Guide Holistic Therapies for Adults with Neck Pain

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Typically the patients received two different types of CTs Table 5. Swedish massage was the most common therapy to be combined with several other types of CTs. Shiatsu and qigong were the two most common CTs to be combined together Table 5. Manipulative therapy was the most common CT to be integrated as a single add-on treatment to conventional care Table 5.

There were no reports of crucial adverse events with either type of care. Assessment and data collection procedures were feasible throughout the study. This included the physicians' screening of potential study participants during routine clinical practice, the referral to the head general practitioner and the verification of eligibility and obtaining oral and written informed consent. However, it was not possible to verify the total number of patients screened at the participating primary care units.

Back and neck pain

Similarly, logistical barriers such as incompatibility between different providers' documentation and electronic patient record systems hindered mutual access to records of conventional or complementary care provided outside of the IM-team. Documentation of IM care was also challenging, e. The patient recruitment process was feasible and resulted in a high success rate, i. Facilitators may have been general practitioner assurance, e. The head general practitioner's personal experience of professional CT provision, e.

Swedish massage and acupuncture, may have been an additional recruitment facilitator. This was known to several of the collaborating physicians and may have increased their trust in the project and willingness to refer patients. Adding to this we found that physicians who worked at the same primary care unit as the head general practitioner referred the most patients to the trial.

Perhaps regular informal contact among colleagues facilitated opportunities for queries and constructive dialogues in familiar biomedical terms about the rational for IM in primary care. Communicating in the same "language" in relation to biomedicine and CTs has indeed been suggested to increase understanding across different health care disciplines [ 43 , 44 ]. One retention barrier may have been the use of postal questionnaires administered outside of the primary care units to collect data.

Follow-up strategies "closer" to the patients, e. However, a prerequisite for such strategies include the availability of resources and adequate funding which the current study did not have [ 21 ]. Additional facilitators for achieving high retention rates may include recruiting patients via media advertising or different health related registers, businesses or insurance companies. However, we decided against such external recruitment approaches reasoning that patients enrolled through active media advertising may behave differently e.

Hence the selected recruitment strategy may have increased the generalisability of findings in relation to the target population and clinical setting in the particular area, i. No patients dropped out due to crucial adverse effects with either type of care or due to the slight extra cost of receiving CTs in the IM model. This supports the IM and conventional care models as safe treatment options, as well as the feasibility of letting patients partly contribute to the costs for CT provision.

This may have important clinical implications for implementation and sustainability of IM in public health care settings where CTs are not normally reimbursed. Future studies will have to investigate at what levels the economical thresholds lies and how much patients are willing to financially contribute for IM health services in different clinical settings. Conventional care provision complied with the recommended primary care guidelines [ 23 ].

Acupuncture was the least provided CT, mainly due to difficulties recruiting an acupuncturist. The IM team compensated for this by providing shiatsu, a CT largely sharing the philosophy of acupuncture. Manipulative therapy was provided by a naprapath, a common provider of this type of care in Sweden. Future IM approaches may want to consider other recognised manipulative therapy professions including e.

However, this limited cost approximation did not include data on e.

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Future studies are warranted and should consider collection of more detailed cost related data, e. Such evidence has immediate implications for health policy and decision-making regarding the implementation of IM in conventional primary care.

The pilot trial analyses did not result in any statistically significant differences between the groups' outcome changes over time. Imputing missing data with the last observed measures intention-to-treat did not change the results, i. Exploring outcome differences and effect sizes between the groups returned few clinically relevant differences.

The outcome measures that displayed the largest clinical differences supporting IM, albeit within small ranges, were the SF quality of life domain vitality and the decreased use of prescription and non-prescription analgesics.


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Clearly, less use of prescription analgesics if confirmed is an important clinical finding that may reduce reported negative side effects linked to prolonged use of such drugs [ 45 , 46 ]. Other small trends in favour of IM were seen in two of the exploratory IM tailored outcomes in terms of decreased disability and less stress. However, the added CT treatments for the IM group might have exposed those patients to a more intensive management, which in turn may help to explain the trend towards more positive results for IM identified for some variables.

This increased "attention" effect is purposively part of the IM model and allowed for in pragmatic and exploratory approaches towards investigating differences between models of care. The concurrent use of CTs out of the study allowed for in this pragmatic pilot study, although not actively recommended to patients we simply monitored their self-reported use , may have contaminated the trial and contributed to the lack of significant differences between groups.

Nonetheless, to inflict or restrict self-initiated health care strategies or utilisation patterns, or to quantify and distinguish between placebo or non-specific effects of attention from more specific effects of e.

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Although such rather costly and complicated investigations would provide high internal validity, the generalisability of findings from such trials to regular primary health care provision can sometimes be questioned [ 20 ]. The current results with generally small clinical differences and effect sizes between groups may challenge a narrow use of outcomes measures in isolation to understand the relevance of IM in primary care.


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The findings may further attest to the need of identifying additional more relevant evaluation strategies, as suggested by recent outcomes research targeting IM and complex health interventions [ 47 ]. The trend of decreased use of prescription and non-prescription analgesics for IM in this pilot trial may support that the use of drugs and health care resources might indeed be one such important target area. Aspects of prevention, lifestyle changes and health promotion are other potentially important areas suggested, e. Lastly, an iterative cycle integrating and triangulating complementing quantitative and qualitative investigative procedures might be one of the best approaches towards exploring complex interventions such as the implementation of IM in clinical care settings [ 49 ].

Strong points in this study were successful screening and recruitment procedures; feasible CT provision within conventional care; comprehensive results on the characteristics of IM care with expected high external validity; acquisition of data to explore statistical and clinical differences between groups and to adequately power a future large-scale trial. Limitations included a relatively high drop out rate after 16 weeks; underestimated variability and lack of power to detect statistically significant differences between the groups; no blocking in the randomisation procedure; several outcome measures of explorative nature lacking proper scientific validity; scarce results on the use of health care resources, costs and cost savings.

We have discussed some implications of this for future research strategies including the need to continue investigations into relevant combinations of outcomes measures to adequately target and understand the relevance of IM for back and neck pain management in primary care settings. It has been proposed that for many patients the process of care may be as important as the outcomes of treatment [ 50 ] which may explain in part the relatively large utilisation of CTs among consumers and patients globally [ 51 ].

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Indeed, care processes themselves may influence care outcomes, not merely in terms of satisfaction with care but also with respect to patients' state of health and treatment effectiveness [ 50 ]. Accordingly, the IM model emphasized care processes along with care outcomes, and considering some of the clinical trends reported here, aspects of IM care might be important to consider in primary health care reform.

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Recruiting regular primary care patients in routine clinical practice was feasible. Exploring clinically relevant differences and the use of SF as the basis for a main outcome measure showed that the sample sizes needed per arm would range from 60 vitality to role emotion to adequately power a full-scale trial. The findings attest to the need to further investigate IM as a complex health intervention and to continue to explore relevant combinations of outcomes to help understand the relevance of IM in primary care, e.

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