Michele Maiers

Supervised exercise, spinal manipulation, and home exercise for chronic low back pain: a randomized clinical trial

BACKGROUND CONTEXT Several conservative therapies have been shown to be beneficial in the treatment of chronic low back pain (CLBP), including different forms of exercise and spinal manipulative therapy (SMT). The efficacy of less time-consuming and less costly self-care interventions, for example, home exercise, remains inconclusive in CLBP populations. PURPOSE The purpose of this study was to assess the relative efficacy of supervised exercise, spinal manipulation, and home exercise for the treatment of CLBP. STUDY DESIGN/SETTING An observer-blinded and mixed-method randomized clinical trial conducted in a university research clinic in Bloomington, MN, USA. PATIENT SAMPLE Individuals, 18 to 65 years of age, who had a primary complaint of mechanical LBP of at least 6-week duration with or without radiating pain to the lower extremity were included in this trial. OUTCOME MEASURES Patient-rated outcomes were pain, disability, general health status, medication use, global improvement, and satisfaction. Trunk muscle endurance and strength were assessed by blinded examiners, and qualitative interviews were performed at the end of the 12-week treatment phase. METHODS This prospective randomized clinical trial examined the short- (12 weeks) and long-term (52 weeks) relative efficacy of high-dose, supervised low-tech trunk exercise, chiropractic SMT, and a short course of home exercise and self-care advice for the treatment of LBP of at least 6-week duration. The study was approved by local institutional review boards. RESULTS A total of 301 individuals were included in this trial. For all three treatment groups, outcomes improved during the 12 weeks of treatment. Those who received supervised trunk exercise were most satisfied with care and experienced the greatest gains in trunk muscle endurance and strength, but they did not significantly differ from those receiving chiropractic spinal manipulation or home exercise in terms of pain and other patient-rated individual outcomes, in both the short- and long-term. CONCLUSIONS For CLBP, supervised exercise was significantly better than chiropractic spinal manipulation and home exercise in terms of satisfaction with treatment and trunk muscle endurance and strength. Although the short- and long-term differences between groups in patient-rated pain, disability, improvement, general health status, and medication use consistently favored the supervised exercise group, the differences were relatively small and not statistically significant for these individual outcomes.

Spinal manipulative therapy and exercise for seniors with chronic neck pain

BACKGROUND CONTEXT Neck pain, common among the elderly population, has considerable implications on health and quality of life. Evidence supports the use of spinal manipulative therapy (SMT) and exercise to treat neck pain; however, no studies to date have evaluated the effectiveness of these therapies specifically in seniors. PURPOSE To assess the relative effectiveness of SMT and supervised rehabilitative exercise, both in combination with and compared to home exercise (HE) alone for neck pain in individuals ages 65 years or older. STUDY DESIGN/SETTING Randomized clinical trial. PATIENT SAMPLE Individuals 65 years of age or older with a primary complaint of mechanical neck pain, rated ≥3 (0-10) for 12 weeks or longer in duration. OUTCOME MEASURES Patient self-report outcomes were collected at baseline and 4, 12, 26, and 52 weeks after randomization. The primary outcome was pain, measured by an 11-box numerical rating scale. Secondary outcomes included disability (Neck Disability Index), general health status (Medical Outcomes Study Short Form-36), satisfaction (7-point scale), improvement (9-point scale), and medication use (days per week). METHODS This study was funded by the US Department of Health and Human Services, Health Resources and Services Administration. Linear mixed model analyses were used for comparisons at individual time points and for short- and long-term analyses. Blinded evaluations of objective outcomes were performed at baseline and 12 weeks. Adverse event data were collected at each treatment visit. RESULTS A total of 241 participants were randomized, with 95% reporting primary outcome data at all time points. After 12 weeks of treatment, the SMT with home exercise group demonstrated a 10% greater decrease in pain compared with the HE-alone group, and 5% change over supervised plus home exercise. A decrease in pain favoring supervised plus HE over HE alone did not reach statistical significance. Compared with the HE group, both combination groups reported greater improvement at week 12 and more satisfaction at all time points. Multivariate longitudinal analysis incorporating primary and secondary patient-rated outcomes showed that the SMT with HE group was superior to the HE-alone group in both the short- and long-term. No serious adverse events were observed as a result of the study treatments. CONCLUSIONS SMT with HE resulted in greater pain reduction after 12 weeks of treatment compared with both supervised plus HE and HE alone. Supervised exercise sessions added little benefit to the HE-alone program.

Integrative care for the management of low back pain: use of a clinical care pathway

BackgroundFor the treatment of chronic back pain, it has been theorized that integrative care plans can lead to better outcomes than those achieved by monodisciplinary care alone, especially when using a collaborative, interdisciplinary, and non-hierarchical team approach. This paper describes the use of a care pathway designed to guide treatment by an integrative group of providers within a randomized controlled trial.MethodsA clinical care pathway was used by a multidisciplinary group of providers, which included acupuncturists, chiropractors, cognitive behavioral therapists, exercise therapists, massage therapists and primary care physicians. Treatment recommendations were based on an evidence-informed practice model, and reached by group consensus. Research study participants were empowered to select one of the treatment recommendations proposed by the integrative group. Common principles and benchmarks were established to guide treatment management throughout the study.ResultsThirteen providers representing 5 healthcare professions collaborated to provide integrative care to study participants. On average, 3 to 4 treatment plans, each consisting of 2 to 3 modalities, were recommended to study participants. Exercise, massage, and acupuncture were both most commonly recommended by the team and selected by study participants. Changes to care commonly incorporated cognitive behavioral therapy into treatment plans.ConclusionThis clinical care pathway was a useful tool for the consistent application of evidence-based care for low back pain in the context of an integrative setting.Trial registrationClinicalTrials.gov NCT00567333

Ways of Knowing: Integrating Research Into CAM Education and Holism Into Conventional Health Professional Education

Content on integrative healthcare and complementary and alternative medicine is being taught in hundreds of educational programs across the country. Nursing, medical, osteopathic, chiropractic, acupuncture, naturopathic, and other programs are finding creative and innovative ways to include these approaches in new models of education and practice. This column spotlights such innovations in integrative healthcare and CAM education and presents readers with specific educational interventions they can adapt into new or ongoing educational efforts at their institution or programs. We invite readers to submit brief descriptions of efforts in their institutions that reflect the creativity, diversity, and interdisciplinary nature of the field. Please submit to Dr Sierpina at vssierpi@utmb.edu or Dr Kreitzer at kreit003@umn.edu. Submissions should be no more than 500 to 1500 words. Please include any Web site or other resource that is relevant, as well as contact information.

EVIDENCE INFORMED PRACTICE AS THE CATALYST FOR CULTURE CHANGE IN CAM

The NIH National Center for Complementary and Alternative Medicine (NCCAM) has funded two rounds of R25 education grants. The first set of R25 grants were awarded to conventional schools and focused on integrating CAM content into health professions education programs. Grants were awarded to medical and nursing schools predominantly, with one grant going to the American Medical Student Association and one grant being awarded to an institution integrating CAM into nursing, medicine and pharmacy. The second round of R25 grants were awarded to CAM institutions and focused on introducing evidence-based practice into curricula of CAM schools including schools of chiropractic, naturopathic, and acupuncture and Oriental medicine. Although not an explicit objective of the grant program, one of the most significant and enduring outcomes reported by investigators has been culture change. This article describes individual and organizational culture changes that occurred at Northwestern Health Sciences University.

The Development of a Prospective Data Collection Process in a Traditional Chinese Medicine Teaching Clinic

OBJECTIVE There is a growing need for students and practitioners of Traditional Chinese Medicine to gain experience with standardized data collection, patient outcomes measurement, and practice-based research. The purpose of this paper is to describe the development of a process for standardized data collection that could eventually be adopted for clinical, research, and quality assurance purposes. SETTINGS/LOCATION The setting for this study was an acupuncture and Oriental medicine teaching clinic in Bloomington, Minnesota. METHODS Four (4) aspects of data collection were assessed and improved, including intake and post-treatment questionnaires, follow-up with patients, integration of data collection into clinic flow, and commitment of resources to the project. OUTCOME MEASURES The outcomes measures were data collection and missing data rates, burden on patients and clinic staff, and efficiency of data entry. RESULTS Revision to the data collection process resulted in decreased burden to patients and staff, more detailed and aggressive follow-up protocols, enhanced training for clinic staff, and increased personnel and data-related resources. CONCLUSIONS The systematic collection of descriptive and clinical characteristics can be accomplished in a teaching clinic with thoughtful attention paid to data collection protocols, dedicated resources, and the involvement of all relevant personnel.

P02.129. Individualized chiropractic and integrative care for low back pain: a randomized clinical trial.

Purpose To determine the relative effectiveness of multidisciplinary integrative care compared to chiropractic care for chronic LBP in patients over 18 years of age using pain as the primary outcome measure. Secondary outcomes were patient self-reported disability, global perceived effect, general health status, satisfaction, self-efficacy, fear avoidance behavior, lumbar dynamic motion, and trunk muscle strength and endurance.

Chiropractic in Global Health and wellbeing: a white paper describing the public health agenda of the World Federation of Chiropractic

The World Federation of Chiropractic supports the involvement of chiropractors in public health initiatives, particularly as it relates to musculoskeletal health. Three topics within public health have been identified that call for a renewed professional focus. These include healthy ageing; opioid misuse; and women’s, children’s, and adolescents’ health. The World Federation of Chiropractic aims to enable chiropractors to proactively participate in health promotion and prevention activities in these areas, through information dissemination and coordinated partnerships. Importantly, this work will align the chiropractic profession with the priorities of the World Health Organization. Successful engagement will support the role of chiropractors as valued partners within the broader healthcare system and contribute to the health and wellbeing of the communities they serve.

OA06.03. Spinal manipulative therapy, supervised rehabilitative exercise and home exercise for seniors with neck pain

Purpose Neck pain (NP) is a common condition in old age, leading to impaired functional ability and decreased independence. Spinal manipulation and exercise are common and effective treatments for the general NP population; however, their effectiveness among seniors is unknown. The primary aim of this randomized clinical trail was to assess the relative shortand long-term clinical effectiveness of spinal manipulative therapy (SMT) and supervised rehabilitative exercise (SRE), both in combination with and compared to home exercise (HE) alone, in NP patients 65 years and older.

OA11.01. Integrative care for the management of low back pain: design of a clinical care pathway

Purpose For the treatment of chronic back pain, it has been theorized that integrative care plans can lead to better outcomes than those achieved by monodisciplinary care alone, especially when using a collaborative, interdisciplinary, and non-hierarchical team approach. This paper describes the development and implementation of a care pathway designed to guide treatment by an integrative group of providers within a randomized controlled trial.