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Hohenschurz-Schmidt DJ, Cherkin D, Rice AS, Dworkin RH, Turk DC, McDermott MP, Bair MJ, DeBar LL, Edwards RR, Farrar JT, Kerns RD, Markman JD, Rowbotham MC, Sherman KJ, Wasan AD, Cowan P, Desjardins P, Ferguson M, Freeman R, Gewandter JS, Gilron I, Grol-Prokopczyk H, Hertz SH, Iyengar S, Kamp C, Karp BI, Kleykamp BA, Loeser JD, Mackey S, Malamut R, McNicol E, Patel KV, Sandbrink F, Schmader K, Simon L, Steiner DJ, Veasley C, Vollert J. Research objectives and general considerations for pragmatic clinical trials of pain treatments: IMMPACT statement. Pain 2023; 164:1457-1472. [PMID: 36943273 PMCID: PMC10281023 DOI: 10.1097/j.pain.0000000000002888] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 01/09/2023] [Accepted: 01/12/2023] [Indexed: 03/23/2023]
Abstract
ABSTRACT Many questions regarding the clinical management of people experiencing pain and related health policy decision-making may best be answered by pragmatic controlled trials. To generate clinically relevant and widely applicable findings, such trials aim to reproduce elements of routine clinical care or are embedded within clinical workflows. In contrast with traditional efficacy trials, pragmatic trials are intended to address a broader set of external validity questions critical for stakeholders (clinicians, healthcare leaders, policymakers, insurers, and patients) in considering the adoption and use of evidence-based treatments in daily clinical care. This article summarizes methodological considerations for pragmatic trials, mainly concerning methods of fundamental importance to the internal validity of trials. The relationship between these methods and common pragmatic trials methods and goals is considered, recognizing that the resulting trial designs are highly dependent on the specific research question under investigation. The basis of this statement was an Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT) systematic review of methods and a consensus meeting. The meeting was organized by the Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks (ACTTION) public-private partnership. The consensus process was informed by expert presentations, panel and consensus discussions, and a preparatory systematic review. In the context of pragmatic trials of pain treatments, we present fundamental considerations for the planning phase of pragmatic trials, including the specification of trial objectives, the selection of adequate designs, and methods to enhance internal validity while maintaining the ability to answer pragmatic research questions.
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Affiliation(s)
- David J. Hohenschurz-Schmidt
- Pain Research, Department of Surgery & Cancer, Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Dan Cherkin
- Department of Family Medicine, University of Washington and Kaiser Permanente Washington Health Research Institute, Seattle, WA, United States
| | - Andrew S.C. Rice
- Pain Research, Department of Surgery & Cancer, Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Robert H. Dworkin
- Department of Anesthesiology and Perioperative Medicine, University of Rochester Medical Center, Rochester, NY, United States
| | - Dennis C. Turk
- Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, United States
| | - Michael P. McDermott
- Department of Biostatistics and Computational Biology, University of Rochester, Rochester, NY, United States
| | - Matthew J. Bair
- VA Center for Health Information and Communication, Regenstrief Institute, and Indiana University School of Medicine, Indianapolis, IN, United States
| | - Lynn L. DeBar
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, United States
| | | | - John T. Farrar
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, PA, United States
| | - Robert D. Kerns
- Departments of Psychiatry, Neurology and Psychology, Yale University, New Haven, CT, United States
| | - John D. Markman
- Neuromedicine Pain Management and Translational Pain Research, University of Rochester School of Medicine and Dentistry, Rochester, NY, United States
| | - Michael C. Rowbotham
- Department of Anesthesia, University of California San Francisco School of Medicine, San Francisco, CA, United States
| | - Karen J. Sherman
- Kaiser Permanente Washington Health Research Institute and Department of Epidemiology, University of Washington, Seattle WA, United States
| | - Ajay D. Wasan
- Departments of Anesthesiology & Perioperative Medicine, and Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Penney Cowan
- American Chronic Pain Association, Rocklin, CA, United States
| | - Paul Desjardins
- Department of Diagnostic Sciences, School of Dental Medicine, Rutgers University, Newark, NJ, United States
| | - McKenzie Ferguson
- Department of Pharmacy Practice, Southern Illinois University Edwardsville, Edwardsville, IL, United States
| | - Roy Freeman
- Department of Neurology, Harvard Medical School, Boston, MA, United States
| | - Jennifer S. Gewandter
- Department of Anesthesiology and Perioperative, University of Rochester, Rochester, NY, United States
| | - Ian Gilron
- Departments of Anesthesiology & Perioperative Medicine, Biomedical & Molecular Sciences, Centre for Neuroscience Studies, and School of Policy Studies, Queen's University, Kingston, ON, Canada
| | - Hanna Grol-Prokopczyk
- Department of Sociology, University at Buffalo, State University of New York, Buffalo NY, United States
| | - Sharon H. Hertz
- Hertz and Fields Consulting, Inc, Silver Spring, MD, United States
| | | | - Cornelia Kamp
- Center for Health and Technology (CHeT), Clinical Materials Services Unit (CMSU), University of Rochester Medical Center, Rochester, NY, United States
| | | | - Bethea A. Kleykamp
- Department of Anesthesiology and Perioperative Medicine, University of Rochester Medical Center, Rochester, NY, United States
| | - John D. Loeser
- Departments of Neurological Surgery and Anesthesia and Pain Medicine, University of Washington, Seattle, WA, United States
| | - Sean Mackey
- Department of Anesthesiology, Perioperative, and Pain Medicine, Neurosciences and Neurology, Stanford University School of Medicine, Palo Alto, CA, United States
| | | | - Ewan McNicol
- Department of Pharmacy Practice, Massachusetts College of Pharmacy and Health Sciences, Boston, MA, United States
| | - Kushang V. Patel
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, United States
| | - Friedhelm Sandbrink
- Department of Neurology, Washington DC Veterans Affairs Medical Center, Washington, DC, United States
- Department of Neurology, George Washington University, Washington, DC, United States
| | - Kenneth Schmader
- Department of Medicine-Geriatrics, Center for the Study of Aging, Duke University Medical Center, and Geriatrics Research Education and Clinical Center, Durham VA Medical Center, Durham, NC, United States
| | - Lee Simon
- SDG, LLC, Cambridge, MA, United States
| | | | - Christin Veasley
- Chronic Pain Research Alliance, North Kingstown, RI, United States
| | - Jan Vollert
- Pain Research, Department of Surgery and Cancer, Imperial College London, London, United Kingdom
- Division of Neurological Pain Research and Therapy, Department of Neurology, University Hospital of Schleswig-Holstein, Campus Kiel, Germany
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital Muenster, Muenster, Germany
- Neurophysiology, Mannheim Center of Translational Neuroscience (MCTN), Medical Faculty Mannheim, Heidelberg University, Heidelberg, Germany
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Hohenschurz-Schmidt D, Vase L, Scott W, Annoni M, Ajayi OK, Barth J, Bennell K, Berna C, Bialosky J, Braithwaite F, Finnerup NB, Williams ACDC, Carlino E, Cerritelli F, Chaibi A, Cherkin D, Colloca L, Côté P, Darnall BD, Evans R, Fabre L, Faria V, French S, Gerger H, Häuser W, Hinman RS, Ho D, Janssens T, Jensen K, Johnston C, Juhl Lunde S, Keefe F, Kerns RD, Koechlin H, Kongsted A, Michener LA, Moerman DE, Musial F, Newell D, Nicholas M, Palermo TM, Palermo S, Peerdeman KJ, Pogatzki-Zahn EM, Puhl AA, Roberts L, Rossettini G, Tomczak Matthiesen S, Underwood M, Vaucher P, Vollert J, Wartolowska K, Weimer K, Werner CP, Rice ASC, Draper-Rodi J. Recommendations for the development, implementation, and reporting of control interventions in efficacy and mechanistic trials of physical, psychological, and self-management therapies: the CoPPS Statement. BMJ 2023; 381:e072108. [PMID: 37230508 DOI: 10.1136/bmj-2022-072108] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Affiliation(s)
- David Hohenschurz-Schmidt
- Pain Research, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK
- Research Department, University College of Osteopathy, London, UK
| | - Lene Vase
- Department of Psychology and Behavioural Sciences, School of Business and Social Sciences, Aarhus University, Denmark
| | - Whitney Scott
- Health Psychology Section, Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King's College London; INPUT Pain Management Unit, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Marco Annoni
- Italian National Research Council, Interdepartmental Centre for Research Ethics and Integrity, Rome, Italy
| | - Oluwafemi K Ajayi
- Department of Arts and Music, College of Human Sciences, University of South Africa, Pretoria, South Africa
| | - Jürgen Barth
- Institute for Complementary and Integrative Medicine, University Hospital Zurich and University of Zurich, Switzerland
| | - Kim Bennell
- Centre for Health, Exercise and Sports Medicine, Department of Physiotherapy, University of Melbourne, VIC, Australia
| | - Chantal Berna
- Centrer for Integrative and Complementary Medicine, Pain Center, Division of Anesthesiology, Sense Institute, Lausanne University Hospital, Lausanne University, Lausanne, Switzerland
| | - Joel Bialosky
- Department of Physical Therapy, University of Florida, Gainesville FL, USA; Brooks-PHHP Research Collaboration, Jacksonville, FL, USA
| | | | - Nanna B Finnerup
- Danish Pain Research Centre, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Amanda C de C Williams
- Research Department of Clinical, Educational & Health Psychology, University College London, London, UK
| | - Elisa Carlino
- Department of Neuroscience Rita Levi Montalcini, University of Turin, Turin, Italy
| | | | - Aleksander Chaibi
- Department for Interdisciplinary Health Sciences, Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Dan Cherkin
- Osher Center for Integrative Health, Department of Family Medicine, University of Washington, Seattle, WA, USA
| | - Luana Colloca
- Department of Pain and Translational Symptom Science, School of Nursing; Department of Anesthesiology, School of Medicine; University of Maryland, Baltimore, MD, USA
| | - Pierre Côté
- Faculty of Health Sciences, Institute for Disability and Rehabilitation Research, Ontario Tech University, Oshawa, ON, Canada
| | - Beth D Darnall
- Stanford Pain Relief Innovations Lab; Stanford University School of Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Stanford, CA, USA
| | - Roni Evans
- Integrative Health & Wellbeing Research Program; Center for Spirituality and Healing, University of Minnesota, Minneapolis, MN, USA
| | - Laurent Fabre
- Centre Européen d'Enseignement Supérieur de l'Ostéopathie, Paris, France
| | - Vanda Faria
- Department of Psychology, Uppsala University, Uppsala, Sweden; Smell & Taste Clinic, Department of Otorhinolaryngology, TU Dresden, Dresden, Germany; Brain and Eye Pain Imaging Lab, Pain and Affective Neuroscience Center, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA; Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Simon French
- Department of Chiropractic, Faculty of Medicine, Health and Human Sciences, Macquarie University, NSW, Australia
| | - Heike Gerger
- Erasmus MC, University Medical Centre Rotterdam, Department of General Practice, Rotterdam, the Netherlands; Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, the Netherlands
| | - Winfried Häuser
- Department Psychosomatic Medicine and Psychotherapy, Technische Universität München, Munich, Germany
| | - Rana S Hinman
- Centre for Health, Exercise & Sports Medicine, University of Melbourne, Melbourne, VIC, Australia
| | - Dien Ho
- Center for Health Humanities, School of Arts and Sciences, Massachusetts College of Pharmacy and Health Sciences, Boston MA, USA
| | - Thomas Janssens
- Health Psychology, KU Leuven; Ebpracticenet, Leuven, Belgium
| | - Karin Jensen
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Chris Johnston
- BC Patient Safety & Quality Council's Patient Voices Network; Health Research BC's Partnership-Ready Network; Health Standards Organization's Emergency Management Technical Committee & Working Group
| | - Sigrid Juhl Lunde
- Department of Psychology and Behavioural Sciences, School of Business and Social Sciences, Aarhus University, Denmark
| | - Francis Keefe
- Duke University, School of Medicine, Durham, NC, USA
| | - Robert D Kerns
- Departments of Psychiatry, Neurology, and Psychology, Yale University, New Haven, CT, USA
| | - Helen Koechlin
- Division of Psychosomatics and Psychiatry, University Children's Hospital Zurich; Division of Child and Adolescent Health Psychology, Department of Psychology, University of Zurich, Zurich, Switzerland; Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Alice Kongsted
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark; Chiropractic Knowledge Hub, Odense, Denmark
| | - Lori A Michener
- Division of Biokinesiology and Physical Therapy, University of Southern California, Los Angeles CA, USA
| | - Daniel E Moerman
- College of Arts, Sciences, and Letters, Behavioral Sciences, University of Michigan, Dearborn, MI, USA
| | - Frauke Musial
- National Research Centre in Complementary and Alternative Medicine, Department of Community Medicine, Faculty of Health Science UiT, Arctic University of Norway, Tromsø, Norway
| | | | - Michael Nicholas
- Pain Management Research Institute, University of Sydney Medical School (Northern) and Kolling Institute of Medical Research at Royal North Shore Hospital, Sydney, Australia
| | - Tonya M Palermo
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA
| | - Sara Palermo
- Diagnostic and Technology Department, Neuroradiology Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy; Department of Psychology, University of Turin, Turin, Italy
| | - Kaya J Peerdeman
- Unit Health, Medical and Neuropsychology, Leiden University, Leiden, the Netherlands
| | - Esther M Pogatzki-Zahn
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany
| | | | - Lisa Roberts
- University of Southampton and University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Giacomo Rossettini
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, Campus of Savona, Savona, Italy; School of Physiotherapy, University of Verona, Verona, Italy
| | - Susan Tomczak Matthiesen
- Department of Psychology and Behavioural Sciences, School of Business and Social Sciences, Aarhus University, Denmark
| | - Martin Underwood
- Warwick Clinical Trials Unit; University of Warwick, Coventry, UK; University Hospitals Coventry and Warwickshire, Coventry, UK
| | - Paul Vaucher
- School of Health Sciences Fribourg, HES-SO University of Applied Sciences and Arts Western Switzerland, Switzerland
| | - Jan Vollert
- Pain Research, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK; Division of Neurological Pain Research and Therapy, Department of Neurology, University Hospital of Schleswig-Holstein, Campus Kiel, Germany; Neurophysiology, Mannheim Centre of Translational Neuroscience, Medical Faculty Mannheim, Heidelberg University, Germany; Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital Muenster, Germany
| | - Karolina Wartolowska
- Nuffield Department of Clinical Neurosciences, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - Katja Weimer
- Department of Psychosomatic Medicine and Psychotherapy, Ulm University Medical Centre, Ulm, Germany
| | - Christoph Patrick Werner
- School of Psychology, Faculty of Science, University of Sydney, Australia; Department of Clinical Research, University Hospital Basel, Switzerland
| | - Andrew S C Rice
- Pain Research, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK
| | - Jerry Draper-Rodi
- Research Department, University College of Osteopathy, London, UK
- National Council for Osteopathic Research, London, UK
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Hsu C, Evers S, Balderson BH, Sherman KJ, Foster NE, Estlin K, Levine M, Cherkin D. Adaptation and Implementation of the STarT Back Risk Stratification Strategy in a US Health Care Organization: A Process Evaluation. Pain Med 2020; 20:1105-1119. [PMID: 30272177 DOI: 10.1093/pm/pny170] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To support implementation of effective treatments for back pain that can be delivered to a range of people, we summarize learnings from our process evaluation of the MATCH trial's implementation of an adaptation of the STarT Back risk-stratified care model. DESIGN Our logic model-driven evaluation focused primarily on qualitative data sources. SETTING This study took place in a US-based health care delivery system that had adapted and implemented the STarT Back stratified care approach. This was the first formal test of the strategy in a US setting. METHODS Data collection included observation of implementation activities, staff/provider interviews, and post-training evaluation questionnaires. Data were analyzed using thematic analysis of qualitative data and descriptive statistics for questionnaire data. RESULTS We found that both primary care teams and physical therapists at intervention clinics gave the training high scores on evaluation questionnaires and reported in the interviews that they found the training engaging and useful. However, there was significant variation in the extent to which the risk stratification strategy was incorporated into care. Some primary care providers reported that the intervention changed their conversations with patients and increased their confidence in working with patients with back pain. Providers using the STarT Back tool did not change referral rates for recommended matched treatments. CONCLUSIONS These insights provide guidance for future efforts to adapt and implement the STarT Back strategy and other complex practice change interventions. They emphasize the need for primary care-based interventions to minimize complexity and the need for ongoing monitoring and feedback.
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Affiliation(s)
- Clarissa Hsu
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington, USA
| | - Sarah Evers
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington, USA
| | - Benjamin H Balderson
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington, USA
| | - Karen J Sherman
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington, USA
| | - Nadine E Foster
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences, Keele University, Keele, Staffordshire, UK
| | - Katherin Estlin
- Open Door Fortuna Community Health Center, Fortuna, California
| | | | - Dan Cherkin
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington, USA
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Evers S, Hsu C, Sherman KJ, Balderson B, Hawkes R, Brewer G, La Porte AM, Yeoman J, Cherkin D. Patient Perspectives on Communication with Primary Care Physicians about Chronic Low Back Pain. Perm J 2018; 21:16-177. [PMID: 29035178 DOI: 10.7812/tpp/16-177] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVES Chronic low back pain (CLBP) is a common health problem with challenges for providing satisfactory care. This study was undertaken to identify opportunities to improve key aspects of physicians' communications with CLBP-affected patients. METHODS A series of 3 focus groups, each with 7 to 11 patients with CLBP, were recruited from primary care settings and grouped by risk level of reduced function resulting from back pain, to elicit perspectives about interactions with their primary care physicians. Analysis of focus group transcripts used an iterative process based on a thematic approach and a priori concepts. RESULTS A total of 28 patients participated in the focus groups. Patient comments about communicating with physicians around CLBP fit into themes of listening and empathy, validating pain experiences, conducting effective CLBP assessment, providing clear diagnosis and information, and collaboratively working on treatment. Patients shared that physicians can foster positive interactions with CLBP-affected patients by sharing personal experiences of chronic pain, being truthful about not having all the answers and being clear about how patients can benefit from referrals, reviewing the patient's previous treatments before beginning conversations about treatment options, providing follow-up instructions, giving patients a diagnosis beyond "chronic pain," and explaining the role of imaging in their care. CONCLUSION This study provides specific steps that physicians in the US can take to improve physician-patient interactions during primary care visits pertaining to CLBP. The findings could inform physician training, development of educational materials for patients, and future research.
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Affiliation(s)
- Sarah Evers
- Research Associate at Kaiser Permanente Washington Health Research Institute in Seattle.
| | - Clarissa Hsu
- Assistant Investigator at Kaiser Permanente Washington Health Research Institute in Seattle.
| | - Karen J Sherman
- Scientific Investigator at Kaiser Permanente Washington Health Research Institute in Seattle.
| | - Ben Balderson
- Research Associate at Kaiser Permanente Washington Health Research Institute and a Psychologist for Kaiser Permanente Washington-Behavioral Health in Seattle.
| | - Rene Hawkes
- Project Manager at Kaiser Permanente Washington Health Research Institute in Seattle.
| | - Georgie Brewer
- Patient Partner at Kaiser Permanente Washington Health Research Institute in Seattle.
| | - Anne-Marie La Porte
- Patient Partner at Kaiser Permanente Washington Health Research Institute in Seattle.
| | - John Yeoman
- Patient Partner at Kaiser Permanente Washington Health Research Institute in Seattle.
| | - Dan Cherkin
- Emeritus Senior Scientific Investigator at Kaiser Permanente Washington Health Research Institute in Seattle.
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Foster NE, Anema JR, Cherkin D, Chou R, Cohen SP, Gross DP, Ferreira PH, Fritz JM, Koes BW, Peul W, Turner JA, Maher CG. Prevention and treatment of low back pain: evidence, challenges, and promising directions. Lancet 2018; 391:2368-2383. [PMID: 29573872 DOI: 10.1016/s0140-6736(18)30489-6] [Citation(s) in RCA: 1146] [Impact Index Per Article: 191.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Revised: 07/18/2017] [Accepted: 10/20/2017] [Indexed: 12/15/2022]
Abstract
Many clinical practice guidelines recommend similar approaches for the assessment and management of low back pain. Recommendations include use of a biopsychosocial framework to guide management with initial non-pharmacological treatment, including education that supports self-management and resumption of normal activities and exercise, and psychological programmes for those with persistent symptoms. Guidelines recommend prudent use of medication, imaging, and surgery. The recommendations are based on trials almost exclusively from high-income countries, focused mainly on treatments rather than on prevention, with limited data for cost-effectiveness. However, globally, gaps between evidence and practice exist, with limited use of recommended first-line treatments and inappropriately high use of imaging, rest, opioids, spinal injections, and surgery. Doing more of the same will not reduce back-related disability or its long-term consequences. The advances with the greatest potential are arguably those that align practice with the evidence, reduce the focus on spinal abnormalities, and ensure promotion of activity and function, including work participation. We have identified effective, promising, or emerging solutions that could offer new directions, but that need greater attention and further research to determine if they are appropriate for large-scale implementation. These potential solutions include focused strategies to implement best practice, the redesign of clinical pathways, integrated health and occupational interventions to reduce work disability, changes in compensation and disability claims policies, and public health and prevention strategies.
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Affiliation(s)
- Nadine E Foster
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences, Keele University, Staffordshire, UK.
| | - Johannes R Anema
- Department of Public and Occupational Health and Amsterdam Public Health Research Institute, VU University Medical Centre, Amsterdam, Netherlands
| | - Dan Cherkin
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - Roger Chou
- Department of Clinical Epidemiology and Medical Informatics and Department of Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Steven P Cohen
- Johns Hopkins School of Medicine, Baltimore, MD, USA; Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Douglas P Gross
- Department of Physical Therapy, University of Alberta, Edmonton, AB, Canada
| | - Paulo H Ferreira
- Faculty of Health Sciences, University of Sydney, Sydney, NSW, Australia
| | - Julie M Fritz
- Department of Physical Therapy and Athletic Training, University of Utah, Salt Lake City, UT, USA
| | - Bart W Koes
- Department of General Practice, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Wilco Peul
- Department of Neurosurgery, Leiden University, Leiden, Netherlands
| | - Judith A Turner
- Department of Psychiatry and Behavioral Sciences, and Department of Rehabilitation Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Chris G Maher
- Sydney School of Public Health, University of Sydney, NSW, Australia
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Jones SMW, Lange J, Turner J, Cherkin D, Ritenbaugh C, Hsu C, Berthoud H, Sherman K. Development and Validation of the EXPECT Questionnaire: Assessing Patient Expectations of Outcomes of Complementary and Alternative Medicine Treatments for Chronic Pain. J Altern Complement Med 2016; 22:936-946. [PMID: 27689427 DOI: 10.1089/acm.2016.0242] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Patient expectations may be associated with outcomes of complementary and alternative medicine (CAM) treatments for chronic pain. However, a psychometrically sound measure of such expectations is needed. OBJECTIVES The purpose of this study was to develop and evaluate a questionnaire to assess individuals' expectations regarding outcomes of CAM treatments for chronic low back pain (CLBP), as well as a short form of the questionnaire. METHODS An 18-item draft questionnaire was developed through literature review, cognitive interviews with individuals with CLBP, CAM practitioners, and expert consultation. Two samples completed the questionnaire: (1) a community sample (n = 141) completed it via an online survey before or soon after starting a CAM treatment for CLBP, and (2) participants (n = 181) in randomized clinical trials evaluating CAM treatments for CLBP or fibromyalgia completed it prior to or shortly after starting treatment. Factor structure, internal consistency, test-retest reliability, and criterion validity were examined. RESULTS Based on factor analyses, 10 items reflecting expectations (used to create a total score) and three items reflecting hopes (not scored) were selected for the questionnaire. The questionnaire had high internal consistency, moderate test-retest reliability, and moderate correlations with other measures of expectations. A three-item short form also had adequate reliability and validity. CONCLUSIONS The Expectations for Complementary and Alternative Medicine Treatments (EXPECT) questionnaire can be used in research to assess individuals' expectations of treatments for chronic pain. It is recommended that the three hope questions are included (but not scored) to help respondents distinguish between hopes and expectations. The short form may be appropriate for clinical settings and when expectation measurement is not a primary focus.
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Affiliation(s)
| | - Jane Lange
- 2 Fred Hutchinson Cancer Research Center , Seattle, WA
| | | | - Dan Cherkin
- 1 Group Health Research Institute , Seattle, WA
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Turner J, Sherman K, Anderson M, Balderson B, Cook A, Cherkin D. (481) Catastrophizing, pain self-efficacy, mindfulness, and acceptance: relationships and changes among individuals receiving CBT, MBSR, or usual care for chronic back pain. The Journal of Pain 2015. [DOI: 10.1016/j.jpain.2015.01.401] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Bayley PJ, Isaac L, Kong JY, Adamson MM, Ashford JW, Mahoney LA, Beltran M, Brown-Elhillali A, Held A, Ajayi A, Belcher H, Bond A, Mason H, Lemaster C, Shaw S, Mullin C, Holick E, Saper R, Braun TD, Riley KE, Park CL, Trehern AE, Davis MB, Mastronardi EL, Butzer B, Khalsa SBS, Shorter SM, Reinhardt KM, Cope S, Cheung C, Justice C, Wyman J, Cook-Cottone CP, Daly LA, Haden SC, Hagins M, Danhauer SC, Griffin LP, Avis NE, Sohl SJ, Lawrence J, Jesse MT, Addington EL, Messino MJ, Giguere JK, Lucas SL, Wiliford SK, Shaw E, de Manincor M, Bensoussan A, Smith C, Fahey P, Bourchier S, Desrochers DIM, Viswanathan S, Partharasathy BR, Doherty K, Moye J, Walsh C, Pokaski-Azar J, Gosian J, Chapman J, King K, Sohl S, Danhauer S, Dunbar E, Gabriel MG, Huebner M, Hofmann SG, Khalsa SBS, Gaskins RB, Jennings E, Thind H, Fava JL, Hartman S, Bock BC, Gramann P, Haaz S, Bingham CO, Bartlett SJ, Hagins M, States R, Selfe T, Innes K, Harris AR, Jennings PA, Abenavoli RM, Katz DA, Hudecek KM, Greenberg MT, Jeter PE, Nkodo AF, Haaz S, Dagnelie G, Keosaian JE, Lemaster CM, Chao M, Saper RB, King KD, Gosian J, Doherty K, Walsh C, Pokaski Azar J, Chapman J, Danhauer SC, Moye J, Kinser P, Bourguignon C, Taylor A, Mahoney LA, Bayley PJ, Collery LM, Menzies-Toman D, Nilsson M, Frykman V, Noggle JJ, Braun T, Khalsa SBS, Nosaka M, Okamura H, Fukatu N, Potts A, Weidknecht K, Coulombe S, Davies B, Ryan C, Day D, Reale J, Staples JK, Knoefel J, Herman C, Riley KE, Park CL, Bedesin EY, Stewart VM, Riley KE, Braun TD, Park CL, Pescatello LS, Davis MB, Trehern AE, Mastronardi EL, Rioux J, Rosen RK, Thind H, Gaskins R, Jennings E, Morrow K, Williams D, Bock B, Rousseau D, Jackson E, Schmid AA, Miller KK, Van Puymbroeck M, Debaun EL, Schalk N, Dierks TD, Altenburger P, Damush T, Williams LS, Selman L, Citron T, Howie-Esquivel J, McDermott K, Milic M, Donesky D, Shook A, Ruzic R, Galloway F, Van Puymbroeck M, Miller KK, Schalk N, Schmid AA, Ward LJ, Stebbings S, Sherman K, Cherkin D, Baxter GD, West JI, Duffy N, Liang B. 2013 SYR Accepted Poster Abstracts. Int J Yoga Therap 2013; 23:32-53. [PMID: 24016822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
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Eisenberg D, Buring J, Hrbek A, Davis R, Connelly M, Cherkin D, Levy D, Cunningham M, O'Connor B, Post D. OA11.02. A model of integrative care for low back pain. Altern Ther Health Med 2012. [PMCID: PMC3373735 DOI: 10.1186/1472-6882-12-s1-o42] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Ward L, Stebbings S, Cherkin D, Baxter D. P02.41. Yoga for musculoskeletal conditions: a systematic review of intervention protocols. BMC Complement Altern Med 2012. [PMCID: PMC3373782 DOI: 10.1186/1472-6882-12-s1-p97] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Ward L, Stebbings S, Sherman K, Cherkin D, Baxter D. P05.47. Yoga for musculoskeletal conditions: a Delphi survey to establish international consensus of core intervention components. Altern Ther Health Med 2012. [PMCID: PMC3373941 DOI: 10.1186/1472-6882-12-s1-p407] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Oberg E, Bradley R, Sherman K, Hsu C, Calabrese C, Cherkin D. P05.52 . Patient-reported experiences with adjunctive naturopathic care for type 2 diabetes in CAM-naïve patients. BMC Complement Altern Med 2012. [PMCID: PMC3373932 DOI: 10.1186/1472-6882-12-s1-p412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Sherman K, Wellman R, Cook A, Cherkin D. OA11.03. Mediators of the effects of yoga and stretching on chronic low back pain (cLBP) outcomes: results from the YES RCT. Altern Ther Health Med 2012. [PMCID: PMC3373559 DOI: 10.1186/1472-6882-12-s1-o43] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Bradley R, Sherman K, Catz S, Calabrese C, Oberg E, Cherkin D. OA07.04. Self-care, use of CAM and satisfaction with health care in people with inadequately controlled Type 2 diabetes. BMC Complement Altern Med 2012. [PMCID: PMC3373685 DOI: 10.1186/1472-6882-12-s1-o28] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Bradley R, Sherman K, Catz S, Oberg E, Calabrese C, Cherkin D. P02.100. Adjunctive naturopathic care in type 2 diabetes: patient-reported and clinical outcomes. Altern Ther Health Med 2012. [PMCID: PMC3373555 DOI: 10.1186/1472-6882-12-s1-p156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Bradley R, Sherman KJ, Catz S, Calabrese C, Oberg EB, Jordan L, Grothaus L, Cherkin D. Adjunctive naturopathic care for type 2 diabetes: patient-reported and clinical outcomes after one year. Altern Ther Health Med 2012; 12:44. [PMID: 22512949 PMCID: PMC3403984 DOI: 10.1186/1472-6882-12-44] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2012] [Accepted: 04/18/2012] [Indexed: 11/25/2022]
Abstract
Background Several small, uncontrolled studies have found improvements in self-care behaviors and reductions in clinical risk in persons with type 2 diabetes who received care from licensed naturopathic physicians. To extend these findings and determine the feasibility and promise of a randomized clinical trial, we conducted a prospective study to measure the effects of adjunctive naturopathic care (ANC) in primary care patients with inadequately controlled type 2 diabetes. Methods Forty patients with type 2 diabetes were invited from a large integrated health care system to receive up to eight ANC visits for up to one year. Participants were required to have hemoglobin A1c (HbA1c) values between 7.5-9.5 % and at least one additional cardiovascular risk factor (i.e., hypertension, hyperlipidemia or overweight). Standardized instruments were administered by telephone to collect outcome data on self-care, self-efficacy, diabetes problem areas, perceived stress, motivation, and mood. Changes from baseline scores were calculated at 6- and 12-months after entry into the study. Six and 12-month changes in clinical risk factors (i.e., HbA1c, lipid and blood pressure) were calculated for the ANC cohort, and compared to changes in a cohort of 329 eligible, non-participating patients constructed using electronic medical records data. Between-cohort comparisons were adjusted for age, gender, baseline HbA1c, and diabetes medications. Six months was pre-specified as the primary endpoint for outcome assessment. Results Participants made 3.9 ANC visits on average during the year, 78 % of which occurred within six months of entry into the study. At 6-months, significant improvements were found in most patient-reported measures, including glucose testing (P = 0.001), diet (P = 0.001), physical activity (P = 0.02), mood (P = 0.001), self-efficacy (P = 0.0001) and motivation to change lifestyle (P = 0.003). Improvements in glucose testing, mood, self-efficacy and motivation to change lifestyle persisted at 12-months (all P < 0.005). For clinical outcomes, mean HbA1c decreased by −0.90 % (P = 0.02) in the ANC cohort at 6-months, a −0.51 % mean difference compared to usual care (P = 0.07). Reductions at 12-months were not statistically significant (−0.34 % in the ANC cohort, P = 0.14; -0.37 % difference compared to the usual care cohort, P = 0.12). Conclusions Improvements were noted in self-monitoring of glucose, diet, self-efficacy, motivation and mood following initiation of ANC for patients with inadequately controlled type 2 diabetes. Study participants also experienced reductions in blood glucose that exceeded those for similar patients who did not receive ANC. Randomized clinical trials will be necessary to determine if ANC was responsible for these benefits.
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Furlan AD, Yazdi F, Tsertsvadze A, Gross A, Van Tulder M, Santaguida L, Cherkin D, Gagnier J, Ammendolia C, Ansari MT, Ostermann T, Dryden T, Doucette S, Skidmore B, Daniel R, Tsouros S, Weeks L, Galipeau J. Complementary and alternative therapies for back pain II. Evid Rep Technol Assess (Full Rep) 2010:1-764. [PMID: 23126534 PMCID: PMC4781408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
BACKGROUND Back and neck pain are important health problems with serious societal and economic implications. Conventional treatments have been shown to have limited benefit in improving patient outcomes. Complementary and Alternative Medicine (CAM) therapies offer additional options in the management of low back and neck pain. Many trials evaluating CAM therapies have poor quality and inconsistent results. OBJECTIVES To systematically review the efficacy, effectiveness, cost-effectiveness, and harms of acupuncture, spinal manipulation, mobilization, and massage techniques in management of back, neck, and/or thoracic pain. DATA SOURCES MEDLINE, Cochrane Central, Cochrane Database of Systematic Reviews, CINAHL, and EMBASE were searched up to 2010; unpublished literature and reference lists of relevant articles were also searched. study selection: All records were screened by two independent reviewers. Primary reports of comparative efficacy, effectiveness, harms, and/or economic evaluations from randomized controlled trials (RCTs) of the CAM therapies in adults (age ≥ 18 years) with back, neck, or thoracic pain were eligible. Non-randomized controlled trials and observational studies (case-control, cohort, cross-sectional) comparing harms were also included. Reviews, case reports, editorials, commentaries or letters were excluded. DATA EXTRACTION Two independent reviewers using a predefined form extracted data on study, participants, treatments, and outcome characteristics. RESULTS 265 RCTs and 5 non-RCTs were included. Acupuncture for chronic nonspecific low back pain was associated with significantly lower pain intensity than placebo but only immediately post-treatment (VAS: -0.59, 95 percent CI: -0.93, -0.25). However, acupuncture was not different from placebo in post-treatment disability, pain medication intake, or global improvement in chronic nonspecific low back pain. Acupuncture did not differ from sham-acupuncture in reducing chronic non-specific neck pain immediately after treatment (VAS: 0.24, 95 percent CI: -1.20, 0.73). Acupuncture was superior to no treatment in improving pain intensity (VAS: -1.19, 95 percent CI: 95 percent CI: -2.17, -0.21), disability (PDI), functioning (HFAQ), well-being (SF-36), and range of mobility (extension, flexion), immediately after the treatment. In general, trials that applied sham-acupuncture tended to produce negative results (i.e., statistically non-significant) compared to trials that applied other types of placebo (e.g., TENS, medication, laser). Results regarding comparisons with other active treatments (pain medication, mobilization, laser therapy) were less consistent Acupuncture was more cost-effective compared to usual care or no treatment for patients with chronic back pain. For both low back and neck pain, manipulation was significantly better than placebo or no treatment in reducing pain immediately or short-term after the end of treatment. Manipulation was also better than acupuncture in improving pain and function in chronic nonspecific low back pain. Results from studies comparing manipulation to massage, medication, or physiotherapy were inconsistent, either in favor of manipulation or indicating no significant difference between the two treatments. Findings of studies regarding costs of manipulation relative to other therapies were inconsistent. Mobilization was superior to no treatment but not different from placebo in reducing low back pain or spinal flexibility after the treatment. Mobilization was better than physiotherapy in reducing low back pain (VAS: -0.50, 95 percent CI: -0.70, -0.30) and disability (Oswestry: -4.93, 95 percent CI: -5.91, -3.96). In subjects with acute or subacute neck pain, mobilization compared to placebo significantly reduced neck pain. Mobilization and placebo did not differ in subjects with chronic neck pain. Massage was superior to placebo or no treatment in reducing pain and disability only amongst subjects with acute/sub-acute low back pain. Massage was also significantly better than physical therapy in improving back pain (VAS: -2.11, 95 percent CI: -3.15, -1.07) or disability. For subjects with neck pain, massage was better than no treatment, placebo, or exercise in improving pain or disability, but not neck flexibility. Some evidence indicated higher costs for massage use compared to general practitioner care for low back pain. Reporting of harms in RCTs was poor and inconsistent. Subjects receiving CAM therapies reported soreness or bleeding on the site of application after acupuncture and worsening of pain after manipulation or massage. In two case-control studies cervical manipulation was shown to be significantly associated with vertebral artery dissection or vertebrobasilar vascular accident. CONCLUSIONS Evidence was of poor to moderate grade and most of it pertained to chronic nonspecific pain, making it difficult to draw more definitive conclusions regarding benefits and harms of CAM therapies in subjects with acute/subacute, mixed, or unknown duration of pain. The benefit of CAM treatments was mostly evident immediately or shortly after the end of the treatment and then faded with time. Very few studies reported long-term outcomes. There was insufficient data to explore subgroup effects. The trial results were inconsistent due probably to methodological and clinical diversity, thereby limiting the extent of quantitative synthesis and complicating interpretation of trial results. Strong efforts are warranted to improve the conduct methodology and reporting quality of primary studies of CAM therapies. Future well powered head to head comparisons of CAM treatments and trials comparing CAM to widely used active treatments that report on all clinically relevant outcomes are needed to draw better conclusions.
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Hsu C, Bluespruce J, Sherman K, Cherkin D. Unanticipated benefits of CAM therapies for back pain: an exploration of patient experiences. J Altern Complement Med 2010; 16:157-63. [PMID: 20180688 DOI: 10.1089/acm.2009.0188] [Citation(s) in RCA: 122] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES The goal of this research was to provide insight into the full range of meaningful outcomes experienced by patients who participate in clinical trials of complementary and alternative medicine (CAM) therapies. DESIGN Data for this study were assembled from five randomized trials evaluating six different CAM treatments for back pain. A conventional qualitative content analysis was conducted on responses to open-ended questions asked at the end of telephone interviews assessing treatment outcomes. SUBJECTS A total of 884 study participants who received CAM therapies completed post-treatment interviews. Of these, 327 provided qualitative data used in the analyses. RESULTS Our analysis identified a range of positive outcomes that participants in CAM trials considered important but were not captured by standard quantitative outcome measures. Positive outcome themes included increased options and hope, increased ability to relax, positive changes in emotional states, increased body awareness, changes in thinking that increased the ability to cope with back pain, increased sense of well-being, improvement in physical conditions unrelated to back pain, increased energy, increased patient activation, and dramatic improvements in health or well-being. The first five of these themes were mentioned for all of the CAM treatments, while others tended to be more treatment specific. A small fraction of these effects were considered life transforming. CONCLUSIONS Our findings suggest that standard measures used to assess the outcomes of CAM treatments fail to capture the full range of outcomes that are important to patients. In order to capture the full impact of CAM therapies, future trials should include a broader range of outcomes measures.
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Affiliation(s)
- Clarissa Hsu
- Center for Community Health and Evaluation, Group Health Research Institute, Seattle, WA, USA
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Furlan AD, van Tulder M, Cherkin D, Tsukayama H, Lao L, Koes B, Berman B. Acupuncture and dry-needling for low back pain: an updated systematic review within the framework of the cochrane collaboration. Spine (Phila Pa 1976) 2005; 30:944-63. [PMID: 15834340 DOI: 10.1097/01.brs.0000158941.21571.01] [Citation(s) in RCA: 220] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
OBJECTIVES To assess the effects of acupuncture and dry-needling for the treatment of nonspecific low back pain. BACKGROUND Low back pain is usually a self-limiting condition that tends to improve spontaneously over time. However, for many people, back pain becomes a chronic or recurrent problem for which a large variety of therapeutic interventions are employed. SEARCH STRATEGY We updated the searches from 1996 to February 2003 in CENTRAL, MEDLINE, and EMBASE. We also searched the Chinese Cochrane Centre database of clinical trials and Japanese databases to February 2003. SELECTION CRITERIA Randomized controlled trials of acupuncture (that involved needling) or dry-needling for adults with nonspecific acute/subacute or chronic low back pain. DATA COLLECTION AND ANALYSIS Two reviewers independently assessed methodologic quality (using the criteria recommended by the Cochrane Back Review Group) and extracted data. The trials were combined using meta-analysis methods or levels of evidence when the data reported did not allow statistical pooling. RESULTS Thirty-five randomized clinical trials were included: 20 were published in English, 7 in Japanese, 5 in Chinese, and 1 each in Norwegian, Polish, and German. There were only 3 trials of acupuncture for acute low back pain. These studies did not justify firm conclusions because of their small sample sizes and low methodologic quality. For chronic low back pain, there is evidence of pain relief and functional improvement for acupuncture compared to no treatment or sham therapy. These effects were only observed immediately after the end of the sessions and in short-term follow-up. There is also evidence that acupuncture, added to other conventional therapies, relieves pain and improves function better than the conventional therapies alone. However, the effects are only small. Dry-needling appears to be a useful adjunct to other therapies for chronic low back pain. No clear recommendations could be made about the most effective acupuncture technique. CONCLUSIONS The data do not allow firm conclusions regarding the effectiveness of acupuncture for acute low back pain. For chronic low back pain, acupuncture is more effective for pain relief and functional improvement than no treatment or sham treatment immediately after treatment and in the short-term only. Acupuncture is not more effective than other conventional and "alternative" treatments. The data suggest that acupuncture and dry-needling may be useful adjuncts to other therapies for chronic low back pain. Because most of the studies were of lower methodologic quality, there is a clear need for higher quality trials in this area.
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Cherkin D, Sherman KJ. Conceptualization and evaluation of an optimal healing environment for chronic low-back pain in primary care. J Altern Complement Med 2005; 10 Suppl 1:S171-8. [PMID: 15630834 DOI: 10.1089/1075553042245764] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
This paper describes what a primary care-based optimal healing environment (OHE) might look like for chronic low-back pain, and presents a research protocol to evaluate the effect of such an environment on a variety of important patient and clinician outcomes. Such an environment may be conceived of as having three major components: (1) the health care environment in which the primary care team works; (2) the cognitive, technical, clinical and organizational skills of the team, and; (3) the "healing" skills of the team members, particularly the primary care physician. A variety of study designs available for evaluating the effects of an OHE on patient and clinical outcomes are described. Decisions about study site and population, appropriate outcome measures, required sample sizes, methods of patient recruitment, treatment protocol and analytic issues would need to be tailored to the specific requirements of the study. Because many elements of an OHE designed for chronic back pain seen in primary care settings would also be relevant for the other 98% of primary care visits, it is preferable to design, implement and evaluate an OHE for primary care practice in general than for only a specific condition.
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Affiliation(s)
- Dan Cherkin
- Group Health Center for Health Services, Seattle, WA 98101, USA.
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Cherkin D, Sherman KJ. Conceptualization and Evaluation of an Optimal Healing Environment for Chronic Low-Back Pain in Primary Care. J Altern Complement Med 2004. [DOI: 10.1089/acm.2004.10.s-171] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Affiliation(s)
- Dan Cherkin
- Group Health Center for Health Services, Seattle, WA
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Cherkin D, Sherman K, Eisenberg D. Back pain. Beyond the backache. Newsweek 2002; 140:56. [PMID: 12501512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/28/2023]
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Cherkin D, Street J. Alternative medicine--the case of herbal remedies. N Engl J Med 1999; 340:565; author reply 566. [PMID: 10026043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
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Cherkin D. Why patients use alternative medicine. JAMA 1998; 280:1660; author reply 1661. [PMID: 9831988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
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Shekelle PG, Andersson G, Bombardier C, Cherkin D, Deyo R, Keller R, Lee C, Liang M, Lipscomb B, Spratt K. A brief introduction to the critical reading of the clinical literature. Spine (Phila Pa 1976) 1994; 19:2028S-2031S. [PMID: 7801178 DOI: 10.1097/00007632-199409151-00002] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Clinicians are bombarded by reports of new diagnostic tests or treatments for patients with spine problems. To provide the best possible patient care, clinicians need to be able to critically appraise the results of such studies for validity and relevance to patient care. Important questions to be asked of any description of diagnostic or treatment studies are the following questions: 1) Are the patients described in detail so that you can decide whether they are comparable to those that you see in your practice? 2) Are the treatments or assessments described well enough so that you could provide the same for your patients? 3) Was a clinically relevant endpoint measured? 4) Is there an appropriate comparison group? 5) Are potential sources of bias appropriately attended to? 6) Are the results clinically significant?
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Abstract
OBJECTIVE To assess the effects of a practice style of back pain management consistent with self-care (infrequent prescribing of pain medications and bed rest) on long-term functional outcomes, costs of care, and patient satisfaction. DESIGN A quasi-experimental observational study in which primary care physicians (n = 44) were categorized according to one of three practice style groups defined by a low, moderate, or high frequency of prescribing pain medications and bed rest for many patients (average, 24 patients per physician). SETTING Primary care practices of a large, staff model health maintenance organization, Group Health Cooperative of Puget Sound. PATIENTS Consecutive patients with back or neck pain of participating primary care physicians. Patients were interviewed 1 month (n = 1071) and 1 year and 2 years (n = 911) after their index visits. RESULTS Patients in the three practice style groups rated similarly the quality of medical care received for back pain. Patients treated by physicians who infrequently prescribed pain medications and bed rest were more satisfied with education about back pain. On a scale of 0 to 10, the mean rating of agreement with the statement, "After your visit the doctor, you fully understood how to take care of your back problem," was 5.6 +/- 3.6 among patients of physicians who frequently prescribed medication and rest and was 6.6 +/- 3.5) among those who infrequently prescribed medication and bed rest. At 1 month, 30% of patients of physicians who infrequently prescribed medications and bed rest were graded as having moderate to severe activity limitation because of back pain, whereas 37% of patients in the moderate group had this grading, and 46% of patients of physicians who frequently prescribed were graded as having moderate to severe activity limitation. Differences in activity limitation by practice style group were no longer evident at 1 or 2 years of follow-up. The total 1-year costs of back care were higher among patients seen by physicians who frequently prescribed bed rest and pain medications (cost, $768 +/- $1592) than among those seen by physicians who infrequently prescribed (cost, $428 +/- $665), due largely to differences in inpatient and specialty care costs. The adjusted difference in costs, after controlling for case-mix variables, was $277 (95% Cl, $85.50 to $471.32). CONCLUSIONS A practice style consistent with back pain self-care yielded similar long-term pain and functional outcomes at lower cost and was associated with higher satisfaction with patient education compared with a practice style characterized by more frequent prescribing of pain medications and bed rest.
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Affiliation(s)
- M Von Korff
- Center for Health Studies, Group Health Cooperative of Puget Sound, Seattle, WA 98101
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Abstract
Outcomes of primary care back pain patients (N = 1128) were studied at 1 year after seeking care. Changes in depression depending on outcome, and predictors of poor outcome were evaluated. Less than one back pain patient in five reported recent onset (first onset within the previous 6 months). One year after seeking care, the large majority of both recent and nonrecent-onset patients reported having back pain in the previous month (69% vs. 82%). A significant minority of both recent and nonrecent-onset patients had either a poor functional outcome (14% vs. 21%) or continuing high intensity pain without appreciable disability (10% vs. 16%). Predictors of poor outcome included pain-related disability, days in pain, lower educational attainment, and female gender. Among initially dysfunctional patients with persistent pain, one half were improved and one third had a good outcome at the 1-year follow-up. Among initially dysfunctional patients who experienced a good outcome, elevated depressive symptoms improved to normal levels at follow-up. The outcome of back pain was predicted by pain-related disability and days in pain rather than by recency of onset, so it may be more meaningful to distinguish characteristic levels of pain intensity, pain-related disability, and pain persistence than to classify patients as acute or chronic.
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Affiliation(s)
- M Von Korff
- Center for Health Studies, Group Health Cooperative of Puget Sound, Seattle, Washington
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Abstract
We wished to determine whether patient satisfaction was related to physicians' confidence in their abilities to effectively manage low back pain, and to examine their attitudes about patients with back pain. The confidence and attitudes of primary care providers were determined using self-administered questionnaires. Patient satisfaction with care was assessed during telephone interviews conducted 3 weeks after a clinic visit for low back pain. The study was conducted in a primary care clinic of a large health maintenance organization. Completed surveys were obtained from 21 primary care providers (18 physicians and three physician assistants) and 270 of their patients with low back pain. Three satisfaction scales specific to low back pain were used to measure patient satisfaction with regard to information received from provider, caring, and effectiveness of treatment. The results showed that the providers' attitudes about patients with low back pain were not associated with any of the patient satisfaction measures. However, patients of more confident providers were significantly more satisfied with the information they received than were patients of less confident providers. These differences could not be explained by years in practice, length of visit, patient demographics, or the severity and duration of low back pain. These findings suggest that providers who have more confidence in their abilities to effectively manage low back pain may in fact be more effective patient educators.
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Affiliation(s)
- T Bush
- Group Health Cooperative of Puget Sound, Center for Health Studies, Seattle, Wash
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Cherkin D, Barlow B. Survey strategies discussed: using more than one questionnaire. Am J Public Health 1992; 82:127-8. [PMID: 1536323 PMCID: PMC1694426 DOI: 10.2105/ajph.82.1.127-b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Cherkin D, Deyo RA, Berg AO, Bergman JJ, Lishner DM. Evaluation of a physician education intervention to improve primary care for low-back pain. I. Impact on physicians. Spine (Phila Pa 1976) 1991; 16:1168-72. [PMID: 1836676 DOI: 10.1097/00007632-199110000-00007] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
In an effort to improve the cost-effectiveness of primary care for low-back pain, we developed, implemented, and evaluated a physician education intervention. The program was designed to provide family physicians with specific information, tools, and techniques that our previous studies and the literature suggested should be associated with more satisfying and cost-effective care for low-back pain. The in-clinic educational intervention included feedback of the findings of our previous studies of care for back pain (comparing family physicians and chiropractors), an up-to-date summary of scientific knowledge relevant to the management of back pain in primary care, a videotape contrasting ineffective and effective patient encounters, and a clinical assessment form for low-back pain. The back pain-related beliefs, attitudes, and behaviors of 15 primary care providers in a large health maintenance organization clinic and of 14 family physicians in six group practices were assessed before and after the intervention. Significant increases were noted in the proportions of providers who felt confident they knew how to manage low-back pain, who believed their patients were satisfied, and who claimed they reassured patients that they did not have serious disease. The intervention, however, had little impact on the prevalence of negative feelings about patients with back pain or frustration with patients who wanted their doctor to "fix" their problem. The intervention had a similar impact on health maintenance organization and fee-for-service physicians.
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Affiliation(s)
- D Cherkin
- Center for Health Studies, Seattle Veterans Affairs Medical Center, Washington
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Abstract
A physician education intervention was previously found to have significantly improved perceived physician knowledge, confidence, and patient-reassuring behavior in the treatment of low-back pain. This study examined whether this intervention, presented in a health maintenance organization clinic, had an effect on patient outcomes. Outcomes of care for 148 patients seen for low-back pain before the intervention were compared with outcomes of care for 157 patients seen after the intervention. Patients were telephoned 2-4 weeks after their back-pain visit and were asked about symptom improvement, amount of disability, and satisfaction with care. Satisfaction was measured with a three-dimensional instrument for low-back pain developed specifically for this study, which was found to be valid and reliable. The preintervention and postintervention patient cohorts were similar in terms of key baseline variables. Despite its apparent benefit to physicians, the intervention did not result in significant improvements in any patient outcomes, even for the subset of patients whose physicians had perceived the greatest benefit.
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Affiliation(s)
- D Cherkin
- Center for Health Studies, Seattle, Washington
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Affiliation(s)
- R A Deyo
- Department of Medicine, University of Washington, Seattle
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Deyo RA, Cherkin D, Conrad D. The Back Pain Outcome Assessment Team. Health Serv Res 1990; 25:733-7. [PMID: 2147670 PMCID: PMC1065661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Affiliation(s)
- R A Deyo
- Back Pain Outcome Assessment Team, University of Washington, Seattle 98195
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Abstract
Family physicians in the State of Washington were surveyed about their knowledge and views about chiropractors; 79 per cent (476) responded. Sixty-six per cent indicated discomfort with what they believed chiropractors do while acknowledging their effectiveness for some patients; 25 per cent viewed chiropractors as an excellent source of care for some musculoskeletal problems and only 3 per cent dismissed chiropractors as quacks that patients should avoid; 57 per cent admitted having encouraged patients to see a chiropractor. These views are less negative than those of organized medicine.
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Affiliation(s)
- D Cherkin
- Center for Health Studies of Group Health Cooperative of Puget Sound, Seattle, WA 98121
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Schneeweiss R, Rosenblatt R, Cherkin D, Hart G. Clustering diagnoses. Fam Pract 1985; 2:252-3. [PMID: 4085709 DOI: 10.1093/fampra/2.4.252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
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Abstract
Use of oral contraceptives was associated with a significant increase in the frequency of dry socket after extraction of mandibular third molars. The probability of dry socket increases with the estrogen dose in the oral contraceptive. The risk of dry socket associated with oral contraceptives can be minimized by performing extractions during days 23 through 28 of the tablet cycle.
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Abstract
An evaluation of the American Medical Association's (AMA) Physician Masterfile is presented here on a state level. Both completeness and reliability of the AMA data were assessed for physicians licensed and living in Washington State. Comparison of the AMA data with state -LICENsure data indicated excellent agreement, with only a small proportion of license physicians "missing" from the AMA Masterfile. Their absence was due largely to differences in the manner in which the two systems updated their files. The reliability of the AMA data was checked by comparing it with similar, independently gathered survey data on birth date, birthplace, medical school, type of practice, specialty, board certifications, and employer. In general, despite some minor deficiencies, the AMA data were shown to be highly reliable.
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