Perceptions of other integrative health therapies by Veterans with pain who are receiving massage

Surgical Patients' Attitudes, Norms, and Behaviors Regarding Pain

The study purpose was to examine the attitudes, norms, and behaviors of surgical patients of different ethnic/cultural backgrounds regarding pain and pain management. The study was a descriptive qualitative study guided by the Theory of Planned Behaviors and the Theory of Transcultural Nursing. The sample consisted of 12 postoperative patients on a surgical observation unit within 48 hours of surgery. The results indicated the majority of patients expected to feel pain after surgery and wanted pain to be treated completely. However, overall, pain indicates that something is wrong. Patients expect nurses to assess their pain frequently, view the pain site, and to act promptly to relieve pain, otherwise they feel ignored. Patients had limited knowledge about the pharmacological treatments, and prefer to combine medications with non-pharmacologic and complementary therapies. The clinical implications indicate the expectation of a comprehensive postoperative pain assessment, and education regarding pharmacological, non-pharmacological, and complementary pain treatments.

Whole Health Use and Interest Across Veterans With Co-Occurring Chronic Pain and PTSD: An Examination of the 18 VA Medical Center Flagship Sites

Objective

Veterans Healthcare Administration (VHA) conducted a large demonstration project of a holistic Whole Health approach to care in 18 medical centers, which included making complementary and integrative health (CIH) therapies more widely available. This evaluation examines patterns of service use among Veterans with chronic pain, comparing those with and without PTSD.

Methods

We assessed the use of Whole Health services in a cohort of Veterans with co-occurring chronic pain and PTSD (n = 1698; 28.9%), comparing them to Veterans with chronic musculoskeletal pain only (n = 4170; 71.1%). Data was gathered from VA electronic medical records and survey self-report. Whole Health services were divided into Core Whole Health services (e.g., Whole Health coaching) and CIH services (e.g., yoga). Logistic regression was used to determine whether Veterans with co-occurring chronic pain and PTSD utilized more Whole Health services compared to Veterans with chronic pain but without PTSD.

Results

A total of 40.1% of Veterans with chronic pain and PTSD utilized Core Whole Health services and 53.2% utilized CIH therapies, compared to 28.3% and 40.0%, respectively, for Veterans with only chronic pain. Adjusting for demographics and additional comorbidities, Veterans with comorbid chronic pain and PTSD were 1.24 ( 95% CI: 1.12, 1.35, P ≤ .001) times more likely than Veterans with chronic pain only to use Core Whole Health services, and 1.23 ( 95% CI: 1.14, 1.31, P ≤ .001) times more likely to use CIH therapies. Survey results also showed high interest levels in Core Whole Health services and CIH therapies among Veterans who were not already using these services.

Conclusion

Early implementation efforts in VHA led to high rates of use of Core Whole Health and CIH therapy use among Veterans with co-occurring chronic pain and PTSD. Future assessments should examine how well these additional services are meeting the needs of Veterans in both groups.

Care Outcomes for Chiropractic Outpatient Veterans (COCOV): a qualitative study with veteran stakeholders from a pilot trial of multimodal chiropractic care

BACKGROUND

Low back pain (LBP) is common among military veterans seeking treatment in Department of Veterans Affairs (VA) healthcare facilities. As chiropractic services within VA expand, well-designed pragmatic trials and implementation studies are needed to assess clinical effectiveness and program uptake. This study evaluated veteran stakeholder perceptions of the feasibility and acceptability of care delivery and research processes in a pilot trial of multimodal chiropractic care for chronic LBP.

METHODS

The qualitative study was completed within a mixed-method, single-arm, pragmatic, pilot clinical trial of chiropractic care for LBP conducted in VA chiropractic clinics. Study coordinators completed semi-structured, in person or telephone interviews with veterans near the end of the 10-week trial. Interviews were audiorecorded and transcribed verbatim. Qualitative content analysis using a directed approach explored salient themes related to trial implementation and delivery of chiropractic services.

RESULTS

Of 40 participants, 24 completed interviews (60% response; 67% male gender; mean age 51.7 years). Overall, participants considered the trial protocol and procedures feasible and reported that the chiropractic care and recruitment methods were acceptable. Findings were organized into 4 domains, 10 themes, and 21 subthemes. Chiropractic service delivery domain encompassed 3 themes/8 subthemes: scheduling process (limited clinic hours, scheduling future appointments, attendance barriers); treatment frequency (treatment sufficient for LBP complaint, more/less frequent treatments); and chiropractic clinic considerations (hire more chiropractors, including female chiropractors; chiropractic clinic environment; patient-centered treatment visits). Outcome measures domain comprised 3 themes/4 subthemes: questionnaire burden (low burden vs. time-consuming or repetitive); relevance (items relevant for LBP study); and timing and individualization of measures (questionnaire timing relative to symptoms, personalized approach to outcomes measures). The online data collection domain included 2 themes/4 subthemes: user concerns (little difficulty vs. form challenges, required computer skills); and technology issues (computer/internet access, junk mail). Clinical trial planning domain included 2 themes/5 subthemes: participant recruitment (altruistic service by veterans, awareness of chiropractic availability, financial compensation); and communication methods (preferences, potential barriers).

CONCLUSIONS

This qualitative study highlighted veteran stakeholders' perceptions of VA-based chiropractic services and offered important suggestions for conducting a full-scale, veteran-focused, randomized trial of multimodal chiropractic care for chronic LBP in this clinical setting.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03254719.

Virtual reality for management of cancer pain: Study rationale and design

Background

Patients with cancer commonly experience acute and/or chronic moderate to severe pain related to disease, treatment, or both. While pain management strategies typically focus on drug therapies, non-pharmacological interventions may prove beneficial without risk of significant clinical side effects or contraindications. One novel strategy, virtual reality, has been shown to improve pain control in addition to usual pharmacological interventions.

Methods

This is a prospective, two-armed, single center randomized controlled study of a virtual reality intervention in 128 hospitalized subjects with cancer reporting pain rated at least 4/10 compared to an active control intervention, two-dimensional guided imagery. The primary outcome is change in self-reported pain score. Secondary end points include changes in self-reported distress, quality of life, and satisfaction with pain management. We will also explore patient preferences for distraction therapy content and themes through quantitative analysis of survey data, semi-structured interviews, and a collaging exercise.

Conclusion

This randomized controlled study aims to provide empiric data to support application and expansion of novel technologies such as virtual reality to augment usual pharmacological pain management strategies in hospitalized patients with cancer.

Transforming Health and Resiliency Through Integration of Values-based Experiences: Implementation of an Electronic Evidence-based Whole Health Clinical Program

BACKGROUND

Complementary and integrative health (CIH) is the foundation of the Department of Veterans Affairs (VA) Whole Health System program (WH), including Transforming Health and Resiliency through Integration of Values-based Experiences (THRIVE). The global COVID-19 pandemic prompted an urgent need to provide services such as THRIVE while following guidelines for social distancing.

OBJECTIVE

The objective of this paper was to describe the systematic implementation of THRIVE using an electronic delivery model.

METHODS

The study involved an observational clinical program implementation project using the RE-AIM framework to contextualize the implementation strategies and results, and then the implementation of an electronically delivered CIH group medical appointment program (eTHRIVE).

RESULTS

Clinical staff transitioned to 100% electronic delivery of the THRIVE curriculum using the new eTHRIVE delivery model. The current electronic delivery model, eTHRIVE, has effectively enrolled 10-12 veterans per cohort, with 8 cohorts, totaling 87 veterans to date. eTHRIVE attrition has been 6% (5/87) since initiation.

CONCLUSIONS

The current climate of the VA WH programmatic initiative combined with the public health needs during a global pandemic prompted the move of THRIVE program into an electronic format to broaden scalability and reach.

A complementary and integrative health group-based program pilot demonstrates positive health outcomes with female Veterans

INTRODUCTION

Transforming Health and Resiliency through Integration of Values-based Experiences (THRIVE) is an evidence-based 14-week curriculum-based group medical appointment clinical program. THRIVE is based on principles of integrative medicine, positive psychology, and acceptance and commitment therapy. The goal of this paper is to review findings from a local THRIVE program implementation piloted in the Women's Health outpatient clinics on mental and physical health indicators.

MATERIALS AND METHODS

Pilot data were obtained for 14 THRIVE cohorts of female veterans enrolled from outpatient clinics at the James A. Haley veterans' Hospital in Tampa, FL between 2016 and 2018 (N = 201). THRIVE assessments were conducted as part of the THRIVE program, at the first visit (baseline), mid-way, and at the end of the program. Data were collected using self-administered paper-pencil method on standardized scales for physical and mental health (Patient Health Questionnaire, Generalized Anxiety Disorder Questionnaire, Acceptance and Action Questionnaire-II, Satisfaction With Life Scale, and the physical and mental function components of the Short Form Survey). Linear mixed effects models were used to examine change in physical and mental health scales over time while adjusting for age, race (white vs. other), and cohort. In addition, we examined whether the rate of change differed by age or race.

RESULTS

Improvement was seen for most scales across the 3 assessments (p < 0.05) with the exception of physical composite score of the Short Form Survey (p = 0.487). Participants reported that pain interfering with work significantly decreased from "quite a bit" at baseline to "moderately" by assessment 3 (p = 0.042). Older ages had lower baseline scores on the Patient Health Questionnaire and Acceptance and Action Questionnaire than younger ages, but younger ages had a greater rate of improvement over the intervention (p for interaction 0.016 and 0.056, respectively). Whites reported greater improvement in life satisfaction than non-whites (p for interaction 0.043). For physical composite score, whites had higher baseline score, but did not report significant improvement in physical function over the assessment period, while non-whites had lower baseline score, but did report significant improvement in physical function (p for interaction 0.059). Non-white veterans reported more pain interfering with work relative to white veterans (OR 5.9, 95% CI 1.79-19.43, p = 0.004).

CONCLUSIONS

We found significant improvement on self-reported mental health scales as well as improvement in how much pain interferes with work in a pilot sample of women veterans over the 14-week program.

Investigation into clients' perception of postoperative physiotherapy for dogs undergoing cranial cruciate ligament disease surgery

AIM

To evaluate clients' understanding, perception and experience of postoperative physiotherapy after undergoing an osteotomy technique for cranial cruciate ligament disease (CCLD).

METHOD

A retrospective questionnaire was sent to 202 owners of dogs that underwent CCLD surgery at the Queen Mother Hospital for Animals between 1 January 2015 and 31 December 2017, with 63 responses obtained.

RESULTS

Significant differences were found in choice of physiotherapy between clients recommended or not by their vets (p<0.01), and between those offered additional information and those who were not (p<0.01). Of those who chose physiotherapy, 85% had a satisfactory experience. No difference was found in choice of physiotherapy between clients aware of its availability and those who were not (p=0.069). No association was found between cost of the service and clients' perception of cost-worthiness (p=0.169) or between cost-worthiness and recovery outcome (p=0.420). A correlation was found between clients' perception of cost-worthiness and satisfaction level (p=0.03). Clients' knowledge was related to the choice of physiotherapy (p=0.01), but not to other investigated factors. A significant relationship was found between clients' age and choice of physiotherapy (p=0.01), with younger clients choosing physiotherapy more often.

CONCLUSION

Veterinarians recommending physiotherapy and providing accurate information affect clients' decision to choose, and perception of, physiotherapy, in addition to clients' own knowledge.

Veteran Experiences Seeking Non-pharmacologic Approaches for Pain

Introduction

Pain is a longstanding and growing concern among US military veterans. Although many individuals rely on medications, a growing body of literature supports the use of complementary non-pharmacologic approaches when treating pain. Our objective is to characterize veteran experiences with and barriers to accessing alternatives to medication (e.g., non-pharmacologic treatments or non-pharmacologic approaches) for pain in primary care.

Materials and Methods

Data for this qualitative analysis were collected as part of the Effective Screening for Pain (ESP) study (2012-2017), a national randomized controlled trial of pain screening and assessment methods. This study was approved by the Veterans Affairs (VA) Central IRB and veteran participants signed written informed consent. We recruited a convenience sample of US military veterans in four primary care clinics and conducted semi-structured interviews (25-65 min) elucidating veteran experiences with assessment and management of pain in VA Healthcare Systems. We completed interviews with 36 veterans, including 7 females and 29 males, from three VA health care systems. They ranged in age from 28 to 94 yr and had pain intensity ratings ranging from 0 to 9 on the "pain now" numeric rating scale at the time of the interviews. We analyzed interview transcripts using constant comparison and produced mutually agreed upon themes.

Results

Veteran experiences with and barriers to accessing complementary non-pharmacologic approaches for pain clustered into five main themes: communication with provider about complementary approaches ("one of the best things the VA has ever given me was pain education and it was through my occupational therapist"), care coordination ("I have friends that go to small clinic in [area A] and I still see them down in [facility in area B] and they're going through headaches upon headaches in trying to get their information to their primary care docs"), veteran expectations about pain experience ("I think as a society we have shifted the focus to if this doctor doesn't relieve me of my pain I will find someone who does"), veteran knowledge and beliefs about various complementary non-pharmacologic approaches ("how many people know that tai chi will help with pain?… Probably none. I saw them doing tai chi down here at the VA clinic and the only reason I knew about it was because I saw it being done"), and access ("the only physical therapy I ever did… it helped…but it was a two-and-a-half-hour drive to get there three times a week… I can't do this"). Specific access barriers included local availability, time, distance, scheduling flexibility, enrollment, and reimbursement.

Conclusion

The veterans in this qualitative study expressed interest in using non-pharmacologic approaches to manage pain, but voiced complex multi-level barriers. Limitations of our study include that interviews were conducted only in five clinics and with seven female veterans. These limitations are minimized in that the clinics covered are diverse ranging to include urban, suburban, and rural residents. Future implementation efforts can learn from the veterans' voice to appropriately target veteran concerns and achieve more patient-centered pain care.

Providers' and Administrators' Perceptions of Complementary and Integrative Health Practices Across the Veterans Health Administration

OBJECTIVES

Use of complementary and integrative health (CIH) therapies is being promoted by the Veterans Health Administration (VA), but promotion may not equate to adoption. The purpose of this study was to explore whether perceptions regarding CIH at one VA medical center (VAMC) were similar to perceptions from a sample of other VAMCs.

DESIGN

This article reports a subset of qualitative findings from a mixed-methods study.

SETTING/PARTICIPANTS

Sites were recruited through a VA-wide CIH listserver. On the basis of site description (e.g., therapies offered, interest in CIH), sustained site interest, and geographic location, recorded interviews of 22 persons were conducted at 6 sites across the country.

OUTCOME MEASURES

Interviewees were asked the same questions as the single-site VAMC study respondents.

RESULTS

Variable access to CIH services across the VA created the need for workarounds. Multiple barriers (e.g., limited space and challenging credentialing) and facilitators (e.g., strong champion and high veteran demand) were cited. Respondents described nonpharmacologic pain control, the usefulness in treating mental health and/or post-traumatic stress disorder issues, and improvement of staff morale as additional reasons to promote CIH. Findings confirmed those from the earlier single-site VAMC phase of the study. Even the highest-performing sites reported struggling to meet veterans' demands for delivery of CIH.

CONCLUSIONS

Almost half of active-duty military personnel report the use of at least one type of CIH therapy. As active-duty personnel transition to veteran status, both their physical and mental healthcare needs can potentially benefit from CIH therapies. The VA must actively support local enthusiastic CIH proponents and receive congressional support if it is to actually meet its stated goal of providing personalized, proactive, patient-driven healthcare through the promotion of comprehensive CIH services to veterans.