Integrative oncology from a bibliometric point of view

OBJECTIVES

The aim of this article is to analyze the development of integrative oncology from a bibliometric point of view. The publication and citation patterns of publications are analyzed and their contents mapped.

DESIGN

This study is based on bibliometric methods. The data sets consist of 7 025 respectively 4 990 publications over the time period 1966-2016, shown in PubMed and Web of Science.

RESULTS

The expansion of the numbers of these publications took place in the late 1990s/early 2000s. Research is dominated by authors located in the USA, China and Germany who are working at well-established research universities and university hospitals. The clinical share of publications is relatively small, and few studies are classified according to clinical phase. Content analysis revealed that much of the clinical research is based on surveys, and that content reflects the intersection of complementary therapies and cancer research. The latter aspect is less obvious in pre-clinical research. The most frequent journals in the material show a focus on complementary and alternative therapies or on integrative oncology, although journals focused on oncology or general/internal medicine were well-represented in the material as a whole. The most-cited publications were review articles and surveys.

CONCLUSIONS

Integrative oncology has been established as a small, but distinct, research domain. There are several signs of specialization in integrative oncology, but also in its integration into general medical and oncological research.

Chronic non-cancer pain management by nurses in specialist pain clinics

BACKGROUND

Chronic non-cancer pain (CNCP) is one of the major causes of disability globally, and patients who suffer from it are a complex population, which makes it difficult to provide effective care. Specialist pain clinics and nursing professionals in them are the main care providers, but there is little research conducted in this field.

AIM

To explore the attitudes and knowledge of nurses working in specialist pain clinics regarding care of CNCP patients.

METHODS

Qualitative phenomenological approach. Sixteen semi-structured interviews were conducted in 2017 with nurses who worked in specialist pain clinics in six hospitals in southern Spain.

RESULTS

Data analysis led to the formation of two categories, 'being trained and improving knowledge in CNCP' and 'the challenge of caring for patients with CNCP', and five subcategories.

CONCLUSION

The need for care in CNCP is not covered by nurses in all the areas it requires. Lack of time, staffing issues, and specific training in this area makes it difficult to provide care. However, some areas for improvement are proposed, such as psychological interventions, group workshops, continuous training, and multidisciplinary teams.

Postdeployment Polytrauma Diagnoses Among Soldiers and Veterans Using the Veterans Health Affairs Polytrauma System of Care and Receipt of Opioids, Nonpharmacologic, and Mental Health Treatments

OBJECTIVES

To determine the proportion of Army soldiers who utilized care in the Veterans Health Administration (VHA) Polytrauma System of Care (PSC) within the postdeployment year and to describe prevalence of polytrauma diagnoses, and receipt of opioids, nonpharmacologic treatments (NPTs), and mental health treatments in the VHA during the year following first PSC utilization.

SETTING

VHA's 4-tiered integrated PSC network of specialized rehabilitation services for military members and veterans with polytrauma.

PARTICIPANTS

Soldiers and veterans who used the PSC during the postdeployment year after an Afghanistan or Iraq deployment ending in fiscal years 2008-2011.

DESIGN

Population-based cohort study.

MAIN MEASURES

Prevalence of polytrauma diagnoses (ie, traumatic brain injury [TBI], posttraumatic stress disorder [PTSD], and chronic pain [CP]), VHA utilization rates of opioid prescriptions, NPT, and specialty mental health treatment within 1 year of PSC utilization.

RESULTS

In total, 2.6% of the sample (n = 16 590) used the PSC during the postdeployment year. Among PSC users, CP (76.5%), PTSD (53.1%), and TBI (48.6%) were common and more frequently found together than in isolation; 26.6% filled an opioid prescription, 35.5% received at least 1 NPT, and 83.8% received specialty mental health treatment in the VHA within 1 year of PSC utilization.

CONCLUSION

CP was the most common polytrauma condition among PSC users, highlighting the importance of incorporating interdisciplinary pain management approaches within the PSC, with an effort to reduce reliance on long-term opioid therapy and improve rehabilitation.

An Innovative Electronic Health Toolkit (Our Whole Lives for Chronic Pain) to Reduce Chronic Pain in Patients With Health Disparities: Open Clinical Trial

Background

Chronic pain affects millions of Americans. Our Whole Lives, an electronic health (eHealth) toolkit for Chronic Pain (Our Whole Lives for Chronic Pain [OWLCP]), is a mind-body chronic pain management platform that teaches self-management strategies to reduce pain impact and pain medication use.

Objective

The primary goal of this study was to evaluate the feasibility of OWLCP in reducing pain impact and pain-related outcomes.

Methods

We conducted a pre-post clinical study (2 cohorts) to assess the feasibility of OWLCP usage among low-income patients with chronic pain. Outcome data, collected at baseline and 9 weeks, included Patient-Reported Outcomes Measurement Information System (PROMIS-29), pain self-efficacy, and pain medication use. In the statistical analysis, we used descriptive statistics, logistic regression, linear regression, and qualitative methods.

Results

Among the enrolled 43 participants, the average age was 50 years, (39/43) 91% were female, (16/43) 37% were black, and (7/43) 16% were Hispanic. From baseline to follow-up, the PROMIS measures showed a reduction in depression (P=.02), pain interference (P=.003), and average pain impact score (P=.007). Pain self-efficacy increased ((P<.001), whereas opioid use had a 13% reduction (P=.03).

Conclusions

The eHealth chronic pain management platform, OWLCP, is a potential tool to reduce the impact of chronic pain for low-income racially diverse populations.

Vocal Music Therapy for Chronic Pain: A Mixed Methods Feasibility Study

Objective: The purpose of this study was to determine the feasibility and preliminary effects of a vocal music therapy (VMT) program on chronic pain management.

Design: A mixed methods intervention design was used in which qualitative data were embedded within a randomized controlled trial.

Setting: An urban nurse-management health center on the East Coast of the United States.

Subjects: Participants (N = 43) were predominantly Black (79%) and female (76.7%) with an average pain duration of 10 years.

Intervention: Participants were randomly allocated to a 12-week VMT program or a waitlist control.

Outcome measures: We tracked consent rate (percentage of participants enrolled out of total number screened), attrition rate, and treatment adherence. We used PROMIS^® (Patient Reported Outcomes Measurement Information System) tools to measure pain interference, pain-related self-efficacy, pain intensity, depression, anxiety, positive effect, and well-being, ability to participate in social activities, and satisfaction with social roles at baseline and week 12. VMT participants also completed the Patient Global Impression of Change Scale. We conducted semistructured interviews to better understand participants' experience of the intervention.

Results: The consent rate was 56%. The attrition rate was 23%. Large treatment effects (partial eta squared) were obtained for self-efficacy (0.20), depression (0.26), and ability to participate in social activities (0.24). Medium effects were found for pain intensity (0.10), anxiety (0.06), positive effect, and well-being (0.06), and small effects for pain interference (0.03) and satisfaction with social roles (0.03). On average, participants felt moderately better after completion of the VMT program (M = 4.93, standard deviation = 1.98). Qualitative findings suggest that VMT resulted in better self-management of pain, enhanced psychological well-being, and stronger social and spiritual connections.

Conclusions: Recruitment into the 12-week program was challenging, but quantitative and qualitative findings suggest significant benefits of VMT for chronic pain management.

Dietary Ingredients Requiring Further Research Before Evidence-Based Recommendations Can Be Made for Their Use as an Approach to Mitigating Pain

OBJECTIVE

Approximately 55-76% of Service members use dietary supplements for various reasons; although such use has become popular, decisions are often driven by information that is not evidence-based. This work evaluates whether current research on dietary ingredients for chronic musculoskeletal pain provides sufficient evidence to inform decisions for practice and self-care, specifically for Special Operations Forces personnel.

METHODS

A steering committee convened to develop research questions and factors required for decision-making. Key databases were searched through August 2016. Eligible systematic reviews and randomized controlled trials were assessed for methodological quality. Meta-analysis was applied where feasible. Grading of Recommendations, Assessment, Development and Evaluation was used to determine confidence in the effect estimates. The committee used a decision table to make evidence-informed judgments across decision-making factors and recommendations for practice and self-care use.

RESULTS

Nineteen dietary ingredients were assessed. No recommendations were given for boswellia, ginger, rose hip, or s-adenosyl-L-methionine (SAMe); specifically, although ginger can be obtained via food, no recommendation is provided for use as a supplement due to unclear research. Further, there were insufficient strong research on boswellia and SAMe and possible compliance issues (i.e., high number of capsules required daily) associated with rose hip.

CONCLUSIONS

No recommendations were made when the evidence was low quality or trade-offs were so closely balanced that any recommendation would be too speculative. Research recommendations are provided to enhance the quality and body of evidence for the most promising ingredients. Clinicians and those with chronic pain can rely on evidence-based recommendations to inform their decisions.

Treatment of Low Back Pain With Opioids and Nonpharmacologic Treatment Modalities for Army Veterans

BACKGROUND

In the Veterans Health Administration (VHA) there is growing interest in the use of nonpharmacologic treatment (NPT) for low back pain (LBP) as pain intensity and interference do not decrease with opioid use.

OBJECTIVES

To describe overall and facility-level variation in the extent to which specific NPT modalities are used in VHA for LBP, either alone or as adjuncts to opioid medications, and to understand associations between veterans' clinical and demographic characteristics and type of treatment.

RESEARCH DESIGN

This retrospective cohort study examined use of opioids and 21 specific NPT modalities used by veterans.

SUBJECTS

VHA-enrolled Iraq and Afghanistan veterans who utilized care in ("linked" to) 130 VHA facilities within 12 months after their separation from the Army between fiscal years 2008-2011, and who were diagnosed with LBP within 12 months after linkage (n=49,885).

MEASURES

Measures included per patient: days' supply of opioids, number of visits for NPT modalities, and pain scores within one year after a LBP diagnosis.

RESULTS

Thirty-four percent of veterans filled a prescription for opioids, 35% utilized at least 1 NPT modality, and 15% used both within the same year. Most patients with LBP receiving NPT, on average, had moderate pain (36%), followed by low pain (27%), severe pain (15%), and no pain (11%). Eleven percent had no pain scores recorded.

CONCLUSIONS

About 65% of VHA patients with a LBP diagnosis did not receive NPT, and about 43% of NPT users also were prescribed an opioid. Understanding utilization patterns and their relationship with patient characteristics can guide pain management decisions and future study.

Psychosocial Issues and Lifestyle Changes for the Renal Patient

This article provides an overview of the psychosocial issues faced by those with renal disease. The article discusses the physiologic connection between anxiety, depression, and pain-symptoms commonly seen in renal disease and other chronic illnesses. The application of integrative medicine or nonallopathic medicine and its role in the management of anxiety, depression, and pain are presented. Also presented is evidence surrounding several frequently used nonallopathic modalities appropriate for incorporation into a comprehensive management regimen for renal patients to reduce symptom burden. The article concludes with a discussion on the role of palliative care in treatment decisions for renal patients.

Associations of Early Treatments for Low-Back Pain with Military Readiness Outcomes

BACKGROUND

Chronic low-back pain (LBP) is a frequent cause of work absence and disability, and is frequently associated with long-term use of opioids.

OBJECTIVE

To describe military readiness-related outcomes at follow-up in soldiers with LBP grouped by the type of early treatment received for their LBP. Treatment groups were based on receipt of opioid or tramadol prescription and receipt of nonpharmacologic treatment modalities (NPT). Design, Subjects, Measures: A retrospective longitudinal analysis of U.S. soldiers with new LBP episodes persisting more than 90 days between October 2012 and September 2014. Early treatment groups were constructed based on utilization of services within 30 days of the first LBP claim. Outcomes were measured 91-365 days after the first LBP claim. Outcomes were constructed to measure five indicators of limitations of military readiness: military duty limitations, pain-related hospitalization, emergency room visit for LBP, pain score of moderate/severe, and prescription for opioid/tramadol.

RESULTS

Among soldiers with no opioid receipt in the prior 90 days, there were 30,612 new episodes of LBP, which persisted more than 90 days. Multivariable logistic regression models found that compared to the reference group (no NPT, no opioids/tramadol receipt), soldiers who received early NPT-only had lower likelihoods for military duty limitations, pain-related hospitalization, and opioid/tramadol prescription at follow-up, while soldiers' that started with opioid receipt (at alone or follow-up in conjunction with NPT) exhibited higher likelihoods on many of these negative outcomes.

CONCLUSION

This observational study of soldiers with a new episode of LBP and no opioid receipt in the prior 90 days suggests that early receipt of NPT may be associated with small, significant gains in ability to function as a soldier and reduced reliance on opioid/tramadol medication. While further research is warranted, increased access to NPT at the beginning of LBP episodes should be considered.

Level of readiness of chronic pain patients to practise active self-care

BACKGROUND

Given the limited alleviation of chronic pain with pharmacological treatments, various nonpharmacological and self-care approaches are often proposed that require patients' motivation.

OBJECTIVE

To evaluate the level of readiness (LOR) to practise different types of active self-care among chronic pain patients.

METHOD

A quantitative cross-sectional survey was conducted among all chronic pain patients seeking care at the Pain Center of an academic hospital from June 2013 to March 2015. Sociodemographic data, pain characteristics, treatments and the LOR to practise active self-care were investigated.

RESULTS

Among the 1524 eligible patients, 639 (41.9%) were included. The median pain duration was 8.5 years (interquartile range = 7.5). Two-thirds (63.7%) of the patients reported high pain-related disability, and 64.6% had used opioids during the previous six months. Most patients had a high (44.1%) or moderate (24.6%) LOR to practise active self-care. Multivariable multinomial regression analysis showed that independent factors associated with a high LOR were a higher level of education (relative risk ratio (RRR) = 3.42, 95% confidence interval (CI): 1.90-6.13, p < 0.001), unemployed status due to medical condition (RRR = 2.92, 95% CI: 1.30-6.56, p = 0.009), the use of dietary supplements 'against pain' (RRR = 2.77, 95% CI: 1.52-5.04, p = 0.001) and neuropathic pain characteristics (RRR = 1.80, 95% CI: 1.40-3.12, p = 0.036). Older age was a factor predicting a lower LOR (RRR = 0.97, 95% CI: 0.94-0.99, p = 0.039). Long-term chronic pain, severe pain-related disability and the presence of a mood disorder were not associated with a lower LOR.

CONCLUSION

Most chronic pain patients, including those severely affected, indicated their readiness to practise active self-care methods.

SIGNIFICANCE

Most chronic pain patients, even those severely affected, appeared to be ready to practise active self-care therapies and we believe that further studies are needed to investigate their impact on pain and quality of life.

Advocating for integrative medicine: providers' stories of resonance, negotiation, and community

Integrative medicine (IM) is a holistic health care option that blends complementary, alternative medicine with biomedical models of care. Many medical care facilities do not offer IM treatment for patients, yet the demand for IM is growing. Therefore, IM providers are in the position of educating and promoting IM to patients and other medical practitioners. There is limited research literature focusing on how IM providers communicate advocacy for IM. Therefore, this research is designed to explore the perspectives of providers about the ways that they communicate advocacy for IM in their lives and their medical practice. Interview data we collected at The Center reveals the ways that IM providers continuously advocate for IM through their resonance with IM philosophy, by negotiating systemic tensions that revolve around IM, and by forming communities of practice with patients and other providers. Results of this investigation offer insight about IM, communication, and advocacy.

The Complementary Health Approaches for Pain Survey (CHAPS): Validity testing and characteristics of a rural population with pain

Objectives

Little is known about patterns and correlates of Complementary Health Approaches (CHAs) in chronic pain populations, particularly in rural, underserved communities. This article details the development and implementation of a new survey instrument designed to address this gap, the Complementary Health Approaches for Pain Survey (CHAPS).

Design

Following pilot-testing using pre-specified criteria to assess quality and comprehension in our target population, and after feedback regarding face-validity from content experts and stakeholders, the final cross-sectional self-report survey required 10–12 minutes to complete. It contained 69 demographic, lifestyle and health-related factors, and utilized a Transtheoretical Model (TTM) underpinning to assess short- and long-term use of 12 CHAs for pain management. Twenty additional items on pain severity, feelings, clinical outcomes, and activities were assessed using the Short-Form Global Pain Scale (SF-GPS); Internal reliability was assessed using Cronbach’s alpha.

Settings/location

Investigators conducted consecutive sampling in four West Virginia pain management and rheumatology practices.

Participants

301 Appalachian adult patients seeking conventional care for pain management.

Results

Response rates were high (88% ± 4.1%). High quality and comprehension deemed the CHAPS an appropriate measurement tool in a rural population with pain. Missing data were unrelated to patient characteristics. Participants predominantly experienced chronic pain (93%), had five or more health conditions (56%, Mean = 5.4±3.1), were white (92%), female (57%), and middle-aged (Mean = 55.6 (SD = 13.6) years). Over 40% were disabled (43%) and/or obese (44%, Mean BMI = 33.4±31.5). Additionally, 44% used opioids, 31% used other prescription medications, and 66% used at least one CHA for pain, with 48% using CHAs for greater than 6 months. There was high internal reliability of the SF-GPS (alpha = .93) and satisfactory internal reliability for each of the five TTM stages across (all) twelve CHAs: precontemplation (0.89), contemplation (0.72), preparation (0.75), action (0.70), and maintenance (0.70).

Conclusions

The CHAPS is the first comprehensive measurement tool to assess CHA use specifically for pain management. Ease of administration in a population with pain support further use in population- and clinic-based studies in similar populations.

Self-management of cardiac pain in women: an evidence map

OBJECTIVE

To describe the current evidence related to the self-management of cardiac pain in women using the process and methodology of evidence mapping.

DESIGN AND SETTING

Literature search for studies that describe the self-management of cardiac pain in women greater than 18 years of age, managed in community, primary care or outpatient settings, published in English or a Scandinavian language between 1 January 1990 and 24 June 2016 using AMED, CINAHL, ERIC, EMBASE, MEDLINE, Proquest, PsychInfo, the Cochrane Library, Scopus, Swemed+, Web of Science, the Clinical Trials Registry, International Register of Controlled Trials, MetaRegister of Controlled Trials, theses and dissertations, published conference abstracts and relevant websites using GreyNet International, ISI proceedings, BIOSIS and Conference papers index. Two independent reviewers screened using predefined eligibility criteria. Included articles were classified according to study design, pain category, publication year, sample size, per cent women and mean age.

INTERVENTIONS

Self-management interventions for cardiac pain or non-intervention studies that described views and perspectives of women who self-managed cardiac pain.

PRIMARY AND SECONDARY OUTCOMES MEASURES

Outcomes included those related to knowledge, self-efficacy, function and health-related quality of life.

RESULTS

The literature search identified 5940 unique articles, of which 220 were included in the evidence map. Only 22% (n=49) were intervention studies. Sixty-nine per cent (n=151) of the studies described cardiac pain related to obstructive coronary artery disease (CAD), 2% (n=5) non-obstructive CAD and 15% (n=34) postpercutaneous coronary intervention/cardiac surgery. Most were published after 2000, the median sample size was 90 with 25%-100% women and the mean age was 63 years.

CONCLUSIONS

Our evidence map suggests that while much is known about the differing presentations of obstructive cardiac pain in middle-aged women, little research focused on young and old women, non-obstructive cardiac pain or self-management interventions to assist women to manage cardiac pain.

PROSPERO REGISTRATION NUMBER

CRD42016042806.

Effects of Tai Chi versus Physical Therapy on Mindfulness in Knee Osteoarthritis

Tai Chi mind-body exercise is widely believed to improve mindfulness through incorporating meditative states into physical movements. A growing number of studies indicate that Tai Chi may improve health in knee osteoarthritis (OA), a chronic pain disease and a primary cause of global disability. However, little is known about the contribution of mindfulness to treatment effect of Tai Chi practice. Therefore, our purpose was to investigate the effect of Tai Chi mind-body practice compared to physical therapy (PT) on mindfulness in knee OA. Adults with radiographic-confirmed, symptomatic knee OA were randomized to either 12 weeks (twice weekly) of Tai Chi or PT. Participants completed the Five Facet Mindfulness Questionnaire (FFMQ) before and after intervention along with commonly-used patient-reported outcomes for pain, physical function, and other health-related outcomes. Among 86 participants (74% female, 48% white, mean age 60 years, 85% at least college educated), mean total FFMQ was 142±17. Despite substantial improvements in pain, function, and other health-related outcomes, each treatment group's total FFMQ did not significantly change from baseline (Tai Chi= 0.76, 95% CI: -2.93, 4.45; PT= 1.80, 95% CI: -2.33, 5.93). The difference in total FFMQ between Tai Chi and PT was not significant (-1.04 points, 95% CI: -6.48, 4.39). Mindfulness did not change after Tai Chi or PT intervention in knee OA, which suggests that Tai Chi may not improve health in knee OA through cultivating mindfulness. Further study is needed to identify underlying mechanisms of effective mind-body interventions among people with knee OA.

Pain and Complementary Therapies

Treatment of both acute and chronic pain typically involves a combination of pharmacologic and provider-based interventions, which is effective for some patients but not for others. Use of pain medications, especially repeated and frequent usage, involves the risk of adverse reactions, overuse, and dependency. Complementary and alternative therapies (CAT) offer an alternative or adjunctive method to decrease the pain experience and enhance function and quality of life. Various evidence-based CAT methods have been proved to be effective in the management of both acute and chronic pain. Nurses are well placed to implement various CAT modalities.

Mindfulness is associated with psychological health and moderates pain in knee osteoarthritis

OBJECTIVE

Previous studies suggest that higher mindfulness is associated with less pain and depression. However, the role of mindfulness has never been studied in knee osteoarthritis (OA). We evaluate the relationships between mindfulness and pain, psychological symptoms, and quality of life in knee OA.

METHOD

We performed a secondary analysis of baseline data from our randomized comparative trial in participants with knee OA. Mindfulness was assessed using the Five Facet Mindfulness Questionnaire (FFMQ). We measured pain, physical function, quality of life, depression, stress, and self-efficacy with commonly-used patient-reported measures. Simple and multivariable regression models were utilized to assess associations between mindfulness and health outcomes. We further tested whether mindfulness moderated the pain-psychological outcome associations.

RESULTS

Eighty patients were enrolled (60.3 ± 10.3 years; 76.3% female, body mass index: 33.0 ± 7.1 kg/m²). Total mindfulness score was associated with mental (beta = 1.31, 95% CI: 0.68, 1.95) and physical (beta = 0.69, 95% CI:0.06, 1.31) component quality of life, self-efficacy (beta = 0.22, 95% CI:0.07, 0.37), depression (beta = -1.15, 95% CI:-1.77, -0.54), and stress (beta = -1.07, 95% CI:-1.53, -0.60). Of the five facets, the Describing, Acting-with-Awareness, and Non-judging mindfulness facets had the most associations with psychological health. No significant association was found between mindfulness and pain or function (P = 0.08-0.24). However, we found that mindfulness moderated the effect of pain on stress (P = 0.02).

CONCLUSION

Mindfulness is associated with depression, stress, self-efficacy, and quality of life among knee OA patients. Mindfulness also moderates the influence of pain on stress, which suggests that mindfulness may alter the way one copes with pain. Future studies examining the benefits of mind-body therapy, designed to increase mindfulness, for patients with OA are warranted.

Scientific Evaluation and Review of Claims in Health Care (SEaRCH): A Streamlined, Systematic, Phased Approach for Determining "What Works" in Healthcare

Background: Answering the question of “what works” in healthcare can be complex and requires the careful design and sequential application of systematic methodologies. Over the last decade, the Samueli Institute has, along with multiple partners, developed a streamlined, systematic, phased approach to this process called the Scientific Evaluation and Review of Claims in Health Care (SEaRCH™). The SEaRCH process provides an approach for rigorously, efficiently, and transparently making evidence-based decisions about healthcare claims in research and practice with minimal bias.

Methods: SEaRCH uses three methods combined in a coordinated fashion to help determine what works in healthcare. The first, the Claims Assessment Profile (CAP), seeks to clarify the healthcare claim and question, and its ability to be evaluated in the context of its delivery. The second method, the Rapid Evidence Assessment of the Literature (REAL^©), is a streamlined, systematic review process conducted to determine the quantity, quality, and strength of evidence and risk/benefit for the treatment. The third method involves the structured use of expert panels (EPs). There are several types of EPs, depending on the purpose and need. Together, these three methods—CAP, REAL, and EP—can be integrated into a strategic approach to help answer the question “what works in healthcare?” and what it means in a comprehensive way.

Discussion: SEaRCH is a systematic, rigorous approach for evaluating healthcare claims of therapies, practices, programs, or products in an efficient and stepwise fashion. It provides an iterative, protocol-driven process that is customized to the intervention, consumer, and context. Multiple communities, including those involved in health service and policy, can benefit from this organized framework, assuring that evidence-based principles determine which healthcare practices with the greatest promise are used for improving the public's health and wellness.

Self-Administered Mind-Body Practices for Reducing Health Disparities: An Interprofessional Opinion and Call to Action

Health disparities (HD) continue to persist in the United States which underscores the importance of using low-cost, accessible, evidence-based strategies that can improve health outcomes, especially for chronic conditions that are prevalent among underserved minority populations. Complementary/integrative health modalities, particularly self-administered mind-body practices (MBP), can be extremely useful in reducing HD because they are intrinsically patient-centered and they empower patients to actively engage in self-care of health and self-management of symptoms. Interprofessional healthcare providers and patients can engage in powerful partnerships that encompass self-administered MBP to improve health. This is a call to action for interprofessional researchers to engage in high-quality research regarding efficacy and cost-effectiveness of self-administered MBP, for practitioners to engage patients in self-administered MBP for health promotion, disease prevention, and symptom management, and for healthcare institutions to integrate self-administered MBP into conventional health practices to reduce HD in their communities.

The Impact of Massage Therapy on Function in Pain Populations-A Systematic Review and Meta-Analysis of Randomized Controlled Trials: Part III, Surgical Pain Populations

OBJECTIVE

Pain is multi-dimensional and may be better addressed through a holistic, biopsychosocial approach. Massage therapy is commonly practiced among patients seeking pain management; however, its efficacy is unclear. This systematic review and meta-analysis is the first to rigorously assess the quality of the evidence for massage therapy's efficacy in treating pain, function-related, and health-related quality of life outcomes in surgical pain populations.

METHODS

Key databases were searched from inception through February 2014. Eligible randomized controlled trials were assessed for methodological quality using SIGN 50 Checklist. Meta-analysis was applied at the outcome level. A professionally diverse steering committee interpreted the results to develop recommendations.

RESULTS

Twelve high quality and four low quality studies were included in the review. Results indicate massage therapy is effective for treating pain [standardized mean difference (SMD) = -0.79] and anxiety (SMD = -0.57) compared to active comparators.

CONCLUSION

Based on the available evidence, weak recommendations are suggested for massage therapy, compared to active comparators for reducing pain intensity/severity and anxiety in patients undergoing surgical procedures. This review also discusses massage therapy safety, challenges within this research field, how to address identified research gaps, and next steps for future research.

The Impact of Massage Therapy on Function in Pain Populations-A Systematic Review and Meta-Analysis of Randomized Controlled Trials: Part II, Cancer Pain Populations

PURPOSE

Pain is multi-dimensional and may be better addressed through a holistic, biopsychosocial approach. Massage therapy is commonly practiced among patients seeking pain management; however, its efficacy is unclear. This systematic review and meta-analysis is the first to rigorously assess the quality of massage therapy research and evidence for its efficacy in treating pain, function-related and health-related quality of life in cancer populations.

METHODS

Key databases were searched from inception through February 2014. Eligible randomized controlled trials were assessed for methodological quality using the SIGN 50 Checklist. Meta-analysis was applied at the outcome level. A diverse steering committee interpreted the results to develop recommendations.

RESULTS

Twelve high quality and four low quality studies were subsequently included in the review. Results demonstrate massage therapy is effective for treating pain compared to no treatment [standardized mean difference (SMD)  = -.20] and active (SMD = -0.55) comparators. Compared to active comparators, massage therapy was also found to be beneficial for treating fatigue (SMD = -1.06) and anxiety (SMD = -1.24).

CONCLUSION

Based on the evidence, weak recommendations are suggested for massage therapy, compared to an active comparator, for the treatment of pain, fatigue, and anxiety. No recommendations were suggested for massage therapy compared to no treatment or sham control based on the available literature to date. This review addresses massage therapy safety, research challenges, how to address identified research gaps, and necessary next steps for implementing massage therapy as a viable pain management option for cancer pain populations.

Quality of conduct and reporting in rapid reviews: an exploration of compliance with PRISMA and AMSTAR guidelines

BACKGROUND

Rapid reviews are an accelerated evidence synthesis approach intended to meet the timely needs of decision-makers in healthcare settings. Quality of conduct and reporting has been described in the rapid review literature; however, no formal assessment has been carried out using available instruments. The objective of this study was to explore compliance with conduct and reporting guidelines in rapid reviews published or posted online during 2013 and 2014.

METHODS

We performed a comprehensive literature search for rapid reviews using multiple bibliographic databases (e.g. PubMed, MEDLINE, EMBASE, the Cochrane Library) through December 31, 2014. Grey literature was searched thoroughly, and health technology assessment agencies were surveyed to identify additional rapid review products. Candidate reviews were assessed for inclusion using pre-specified eligibility criteria. Detailed data was collected from the included reviews on study and reporting characteristics and variables significant to rapid reviews (e.g. nomenclature, definition). We evaluated the quality of conduct and reporting of included rapid reviews using the A Measurement Tool to Assess Systematic Reviews (AMSTAR) and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklists. Compliance with each checklist item was examined, and the sum of adequately reported items was used to describe overall compliance. Rapid reviews were stratified to explore differences in compliance related to publication status. The association between compliance and time to completion or length of publication was explored through univariate regression.

RESULTS

Sixty-six rapid reviews were included. There were heterogeneous nomenclature, research questions and approaches to rapid reviews. Compliance with AMSTAR and PRISMA checklists was poor. Published rapid reviews were compliant with individual PRISMA items more often than unpublished reviews, but no difference was seen in AMSTAR item compliance overall. There was evidence of an association between length of publication and time to completion and the number of adequately reported PRISMA or AMSTAR items.

CONCLUSIONS

Transparency and inadequate reporting are significant limitations of rapid reviews. Scientific editors, authors and producing agencies should ensure that the reporting of conduct and findings is accurate and complete. Further research may be warranted to explore reporting and conduct guidelines specific to rapid reviews and how these guidelines may be applied across the spectrum of rapid review approaches.

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.

Rapid Evidence Assessment of the Literature (REAL(©)): streamlining the systematic review process and creating utility for evidence-based health care

BACKGROUND

Systematic reviews (SRs) are widely recognized as the best means of synthesizing clinical research. However, traditional approaches can be costly and time-consuming and can be subject to selection and judgment bias. It can also be difficult to interpret the results of a SR in a meaningful way in order to make research recommendations, clinical or policy decisions, or practice guidelines. Samueli Institute has developed the Rapid Evidence Assessment of the Literature (REAL) SR process to address these issues. REAL provides up-to-date, rigorous, high quality SR information on health care practices, products, or programs in a streamlined, efficient and reliable manner. This process is a component of the Scientific Evaluation and Review of Claims in Health Care (SEaRCH™) program developed by Samueli Institute, which aims at answering the question of "What works?" in health care.

METHODS/DESIGN

The REAL process (1) tailors a standardized search strategy to a specific and relevant research question developed with various stakeholders to survey the available literature; (2) evaluates the quantity and quality of the literature using structured tools and rulebooks to ensure objectivity, reliability and reproducibility of reviewer ratings in an independent fashion and; (3) obtains formalized, balanced input from trained subject matter experts on the implications of the evidence for future research and current practice.

RESULTS

Online tools and quality assurance processes are utilized for each step of the review to ensure a rapid, rigorous, reliable, transparent and reproducible SR process.

CONCLUSIONS

The REAL is a rapid SR process developed to streamline and aid in the rigorous and reliable evaluation and review of claims in health care in order to make evidence-based, informed decisions, and has been used by a variety of organizations aiming to gain insight into "what works" in health care. Using the REAL system allows for the facilitation of recommendations on appropriate next steps in policy, funding, and research and for making clinical and field decisions in a timely, transparent, and cost-effective manner.

Effectiveness of active self-care complementary and integrative medicine therapies: options for the management of chronic pain symptoms

OBJECTIVES

Chronic pain management typically consists of prescription medications or provider-based, behavioral, or interventional procedures that are often ineffective, may be costly, and can be associated with undesirable side effects. Because chronic pain affects the whole person (body, mind, and spirit), patient-centered complementary and integrative medicine (CIM) therapies that acknowledge the patients' roles in their own healing processes have the potential to provide more efficient and comprehensive chronic pain management. Active self-care CIM (ACT-CIM) therapies allow for a more diverse, patient-centered treatment of complex symptoms, promote self-management, and are relatively safe and cost-effective. To date, there are no systematic reviews examining the full range of ACT-CIM used for chronic pain symptom management.

METHODS

A systematic review was conducted, using Samueli Institute's Rapid Evidence Assessment of the Literature methodology, to rigorously assess both the quality of the research on ACT-CIM modalities and the evidence for their efficacy and effectiveness in treating chronic pain symptoms. A working group of subject matter experts was also convened to evaluate the overall literature pool and develop recommendations for the use and implementation of these modalities.

RESULTS

Following key database searches, 146 randomized controlled trials were included in the review, 18 of which directly compared ACT-CIM approaches with one another.

CONCLUSIONS

This article summarizes the current evidence, quality, effectiveness, and safety of these modalities. Recommendations and next steps to move this field of research forward are also discussed. The entire scope of the review is detailed throughout the current Pain Medicine supplement.

An analysis of the various chronic pain conditions captured in a systematic review of active self-care complementary and integrative medicine therapies for the management of chronic pain symptoms

OBJECTIVES

Chronic pain management typically consists of prescription medications or provider-based, behavioral, or interventional procedures that are often ineffective, may be costly, and can be associated with undesirable side effects. Because chronic pain affects the whole person (body, mind, and spirit), patient-centered complementary and integrative medicine (CIM) therapies that acknowledge the patients' roles in their own healing processes have the potential to provide more efficient and comprehensive chronic pain management. Active self-care CIM therapies (ACT-CIM) allow for a more diverse, patient-centered treatment of complex symptoms, promote self-management, and are relatively safe and cost-effective. To date, there are no systematic reviews examining the full range of ACT-CIM used for chronic pain symptom management.

METHODS

A systematic review was conducted, using Samueli Institute's rapid evidence assessment of the literature (REAL©) methodology, to rigorously assess both the quality of the research on ACT-CIM modalities and the evidence for their efficacy and effectiveness in treating chronic pain symptoms. A working group of subject matter experts was also convened to evaluate the overall literature pool and develop recommendations for the use and implementation of these modalities.

RESULTS

Following key database searches, 146 randomized controlled trials, covering 33 different pain conditions, were included in the review.

CONCLUSIONS

This article categorized studies by pain condition, describing the diagnostic criteria used and modalities that seem most effective for each condition. Complexities associated with investigating chronic pain populations are also discussed. The entire scope of the review, categorized by modality rather than pain condition, is detailed throughout the current Pain Medicine supplement.