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Nielsen A, Dyer NL, Lechuga C, McKee MD, Dusek JA. Fidelity to the acupuncture intervention protocol in the ACUpuncture In The EmergencY department for pain management (ACUITY) trial: Expanding the gold standard of STRICTA and CONSORT guidelines. Integr Med Res 2024; 13:101048. [PMID: 38841077 PMCID: PMC11151162 DOI: 10.1016/j.imr.2024.101048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Revised: 05/06/2024] [Accepted: 05/09/2024] [Indexed: 06/07/2024] Open
Abstract
Background Acupuncture shows promise as an effective nonpharmacologic option for reduction of acute pain in the emergency department (ED). Following CONSORT and STRICTA guidelines, randomized controlled trials (RCTs) generally report intervention details and acupoint options, but fidelity to acupuncture interventions, critical to reliability in intervention research, is rarely reported. Methods ACUITY is an NCCIH-funded, multi-site feasibility RCT of acupuncture in 3 EDs (Cleveland, Nashville, and San Diego). ACUITY acupuncturists were trained in study design, responsive acupuncture manualization protocol, logistics and real-time recording of session details via REDCap forms created to track fidelity. Results Across 3 recruiting sites, 79 participants received acupuncture: 51 % women, 43 % Black/African American, with heterogeneous acute pain sites at baseline: 32 % low back, 22 % extremity, 20 % abdominal, 10 % head. Pragmatically, participants were treated in ED common areas (52 %), private rooms (39 %), and semi-private rooms (9 %). Objective tracking found 98 % adherence to the six components of the acupuncture manualization protocol: staging, number of insertion points (M = 13.2, range 2-22), needle retention time (M = 23.5 min, range 4-52), session length (M = 40.3 min, range 20-66), whether general recommendations were provided and completion of the session form. Conclusion To the best of our knowledge, this is the first RCT to assess and report fidelity to an acupuncture protocol. Fidelity monitoring will be fundamental for ACUITY2, which would be a future definitive, multi-site RCT. Furthermore, we recommend that fidelity to acupuncture interventions be added to CONSORT and STRICTA reporting guidelines in future RCTs. Protocol registration The protocol of this study is registered at clinicaltrials.gov: NCT04880733.
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Affiliation(s)
- Arya Nielsen
- Icahn School of Medicine at Mount Sinai, Department of Family Medicine and Community Health, New York, NY, USA
| | - Natalie L. Dyer
- Susan Samueli Integrative Health Institute, University of California- Irvine, Irvine, CA, USA
| | - Claudia Lechuga
- Department of Family and Social Medicine, Albert Einstein College of Medicine, New York, NY, USA
| | - M. Diane McKee
- Department of Family Medicine and Community Health, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Jeffery A. Dusek
- Susan Samueli Integrative Health Institute, University of California- Irvine, Irvine, CA, USA
- Department of Medicine, General Internal Medicine, University of California- Irvine, Irvine, CA, USA
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Elliott T, Merlano Gomez M, Morris D, Wilson C, Pilitsis JG. A scoping review of mechanisms of auricular acupuncture for treatment of pain. Postgrad Med 2024; 136:255-265. [PMID: 38501597 DOI: 10.1080/00325481.2024.2333232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 03/13/2024] [Indexed: 03/20/2024]
Abstract
OBJECTIVES Auricular acupuncture (AA) is becoming increasingly common in primary care clinics, emergency departments and peri-operatively for pain relief. Over the last decade, since the last comprehensive reviews were published, the literature has expanded. In this scoping review, we seek to document the efficacy of AA in treating both acute and chronic pain, describe the mechanism of action of AA in treating pain, and discuss how AA has been integrated into Western medicine to date. METHODS The authors performed a MEDLINE search inclusive of articles from 1966 to June 2023 including articles written in English identifying literature. We included human studies when more than 3 patients were included. Three hundred and fourteen unique articles were identified and 152 were selected by title screen. After abstract review, 117 were chosen for full-text review. Following full-text review, 33 articles were excluded and 21 added from references, totaling 105 articles included in our scoping review. RESULTS AA reduces pain severity in patients with both acute and chronic pain. The best studies in the acute settings have occurred in the peri-operative setting where sham AA is employed, multiple sessions of AA are given, and medication dosing is carefully monitored. In these cases, AA reduced pain and post-operative medications. In patients with chronic pain, multiple sessions of AA resulted not only in pain relief but also in improvements in function and disability. Literature suggests that AA works through multiple mechanisms with the most compelling data coupled to the autonomic nervous system and neuroendocrine system. Curriculums designed to teach AA and aid in implementation have been published. CONCLUSION AA is an accessible, effective means of pain relief. AA is relatively straightforward to learn, and protocols and curriculums exist to teach healthcare professionals this valuable skill. Overcoming implementation barriers, including patient education, are essential next steps.
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Affiliation(s)
- Trish Elliott
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL, USA
| | - Maria Merlano Gomez
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL, USA
| | - Deborah Morris
- Department of Neurosurgery, University of Arizona College of Medicine, Tucson, AZ, USA
| | - Candy Wilson
- Christine E. Lynn College of Nursing, Florida Atlantic University, Boca Raton, FL, USA
| | - Julie G Pilitsis
- Department of Neurosurgery, University of Arizona College of Medicine, Tucson, AZ, USA
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DeBar LL, Justice M, Avins AL, Cook A, Eng CM, Herman PM, Hsu C, Nielsen A, Pressman A, Stone KL, Teets RY, Wellman R. Acupuncture for chronic low back pain in older adults: Design and protocol for the BackInAction pragmatic clinical trial. Contemp Clin Trials 2023; 128:107166. [PMID: 36990274 PMCID: PMC10416311 DOI: 10.1016/j.cct.2023.107166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 03/20/2023] [Accepted: 03/22/2023] [Indexed: 03/29/2023]
Abstract
BACKGROUND Back pain prevalence and burden increase with age; approximately one-third of U.S. adults 65 years of age and older experience lower back pain (LBP). For chronic low back pain (cLBP), typically defined as lasting three months or longer, many treatments for younger adults may be inappropriate for older adults given their greater prevalence of comorbidities with attendant polypharmacy. While acupuncture has been demonstrated to be safe and effective for cLBP in adults overall, few studies of acupuncture have either included or focused on adults ≥65 years old. METHODS The BackInAction study is a pragmatic, multi-site, three-arm, parallel-groups randomized controlled trial designed to test the effectiveness of acupuncture needling for improving back pain-related disability among 807 older adults ≥65 years old with cLBP. Participants are randomized to standard acupuncture (SA; up to 15 treatment sessions across 12 weeks), enhanced acupuncture (EA; SA during first 12 weeks and up to 6 additional sessions across the following 12 weeks), and usual medical care (UMC) alone. Participants are followed for 12 months with study outcomes assessed monthly with the primary outcome timepoint at 6 months. DISCUSSION The BackInAction study offers an opportunity to further understand the effectiveness, dose-dependence, and safety of acupuncture in a Medicare population. Additionally, study results may encourage broader adoption of more effective, safer, and more satisfactory options to the continuing over-reliance on opioid- and invasive medical treatments for cLBP among older adults. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04982315. Clinical trial registration date: July 29, 2021.
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Affiliation(s)
- Lynn L DeBar
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, United States of America.
| | - Morgan Justice
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, United States of America
| | - Andrew L Avins
- Kaiser Permanente Northern California Division of Research, Oakland, CA, United States of America; University of California Department of Epidemiology and Biostatistics, San Francisco, CA, United States of America
| | - Andrea Cook
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, United States of America
| | - Carolyn M Eng
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, United States of America
| | | | - Clarissa Hsu
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, United States of America
| | - Arya Nielsen
- Icahn School of Medicine at Mount Sinai, Department of Family Medicine & Community Health, New York, NY, United States of America
| | - Alice Pressman
- University of California Department of Epidemiology and Biostatistics, San Francisco, CA, United States of America; Sutter Health California Pacific Medical Center Research Institute, San Francisco, CA, United States of America; Sutter Health Center for Health Systems Research, Walnut Creek, CA, United States of America
| | - Katie L Stone
- University of California Department of Epidemiology and Biostatistics, San Francisco, CA, United States of America; Sutter Health California Pacific Medical Center Research Institute, San Francisco, CA, United States of America
| | - Raymond Y Teets
- Institute for Family Health, New York, NY, United States of America
| | - Robert Wellman
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, United States of America
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Teets R, Nielsen A, Moonaz S, Anderson BJ, Mah DM, Walter E, Milanes M, Jyung H, Soto Cossio LE, Meissner P, McKee MD, Kligler B. Group Acupuncture Therapy With Yoga Therapy for Chronic Neck, Low Back, and Osteoarthritis Pain in Safety Net Settings for an Underserved Population: A Feasibility Pilot Study. GLOBAL ADVANCES IN INTEGRATIVE MEDICINE AND HEALTH 2023; 12:27536130231202515. [PMID: 37779670 PMCID: PMC10540610 DOI: 10.1177/27536130231202515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Revised: 08/24/2023] [Accepted: 08/28/2023] [Indexed: 10/03/2023]
Abstract
Background Acupuncture and yoga have both been shown to be effective in chronic pain. Underrepresented populations have poorer pain outcomes with less access to effective pain care. Objective To assess the feasibility of bundling group acupuncture with yoga therapy for chronic neck, back or osteoarthritis pain in safety net settings. Methods This was a feasibility pilot in Bronx and Harlem primary care community health centers. Participants with chronic neck, back or osteoarthritis pain received acupuncture and yoga therapy over a 10-week period. Participants received 10 weekly acupuncture treatments in group setting; with Yoga therapy sessions beginning immediately following the 3rd session. Primary outcome was pain interference and pain intensity on the Brief Pain Inventory (BPI); Outcomes were measured at baseline, 10-week close of intervention, and 24-week follow-up. Results 93 patients were determined to be eligible and completed the baseline interview. The majority of participants were non-White and Medicaid recipients. 78 (84%) completed the intervention and 10-week survey, and 58 (62%) completed the 24-week post intervention survey. Participants received an average number of 6.5 acupuncture sessions (out of a possible 10), and 4 yoga sessions (out of a possible 8) over the 10-week intervention. Patients showed statistically significant improvements in pain at the close of the intervention and at a somewhat lesser rate, at 24-weeks post intervention. Challenges included telephone outreach and site coordination integrating acupuncture with yoga therapy. The trial also had to be stopped early due to the COVID-19 pandemic. Conclusions Bundling acupuncture therapy and yoga therapy is feasible for an underrepresented population with chronic pain in urban community health centers with preliminary indications of acceptability and benefit to participants.
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Affiliation(s)
- Raymond Teets
- Department of Family Medicine & Community Health, Icahn School of Medicine at Mount Sinai, Woodstock, NY, USA
- Institute for Family Health, New York, NY, USA
| | - Arya Nielsen
- Department of Family Medicine & Community Health, Icahn School of Medicine at Mount Sinai, Woodstock, NY, USA
| | - Steffany Moonaz
- Department of Clinical and Health Services Research, Southern California University of Health Sciences, Whittier, CA, USA
| | - Belinda J Anderson
- College of Health Professions, Pace University, New York, NY, USA
- Department of Family and Social Medicine, Albert Einstein College of Medicine, Bronx, NY, USA
- Pacific College of Health and Science, New York, NY, USA
| | - Donna M Mah
- Pacific College of Health and Science, New York, NY, USA
| | - Eve Walter
- Department of Family Medicine & Community Health, Icahn School of Medicine at Mount Sinai, Woodstock, NY, USA
- Institute for Family Health, New York, NY, USA
| | | | - Hyowoun Jyung
- Department of Family Medicine & Community Health, Icahn School of Medicine at Mount Sinai, Woodstock, NY, USA
- Institute for Family Health, New York, NY, USA
| | | | - Paul Meissner
- Department of Family and Social Medicine, Albert Einstein College of Medicine, Bronx, NY, USA
| | - M Diane McKee
- Department of Family and Social Medicine, Albert Einstein College of Medicine, Bronx, NY, USA
- Family Medicine & Community Health, University of Massachusetts Medical School, North Worcester, NY, USA
| | - Benjamin Kligler
- Department of Family Medicine & Community Health, Icahn School of Medicine at Mount Sinai, Woodstock, NY, USA
- Department of Family and Social Medicine, Albert Einstein College of Medicine, Bronx, NY, USA
- Integrative Health Coordinating Center, US Veterans Health Administration, Washington, NY, USA
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Eucker SA, Glass O, Staton CA, Knisely MR, O'Regan A, De Larco C, Mill M, Dixon A, TumSuden O, Walker E, Dalton JC, Limkakeng A, Maxwell AMW, Gordee A, Kuchibhatla M, Chow S. Acupuncture for acute musculoskeletal pain management in the emergency department and continuity clinic: a protocol for an adaptive pragmatic randomised controlled trial. BMJ Open 2022; 12:e061661. [PMID: 36153034 PMCID: PMC9511597 DOI: 10.1136/bmjopen-2022-061661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 09/05/2022] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Chronic musculoskeletal pain causes a significant burden on health and quality of life and may result from inadequate treatment of acute musculoskeletal pain. The emergency department (ED) represents a novel setting in which to test non-pharmacological interventions early in the pain trajectory to prevent the transition from acute to chronic pain. Acupuncture is increasingly recognised as a safe, affordable and effective treatment for pain and anxiety in the clinic setting, but it has yet to be established as a primary treatment option in the ED. METHODS AND ANALYSIS This pragmatic clinical trial uses a two-stage adaptive randomised design to determine the feasibility, acceptability and effectiveness of acupuncture initiated in the ED and continued in outpatient clinic for treating acute musculoskeletal pain. The objective of the first (treatment selection) stage is to determine the more effective style of ED-based acupuncture, auricular acupuncture or peripheral acupuncture, as compared with no acupuncture. All arms will receive usual care at the discretion of the ED provider blinded to treatment arm. The objective of the second (effectiveness confirmation) stage is to confirm the impact of the selected acupuncture arm on pain reduction. An interim analysis is planned at the end of stage 1 based on probability of being the best treatment, after which adaptations will be considered including dropping the less effective arm, sample size re-estimation and unequal treatment allocation ratio (eg, 1:2) for stage 2. Acupuncture treatments will be delivered by licensed acupuncturists in the ED and twice weekly for 1 month afterward in an outpatient clinic. ETHICS AND DISSEMINATION This study has been reviewed and approved by the Duke University Health System Institutional Review Board. Informed consent will be obtained from all participants. Results will be disseminated through peer-review publications and public and conference presentations. TRIAL REGISTRATION NUMBER NCT04290741.
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Affiliation(s)
- Stephanie A Eucker
- Department of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, USA
- Department of Orthopaedic Surgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Oliver Glass
- Department of Medicine, Division of General Internal Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Catherine A Staton
- Department of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, USA
- Duke Global Health Institute, Durham, North Carolina, USA
| | | | - Amy O'Regan
- Department of Population Health Sciences, Duke University, Durham, North Carolina, USA
| | - Christi De Larco
- Department of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Michelle Mill
- Department of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Austin Dixon
- Department of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Olivia TumSuden
- UNC Adams School of Dentistry, Chapel Hill, North Carolina, USA
| | - Erica Walker
- Department of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Juliet C Dalton
- Duke Office of Clinical Research, Duke University, Durham, North Carolina, USA
| | - Alexander Limkakeng
- Department of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | | | - Alex Gordee
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina, USA
| | - Maggie Kuchibhatla
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina, USA
- Center for Aging, Duke University, Durham, North Carolina, USA
| | - Sheinchung Chow
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina, USA
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Graca S, Citkovitz C. From Bench to Bedside and Back Again: Developments in the Evidence-Informed Practice (and Practice-Informed Research) of Acupuncture. JOURNAL OF INTEGRATIVE AND COMPLEMENTARY MEDICINE 2022; 28:613-617. [PMID: 35862030 DOI: 10.1089/jicm.2022.0630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Affiliation(s)
- Sandro Graca
- Department of Research, Northern College of Acupuncture, York, United Kingdom
| | - Claudia Citkovitz
- Massachusetts College of Pharmacy and Health Sciences, New England College of Acupuncture, Worcester, MA, USA
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Nielsen A, Olson J, Quesada M, Zhu C, Raskin E, Vang B, Painovich J, Scott M, Xiong VJ, Dusek JA. Acupuncture intervention for acute pain in the Emergency Department trial: a consensus process. Acupunct Med 2022; 40:339-346. [PMID: 35229658 PMCID: PMC10948001 DOI: 10.1177/09645284221076507] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
PURPOSE This document describes the consensus process and intervention for a National Institutes of Health (NIH)-funded multi-site feasibility study utilizing acupuncture for ACUte paIn in The EmergencY Department (ACUITY). The acupuncture intervention is designed to be flexible and responsive to the most common Emergency Department (ED) scenarios, including trauma, acute pain of the low back, abdomen and/or musculoskeletal system, renal colic and headache. BACKGROUND Opioids remain a primary treatment for acute ED pain with attendant risk of adverse effects, addiction liability, diversion and death. Effective/safer options for acute pain are needed. Although acupuncture therapy has shown promise for acute pain in the ED alone or in conjunction with usual care, pragmatic trials are needed to obtain definitive and generalizable evidence. METHODS An Acupuncture Advisory Panel was convened that included nine acupuncture experts with 5-44 years of experience in practice and 2-16 years of experience in the acute pain care setting. A modified Delphi process was used with provision of a literature review, surveys of our panel members, three online discussions and email discussion as needed. The STandards for Reporting Interventions in Controlled Trials (STRICTA) checklist was used as a guide. RESULTS A responsive acupuncture intervention was agreed on for ACUITY. Session forms were fashioned in REDCap (Research Electronic Data Capture program to capture essential treatment data, assess fidelity and inform our design for a future pragmatic multi-site randomized controlled trial (RCT) of acupuncture in the ED, and for use by other future researchers. CONCLUSION Development of a responsive manualization intervention provides the appropriate framework for conducting a future, pragmatic, multi-site, definitive RCT of acupuncture in the ED. TRIAL REGISTRATION NUMBER NCT04880733 (ClinicalTrials.gov).
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Affiliation(s)
- Arya Nielsen
- Department of Family Medicine and Community Health, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Juli Olson
- Department of Veterans Affairs, Central Iowa, Des Moines, IA, USA
| | - Megan Quesada
- University Hospitals Connor Whole Health, Cleveland Medical Center, Cleveland, OH, USA
| | - Chongbin Zhu
- Osher Center for Integrative Medicine at Vanderbilt, Vanderbilt Health, Nashville, TN, USA
| | - Erin Raskin
- Center for Integrative Medicine, University of California San Diego, San Diego, CA, USA
| | - Bobbee Vang
- Penny George Institute For Health and Healing, Abbott Northwestern Hospital, Minneapolis, MN, USA
| | | | - Megan Scott
- Tanya I. Edwards, MD Center for Integrative and Lifestyle Medicine at Cleveland Clinic, Cleveland, OH, USA
| | - Vashir J Xiong
- Integrated Medicine, Advocate Aurora Healthcare, Milwaukee, WI, USA
| | - Jeffery A Dusek
- University Hospitals Connor Whole Health, Cleveland Medical Center, Cleveland, OH, USA
- Department of Family Medicine and Community Health, Case Western Reserve University, Cleveland, OH, USA
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Dusek JA, Kallenberg GA, Hughes RM, Storrow AB, Coyne CJ, Vago DR, Nielsen A, Karasz A, Kim RS, Surdam J, Segall T, McKee MD. Acupuncture in the emergency department for pain management: A BraveNet multi-center feasibility study. Medicine (Baltimore) 2022; 101:e28961. [PMID: 35244059 PMCID: PMC8896475 DOI: 10.1097/md.0000000000028961] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 02/11/2022] [Indexed: 12/22/2022] Open
Abstract
PURPOSE Pain accounts for up to 78% of emergency department (ED) patient visits and opioids remain a primary method of treatment despite risks of addiction and adverse effects. While prior acupuncture studies are promising as an alternative opioid-sparing approach to pain reduction, successful conduct of a multi-center pilot study is needed to prepare for a future definitive randomized control trial (RCT). METHODS Acupuncture in the Emergency Department for Pain Management (ACUITY) is funded by the National Center for Complementary and Integrative Health. The objectives are to: conduct a multi-center feasibility RCT, examine feasibility of data collection, develop/deploy a manualized acupuncture intervention and assess feasibility/implementation (barrier/facilitators) in 3 EDs affiliated with the BraveNet Practice Based Research Network.Adults presenting to a recruiting ED with acute non-emergent pain (e.g., musculoskeletal, back, pelvic, noncardiac chest, abdominal, flank or head) of ≥4 on a 0-10-point Numeric Rating Scale will be eligible. ED participants (n = 165) will be equally randomized to Acupuncture or Usual Care.At pre-, post-, and discharge time-points, patients will self-assess pain and anxiety using the Numeric Rating Scale. Pain, anxiety, post-ED opioid use and adverse events will be assessed at 1 and 4 weeks. Opioid utilization in the ED and discharge prescriptions will be extracted from patients' electronic medical records.Acupuncture recipients will asked to participate in a brief qualitative interview about 3 weeks after their discharge. ED providers and staff will also be interviewed about their general perspectives/experiences related to acupuncture in the ED and implementation of acupuncture in ACUITY. RESULTS Recruitment began on 5/3/21. As of 12/7/21: 84 patients have enrolled, the responsive acupuncture intervention has been developed and deployed, and 26 qualitative interviews have been conducted. CONCLUSION Successful conduct of ACUITY will provide the necessary framework for conducting a future, multi-center, definitive RCT of acupuncture in the ED. CLINICAL TRIALSGOV NCT04880733 https://clinicaltrials.gov/ct2/show/NCT04880733.
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Affiliation(s)
- Jeffery A. Dusek
- UH Connor Whole Health, University Hospitals, Cleveland, OH
- Department of Family Medicine and Community Health, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Gene A. Kallenberg
- Department of Family Medicine, University of California San Diego, La Jolla, CA
| | - Robert M. Hughes
- Department of Emergency Medicine, Case Western Reserve University School of Medicine, Cleveland OH
- Clinical Decision Unit, University Hospitals, Cleveland Medical Center, Cleveland, OH
| | - Alan B. Storrow
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Christopher J. Coyne
- Department of Emergency Medicine and Department of Radiation Medicine and Applied Sciences University of California San Diego La Jolla, CA
| | - David R. Vago
- Department of Physical Medicine and Rehabilitation and Department of Psychiatry, Vanderbilt University Medical Center, Nashville, TN
| | - Arya Nielsen
- Department of Family Medicine and Community Health Icahn School of Medicine at Mount Sinai, New York, NY
| | - Alison Karasz
- Department of Family Medicine and Social Medicine, Albert Einstein College of Medicine/Montefiore, New York, NY
| | - Ryung S. Kim
- Department of Epidemiology and Population Health and Institute of Clinical and Translational Research, Albert Einstein College of Medicine/Montefiore, New York, NY
| | - Jessica Surdam
- UH Connor Whole Health, University Hospitals, Cleveland, OH
| | - Tracy Segall
- UH Connor Whole Health, University Hospitals, Cleveland, OH
| | - M. Diane McKee
- Department of Family Medicine and Community Health, University of Massachusetts School of Medicine, Worcester, MA
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Nielsen A, Ocker L, Majd I, Draisin JA, Taromina K, Maggenti MT, Long J, Nolting M, Sherman KJ. Acupuncture Intervention Protocol: Consensus Process for a Pragmatic Randomized Controlled Trial of Acupuncture for Management of Chronic Low Back Pain in Older Adults: An NIH HEAL Initiative Funded Project. Glob Adv Health Med 2021; 10:21649561211007091. [PMID: 34104574 PMCID: PMC8161858 DOI: 10.1177/21649561211007091] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 02/09/2021] [Accepted: 03/12/2021] [Indexed: 12/13/2022] Open
Abstract
Objective The aim of this article is to describe the consensus process used to develop an acupuncture intervention protocol for an NIH-funded pragmatic randomized controlled trial (PRCT) of acupuncture for the management of chronic low back (cLBP) in older adults (BackInAction). Background CLBP is among leading causes of disability worldwide: almost 33% of US adults 65 and older experience LBP. Acupuncture is effective for cLBP but there is no specific data on older adults. The National Institutes for Health (NIH) funded a PRCT of acupuncture needling for this population. An essential trial milestone was development of a consensus intervention protocol. Methods An Acupuncture Advisory Panel (AAP) was formed with nine members: two physician-acupuncturists, six licensed acupuncturists representing diverse work backgrounds, and an acupuncture researcher. We used a modified Delphi process that included provision of acupuncture trial data, survey data describing how each expert treats cLBP, three conference calls, and between-call email discussion. Results Lively and professional discussions led to a consensus intervention protocol for the BackInAction trial that included steps/staging of care, recommendations for parameters of care session length, number of needle insertion sites, insertion depths, needle retention times, recommended types of needles, both local and distal areas of the body to be treated, acupuncture point options, auricular point options, self-care options, and minimum number of sessions considered ideal. Conclusion Using a modified Delphi process, an expert AAP created a consensus intervention protocol for the PRCT of acupuncture needling for cLBP in patients 65 and older.
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Affiliation(s)
- Arya Nielsen
- Department of Family Medicine & Community Health, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Laura Ocker
- Multnomah County, Integrated Clinical Services, Portland, Oregon
| | - Iman Majd
- Department of Family Medicine, University of Washington, Seattle, Washington
| | - Jeff A Draisin
- Institute for Health and Healing, San Francisco, California
| | | | | | | | | | - Karen J Sherman
- Kaiser Permanente Washington Health Research Institute; Department of Epidemiology, University of Washington, Seattle, Washington
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Anderson BJ, Meissner P, Mah DM, Nielsen A, Moonaz S, McKee MD, Kligler B, Milanes M, Guerra H, Teets R. Barriers and Facilitators to Implementing Bundled Acupuncture and Yoga Therapy to Treat Chronic Pain in Community Healthcare Settings: A Feasibility Pilot. J Altern Complement Med 2021; 27:496-505. [PMID: 33720749 PMCID: PMC8236295 DOI: 10.1089/acm.2020.0394] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Objective: To identify factors associated with implementing bundled group acupuncture and yoga therapy (YT) to treat underserved patients with chronic pain in community health center (CHC) settings. This is not an implementation science study, but rather an organized approach for identification of barriers and facilitators to implementing these therapies as a precursor to a future implementation science study. Design: This study was part of a single-arm feasibility trial, which aimed to test the feasibility of bundling GA and YT for chronic pain in CHCs. Treatment outcomes were measured before and after the 10-week intervention period. Implementation feasibility was assessed through weekly research team meetings, weekly yoga provider meetings, monthly acupuncture provider meetings, and weekly provider surveys. Settings: The study was conducted in New York City at two Montefiore Medical Group (MMG) sites in the Bronx, and one Institute for Family Health (IFH) site in Harlem. Subjects: Participants in the feasibility trial were recruited from IFH and MMG sites, and needed to have had lower back, neck, or osteoarthritis pain for >3 months. Implementation stakeholders included the research team, providers of acupuncture and YT, referring providers, and CHC staff. Results: Implementation of these therapies was assessed using the Consolidated Framework for Implementation Research. We identified issues associated with scheduling, treatment fidelity, communication, the three-way disciplinary interaction of acupuncture, yoga, and biomedicine, space adaptation, site-specific logistical and operational requirements, and patient-provider language barriers. Issues varied as to their frequency and resolution difficulty. Conclusions: This feasibility trial identified implementation issues and resolution strategies that could be further explored in future implementation studies. Clinical Trial Registration No.: NCT04296344.
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Affiliation(s)
- Belinda J Anderson
- College of Health Professions, Pace University, New York, NY, USA.,School of Nursing and Health Studies, Monmouth University, West Long Branch, NJ, USA.,Department of Family and Social Medicine, Albert Einstein College of Medicine, Bronx, NY, USA.,Pacific College of Health and Science, San Diego, CA, USA
| | - Paul Meissner
- Department of Family and Social Medicine, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Donna M Mah
- Pacific College of Health and Science, San Diego, CA, USA
| | - Arya Nielsen
- Department of Family Medicine and Community Health, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - M Diane McKee
- Family Medicine and Community Health, University of Massachusetts Medical School, Worcester, MA, USA
| | - Benjamin Kligler
- Integrative Health Coordinating Center, US Veterans Health Administration, Washington, DC, USA
| | | | - Hernidia Guerra
- Department of Family and Social Medicine, Albert Einstein College of Medicine, Bronx, NY, USA
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11
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Moonaz S, Whitehead AM, Lawrence L, Natividad D, Kindred D, Nielsen A, Teets R. Yoga therapy DYADS: A novel approach to chronic pain management in underserved populations. Explore (NY) 2020; 18:195-199. [PMID: 33342752 DOI: 10.1016/j.explore.2020.12.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 12/04/2020] [Accepted: 12/05/2020] [Indexed: 02/07/2023]
Abstract
Yoga therapy is an emerging integrative health approach that applies the practices and teachings of yoga for individuals with clinical concerns. It is generally offered as individual sessions between a yoga therapist and client or in a small group setting with several clients who share a clinical concern. Here we describe a third model for consideration- the yoga therapy dyad. A dyad includes two clients working simultaneously with a single yoga therapist and differs from both individual and small group sessions in the potential benefits and challenges. The yoga therapy dyad model that is detailed here was implemented as part of a feasibility trial along with group acupuncture therapy for chronic pain in an underserved population. Underserved populations are at risk for pain and reduced access to care. This pilot may inform future research, policy, education, and clinical practice.
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Affiliation(s)
- S Moonaz
- Maryland University of Integrative Health, 7750 Montpelier Road, Laurel, MD 20723, USA.
| | - A M Whitehead
- Integrative Health Coordinating Center, VHA Office of Patient Centered Care & Cultural Transformation, 810 Vermont Ave NW, Washington, DC 20420, USA
| | | | | | | | - A Nielsen
- Icahn School of Medicine at Mount Sinai, Department of Family Medicine & Community Health, 1425 Madison Avenue, L5-40, New York, NY 10029, USA
| | - R Teets
- Icahn School of Medicine at Mount Sinai, Department of Family Medicine & Community Health, 1425 Madison Avenue, L5-40, New York, NY 10029, USA; Institute for Family Health, 230W 17th St, New York, NY 10011, USA.
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12
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Nielsen A, Teets R, Moonaz S, Anderson BJ, Walter E, Milanes M, Mah DM, Diane McKee M, Kligler B. Group Acupuncture Therapy With Yoga Therapy for Chronic Neck, Low Back, and Osteoarthritis Pain in Safety Net Setting for an Underserved Population: Design and Rationale for a Feasibility Pilot. Glob Adv Health Med 2020; 9:2164956120964716. [PMID: 33150053 PMCID: PMC7580149 DOI: 10.1177/2164956120964716] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Chronic pain is prevalent in the United States, with impact on physical and
psychological functioning as well as lost work productivity. Minority and lower
socioeconomic populations have increased prevalence of chronic pain with less
access to pain care, poorer outcomes, and higher risk of fatal opioid overdose.
Acupuncture therapy is effective in treating chronic pain conditions including
chronic low back pain, neck pain, shoulder pain, and knee pain from
osteoarthritis. Acupuncture therapy, including group acupuncture, is feasible
and effective, and specifically so for underserved and diverse populations at
risk for health outcome disparities. Acupuncture therapy also encourages patient
engagement and activation. As chronic pain improves, there is a natural
progression to want and need to increase activity and movement recovery. Diverse
movement approaches are important for improving range of motion, maintaining
gains, strengthening, and promoting patient engagement and activation. Yoga
therapy is an active therapy with proven benefit in musculoskeletal pain
disorders and pain associated disability. The aim of this quasi-experimental
pilot feasibility trial is to test the bundling of these 2 effective care
options for chronic pain, to inform both the design for a larger randomized
pragmatic effectiveness trial as well as implementation strategies across
underserved settings.
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Affiliation(s)
- Arya Nielsen
- Department of Family Medicine and Community Health, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Ray Teets
- Department of Family Medicine and Community Health, Icahn School of Medicine at Mount Sinai, New York, New York.,Institute for Family Health, New York
| | - Steffany Moonaz
- Research Department, Maryland University of Integrative Medicine, Laurel, Maryland
| | - Belinda J Anderson
- College of Health Professions, Pace University, New York.,Department of Family and Social Medicine, Albert Einstein College of Medicine, New York.,Pacific College of Health and Science, San Diego, California and New York
| | - Eve Walter
- Department of Family Medicine and Community Health, Icahn School of Medicine at Mount Sinai, New York, New York.,Institute for Family Health, New York
| | | | - Donna M Mah
- Pacific College of Health and Science, San Diego, California and New York
| | - M Diane McKee
- Department of Family and Social Medicine, Albert Einstein College of Medicine, New York.,Family Medicine and Community Health, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Benjamin Kligler
- Department of Family Medicine and Community Health, Icahn School of Medicine at Mount Sinai, New York, New York.,Department of Family and Social Medicine, Albert Einstein College of Medicine, New York.,US Veterans Health Administration Integrative Health Coordinating Center, Washington, DC
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13
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McKee MD, Nielsen A, Anderson B, Chuang E, Connolly M, Gao Q, Gil EN, Lechuga C, Kim M, Naqvi H, Kligler B. Individual vs. Group Delivery of Acupuncture Therapy for Chronic Musculoskeletal Pain in Urban Primary Care-a Randomized Trial. J Gen Intern Med 2020; 35:1227-1237. [PMID: 32076985 PMCID: PMC7174252 DOI: 10.1007/s11606-019-05583-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Accepted: 11/25/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Acupuncture has been shown to be effective for the treatment of chronic musculoskeletal back, neck, and osteoarthritis pain. However, access to acupuncture treatment has been limited in medically underserved and low-income populations. OBJECTIVE Acupuncture therapy delivered in groups could reduce cost and expand access. We compared the effectiveness of group versus individual acupuncture for pain and function among ethnically diverse, low-income primary care patients with chronic musculoskeletal pain. DESIGN This was a randomized comparative effectiveness non-inferiority trial in 6 Bronx primary care community health centers. Participants with chronic (> 3 months) back, neck, or osteoarthritis pain were randomly assigned to individual or group acupuncture therapy for 12 weeks. PARTICIPANTS Seven hundred seventy-nine participants were randomized. Mean age was 54.8 years. 35.3% of participants identified as black and 56.9% identified as Latino. Seventy-six percent were Medicaid insured, 60% reported poor/fair health, and 37% were unable to work due to disability. INTERVENTIONS Participants received weekly acupuncture treatment in either group or individual setting for 12 weeks. MAIN MEASURES Primary outcome was pain interference on the Brief Pain Inventory at 12 weeks; secondary outcomes were pain severity (BPI), physical and mental well-being (PROMIS-10), and opiate use. Outcome measures were collected at baseline, 12 and 24 weeks. KEY RESULTS 37.5% of individual arm and 30.3% in group had > 30% improvement in pain interference (d = 7.2%, 95% CI - 0.6%, 15.1%). Non-inferiority of group acupuncture was not demonstrated for the primary outcome assuming a margin of 10%. In the responder analysis of physical well-being, 63.1% of individual participants and 59.5% of group had clinically important improvement at 12 weeks (d = 3.6%, 95% CI - 4.2%, 11.4%). CONCLUSIONS Both individual and group acupuncture therapy delivered in primary care settings reduced chronic pain and improved physical function at 12 weeks; non-inferiority of group was not shown. TRIAL REGISTRATION Clinicaltrials.gov # NCT02456727.
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Affiliation(s)
- M. Diane McKee
- Department of Family and Social Medicine, Albert Einstein College of Medicine, New York, USA
- Department of Family Medicine and Community Health, University of Massachusetts Medical School, Worcester, USA
| | - Arya Nielsen
- Department of Family Medicine & Community Health, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Belinda Anderson
- Department of Family and Social Medicine, Albert Einstein College of Medicine, New York, USA
- Pacific College of Oriental Medicine, Chicago, USA
| | - Elizabeth Chuang
- Department of Family and Social Medicine, Albert Einstein College of Medicine, New York, USA
| | - Mariel Connolly
- Department of Family and Social Medicine, Albert Einstein College of Medicine, New York, USA
| | - Qi Gao
- Department of Family and Social Medicine, Albert Einstein College of Medicine, New York, USA
| | - Eric N Gil
- Department of Family and Social Medicine, Albert Einstein College of Medicine, New York, USA
| | - Claudia Lechuga
- Department of Family and Social Medicine, Albert Einstein College of Medicine, New York, USA
- Institute of Clinical and Translational Research, Albert Einstein College of Medicine, New York, USA
| | - Mimi Kim
- Department of Family and Social Medicine, Albert Einstein College of Medicine, New York, USA
| | - Huma Naqvi
- Department of Rehab Medicine, Albert Einstein College of Medicine, New York, USA
| | - Benjamin Kligler
- Department of Family and Social Medicine, Albert Einstein College of Medicine, New York, USA
- Department of Family Medicine & Community Health, Icahn School of Medicine at Mount Sinai, New York, USA
- Integrative Health Coordinating Center , U.S. Veterans Health Administration, Washington, D.C., USA
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14
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Citkovitz C, Betts D. Obstetrical Acupuncture: Reflections on a Much-Needed Special Issue. Med Acupunct 2019; 31:325-326. [PMID: 32952803 DOI: 10.1089/acu.2019.29132.cit] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Claudia Citkovitz
- Department of Rehabilitation Medicine, NYU Langone Hospital, Brooklyn, NY
| | - Debra Betts
- NICM Health Research Institute, Western Sydney University, Sydney, Australia
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15
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Nielsen A, Wieland LS. Cochrane reviews on acupuncture therapy for pain: A snapshot of the current evidence. Explore (NY) 2019; 15:434-439. [PMID: 31636020 DOI: 10.1016/j.explore.2019.08.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Cochrane is an international non-profit organization established in 1993 to produce and disseminate high quality and unbiased systematic reviews of evidence on health care interventions. At the forefront of systematic review methodology, Cochrane is generally accepted to be among the most carefully prepared and rigorous sources of systematic review evidence. There are numerous Cochrane reviews on nonpharmacologic interventions for pain and multiple Cochrane reviews evaluating acupuncture therapy in pain conditions. But how complete and up to date are those reviews relative to other rigorous systematic reviews with meta-analyses of acupuncture therapy for pain published in the literature? In this 'snapshot' overview, we found 22 relevant Cochrane reviews, some concluding that acupuncture therapy is probably useful for treating specific pain conditions. However, many of the conditions for which acupuncture is most commonly used are either not represented in Cochrane reviews or the existing Cochrane reviews are seriously outdated and do not reflect current evidence. This creates confusion with the risks of adverse effects and addiction liability associated with pain medications, the prevalence of chronic pain, the ongoing opioid epidemic and the need for evidence-based options for pain as part of comprehensive pain care. Clinicians and patients want clarification on safe and effective options to treat pain. Issues involving reviewed trials' inadequate use of sham comparators, of acupuncture as a complex intervention with interactive components and a shift in research focus from efficacy trials to real-world pragmatic trials are discussed in relation to updating Cochrane reviews of acupuncture therapy for pain.
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Affiliation(s)
- Arya Nielsen
- Icahn School of Medicine at Mount Sinai, Department of Family Medicine & Community Health, United States.
| | - L Susan Wieland
- University of Maryland School of Medicine, Center for Integrative Medicine, United States
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