overall assessment of confidence in a review finding. We also set out a proposed research agenda in this area.

METHODS

We developed this paper by gathering feedback from relevant research communities, searching MEDLINE and Web of Science to identify and characterise the existing literature discussing or assessing dissemination bias in qualitative research and its wider implications, developing consensus through project group meetings, and conducting an online survey of the extent, awareness and perceptions of dissemination bias in qualitative research.

RESULTS

We have defined dissemination bias in qualitative research as a systematic distortion of the phenomenon of interest due to selective dissemination of studies or individual study findings. Dissemination bias is important for qualitative evidence syntheses as the selective dissemination of qualitative studies and/or study findings may distort our understanding of the phenomena that these syntheses aim to explore and thereby undermine our confidence in these findings. Dissemination bias has been extensively examined in the context of randomised controlled trials and systematic reviews of such studies. The effects of potential dissemination bias are formally considered, as publication bias, within the GRADE approach. However, the issue has received almost no attention in the context of qualitative research. Because of very limited understanding of dissemination bias and its potential impact on review findings in the context of qualitative evidence syntheses, this component is currently not included in the GRADE-CERQual approach.

CONCLUSIONS

Further research is needed to establish the extent and impacts of dissemination bias in qualitative research and the extent to which dissemination bias needs to be taken into account when we assess how much confidence we have in findings from qualitative evidence syntheses.

Living with ongoing whiplash associated disorders: a qualitative study of individual perceptions and experiences

BACKGROUND

Whiplash associated disorders (WAD) are the most common non-hospitalised injury resulting from a motor vehicle crash. Approximately 50% of individuals with WAD experience on-going pain and disability. Results from intervention trials for individuals with chronic WAD are equivocal and optimal treatment continues to be a challenge. It may be that traditional quantitative measures included in treatment trials have not captured the full benefits patients experience through participation in an intervention. The aim of the present study was to explore participant subjective experiences and perceptions of living with on-going WAD.

METHODS

Twenty-seven individuals with chronic WAD participated in a one-on-one, semi-structured individual telephone interview. All interviews were audio-taped, transcribed verbatim and data were analysed using an inductive thematic analysis process.

RESULTS

Two themes emerged that described the experience of living with chronic WAD. First, all participants described navigating the healthcare system after their whiplash injury to help understand their injury and interpret therapeutic recommendations. Participants highlighted the need to 'find the right healthcare practitioner (HCP)' to help with this process. Many participants also described additional complexities in navigating and understanding healthcare incurred by interactions with compensation and funding systems. Second, participants described a journey of realisation, and the trial and error used to establish self-management strategies to both prevent and relieve pain. Participants described trying to understand the impact of their initial injury in relation to the gradual realisation that there may be on-going residual deficit. Seeking information from multiple sources, including personal experience gained through trial and error, was important in the search for acceptable management strategies.

CONCLUSION

Recovery from a whiplash injury is an adaptive process and more than elimination of pain or disability, therefore may be different from common clinical patient reported outcomes. Early identification of patient understandings of pain, expectations of recovery, symptoms and therapy may help merge patient and HCP understandings. Additionally, helping individuals to recognise symptom triggers and develop appropriate strategies to minimise triggers may actively engage patients in their recovery. Finally, acknowledgement and validation of the whiplash injury by HCPs is seen by many as a necessary step in the recovery process.

Chronic low back pain patients' use of, level of knowledge of and perceived benefits of complementary medicine: a cross-sectional study at an academic pain center

BACKGROUND

Chronic pain patients often use complementary medicine (CM) to alleviate their pain; however, little is known about the use of CM by chronic low back pain (cLBP) patients. We investigated the frequency of use of CM by cLBP patients, the perceived effects of these therapies, patients' knowledge regarding CM, and patient-physician communication regarding CM.

METHOD

A cross-sectional survey was conducted from November 2014 to February 2015. A questionnaire was distributed by physicians to 238 consecutive patients consulting for cLBP at the Pain Center of Lausanne University Hospital, Switzerland. Poisson regression model was used to analyze patients' level of knowledge regarding various CMs, and the logistic regression model was used to assess CM use for cLBP.

RESULTS

The questionnaire was returned by 168 cLBP patients (response rate: 70.6%). Lifetime prevalence of CM use for cLBP was 77.3%. The most commonly used therapies were osteopathy (48.8%), massage (45.2%) and acupuncture (31.6%), rated for their usefulness on a 0-10 scale as a mean ± SD of 5.4 ± 2.7, 5.9 ± 2.5 and 3.8 ± 3.2, respectively. The CM treatment best known by patients was osteopathy, followed by massage and acupuncture. If their doctors proposed CM as a treatment for cLBP, 78% of participants reported being very or somewhat likely to try CM. Respondents with CM health insurance were more likely to use CM (OR = 2.26; 95%CI: 1.07-4.78; p = 0.031) for cLBP. Respondents having experienced cLBP for more than five years were more likely to use CM to treat their cLBP than respondents having experienced cLBP for one year or less (OR = 2.84; 95%CI: 1.02-7.88; p = 0.044).

CONCLUSIONS

More than three-quarters of cLBP patients in our sample did use CM to treat their cLBP. The results showed that the most commonly used therapies were not necessarily the highest rated in terms of perceived usefulness. These results highlight the importance of developing integrative pain centers in which patients may obtain advice regarding CM treatments.

Extent, Awareness and Perception of Dissemination Bias in Qualitative Research: An Explorative Survey

BACKGROUND

Qualitative research findings are increasingly used to inform decision-making. Research has indicated that not all quantitative research on the effects of interventions is disseminated or published. The extent to which qualitative researchers also systematically underreport or fail to publish certain types of research findings, and the impact this may have, has received little attention.

METHODS

A survey was delivered online to gather data regarding non-dissemination and dissemination bias in qualitative research. We invited relevant stakeholders through our professional networks, authors of qualitative research identified through a systematic literature search, and further via snowball sampling.

RESULTS

1032 people took part in the survey of whom 859 participants identified as researchers, 133 as editors and 682 as peer reviewers. 68.1% of the researchers said that they had conducted at least one qualitative study that they had not published in a peer-reviewed journal. The main reasons for non-dissemination were that a publication was still intended (35.7%), resource constraints (35.4%), and that the authors gave up after the paper was rejected by one or more journals (32.5%). A majority of the editors and peer reviewers "(strongly) agreed" that the main reasons for rejecting a manuscript of a qualitative study were inadequate study quality (59.5%; 68.5%) and inadequate reporting quality (59.1%; 57.5%). Of 800 respondents, 83.1% "(strongly) agreed" that non-dissemination and possible resulting dissemination bias might undermine the willingness of funders to support qualitative research. 72.6% and 71.2%, respectively, "(strongly) agreed" that non-dissemination might lead to inappropriate health policy and health care.

CONCLUSIONS

The proportion of non-dissemination in qualitative research is substantial. Researchers, editors and peer reviewers play an important role in this. Non-dissemination and resulting dissemination bias may impact on health care research, practice and policy. More detailed investigations on patterns and causes of the non-dissemination of qualitative research are needed.

Finding Ways to Lift Barriers to Care for Chronic Pain Patients: Outcomes of Using Internet-Based Self-Management Activities to Reduce Pain and Improve Quality of Life

Background. Chronic pain is prevalent, disabling, costly, and undertreated. There is clearly a need to improve patient understanding of ways to manage their pain. Internet-based programs are continually being developed to facilitate mental health improvement, providing tailored content for patients to manage their pain, anxiety, and depression. Objective. To evaluate the impact of Internet-based patient self-management education and activities on patients' pain, anxiety, and quality of life in patients who could not access multidisciplinary pain management. Design. Observational study. Subjects. Two hundred (200) patients (61% females, 39% males, between 18 and 75 years old) from one community pain clinic in Toronto, Canada (Toronto Poly Clinic), participated. Patients had moderate to severe pain, depression, and anxiety. These patients committed to study from a group of 515 patients with chronic noncancer pain of different origins who were stable on their levels of pain, anxiety, and depression for 12 consecutive months before start of study and could not afford noninsured treatment modalities like physiotherapy, psychology, nutrition, or exercise therapy consultation. Methods. Patients were encouraged to visit two Internet sites (a blog and Twitter postings) for educational postings written by the author about exercise, nutrition, mindfulness meditation, disease management methods, evidence-based supplements, daily relaxation exercises, and overall self-management methods 15 minutes per day for six months. Patients were also encouraged to share their ideas and comments on a blog. Activity logs were kept by patients and reviewed by physician at follow-up visits. Compliance was encouraged via weekly email reminders and phone calls during the observation period. Results. Modest improvements were noted in pain, anxiety, depression, and quality of life. Of the patients with moderate or severe pain before treatment, 45% reported mild levels of pain after treatment, with a reduction of severe pain from 40% before treatment to 25% after treatment (p value 0.0184). Conclusion. Self-management support interventions, such as Internet-based educational tools, can be considered to help patients manage their chronic pain, depression, and anxiety and may be helpful to improve the treatment outcome in patients who could not otherwise afford noninsured services.