Andrea Hrbek

Addition of Choice of Complementary Therapies to Usual Care for Acute Low Back Pain: A Randomized Controlled Trial

Study Design. A randomized controlled trial. Objective. To investigate the effectiveness and cost of usual care plus patient choice of acupuncture, chiropractic, or massage therapy (choice) compared with usual care alone in patients with acute low back pain (LBP). Summary of Background Data. Few studies have evaluated care models with facilitated access to and financial coverage for adjunctive complementary and alternative medicine therapies. Methods. A total of 444 patients with acute LBP (<21 days) were recruited from 4 clinical sites and randomized into 2 groups: usual care or choice. Outcomes included symptoms (bothersomeness), functional status (Roland), and satisfaction between baseline and 5 weeks, and cost of medical care in the 12 weeks after randomization. Results. After 5 weeks, providing patients with a choice did not yield clinically important reductions in symptoms (median −4, [interquartile range −7, −2] for usual care, and −5 [−7, −3] for choice; P = 0.002) or improvements in functional status (−8 [−13, −2] for usual care, and −9 [−15, −4] for choice; P = 0.15). Although there was a significantly greater satisfaction with care in the choice group, this came at a net increase in costs of

The Practice of Acupuncture: Who Are the Providers and What Do They Do?

244 per patient. This consisted of a

A survey of training and practice patterns of massage therapists in two US states

99 reduction in the average cost to the insurer for medical care but an additional cost of

Establishing an Integrative Medicine Program Within an Academic Health Center: Essential Considerations.

343, for an average of 6.0 complementary and alternative medicine treatments per patient. Conclusions. A model of care that offered access to a choice of complementary and alternative medicine therapies for acute LBP did not result in clinically significant improvements in symptom relief or functional restoration. This model was associated with greater patient satisfaction but increased total costs. Future evaluations of this choice model should focus on patients with chronic conditions (including chronic back pain) for which conventional medical care is often costly and of limited benefit.

Therapeutic Massage Intervention for Hospitalized Patients with Cancer: A Pilot Study

PURPOSE This study provides basic information about the training and practices of licensed acupuncturists. METHODS Randomly selected licensed acupuncturists in Massachusetts and Washington state were interviewed and asked to record information on 20 consecutive patient visits. RESULTS Most acupuncturists in both states had 3 or 4 years of academic acupuncture training and had received additional “postgraduate” training as well. Acupuncturists treated a wide range of conditions, including musculoskeletal problems (usually back, neck, and shoulder) (33% in Massachusetts and 47% in Washington), general body symptoms (12% and 9%, respectively) such as fatigue, neurological problems (10% and 12%, respectively) (eg, headaches), and psychological complaints (10% and 8%, respectively) (especially anxiety and depression). Traditional Chinese medicine (TCM) was the predominant style of acupuncture used in both states (79% and 86%, respectively). Most visits included a traditional diagnostic assessment (more than 99%), regular body acupuncture (95% and 93%, respectively), and additional treatment modalities (79% and 77%, respectively). These included heat and lifestyle advice (66% and 65%, respectively), most commonly dietary advice and exercise recommendations. Chinese herbs were used in about one third of visits. Although most patients self-referred to acupuncture, about one half received concomitant care from a physician. Acupuncturists rarely communicated with the physicians of their patients who were providing care for the same problem. CONCLUSIONS This study contributes new information about acupuncturists and the care they provide that should be useful to clinicians interested in becoming more knowledgeable about complementary or alternative medical therapies available to their patients.

Characteristics of visits to licensed acupuncturists, chiropractors, massage therapists, and naturopathic physicians.

BackgroundDespite the growing popularity of therapeutic massage in the US, little is known about the training or practice characteristics of massage therapists. The objective of this study was to describe these characteristics.MethodsAs part of a study of random samples of complementary and alternative medicine (CAM) practitioners, we interviewed 226 massage therapists licensed in Connecticut and Washington state by telephone in 1998 and 1999 (85% of those contacted) and then asked a sample of them to record information on 20 consecutive visits to their practices (total of 2005 consecutive visits).ResultsMost massage therapists were women (85%), white (95%), and had completed some continuing education training (79% in Connecticut and 52% in Washington). They treated a limited number of conditions, most commonly musculoskeletal (59% and 63%) (especially back, neck, and shoulder problems), wellness care (20% and 19%), and psychological complaints (9% and 6%) (especially anxiety and depression). Practitioners commonly used one or more assessment techniques (67% and 74%) and gave a massage emphasizing Swedish (81% and 77%), deep tissue (63% and 65%), and trigger/pressure point techniques (52% and 46%). Self-care recommendations, including increasing water intake, body awareness, and specific forms of movement, were made as part of more than 80% of visits. Although most patients self-referred to massage, more than one-quarter were receiving concomitant care for the same problem from a physician. Massage therapists rarely communicated with these physicians.ConclusionThis study provides new information about licensed massage therapists that should be useful to physicians and other healthcare providers interested in learning about massage therapy in order to advise their patients about this popular CAM therapy.

Credentialing Complementary and Alternative Medical Providers

Integrative medicine (IM) refers to the combination of conventional and “complementary” medical services (e.g., chiropractic, acupuncture, massage, mindfulness training). More than half of all medical schools in the United States and Canada have programs in IM, and more than 30 academic health centers currently deliver multidisciplinary IM care. What remains unclear, however, is the ideal delivery model (or models) whereby individuals can responsibly access IM care safely, effectively, and reproducibly in a coordinated and cost-effective way. Current models of IM across existing clinical centers vary tremendously in their organizational settings, principal clinical focus, and services provided; practitioner team composition and training; incorporation of research activities and educational programs; and administrative organization (e.g., reporting structure, use of medical records, scope of clinical practice) and financial strategies (i.e., specific business plans and models for sustainability). In this article, the authors address these important strategic issues by sharing lessons learned from the design and implementation of an IM facility within an academic teaching hospital, the Brigham and Women’s Hospital at Harvard Medical School; and review alternative options based on information about IM centers across the United States. The authors conclude that there is currently no consensus as to how integrative care models should be optimally organized, implemented, replicated, assessed, and funded. The time may be right for prospective research in “best practices” across emerging models of IM care nationally in an effort to standardize, refine, and replicate them in preparation for rigorous cost-effectiveness evaluations.

Patient expectations as predictors of outcome in patients with acute low back pain.

F orty-two (42) percent of Americans use some form of alternative medicine, spending 21.2 billion dollars annually,1 and one of the most commonly sought alternative and complementary medicine (ACM) therapies is therapeutic massage, which was used by an estimated 11 percent of the U.S. adult population in 1998. In that year, adults made an estimated 114 million office visits to receive massage treatments.2 Massage has been used as a therapeutic intervention for a variety of illnesses for thousands of years. The Asian roots of massage go back a t lea s t to 1000 BC and so do the or ig in s o f Ayurvedic medicine. Descriptions of massage appear in the ancient medical texts of India, China, Japan, and Tibet. The European roots of massage can be traced back to the seventh century BC. Massage was associated with the cures offered at the temples of Aesculepius and was described in the writings of Hippocrates. Massage has been used to promote relaxation and relieve pain and has been suggested as a useful adjunctive treatment for symptom control for patients at the end of life. Pain is one of the most common symptoms experienced by dying patients. More than 40 percent of patients’ families reported that patients experienced severe pain in the last 3 days of life.3 Others have reported that 60 percent of patients who have cancer have pain.4,5 In many cases (42 percent), pain was inadequately treated in patients with cancer.6 Nearly 80 percent of hospitalized patients have reported pain, while less than half had any mention of pain noted in progress notes by their doctors.7 Even in palliative medicine and in hospice settings, 64–88 percent of patients had inadequately relieved pain, and the most severe symptoms occurred 2 days prior to death.8 During the last 7 days of life, narcotic usage increased significantly. Although symptoms of pain and nausea were reduced, drowsiness worsened substantially and resulted in worse symptom distress scores. Between 15 and 20 percent of patients needed treatment for pain, requiring complete sedation to obtain relief.9 Caregivers often experience symptoms of anxiety and sadness near the end of a patient’s life. Grief phenomena have been welldescribed. Compared to their experience 6 months following death, feelings of sadness are most intrusive in the 6 weeks following the patient’s death as are symptoms such as tearfulness, depression, and anxiety.10 Physical symptoms, such as pain, are most prominent at 6 weeks as well. Small studies have suggested that interventions that provide support to caregivers can improve their satisfaction with care as well as decreasing their physical and emotional stress.11 Only a few studies on the use of massage at the end of life have been reported. In a small study of massage given to patients in a hospice, investigators reported that slow-stroke back massage resulted in changes in vital signs, suggesting improved relaxation.12 Other studies have indicated that massage may be useful in managing cancer pain.13,14 Studies on other populations have suggested a number of potential benefits of massage that are relevant to patients with metastatic cancer. For example, massage has been shown to promote relaxation, reduce anxiety and depression, and improve sleep patterns.15–18 In addition, other studies have indicated that massage may reduce patients’ experience of pain ,13 ,14 ,19–22 ease breathing,23 faci l i tate weight gain,24–26 and increase alertness.27 Finally, data indicate that giving as well as receiving massage may reduce anxiety and depression,28 suggesting that caregivers may benefit from providing massage to patients. In this pilot study, we provided daily massage to hospitalized patients with metastatic or end stage lung or gastrointestinal (GI) cancer. Hospital admissions were screened daily to identify eligible patients. Patients received daily therapeutic massage and family caregivers were also instructed in the use of massage during hospitalization. Data were collected from massage therapists’ detailed documentation and from patients’ daily questionnaires about their experiences with the massage therapy. We also collected data from medical records via chart reviews and interviews with patients’ nurses and physicians.