Overview

This program at a multi-specialty group practice and an occupational health clinic affiliated with an academic medical center utilized a care model integrating traditional medical therapies and complementary & alternative therapies to improve therapeutic management of low back pain.

Collaborators

David M. Eisenberg, MD
Julie E. Buring, ScD
Andrea L. Hrbek
Roger B. Davis, ScD
Maureen T. Connelly, MD
Daniel C. Cherkin, PhD
Donald B. Levy, MD
Mark Cunningham
Bonnie O’Connor, PhD
Diana E. Post, MD

Status/Stage of Development

Completed

Funding Sources

The intervention was funded by grants from the National Center for Complementary and Alternative Medicine and the Bernard Osher Foundation.

National/Policy Context

  • Low back pain (LBP) is a condition that contributes to a large degree of morbidity amongst adults in the US. 
  • LBP is the most noted condition for which adult patients seek complementary and alternative medical (CAM) therapies. 
  • Previous studies have focused on the benefit of individual CAM therapies, but have not assessed these CAM therapies in conjunction with conventional medical therapies. 

Local/Organizational Context

  • The Harvard Vanguard Medical Associates is a large multi-specialty practice that provides clinical care to adult and pediatric patients through the larger Atrius Health, a non-profit collection of medical practices located in Massachusetts. 
  • The Occupational Health Department at BWH works to maintain a safe work environment by providing a range of services including screenings, risk exposure reducement and return to work visits.   

Patient Population Served and Payor Information

  • The health providers accepted a wide range of insurance types including private, occupational, and Medicare/Medicaid. 

Project Research + Planning

  • The intervention recruited 20 patients between 18-70 years old with presenting complaint of LBP without a known underlying medical diagnosis or traumatic event. 
  • The duration of LBP had to have been more than 21 days and less than 84 days. 
  • For the study involving the project, the participants were randomized to either the integrative care group (medical therapy + adjunctive therapy) or usual care (standard medical therapy alone). 

Training

  • The project relied on a multidisciplinary staff, of MDs, NPs, and CAM providers, who all received extensive training in the diagnosis and treatment of low back pain. 
  • The staff members from each specialty also shared a presentation from the perspective of their respective roles and clinical disciplines.

Tech Involved
  • Electronic medical record
Team Members Involved
  • Dietician
  • NPs
  • OT
  • PAs
  • Physicians
  • PT
Workflow Steps

  • A patient is assigned to the integrated care (IC) or usual care (UC) group.
    • The IC group includes medical doctors such as internists, neurologists, orthopedists, psychiatrists, rheumatologists, occupational therapists, and physical therapists. CAM providers include acupuncturists and nutritionists. 
  • At their initial visit, a medical doctor and CAM provider independently evaluate a patient in the IC group for the severity of LBP symptoms, and determine potential benefits of a specific therapy. 
  • The medical doctor and CAM provider devise and initiate an individualized, 12-week treatment plan for the patient.
  • Each case is discussed with a larger team of providers during weekly meetings to edit a plan or cross-refer to another provider.
  • Patients in the UC group attend regular medical appointments and receive standard therapy.
  • Patients in both the IC and UC group are followed up by telephone at 2, 5, 12 and 36 weeks intervals. 

Budget
  • Unknown
Outcomes

  • 14 patients were included in the integrative care (IC) group and six patients were included in the usual care (UC) group.
  • Severity of Symptoms: The severity of symptoms of LBP were compared between the IC and UC groups at the beginning of the project and at scheduled follow-up calls. The patients rated the severity of their pain and the extent to which they found their pain bothersome on scales of 0-10 (0 = no issues to 10 = worst). At 12 weeks:
    • The IC group had lower mean pain scores of 0.6 compared to the UC group of 5 (p=0.005).
    • The IC group rated the bothersome-ness of their pain with mean a score of 1.4 compared to the UC group of 5.7 (p=0.02).
  • Functional Status: The patients’ mean functional status was measured with the Roland Morris Disability Questionnaire, which assesses functional status with scores of 0-24( 0 = no disability to 24 = high level of disability due to pain). 
    • The IC group had lower Roland scores of 3.9 compared to the UC group of 11 (p=0.08).

Future Outcomes

A proposed future study would assess the financial benefits of an integrated approach to LBP care in addition to its clinical benefits.

Benefits

  • This intervention showed that an integrative approach including medical care and alternative therapies can significantly improve the management of low back pain. 
  • The intervention revealed the importance of extensive training and frequent communication in building an effective multidisciplinary team.

Intervention-Specific Challenges

  • The limited population of 20 patients yielded results that might limit the generalizability of the study to a larger population. 
  • There was a large amount of loss to follow-up in the usual care group.

Sources

  • Atrius Health: About Us. (n.d.). Retrieved July 17, 2019, from https://www.atriushealth.org/about-us 
  • Brigham and Women’s Hospital: Occupational Health Services. (n.d.). Retrieved July 17, 2019, from https://www.brighamandwomens.org/about-bwh/human-resources/occupational-health/about-occupational-health-services 
  • Eisenberg DM, Buring JE, Hrbek AL, Davis RB, Connelly MT, Cherkin DC, Levy DB, Cunningham M, O’Connor B, Post DE. A model of integrative care for low-back pain. J Altern Complement Med. 2012 Apr;18(4):354-62. doi: 10.1089/acm.2011.0408. Epub 2012 Mar 28. PubMed PMID: 22455544; PubMed Central PMCID: PMC3326266.
  • Eisenberg DM, Davis RB, Ettner SL, Appel S, Wilkey S, Van Rompay M, Kessler RC. Trends in alternative medicine use in the United States, 1990-1997: results of a follow-up national survey. JAMA. 1998 Nov 11;280(18):1569-75. PubMed PMID: 9820257.
  • Stratford PW, Riddle DL. A Roland Morris Disability Questionnaire Target Value to Distinguish between Functional and Dysfunctional States in People with Low Back Pain. Physiother Can. 2016;68(1):29-35. doi: 10.3138/ptc.2014-85. PubMed PMID: 27504045; PubMed Central PMCID: PMC4961316.

Innovators
  • Diana Post, MD
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