Stacie A. Salsbury

Collaborative Care for Older Adults with low back pain by family medicine physicians and doctors of chiropractic (COCOA): study protocol for a randomized controlled trial

BackgroundLow back pain is a prevalent and debilitating condition that affects the health and quality of life of older adults. Older people often consult primary care physicians about back pain, with many also receiving concurrent care from complementary and alternative medicine providers, most commonly doctors of chiropractic. However, a collaborative model of treatment coordination between these two provider groups has yet to be tested. The primary aim of the Collaborative Care for Older Adults Clinical Trial is to develop and evaluate the clinical effectiveness and feasibility of a patient-centered, collaborative care model with family medicine physicians and doctors of chiropractic for the treatment of low back pain in older adults.Methods/designThis pragmatic, pilot randomized controlled trial will enroll 120 participants, age 65 years or older with subacute or chronic low back pain lasting at least one month, from a community-based sample in the Quad-Cities, Iowa/Illinois, USA. Eligible participants are allocated in a 1:1:1 ratio to receive 12 weeks of medical care, concurrent medical and chiropractic care, or collaborative medical and chiropractic care. Primary outcomes are self-rated back pain and disability. Secondary outcomes include general and functional health status, symptom bothersomeness, expectations for treatment effectiveness and improvement, fear avoidance behaviors, depression, anxiety, satisfaction, medication use and health care utilization. Treatment safety and adverse events also are monitored. Participant-rated outcome measures are collected via self-reported questionnaires and computer-assisted telephone interviews at baseline, and at 4, 8, 12, 24, 36 and 52 weeks post-randomization. Provider-rated expectations for treatment effectiveness and participant improvement also are evaluated. Process outcomes are assessed through qualitative interviews with study participants and research clinicians, chart audits of progress notes and content analysis of clinical trial notes.DiscussionThis pragmatic, pilot randomized controlled trial uses a mixed method approach to evaluate the clinical effectiveness, feasibility, and participant and provider perceptions of collaborative care between medical doctors and doctors of chiropractic in the treatment of older adults with low back pain.Trial registrationThis trial registered in ClinicalTrials.gov on 04 March 2011 with the ID number of NCT01312233.

Perspectives of older adults on co-management of low back pain by doctors of chiropractic and family medicine physicians: a focus group study.

BackgroundWhile older adults may seek care for low back pain (LBP) from both medical doctors (MDs) and doctors of chiropractic (DCs), co-management between these providers is uncommon. The purposes of this study were to describe the preferences of older adults for LBP co-management by MDs and DCs and to identify their concerns for receiving care under such a treatment model.MethodsWe conducted 10 focus groups with 48 older adults who received LBP care in the past year. Interviews explored participants’ care seeking experiences, co-management preferences, and perceived challenges to successful implementation of a MD-DC co-management model. We analyzed the qualitative data using thematic content analysis.ResultsOlder adults considered LBP co-management by MDs and DCs a positive approach as the professions have complementary strengths. Participants wanted providers who worked in a co-management model to talk openly and honestly about LBP, offer clear and consistent recommendations about treatment, and provide individualized care. Facilitators of MD-DC co-management included collegial relationships between providers, arrangements between doctors to support interdisciplinary referral, computer systems that allowed exchange of health information between clinics, and practice settings where providers worked in one location. Perceived barriers to the co-management of LBP included the financial costs associated with receiving care from multiple providers concurrently, duplication of tests or imaging, scheduling and transportation problems, and potential side effects of medication and chiropractic care. A few participants expressed concern that some providers would not support a patient-preferred co-managed care model.ConclusionsOlder adults are interested in receiving LBP treatment co-managed by MDs and DCs. Older adults considered patient-centered communication, collegial interdisciplinary interactions between these providers, and administrative supports such as scheduling systems and health record sharing as key components for successful LBP co-management.

Training and certification of doctors of chiropractic in delivering manual cervical traction forces: Results of a longitudinal observational study.

Objective : Doctors of chiropractic (DCs) use manual cervical distraction to treat patients with neck pain. Previous research demonstrates variability in traction forces generated by different DCs. This article reports on a training protocol and monthly certification process using bioengineering technology to standardize cervical traction force delivery among clinicians. Methods : This longitudinal observational study evaluated a training and certification process for DCs who provided force-based manual cervical distraction during a randomized clinical trial. The DCs completed a 7-week initial training that included instructional lectures, observation, and guided practice by a clinical expert, followed by 3 hours of weekly practice sessions delivering the technique to asymptomatic volunteers who served as simulated patients. An instrument-modified table and computer software provided the DCs with real-time audible and visual feedback on the traction forces they generated and graphical displays of the magnitude of traction forces as a function of time immediately after the delivery of the treatment. The DCs completed monthly certifications on traction force delivery throughout the trial. Descriptive accounts of certification attempts are provided. Results : Two DCs achieved certification in traction force delivery over 10 consecutive months. No certification required more than 3 attempts at C5 and occiput contacts for 3 force ranges (0-20 N, 21-50 N, and 51-100 N). Conclusions : This study demonstrates the feasibility of a training protocol and certification process using bioengineering technology for training DCs to deliver manual cervical distraction within specified traction force ranges over a 10-month period.

DEVELOPMENT OF FORCE-FEEDBACK TECHNOLOGY FOR TRAINING CLINICIANS TO DELIVER MANUAL CERVICAL DISTRACTION

Objective: Neck pain is a prevalent musculoskeletal (MSK) complaint and costly societal burden. Doctors of chiropractic (DCs) provide manual therapies for neck pain patients to relieve discomfort and improve physical function. Manual cervical distraction (MCD) is a chiropractic procedure for neck pain. During MCD, the patient lies face down on a specially designed chiropractic table. The DC gently moves the head and neck in a cephalic direction while holding a gentle broad manual contact over the posterior neck, to create traction effects. MCD traction force profiles vary between clinicians making standardization of treatment delivery challenging. This paper reports on a bioengineering technology developed to provide clinicians with auditory and graphical feedback on the magnitude of cervical traction forces applied during MCD to simulated patients during training for a randomized controlled trial (RCT). Methods: The Cox flexion-distraction chiropractic table is designed with a moveable headpiece. The table allows for long axis horizontal movement of the head and neck, while the patient’s trunk and legs rest on fixed table sections. We instrument-modified this table with three-dimensional force transducers to measure the traction forces applied by the doctor. Motion Monitor software collects data from force transducers. The software displays the magnitude of traction forces graphically as a function of time. Real-time audible feedback produces a steady tone when measured traction forces are <20N, no tone when forces range between 20-50N, and an audible tone when forces exceed 50N. Peer debriefing from simulated patients reinforces traction force data from the bioengineering technology.

P03.09. Development of an interprofessional model of collaborative care by doctors of chiropractic and medical doctors for older adults with low back pain

Purpose Although low back pain (LBP) is a common reason older adults seek treatment from either medical doctors (MD/DO) or doctors of chiropractic (DC), collaborative care between these providers is rarely reported. The purpose of our study is to develop a model for such collaborative care in LBP patients, based upon an existing integrative medicine model (Hsiao et al., 2006), focusing on four facets of interprofessional collaboration: attitudes, knowledge, referral, and integrative practice.

Effect of Spinal Manipulation of Upper Cervical Vertebrae on Blood Pressure: Results of a Pilot Sham-Controlled Trial

OBJECTIVE The purpose of this pilot sham-controlled clinical trial was to estimate the treatment effect and safety of toggle recoil spinal manipulation for blood pressure management. METHODS Fifty-one participants with prehypertension or stage 1 hypertension (systolic blood pressure ranging from 135 to 159 mm Hg or diastolic blood pressure ranging from 85 to 99 mm Hg) were allocated by an adaptive design to 2 treatments: toggle recoil spinal manipulation or a sham procedure. Participants were seen by a doctor of chiropractic twice weekly for 6 weeks and remained on their antihypertensive medications, as prescribed, throughout the trial. Blood pressure was assessed at baseline and after study visits 1, 6 (week 3), and 12 (week 6), with the primary end point at week 6. Analysis of covariance was used to compare mean blood pressure changes from baseline between groups at each end point, controlling for sex, age, body mass index, and baseline blood pressure. RESULTS Adjusted mean change from baseline to week 6 was greater in the sham group (systolic, -4.2 mm Hg; diastolic, -1.6 mm Hg) than in the spinal manipulation group (systolic, 0.6 mm Hg; diastolic, 0.7 mm Hg), but the difference was not statistically significant. No serious and few adverse events were noted. CONCLUSIONS Six weeks of toggle recoil spinal manipulation did not lower systolic or diastolic blood pressure when compared with a sham procedure. No serious adverse events from either treatment were reported. Our results do not support a larger clinical trial. Further research to understand the potential mechanisms of action involving upper cervical manipulation on blood pressure is warranted before additional clinical investigations are conducted.

Eligibility determination for clinical trials: development of a case review process at a chiropractic research center.

BackgroundSystematic procedures addressing the limitations of eligibility determination are needed to improve the quality of participant recruitment and enrollment in randomized clinical trials. This paper describes an eligibility determination process developed by and in use at a chiropractic research center engaged in community recruitment for clinical trials studying spinal pain conditions.MethodsA team of investigators developed a case review process for application across clinical trials involving chiropractic care. Study personnel representing key study roles including research clinicians, study coordinators, a project manager, and at least one investigator convene in person to determine eligibility for participants following baseline study visit examinations. The research clinician who performed the eligibility examination presents the case and a moderator leads the case review panel through a structured discussion including diagnosis, eligibility criteria, definition review, and clinical precautions. Panel members provide clinical recommendations and determine final eligibility using a structured and moderated voting process.ResultsThrough the case review process for three externally funded clinical trials for participants with neck and low back pain, we presented 697 cases, rendering 472 participants eligible for enrollment and excluding 225 individuals. The most common reasons for case review exclusions across the three trials included neck or back pain not meeting diagnostic classifications, safety concerns related to treatment or testing, referral for further evaluation or treatment, and compliance concerns.ConclusionsThe case review process uses the expertise of study coordinators, research clinicians, project managers, and investigators to render eligibility decisions consistent with study aims for the duration of the trial. This formal eligibility determination process includes steps designed to mitigate the potential for participant misclassification from clinician advocacy or misunderstanding of eligibility criteria, and helps ensure that participants can safely take part in study procedures.Trial registrationThe three trials discussed in this article were registered in ClinicalTrials.gov with the ID numbers of NCT00830596 (27 January 2009), NCT01312233 (04 March 2011), and NCT01765751 (30 May 2012).

Essential literature for the chiropractic profession: a survey of chiropractic research leaders

BackgroundEvidence-based clinical practice (EBCP) is an accepted practice for informed clinical decision making in mainstream health care professions. EBCP augments clinical experience and can have far reaching effects in education, policy, reimbursement and clinical management. The proliferation of published research can be overwhelming—finding a mechanism to identify literature that is essential for practitioners and students is desirable. The purpose of this study was to survey leaders in the chiropractic profession on their opinions of essential literature for doctors of chiropractic, faculty, and students to read or reference.MethodsDeployment of an IRB exempted survey occurred with 68 academic and research leaders using SurveyMonkey®. Individuals were solicited via e-mail in August of 2011; the study closed in October of 2011.Collected data were checked for citation accuracy and compiled to determine multiple responses. A secondary analysis assessed the scholarly impact and Internet accessibility of the recommended literature.ResultsForty-three (43) individuals consented to participate; seventeen (17) contributed at least one article of importance. A total of 41 unique articles were reported. Of the six articles contributed more than once, one article was reported 6 times, and 5 were reported twice.ConclusionsA manageable list of relevant literature was created. Shortcomings of methods were identified, and improvements for continued implementation are suggested. A wide variety of articles were reported as “essential” knowledge; annual or bi-annual surveys would be helpful for the profession.

Interdisciplinary Practice Models for Older Adults With Back Pain: A Qualitative Evaluation

Purpose Older adults seek health care for low back pain from multiple providers who may not coordinate their treatments. This study evaluated the perceived feasibility of a patient-centered practice model for back pain, including facilitators for interprofessional collaboration between family medicine physicians and doctors of chiropractic. Design and Methods This qualitative evaluation was a component of a randomized controlled trial of 3 interdisciplinary models for back pain management: usual medical care; concurrent medical and chiropractic care; and collaborative medical and chiropractic care with interprofessional education, clinical record exchange, and team-based case management. Data collection included clinician interviews, chart abstractions, and fieldnotes analyzed with qualitative content analysis. An organizational-level framework for dissemination of health care interventions identified norms/attitudes, organizational structures and processes, resources, networks-linkages, and change agents that supported model implementation. Results Clinicians interviewed included 13 family medicine residents and 6 chiropractors. Clinicians were receptive to interprofessional education, noting the experience introduced them to new colleagues and the treatment approaches of the cooperating profession. Clinicians exchanged high volumes of clinical records, but found the logistics cumbersome. Team-based case management enhanced information flow, social support, and interaction between individual patients and the collaborating providers. Older patients were viewed positively as change agents for interprofessional collaboration between these provider groups. Implications Family medicine residents and doctors of chiropractic viewed collaborative care as a useful practice model for older adults with back pain. Health care organizations adopting medical and chiropractic collaboration can tailor this general model to their specific setting to support implementation.

Patients receiving chiropractic care in a neurorehabilitation hospital: a descriptive study

Objectives Individuals rehabilitating from complex neurological injury require a multidisciplinary approach, which typically does not include chiropractic care. This study describes inpatients receiving multidisciplinary rehabilitation including chiropractic care for brain injury, spinal cord injury (SCI), stroke, and other complex neurological conditions. Design Chiropractic services were integrated into Crotched Mountain Specialty Hospital (CMSH) through this project. Patient characteristics and chiropractic care data were collected to describe those receiving care and the interventions during the first 15 months when chiropractic services were available. Setting CMSH, a 62-bed subacute multidisciplinary rehabilitation, skilled nursing facility located in Greenfield, New Hampshire, USA. Results Patient mean (SD) age (n=27) was 42.8 (13) years, ranging from 20 to 64 years. Males (n=18, 67%) and those of white race/ethnicity (n=23, 85%) comprised the majority. Brain injury (n=20) was the most common admitting condition caused by trauma (n=9), hemorrhage (n=7), infarction (n=2), and general anoxia (n=2). Three patients were admitted for cervical SCI, 1 for ankylosing spondylitis, 1 for traumatic polyarthropathy, and 2 for respiratory failure with encephalopathy. Other common comorbid diagnoses potentially complicating the treatment and recovery process included myospasm (n=13), depression (n=11), anxiety (n=10), dysphagia (n=8), substance abuse (n=8), and candidiasis (n=7). Chiropractic procedures employed, by visit (n=641), included manual myofascial therapies (93%), mechanical percussion (83%), manual muscle stretching (75%), and thrust manipulation (65%) to address patients with spinal-related pain (n=15, 54%), joint or regional stiffness (n= 14, 50%), and extremity pain (n=13, 46%). Care often required adapting to participant limitations or conditions. Such adaptations not commonly encountered in outpatient settings where chiropractic care is usually delivered included the need for lift assistance, wheelchair dependence, contractures, impaired speech, quadriplegia/paraplegia, and the presence of feeding tubes and urinary catheters. Conclusion Patients suffered significant functional limitations and comorbidity resulting in modifications to the typical delivery of chiropractic care. Chiropractic services focused on relieving musculoskeletal pain and stiffness.