Evaluation of intervention components to maximize yoga practice among people with chronic pain taking opioid agonist therapy: A factorial experiment using the multiphase optimization strategy framework

BACKGROUND

Chronic pain affects up to half of individuals taking opioid agonist therapy (OAT; i.e., methadone and buprenorphine) for opioid use disorder (OUD), and yoga-based interventions may be useful for decreasing pain-related disability. Whereas more yoga practice (i.e., higher "dosage") may improve pain-related outcomes, it can be challenging for people with chronic pain taking OAT to attend class regularly and sustain a regular personal yoga practice. Therefore, we plan to optimize a yoga-based intervention (YBI) package in order to support class attendance and personal practice, thus maximizing the yoga dose received.

STUDY DESIGN

Using the Multiphase Optimization Strategy (MOST) framework, we will conduct a factorial experiment to examine four intervention components that may be added to a weekly yoga class as part of a YBI. Components include: 1) personal practice videos featuring study yoga teachers, 2) two private sessions with a yoga teacher, 3) daily text messages to inspire personal practice, and 4) monetary incentives for class attendance. The primary outcome will be minutes per week engaged in yoga (including class attendance and personal practice). We plan to enroll 192 adults with chronic pain who are taking OAT for OUD in this 2x2x2x2 factorial experiment.

CONCLUSION

Results of the study will guide development of an optimized yoga-based intervention package that maximizes dosage of yoga received. The final treatment package can be tested in a multisite efficacy trial of yoga to reduce pain interference in daily functioning in people with chronic pain who are taking OAT.

TRIAL REGISTRATION

Pre-registration of the study was completed on ClinicalTrials.gov (identifier: NCT04641221).

Abstract P088: Comparison Of Lay Advisor Interventions For Hypertension Across Racial Groups In The United States

Background: Lay advisor interventions for hypertension are frequently tailored to a single racial group. We conducted a systematic review comparing components of lay advisor interventions for hypertension across racial groups in the US.

Methods: Multiple databases were searched from 1980 to 2020 using relevant search terms.

Results: Of 5986 articles, 14 studies were eligible for inclusion: 5 with predominantly white participants, 4 with Black participants, 3 with Hispanic participants and 2 with Asian participants. All studies but two were RCTs.

One study with white participants and one with Hispanic participants were clinic-based; all other studies were community-based. Lay advisors were matched to participants’ social groups in 13 studies and 1 study used health coaches with a bachelor's degree. Home visits were included in 44% (4/9) of studies with minority participants and in no studies with predominantly white participants. Most (4/5) studies with white participants included group education and one study had individual education. All studies with Black participants included only individual education. Two studies with Hispanic participants included group education while one study used health coach phone calls and home BP monitoring. Both studies with Asian participants included group education with follow-up individual education.

For BP outcomes: 3 studies with predominantly white participants, 3 with Black participants, 1 with Hispanic participants, and 2 with Asian participants showed statistically significant improvement. One health coach study with Hispanic participants showed a systolic BP reduction of 19.3 mm Hg; all other studies showed mean systolic BP improvements between 6 to 8.3 mm Hg across races. Three studies examined hypertension control outcomes, of which 2 studies with Asian participants showed improved hypertension control. Individualized low-intensity interventions were as effective as high-intensity interventions.

Conclusion: Lay advisor interventions were effective and mainly community-based across racial groups. Individualized education by lay advisors belonging to patients’ social groups may be a feasible and effective approach for health systems that care for diverse populations.

Yoga, Physical Therapy, and Back Pain Education for Sleep Quality in Low-Income Racially Diverse Adults with Chronic Low Back Pain: a Secondary Analysis of a Randomized Controlled Trial

BACKGROUND

Poor sleep is common among adults with chronic low back pain (cLBP), but the influence of cLBP treatments, such as yoga and physical therapy (PT), on sleep quality is under studied.

OBJECTIVE

Evaluate the effectiveness of yoga and PT for improving sleep quality in adults with cLBP.

DESIGN

Secondary analysis of a randomized controlled trial.

SETTING

Academic safety-net hospital and 7 affiliated community health centers.

PARTICIPANTS

A total of 320 adults with cLBP.

INTERVENTION

Twelve weekly yoga classes, 1-on-1 PT sessions, or an educational book.

MAIN MEASURES

Sleep quality was measured using the Pittsburgh Sleep Quality Index (PSQI) global score (0-21) at baseline, 12 weeks, and 52 weeks. Additionally, we also evaluated how the proportion of participants who achieved a clinically meaningful improvement in sleep quality (> 3-point reduction in PSQI) at 12 weeks varied by changes in pain and physical function at 6 weeks.

KEY RESULTS

Among participants (mean age = 46.0, 64% female, 82% non-white), nearly all (92%) reported poor sleep quality (PSQI > 5) at baseline. At 12 weeks, modest improvements in sleep quality were observed among the yoga (PSQI mean difference [MD] = - 1.19, 95% confidence interval [CI] - 1.82, - 0.55) and PT (PSQI MD = - 0.91, 95% CI - 1.61, - 0.20) groups. Participants who reported a ≥ 30% improvement in pain or physical function at 6 weeks, compared with those who improved < 10%, were more likely to be a sleep quality responder at 12 weeks (odds ratio [OR] = 3.51, 95% CI 1.73, 7.11 and OR = 2.16, 95% CI 1.18, 3.95, respectively). Results were similar at 52 weeks.

CONCLUSION

In a sample of adults with cLBP, virtually all with poor sleep quality prior to intervention, modest but statistically significant improvements in sleep quality were observed with both yoga and PT. Irrespective of treatment, clinically important sleep improvements at the end of the intervention were associated with mid-intervention pain and physical function improvements.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01343927.

Effectiveness of integrative medicine group visits in chronic pain and depressive symptoms: A randomized controlled trial

BACKGROUND

Current treatment options for chronic pain and depression are largely medication-based, which may cause adverse side effects. Integrative Medical Group Visits (IMGV) combines mindfulness techniques, evidence based integrative medicine, and medical group visits, and is a promising adjunct to medications, especially for diverse underserved patients who have limited access to non-pharmacological therapies.

OBJECTIVE

Determine the effectiveness of IMGV compared to a Primary Care Provider (PCP) visit in patients with chronic pain and depression.

DESIGN

9-week single-blind randomized control trial with a 12-week maintenance phase (intervention-medical groups; control-primary care provider visit).

SETTING

Academic tertiary safety-net hospital and 2 affiliated federally-qualified community health centers.

PARTICIPANTS

159 predominantly low income racially diverse adults with nonspecific chronic pain and depressive symptoms.

INTERVENTIONS

IMGV intervention- 9 weekly 2.5 hour in person IMGV sessions, 12 weeks on-line platform access followed by a final IMGV at 21 weeks.

MEASUREMENTS

Data collected at baseline, 9, and 21 weeks included primary outcomes depressive symptoms (Patient Health Questionnaire 9), pain (Brief Pain Inventory). Secondary outcomes included pain medication use and utilization.

RESULTS

There were no differences in pain or depression at any time point. At 9 weeks, the IMGV group had fewer emergency department visits (RR 0.32, 95% CI: 0.12, 0.83) compared to controls. At 21 weeks, the IMGV group reported reduction in pain medication use (Odds Ratio: 0.42, CI: 0.18-0.98) compared to controls.

LIMITATIONS

Absence of treatment assignment concealment for patients and disproportionate group attendance in IMGV.

CONCLUSION

Results demonstrate that low-income racially diverse patients will attend medical group visits that focus on non-pharmacological techniques, however, in the attention to treat analysis there was no difference in average pain levels between the intervention and the control group.

TRIAL REGISTRATION

clinicaltrials.gov NCT02262377.

Observational retrospective study of the association of initial healthcare provider for new-onset low back pain with early and long-term opioid use

OBJECTIVE

This study examined the association of initial provider treatment with early and long-term opioid use in a national sample of patients with new-onset low back pain (LBP).

DESIGN

A retrospective cohort study of patients with new-onset LBP from 2008 to 2013.

SETTING

The study evaluated outpatient and inpatient claims from patient visits, pharmacy claims and inpatient and outpatient procedures with initial providers seen for new-onset LBP.

PARTICIPANTS

216 504 individuals aged 18 years or older across the USA who were diagnosed with new-onset LBP and were opioid-naïve were included. Participants had commercial or Medicare Advantage insurance.

EXPOSURES

The primary independent variable is type of initial healthcare provider including physicians and conservative therapists (physical therapists, chiropractors, acupuncturists).

MAIN OUTCOME MEASURES

Short-term opioid use (within 30 days of the index visit) following new LBP visit and long-term opioid use (starting within 60 days of the index date and either 120 or more days' supply of opioids over 12 months, or 90 days or more supply of opioids and 10 or more opioid prescriptions over 12 months).

RESULTS

Short-term use of opioids was 22%. Patients who received initial treatment from chiropractors or physical therapists had decreased odds of short-term and long-term opioid use compared with those who received initial treatment from primary care physicians (PCPs) (adjusted OR (AOR) (95% CI) 0.10 (0.09 to 0.10) and 0.15 (0.13 to 0.17), respectively). Compared with PCP visits, initial chiropractic and physical therapy also were associated with decreased odds of long-term opioid use in a propensity score matched sample (AOR (95% CI) 0.21 (0.16 to 0.27) and 0.29 (0.12 to 0.69), respectively).

CONCLUSIONS

Initial visits to chiropractors or physical therapists is associated with substantially decreased early and long-term use of opioids. Incentivising use of conservative therapists may be a strategy to reduce risks of early and long-term opioid use.

Blood Lead Levels of Children Using Traditional Indian Medicine and Cosmetics: A Feasibility Study

Background

Traditional Indian cosmetics and Ayurvedic medicines may contain lead. Previous studies have shown a relationship between eye cosmetic use (kohl) in children and elevated blood lead levels (BLLs) > 10 µg/dL. However, an association between Ayurvedic use and elevated BLLs in children is unknown and understudied.

Methods

We assessed the feasibility of collecting BLLs in children attending Ayurvedic outpatient settings in India. Our pilot study took place over 3 days in the summer of 2010 at a large public Ayurveda hospital and a small pediatric clinic in southern India. Using a trained interpreter, we administered a standardized questionnaire in Malayalam, assessing sociodemographics, Ayurvedic medicine use, kohl use, and other potential risk factors for lead exposure, to parents of pediatric outpatients. We also analyzed BLLs using a portable lead analyzer.

Results

The study enrolled 29 children (mean age, 3.8 years). The mean BLL was 6.7 µg/dL (SD = 3.5; range, 3.5-20.2). Seventy-two percent of the children used Ayurvedic medicine in the past 2 years and 55% reported kohl use. Mean BLL of Ayurvedic users and nonusers was 6.2 µg/dL and 8.5 µg/dL, respectively (P = .08). Kohl users had a statistically significant higher BLL than nonusers (8.0 µg/dL vs 5.3 µg/dL, P = .03).

Conclusions

It is feasible to collect BLLs in pediatric Ayurvedic outpatient clinics in southern India. Collaborative relationships with community members and hospital staff were essential. Further research is needed to investigate Ayurveda and kohl use as risk factors for elevated lead burden among Indian children.

Health insurance design and conservative therapy for low back pain

OBJECTIVES

To determine the association of health insurance benefit design features with choice of early conservative therapy for patients with new-onset low back pain (LBP).

STUDY DESIGN

Observational study of 117,448 commercially insured adults 18 years or older presenting with an outpatient diagnosis of new-onset LBP between 2008 and 2013 as recorded in the OptumLabs Data Warehouse.

METHODS

We identified patients who chose a primary care physician (PCP), physical therapist, or chiropractor as their entry-point provider. The main analyses were logistic regression models that estimated the likelihood of choosing a physical therapist versus a PCP and choosing a chiropractor versus a PCP. Key independent variables were health plan type, co-payment, deductible, and participation in a health reimbursement account (HRA) or health savings account (HSA). Models controlled for patient demographic and clinical characteristics.

RESULTS

Selection of entry-point provider was moderately responsive to the incentives that patients faced. Those covered under plan types with greater restrictions on provider choice were less likely to choose conservative therapy compared with those covered under the least restrictive plan type. Results also indicated a general pattern of higher likelihood of treatment with physical therapy at lower levels of patient cost sharing. We did not observe consistent associations between participation in HRAs or HSAs and choice of conservative therapy.

CONCLUSIONS

Modification of health insurance benefit designs offers an opportunity for creating greater value in treatment of new-onset LBP by encouraging patients to choose noninvasive conservative management that will result in long-term economic and social benefits.

Lessons Learned and Strategies for Recruitment of Diverse, Low-income Patients into an Integrative Medical Group Visit Clinical Trial

OBJECTIVE

Description of recruitment methods and lessons learned in a randomized controlled trial of underserved patients using an integrative medical group visits intervention.

METHODS

Comparison of the demographic characteristics of participants screened and consented to the study as well as description of recruitment methods used.

OUTCOME MEASURES

This paper examines the characteristics of patients who were eligible compared to those who were not, characteristics of patients at the different sites, and patient characteristics over time (by comparing various cohorts) based on our experiences recruiting underserved patients.

RESULTS

We screened 338 patients, with 205 (60.6%) meeting eligibility criteria and 159 patients randomized and consented. 133 patients were found ineligible, with the most common reasons being low depression scores (n = 20), manic symptoms (n = 20), and psychotic symptoms (n = 19), and alcohol use (n = 15). We found demographic differences in patients recruited by different methods and at different sites- patients referred by provider letter were older than those referred by self-referral or provider referral (mean age/SD vs. mean age/SD, p = 0.0001). For site-specific differences, patients at DH were older (53 SD = 12.3) than those at the Boston Medical Center (49 SD = 11.3) and CSHC (p = 0.048) in pair-wise comparisons. Patients at DH were also more likely to be white (25%) as compared to BMC (18%) and DH (7%), while those at CSHC were more likely to be black (70%) (p = 0.008).

Novel peer review method for improving controlled substance prescribing in primary care

OBJECTIVE

Determine if peer feedback through a chart review tool (CRT) can impact opioid prescribing for patients with chronic noncancer pain in an outpatient family medicine clinic at an urban, safety-net teaching hospital and to assess providing practices.

DESIGN

A quality improvement (QI) project, comparing preopioid and postopioid prescribing practices.

SETTING

Outpatient family medicine clinic at urban, safety-net teaching hospital.

PATIENTS, PARTICIPANTS

A convenience sample of 16 family medicine physicians.

INTERVENTIONS

A CRT was developed to allow physicians to give peer feedback to one another about their opioid prescribing practices as part of a 1-year QI project. We assessed the deidentified data gathered from the CRT.

MAIN OUTCOME MEASURE(S)

Primary study outcome measures were the amount of opioids prescribed at the end of the QI project compared to the time of initial chart review. We also describe overall prescribing practices.

RESULTS

Ninety-nine patient charts from 14 different physicians were reviewed over 1 year. Sixty percent of patients had at least one violation of the clinic's controlled substance prescribing policy in the prior 6 months, and half of the violations were due to missed appointments with specialists to help manage pain. The mean dose of opioids decreased 2.6 mg morphine equivalent dose (MED)/day from time of chart review until the end of project, compared to a 6.9 mg MED/day increase that occurred from 12 months prior to chart review to the time of chart review (p=0.01). Fourteen patients (16 percent) of patients prescribed opioids were taken-off of opioids after the chart review.

CONCLUSIONS

Use of a CRT in an urban primary care clinic provided helpful insight on prescribing practices and has promise to improve quality of opioid prescribing.

Inpatient Massage Therapy Versus Music Therapy Versus Usual Care: A Mixed-methods Feasibility Randomized Controlled Trial

BACKGROUND

Little is known about the feasibility of providing massage or music therapy to medical inpatients at urban safety-net hospitals or the impact these treatments may have on patient experience.

OBJECTIVE

To determine the feasibility of providing massage and music therapy to medical inpatients and to assess the impact of these interventions on patient experience.

DESIGN

Single-center 3-arm feasibility randomized controlled trial.

SETTING

Urban academic safety-net hospital.

PATIENTS

Adult inpatients on the Family Medicine ward.

INTERVENTIONS

Massage therapy consisted of a standardized protocol adapted from a previous perioperative study. Music therapy involved a preference assessment, personalized compact disc, music-facilitated coping, singing/playing music, and/or songwriting. Credentialed therapists provided the interventions.

MEASUREMENTS

Patient experience was measured with the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) within 7 days of discharge. We compared the proportion of patients in each study arm reporting "top box" scores for the following a priori HCAHPS domains: pain management, recommendation of hospital, and overall hospital rating. Responses to additional open-ended postdischarge questions were transcribed, coded independently, and analyzed for common themes.

RESULTS

From July to December 2014, 90 medical inpatients were enrolled; postdischarge data were collected on 68 (76%) medical inpatients. Participants were 70% females, 43% non-Hispanic black, and 23% Hispanic. No differences between groups were observed on HCAHPS. The qualitative analysis found that massage and music therapy were associated with improved overall hospital experience, pain management, and connectedness to the massage or music therapist.

CONCLUSIONS

Providing music and massage therapy in an urban safety-net inpatient setting was feasible. There was no quantitative impact on HCAHPS. Qualitative findings suggest benefits related to an improved hospital experience, pain management, and connectedness to the massage or music therapist.

Design of the integrative medical group visits randomized control trial for underserved patients with chronic pain and depression

BACKGROUND

Given the public health crisis of opioid overprescribing for pain, there is a need for evidence-based non pharmacological treatment options that effectively reduce pain and depression. We aim to examine the effectiveness of the Integrative Medical Group Visits (IMGV) model in reducing chronic pain and depressive symptoms, as well as increasing pain self-management.

METHODS

This paper details the study design and implementation of an ongoing randomized controlled trial of the IMGV model as compared to primary care visits. The research aims to determine if the IMGV model is effective in achieving: a) a reduction in self-reported pain and depressive symptoms and 2) an improvement in the self-management of pain, through increasing pain self-efficacy and reducing use of self-reported pain medication. We intend to recruit 154 participants to be randomized in our intervention, the IMGV model (n=77) and to usual care (n=77).

CONCLUSIONS

Usual care of chronic pain through pharmacological treatment has mixed evidence of efficacy and may not improve quality of life or functional status. We aim to conduct a randomized controlled trial to evaluate the effectiveness of the IMGV model as compared to usual care in reducing self-reported pain and depressive symptoms as well as increasing pain management skills.

Interprofessional Competencies in Integrative Primary Healthcare

In October 2014, the National Center for Integrative Primary Healthcare (NCIPH) was launched as a collaboration between the University of Arizona Center for Integrative Medicine and the Academic Consortium for Integrative Health and Medicine and supported by a grant from the Health Resources and Services Administration. A primary goal of the NCIPH is to develop a core set of integrative healthcare (IH) competencies and educational programs that will span the interprofessional primary care training and practice spectra and ultimately become a required part of primary care education. This article reports on the first phase of the NCIPH effort, which focused on the development of a shared set of competencies in IH for primary care disciplines. The process of development, refinement, and adoption of 10 "meta-competencies" through a collaborative process involving a diverse interprofessional team is described. Team members represent nursing, the primary care medicine professions, pharmacy, public health, acupuncture, naturopathy, chiropractic, nutrition, and behavioral medicine. Examples of the discipline-specific sub-competencies being developed within each of the participating professions are provided, along with initial results of an assessment of potential barriers and facilitators of adoption within each discipline. The competencies presented here will form the basis of a 45-hour online curriculum produced by the NCIPH for use in primary care training programs that will be piloted in a wide range of programs in early 2016 and then revised for wider use over the following year.

The Safety of Yoga: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

As yoga has gained popularity as a therapeutic intervention, its safety has been questioned in the lay press. Thus, this review aimed to systematically assess and meta-analyze the frequency of adverse events in randomized controlled trials of yoga. MEDLINE/PubMed, Scopus, the Cochrane Library, and IndMED were screened through February 2014. Of 301 identified randomized controlled trials of yoga, 94 (1975-2014; total of 8,430 participants) reported on adverse events. Life-threatening, disabling adverse events or those requiring intensive treatment were defined as serious and all other events as nonserious. No differences in the frequency of intervention-related, nonserious, or serious adverse events and of dropouts due to adverse events were found when comparing yoga with usual care or exercise. Compared with psychological or educational interventions (e.g., health education), more intervention-related adverse events (odds ratio = 4.21, 95% confidence interval: 1.01, 17.67; P = 0.05) and more nonserious adverse events (odds ratio = 7.30, 95% confidence interval: 1.91, 27.92; P < 0.01) occurred in the yoga group; serious adverse events and dropouts due to adverse events were comparable between groups. Findings from this review indicate that yoga appears as safe as usual care and exercise. The adequate reporting of safety data in future randomized trials of yoga is crucial to conclusively judge its safety.

Stress Management and Relaxation Techniques use among underserved inpatients in an inner city hospital

OBJECTIVE

Little is known about the use of Stress Management and Relaxation Techniques (SMART) in racially diverse inpatients. We hope to identify socioeconomic status (SES) factors, health behavior factors, and clinical factors associated with the use of SMART.

DESIGN AND MAIN OUTCOME MEASURES

We conducted a secondary analysis of baseline data from 623 hospitalized patients enrolled in the Re-Engineered Discharge (RED) clinical trial. We assessed socio-demographic characteristics and use of SMART. We used bivariate and multivariate logistic regression to test the association of SMART with socio-demographic characteristics, health behaviors, and clinical factors.

RESULTS

A total of 26.6% of participants reported using SMART and 23.6% used mind body techniques. Thirty six percent of work disabled patients, 39% of illicit drug users, and 38% of participants with depressive symptoms used SMART. Patients who both reported illicit drug use and screened positive for depression had significantly increased odds of using SMART [OR=4.94, 95% CI (1.59, 15.13)]. Compared to non-Hispanic whites, non-Hispanic blacks [0.55 (0.34-0.87)] and Hispanic/other race individuals [0.40 (0.20-0.76)] were less likely to use SMART.

CONCLUSIONS

We found greater utilization of SMART among all racial groups compared to previous national studies. In the inner city inpatient setting, patients with depression, illicit drug use, and work disability reported higher rates of using SMART.

Medical group visits: a feasibility study to manage patients with chronic pain in an underserved urban clinic

BACKGROUND

Chronic pain affects millions of racially diverse Americans. Evidence suggests that group medical visits are effective for treating chronic pain; similarly, a number of studies demonstrate the effectiveness of certain evidence-based complementary therapies in managing pain.

OBJECTIVES

The primary goal of this study is to evaluate the feasibility of the integrative medical group visit (IMGV) care model in an inner-city racially diverse outpatient clinic. IMGV combines patient-centered, non-pharmacologic strategies and principles of mindfulness-based stress-reduction with a group medical visit to reduce pain and associated symptoms.

METHODS

We surveyed patients pre and post an 8-session IMGV program to evaluate changes in pain in the last week (0-10 point scale) and comorbid symptoms including depression (Patient Health Questionaire-8 [PHQ-8]), perceived stress, and sleep quality. We also recorded referrals to the program, patients screened for eligibility, total enrollment, loss to follow-up, and attendance.

RESULTS

Seventy patients joined IMGV, and of these, 65 (93%) enrolled in the study. Over the course of 12 months, 7 groups met (median 9 patients/group; range 8-13 participants). Mean difference in pain level for all patients between baseline and 8 weeks was 0.7 (SD=2.0, P=.005). Mean difference in PHQ-8 depression score for patients with baseline score ≥5 was 2.6 (SD=4.6, P<.001). Statistically significant improvements were also seen in sleep quality and perceived stress.

CONCLUSION

A group visits program combining conventional and integrative medicine for predominantly racially diverse patients is feasible.

A systematic review of the reporting of adverse events associated with medical herb use among children

PURPOSE

Information about the safety of herbal medicine often comes from case reports published in the medical literature, thus necessitating good quality reporting of these adverse events. The purpose of this study was to perform a systematic review of the comprehensiveness of reporting of published case reports of adverse events associated with herb use in the pediatric population.

METHODS

Electronic literature search included 7 databases and a manual search of retrieved articles from inception through 2010. We included published case reports and case series that reported an adverse event associated with exposure to an herbal product by children under the age of 18 years old. We used descriptive statistics. Based on the International Society of Epidemiology's "Guidelines for Submitting Adverse Events Reports for Publication," we developed and assigned a guideline adherence score (0-17) to each case report.

RESULTS

Ninety-six unique journal papers were identified and represented 128 cases. Of the 128 cases, 37% occurred in children under 2 years old, 38% between the ages of 2 and 8 years old, and 23% between the ages of 9 and 18 years old. Twenty-nine percent of cases were the result of an intentional ingestion while 36% were from an unintentional ingestion. Fifty-two percent of cases documented the Latin binomial of the herb ingredients; 41% documented plant part. Thirty-two percent of the cases reported laboratory testing of the herb, 20% documented the manufacturer of the product, and 22% percent included an assessment of the potential concomitant therapies that could have been influential in the adverse events. Mean guideline adherence score was 12.5 (range 6-17).

CONCLUSIONS

There is considerable need for improvement in reporting adverse events in children following herb use. Without better quality reporting, adverse event reports cannot be interpreted reliably and do not contribute in a meaningful way to guiding recommendations for medicinal herb use.

Developing and implementing core competencies for integrative medicine fellowships

The Consortium of Academic Health Centers for Integrative Medicine defines integrative medicine as "the practice of medicine that reaffirms the importance of the relationship between practitioner and patient, focuses on the whole person, is informed by evidence, and makes use of all appropriate therapeutic approaches, health care professionals, and disciplines to achieve optimal health and healing." Over the past three decades, the U.S. public increasingly has sought integrative medicine approaches. In an effort to train medical professionals to adequately counsel patients on the safe and appropriate use of these approaches, medical schools and residencies have developed curricula on integrative medicine for their trainees. In addition, integrative medicine clinical fellowships for postresidency physicians have emerged to provide training for practitioners interested in gaining greater expertise in this emerging field. Currently, 13 clinical fellowships in integrative medicine exist in the United States, and they are predominantly connected to academic medical centers or teaching affiliate hospitals. In 2010, the Consortium of Academic Health Centers for Integrative Medicine, represented by 56 member academic health care institutions with a shared commitment to advance the principles and practices of integrative medicine, convened a two-year task force to draft integrative medicine fellowship core competencies. These competencies would guide fellowship curriculum development and ensure that graduates possessed a common body of knowledge, skills, and attitudes. In this article, the authors discuss the competencies and the task force's process to develop them, as well as associated teaching and assessment methods, faculty development, potential barriers, and future directions.

Participant Characteristics Associated with Symptomatic Improvement from Yoga for Chronic Low Back Pain

Context

Studies suggest that yoga is effective for moderate to severe chronic low back pain (cLBP) in diverse predominantly lower socioeconomic status populations. However, little is known about factors associated with benefit from the yoga intervention.

Objective

Identify factors at baseline independently associated with greater efficacy among participants in a study of yoga for cLBP.

Design

From September–December 2011, a 12-week randomized dosing trial was conducted comparing weekly vs. twice-weekly 75-minute hatha yoga classes for 95 predominantly low-income minority adults with nonspecific cLBP. Participant characteristics collected at baseline were used to determine factors beyond treatment assignment (reported in the initial study) that predicted outcome. We used bivariate testing to identify baseline characteristics associated with improvement in function and pain, and included select factors in a multivariate linear regression.

Setting

Recruitment and classes occurred in an academic safety-net hospital and five affiliated community health centers in Boston, Massachusetts.

Participants

Ninety-five adults with nonspecific cLBP, ages ranging from 20–64 (mean 48) years; 72 women and 23 men.

Outcome measures

Primary outcomes were changes in back-related function (modified Roland-Morris Disability Questionnaire, RMDQ; 0–23) and mean low back pain intensity (0–10) in the previous week, from baseline to week 12.

Results

Adjusting for group assignment, baseline RMDQ, age, and gender, foreign nationality and lower baseline SF36 physical component score (PCS) were independently associated with improvement in RMDQ. Greater than high school education level, cLBP less than 1 year, and lower baseline SF36 PCS were independently associated with improvement in pain intensity. Other demographics including race, income, gender, BMI, and use of pain medications were not associated with either outcome.

Conclusions

Poor physical health at baseline is associated with greater improvement from yoga in back-related function and pain. Race, income, and body mass index do not affect the potential for a person with low back pain to experience benefit from yoga.

02A. Design, Methods, and Outcomes for Recent Clinical Trials Utilizing Ayurvedic Medicine, Yoga, and Meditation

Focus Area: Integrative Approaches to Care

The panel discussants will present on the outcomes of four recent pragmatic trials covering the spectrum of Ayurvedic medicine, yoga, and meditation as therapeutic approaches for both acute and chronic conditions. The presenters will discuss: (1) a pilot study of a whole-systems Ayurveda and Yoga Therapy intervention for obesity; (2) a comparative effectiveness randomized controlled trial of hatha yoga, physical therapy, and education for non-specific chronic low back pain in low-income minority populations; (3) an investigation of the therapeutic usefulness of Shirodhara (Ayurvedic oil dripping therapy) as a treatment for insomnia; and (4) a discussion of the evidence base supporting implementation of meditation interventions in schools and workplace settings. Discussants will present information on study designs, research methodology, and outcome measure selection to highlight special considerations in conducting research on whole medical systems that use multi-target therapies and focus on patient-centered outcomes. Ayurvedic medicine and yoga are characterized by low-cost, noninvasive interventions that can be usefully offered as part of an integrative medicine therapeutic approach.

Massage for perioperative pain and anxiety in placement of vascular access devices

CONTEXT

Despite major advances in cancer treatment, many patients undergo painful procedures during treatment and suffer debilitating side effects as well as report a decrease in quality of life (QOL). This problem is exacerbated for low-income, racial, and ethnic minorities with cancer. Minority cancer patients often enter care with larger tumors and with a more aggressive disease, increasing the risk of debilitating symptoms, such as pain and anxiety. Researchers have never assessed the feasibility and effectiveness of offering massage therapy for low-income, underserved cancer patients who are undergoing port insertion.

OBJECTIVE

This study examined the feasibility of conducting a randomized, controlled trial (RCT) that would assess the use of massage therapy to reduce pain and anxiety in urban patients with cancer who undergo surgical placement of a vascular access device (port). The study also assessed the effectiveness of the intervention in reducing perioperative pain and anxiety.

DESIGN

The research team conducted a 9-month RC T of 60 cancer patients undergoing port placement. The research team randomly assigned patients in a 2:1 ratio to usual care with massage therapy (intervention group) versus usual care with structured attention (control group).

SETTING

The study took place at Boston Medical Center (BMC), which is an urban, tertiary-referral, safety-net hospital.

PARTICIPANTS

Participants were cancer patients undergoing port placement. Sixty-seven percent were racial or ethnic minorities, and the majority were female and unemployed, with annual household incomes <$30 000 and publicly funded health insurance coverage.

INTERVENTION

For the intervention, an expert panel developed a reproducible, standardized massage therapy intended for individuals undergoing surgical port insertion. Both groups received 20-minute interventions immediately pre- and postsurgery. The research team collected data on pain and anxiety before and after the preoperative and postoperative interventions as well as 1 day after the surgery.

OUTCOME MEASURES

With respect to feasibility, the study examined (1) data about recruitment--time to complete enrollment and proportion of racial and ethnic minorities enrolled; (2) participants' retention; and (3) adherence to treatment allocation. The efficacy outcomes included measuring (1) participants' average pain level using an 11-point numerical rating scale (0 = no pain to 10 = worst possible pain) and (2) participants' situational anxiety using the State-Trait Anxiety Inventory (STAI).

RESULTS

The research team assigned the 60 patients to the groups over 53 weeks. Sixty-seven percent of the participants were racial or ethnic minorities. A majority were female and unemployed, with annual household incomes <$30 000 and publicly funded health insurance coverage. Of the 40 patients allocated to massage therapy, the majority (n = 33) received both the pre- and postoperative interventions. Massage therapy participants had a statistically significant, greater reduction in anxiety after the first intervention compared with individuals receiving structured attention (-10.27 vs -5.21, P = .0037).

CONCLUSIONS

Recruitment of low-income, minority patients into an RCT of massage therapy for perioperative pain and anxiety is feasible. Both massage therapy and structured attention proved beneficial for alleviating preoperative anxiety in cancer patients undergoing port placement.

Profile of minority and under-served patients using acupuncture

BACKGROUND

Acupuncture use remains common in the United States, yet little is known of its utilization by minority and underserved populations. Herein we report first visit data capturing patient profiles, types of conditions presented, and self-reports of their experience and satisfaction with acupuncture accessed at a free care clinic with in a large urban safety net hospital.

METHODS

Sixty-one adult, English-speaking acupuncture patients were given a 20 min survey after their first visit to a free care acupuncture clinic.

RESULTS

Patients were from 12 different countries. Fifty-six percent of the participants were minorities. Sixty-five percent of respondents were female. Average age was 42.1. Eighty percent were acupuncture naïve. Patients' health complaints were similar to those of other surveyed mainstream patients with 57% reporting musculoskeletal conditions. Ninety-three percent would recommend a friend or family for acupuncture, 97% rating their overall experience with the acupuncture clinic as either very good or good.

CONCLUSIONS

When made available to a diverse population of patients, acupuncture is utilized and perceived to be helpful. In this survey, patients sought treatment for musculoskeletal conditions and were satisfied with their first visit. Future research is warranted.

Determination of in vitro bioaccessibility of Pb, As, Cd and Hg in selected traditional Indian medicines

In vitro bioaccessibility of Pb, As, Cd and Hg in five traditional Indian medicine samples was measured as a determinant of bioavailability. The method is based on simulation of human digestion in the passage of material from the gastric to intestinal portions of the gastrointestinal tract. Total concentration and concentration in extracts from gastric and intestinal phases were analyzed for Pb, As and Cd by dynamic reaction cell inductively coupled plasma mass spectrometry (DRC-ICP-MS) and for Hg by direct mercury analyzer (DMA). Total lead ranged from 1.9 to 36000 µg g(-1). In each of the samples bioaccessibility of lead was significantly higher (range 28-88%) in the gastric phase than in the intestinal phase (range 1.4-75.4%). Only Ekangvir Ras had measurable arsenic (304 µg g(-1)). Its bioaccessibility in the gastric phase and intestinal phase was 82.6% and 78.1%, respectively. Only Ayu-Nephro-Tone had measurable cadmium (14.4 µg g(-1)). Its bioaccessibility in the gastric phase and intestinal phase was 80.5% and 2.2%, respectively. Three samples had measurable mercury (range 37 µg g(-1)-10000 µg g(-1)). Mercury in these samples was not bioaccessible. For the samples with measurable amount of metal, the estimated daily amount of bioaccessible (EDAB) metal was calculated. When compared with the most liberal published safety guideline, EDAB-Pb in Mahayograj Guggulu and Ekangvir Ras were 37 and 45 fold greater. When compared with the most conservative published safety guideline, all samples had higher EDAB-Pb or EDAB-As than the suggested limits. The EDAB-Cd and EDAB-Hg were acceptably below published safety limits.