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Provider and Patient Perspectives on Opioids

By |October 28, 2017|Chronic Low Back Pain, Chronic Neck Pain, Chronic Pain|

Provider and Patient Perspectives on Opioids and Alternative Treatments for Managing Chronic Pain:
A Qualitative Study

The Chiro.Org Blog

SOURCE:   BMC Fam Pract. 2017 (Mar 24); 17 (1): 164

Lauren S. Penney, Cheryl Ritenbaugh, Lynn L. DeBar,
Charles Elder and Richard A. Deyo

South Texas Veterans Health Care System,
7400 Merton Minter Blvd,
San Antonio, TX, 78229, USA

BACKGROUND:   Current literature describes the limits and pitfalls of using opioid pharmacotherapy for chronic pain and the importance of identifying alternatives. The objective of this study was to identify the practical issues patients and providers face when accessing alternatives to opioids, and how multiple parties view these issues.

METHODS:   Qualitative data were gathered to evaluate the outcomes of acupuncture and chiropractic (A/C) services for chronic musculoskeletal pain (CMP) using structured interview guides among patients with CMP (n = 90) and primary care providers (PCPs) (n = 25) purposively sampled from a managed care health care system as well as from contracted community A/C providers (n = 14). Focus groups and interviews were conducted patients with CMP with varying histories of A/C use. Plan PCPs and contracted A/C providers took part in individual interviews. All participants were asked about their experiences managing chronic pain and experience with and/or attitudes about A/C treatment. Audio recordings were transcribed and thematically coded. A summarized version of the focus group/interview guides is included in the Additional file 1.

RESULTS:   We identified four themes around opioid use:

(1)   attitudes toward use of opioids to manage chronic pain;

(2)   the limited alternative options for chronic pain management;

(3)   the potential of acupuncture and chiropractic (A/C) care as a tool to help manage pain; and

(4)   the complex system around chronic pain management.

Despite widespread dissatisfaction with opioid medications for pain management, many practical barriers challenged access to other options. Most of the participants’ perceived A/C care as helpful for short term pain relief. We identified that problems with timing, expectations, and plan coverage limited A/C care potential for pain relief treatment.

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A Qualitative Study of Changes in Expectations Over Time Among Patients with Chronic Low Back Pain Seeking Four CAM Therapies

By |April 16, 2017|Chiropractic Care, Chronic Pain|

A Qualitative Study of Changes in Expectations Over Time Among Patients with Chronic Low Back Pain Seeking Four CAM Therapies

The Chiro.Org Blog

SOURCE:   BMC Complement Altern Med. 2015 (Feb 5); 15: 12

Emery R Eaves, Karen J Sherman, Cheryl Ritenbaugh,
Clarissa Hsu, Mark Nichter, Judith A Turner,
and Daniel C Cherkin

Department of Family and Community Medicine &
School of Anthropology,
University of Arizona,
Tucson, AZ, USA.

BACKGROUND:   The relationship between patient expectations about a treatment and the treatment outcomes, particularly for Complementary and Alternative Medicine (CAM) therapies, is not well understood. Using qualitative data from a larger study to develop a valid expectancy questionnaire for use with participants starting new CAM therapies, we examined how participants’ expectations of treatment changed over the course of a therapy.

METHODS:   We conducted semi-structured qualitative interviews with 64 participants initiating one of four CAM therapies (yoga, chiropractic, acupuncture, massage) for chronic low back pain. Participants just starting treatment were interviewed up to three times over a period of 3 months. Interviews were transcribed verbatim and analyzed using a qualitative mixed methods approach incorporating immersion/crystallization and matrix analysis for a decontexualization and recontextualization approach to understand changes in thematic emphasis over time.

RESULTS:   Pre-treatment expectations consisted of conjecture about whether or not the CAM therapy could relieve pain and improve participation in meaningful activities. Expectations tended to shift over the course of treatment to be more inclusive of broader lifestyle factors, the need for long-term pain management strategies and attention to long-term quality of life and wellness. Although a shift toward greater acceptance of chronic pain and the need for strategies to keep pain from flaring was observed across participants regardless of therapy, participants varied in their assessments of whether increased awareness of the need for ongoing self-care and maintenance strategies was considered a “positive outcome”. Regardless of how participants evaluated the outcome of treatment, participants from all four therapies reported increased awareness, acceptance of the chronic nature of pain, and attention to the need to take responsibility for their own health.

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Importance of Psychological Factors for the Recovery From a First Episode of Acute Non-specific Neck Pain

By |March 18, 2016|Chronic Pain|

Importance of Psychological Factors for the Recovery From a First Episode of Acute Non-specific Neck Pain – A Longitudinal Observational Study

The Chiro.Org Blog

SOURCE:   Chiropractic & Manual Therapies 2016 (Mar 16); 24: 9

Brigitte Wirth, B. Kim Humphreys and Cynthia Peterson

Chiropractic Medicine Department,
Faculty of Medicine,
University of Zurich and University Hospital Balgrist

It has been established that psychological factors (appear to play) an important role in chronic non-specific neck pain. Particularly anxiety, depression and catastrophizing appear to negatively affect pain intensity and disability in this patient group. [5]To test whether these emotional elements are the natural side-effect of chronic pain as opposed to being causal, these researchers worked with 850 patients with acute non-specific neck pain with no history of previous neck or arm pain.

The results were quite fascinating:

  • They found that the psychological factors measured at baseline had no influence on the self-reported outcome at 1 week and 1 month
  • A high reduction in anxiety between 1 week and 1 month after the first consultation was linked to a significantly higher chance for self-reported improvement at 1 month in both models
  • Poor outcome at 1 and 3 months went along with high levels of anxiety. High baseline anxiety was not a risk factor for poor outcome, but its reduction during the first month was highly related to favorable recovery.
  • In contrast, high level of depression at baseline was fairly related to poor recovery at 3 months.

Thus, patients with acute non-specific neck pain might benefit from adequate information and communication that targets at reducing anxiety by encouraging self-management of the problem.

Background   The influence of psychological factors on acute neck pain is sparsely studied. In a secondary analysis of prospectively collected data, this study investigated how several psychological factors develop in the first three months of acute neck pain and how these factors influence self-perceived recovery.

Methods   Patients were recruited in various chiropractic practices throughout Switzerland between 2010 and 2014. The follow-up telephone interviews were conducted for all patients by research assistants in the coordinating university hospital following a standardized procedure. The population of this study consisted of 103 patients (68 female; mean age = 38.3 ± 13.8 years) with a first episode of acute (<4 weeks) neck pain. Prior to the first treatment, the patients filled in the Bournemouth Questionnaire (BQ). One week and 1 and 3 months later, they completed the BQ again along with the Patient Global Impression of Change (PGIC). The temporal development (repeated measure ANOVA) of the BQ questions 4 (anxiety), 5 (depression), 6 (fear-avoidance) and 7 (pain locus of control) as well as the influence of these scores on the PGIC were investigated (binary logistic regression analyses, receiver operating curves (ROC)).

Results   All psychological parameters showed significant reduction within the first month. The parameter ‘anxiety’ was associated with outcome at 1 and 3 months (p = 0.013, R2 = 0.40 and p = 0.039, R2 = 0.63, respectively). Baseline depression (p = 0.037, R2 = 0.21), but not baseline anxiety, was a predictor for poor outcome. A high reduction in anxiety within the first month was a significant predictor for favorable outcome after 1 month (p < 0.001; R2 = 0.57).

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Chronic Pain Reconsidered

By |December 27, 2015|Chronic Pain|

Chronic Pain Reconsidered

The Chiro.Org Blog

SOURCE:   Pain. 2008 (Aug 31); 138 (2): 267–276 ~ FULL TEXT

Michael Von Korff, and Kate M. Dunn

Group Health Center for Health Studies,
1730 Minor Avenue, Suite 1600,
Seattle, WA 98101-1448, USA.

Chronic pain has been traditionally defined by pain duration, but this approach has limited empirical support and does not account for chronic pain’s multi-dimensionality. This study compared duration-based and prospective approaches to defining chronic pain in terms of their ability to predict future pain course and outcomes for primary care patients with three common pain conditions: back pain (n=971), headache (n=1078), or orofacial pain (n=455).   At baseline, their chronic pain was classified retrospectively based on Pain Days in the prior six months and prospectively with a prognostic Risk Score identifying patients with “possible” or “probable” chronic pain.   The 0-28 Risk Score was based on pain intensity, pain-related activity limitations, depressive symptoms, number of pain sites, and Pain Days.   Pain and behavioral outcomes were assessed at six-month follow-up, and long-term opioid use was assessed two to five years after baseline.   Risk Score consistently predicted clinically significant pain at six months better than did Pain Days alone (area under the curve of 0.74-0.78 for Risk Score vs. 0.63-0.73 for Pain Days).   Risk Score was a stronger predictor of future SF-36 Physical Function, pain-related worry, unemployment, and long-term opioid use than Pain Days alone.   Thus, for these three common pain conditions, a prognostic Risk Score had better predictive validity for pain outcomes than did pain duration alone.   However, chronic pain appears to be a continuum rather than a distinct class, because long-term pain outcomes are highly variable and inherently uncertain.

Keywords:   chronic pain, back pain, headache, orofacial pain, classification, epidemiology

 

From the FULL TEXT Article:

1.   Introduction

Patients seeking care for pain want to know whether their pain is likely to improve or run a chronic course, not only its cause and how it might be relieved and managed [13, 24]. Physicians’ abilities to provide guidance regarding pain’s likely course, as well as clinical and epidemiologic research, are hampered by lack of clear-cut, evidence-based operational criteria for classifying chronic pain [2, 6, 23, 26].

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Prediction of Pain Outcomes in a Randomized Controlled Trial of Dose-response of Spinal Manipulation for the Care of Chronic Low Back Pain

By |November 21, 2015|Chronic Pain, Low Back Pain|

Prediction of Pain Outcomes in a Randomized Controlled Trial of Dose-response of Spinal Manipulation for the Care of Chronic Low Back Pain

The Chiro.Org Blog

SOURCE:   BMC Musculoskelet Disord. 2015 (Aug 19);   16:   205 ~ FULL TEXT

Darcy Vavrek, Mitchell Haas, Moni Blazej Neradilek, and Nayak Polissar

University of Western States,
2900 NE 132nd Ave,
Portland, OR, 97230, USA

BACKGROUND:   No previous studies have created and validated prediction models for outcomes in patients receiving spinal manipulation for care of chronic low back pain (cLBP). We therefore conducted a secondary analysis alongside a dose-response, randomized controlled trial of spinal manipulation.

METHODS:   We investigated dose, pain and disability, sociodemographics, general health, psychosocial measures, and objective exam findings as potential predictors of pain outcomes utilizing 400 participants from a randomized controlled trial. Participants received 18 sessions of treatment over 6-weeks and were followed for a year. Spinal manipulation was performed by a chiropractor at 0, 6, 12, or 18 visits (dose), with a light-massage control at all remaining visits. Pain intensity was evaluated with the modified von Korff pain scale (0-100). Predictor variables evaluated came from several domains: condition-specific pain and disability, sociodemographics, general health status, psychosocial, and objective physical measures. Three-quarters of cases (training-set) were used to develop 4 longitudinal models with forward selection to predict individual “responders” (≥50% improvement from baseline) and future pain intensity using either pretreatment characteristics or post-treatment variables collected shortly after completion of care. The internal validity of the predictor models were then evaluated on the remaining 25% of cases (test-set) using area under the receiver operating curve (AUC), R(2), and root mean squared error (RMSE).

RESULTS:   The pretreatment responder model performed no better than chance in identifying participants who became responders (AUC = 0.479). Similarly, the pretreatment pain intensity model predicted future pain intensity poorly with low proportion of variance explained (R(2) = .065). The post-treatment predictor models performed better with AUC = 0.665 for the responder model and R(2) = 0.261 for the future pain model. Post-treatment pain alone actually predicted future pain better than the full post-treatment predictor model (R(2) = 0.350). The prediction errors (RMSE) were large (19.4 and 17.5 for the pre- and post-treatment predictor models, respectively).

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Low Back Pain in Primary Care: A Description of 1250 Patients

By |October 17, 2015|Chiropractic Care, Chronic Pain, Low Back Pain|

Low Back Pain in Primary Care: A Description of 1250 Patients with Low Back Pain in Danish General and Chiropractic Practice

The Chiro.Org Blog

SOURCE:   Int J Family Med. 2014 (Nov 4);   2014:   106102 ~ FULL TEXT

Lise Hestbaek, Anders Munck, Lisbeth Hartvigsen,
Dorte Ejg Jarbøl, Jens Søndergaard, and Alice Kongsted

Department of Sports Science and Clinical Biomechanics,
University of Southern Denmark,
5230 Odense, Denmark
l.hestbaek@nikkb.dk

Study Design.   Baseline description of a multicenter cohort study.

Objective.   To describe patients with low back pain (LBP) in both chiropractic and general practice in Denmark.

Background.   To optimize standards of care in the primary healthcare sector, detailed knowledge of the patient populations in different settings is needed. In Denmark, most LBP-patients access primary healthcare through chiropractic or general practice.

Methods.   Chiropractors and general practitioners recruited adult patients seeking care for LBP. Extensive baseline questionnaires were obtained and descriptive analyses presented separately for general and chiropractic practice patients, Mann-Whitney rank sum test and Pearson’s chi-square test, were used to test for differences between the two populations.

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