Pain screening in youth with sickle cell disease: A quality improvement study.

BACKGROUND: Youth with sickle cell disease (SCD) face several challenges as they age, including increased pain frequency, duration, and interference. The purpose of this study was to (i) determine the feasibility of routine pain screening; (ii) identify and describe various clinical pain presentations; and (iii) understand preferences/resources related to engaging in integrative health and medicine (IHM) modalities within an outpatient pediatric SCD clinic. METHODS: During routine outpatient visits, patients aged 8-18 completed measures of pain frequency, duration, and chronic pain risk (Pediatric Pain Screening Tool [PPST]). Participants screening positive for (i) persistent or chronic pain or (ii) medium or high risk for persistent symptoms and disability on the PPST were asked to complete measures of pain interference, pain catastrophizing, and interest in/resources for engaging in IHM modalities. RESULTS: Between March 2022 and May 2023, 104/141 (73.8%) patients who attended at least one outpatient visit were screened. Of these 104 (mean age 12.46, 53.8% female, 63.5% HbSS), 34 (32.7%) reported persistent or chronic pain, and 48 (46.2%) reported medium or high risk for persistent symptoms and disability. Patients completing subsequent pain screening measures reported a mean pain interference T-score of 53.2 ± 8.8 and a mean pain catastrophizing total score of 24.3 ± 10.2. Patients expressed highest interest in music (55.6%) and art therapy (51.9%) and preferred in-person (81.5%) over virtual programming (22.2%). CONCLUSIONS: Comprehensive pain screening is feasible within pediatric SCD care. Classifying patients by PPST risk may provide a means of triaging patients to appropriate services to address pain-related psychosocial factors.

Association between spinal manipulative therapy and lumbar spine reoperation after discectomy: a retrospective cohort study.

BACKGROUND: Patients who undergo lumbar discectomy may experience ongoing lumbosacral radiculopathy (LSR) and seek spinal manipulative therapy (SMT) to manage these symptoms. We hypothesized that adults receiving SMT for LSR at least one year following lumbar discectomy would be less likely to undergo lumbar spine reoperation compared to matched controls not receiving SMT, over two years' follow-up. METHODS: We searched a United States network of health records (TriNetX, Inc.) for adults aged ≥ 18 years with LSR and lumbar discectomy ≥ 1 year previous, without lumbar fusion or instrumentation, from 2003 to 2023. We divided patients into two cohorts: (1) chiropractic SMT, and (2) usual care without chiropractic SMT. We used propensity matching to adjust for confounding variables associated with lumbar spine reoperation (e.g., age, body mass index, nicotine dependence), calculated risk ratios (RR), with 95% confidence intervals (CIs), and explored cumulative incidence of reoperation and the number of SMT follow-up visits. RESULTS: Following propensity matching there were 378 patients per cohort (mean age 61 years). Lumbar spine reoperation was less frequent in the SMT cohort compared to the usual care cohort (SMT: 7%; usual care: 13%), yielding an RR (95% CIs) of 0.55 (0.35-0.85; P = 0.0062). In the SMT cohort, 72% of patients had ≥ 1 follow-up SMT visit (median = 6). CONCLUSIONS: This study found that adults experiencing LSR at least one year after lumbar discectomy who received SMT were less likely to undergo lumbar spine reoperation compared to matched controls not receiving SMT. While these findings hold promise for clinical implications, they should be corroborated by a prospective study including measures of pain, disability, and safety to confirm their relevance. We cannot exclude the possibility that our results stem from a generalized effect of engaging with a non-surgical clinician, a factor that may extend to related contexts such as physical therapy or acupuncture. REGISTRATION: Open Science Framework ( https://osf.io/vgrwz ).

Massage therapy for children, adolescents, and young adults: Clinical delivery and effectiveness in hematology and oncology.

BACKGROUND: Children, adolescents, and young adults with hematologic and/or oncologic conditions experience multiple, significant symptoms (e.g., pain, stress, and anxiety), which may be addressed by nonpharmacologic approaches such as massage therapy (MT). The purpose of this study was to describe the clinical delivery of MT provided by a certified pediatric massage therapist and assess effectiveness in two patient groups: those with sickle cell disease (SCD) or hematologic and/or oncologic conditions excluding SCD (HemOnc). METHODS: Investigators conducted a retrospective review of MT sessions provided to patients 0-39 years with hematologic and/or oncologic conditions at a large pediatric academic medical center. RESULTS: Between October 2019 and December 2021, 3015 MT sessions were provided to 243 patients (171 HemOnc; 72 SCD) and documented in the electronic health record. Patients (mean age: 12.21 ± 7.19 years) were generally White (49.4%) or Black/African American (43.2%), non-Hispanic (94.2%), and 52.3% female. Patients in the SCD group (vs. patients in the HemOnc group) reported significantly higher (p < .05) pretreatment pain (6.95 vs. 4.46), stress (6.47 vs. 4.58), and anxiety (6.67 vs. 4.59). All patients reported clinically and statistically significant (p < .001) mean reductions in pain (-2.25 ± 1.87), stress (-2.50 ± 1.73), and anxiety (-2.52 ± 1.69), with patients in the HemOnc group reporting greater mean pain change (-2.54 vs. -1.87) than patients in the SCD group. CONCLUSIONS: This study supports the clinical effectiveness of MT for addressing acute pain, stress, and anxiety among youth with hematologic and/or oncologic conditions. Future research is needed to identify optimal MT utilization.

A Systematic Review of Practiced-Based Research of Complementary and Integrative Health Therapies as Provided for Pain Management in Clinical Settings: Recommendations for the Future and a Call to Action.

OBJECTIVE: The goal of this systematic review was to evaluate practice-based, real-world research of individualized complementary and integrative health (CIH) therapies for pain as provided in CIH outpatient clinics. METHODS: A systematic review was conducted on articles in PubMed, Ovid, Cochrane, Web of Science, Scopus, and Embase published through December 2020. The study was listed in the PROSPERO database (CRD42020159193). Major categories of variables extracted included study details and demographics, interventions, and outcomes. RESULTS: The literature search yielded 3,316 records, with 264 assessed for full-text review. Of those, 23 studies (including ∼8,464 patients) were specific to pain conditions as a main outcome. Studies included chiropractic, acupuncture, multimodal individualized intervention/programs, physiotherapy, and anthroposophic medicine therapy. Retention rates ranged from 53% to 91%, with studies offering monetary incentives showing the highest retention. The 0-10 numerical rating scale was the most common pain questionnaire (n = 10; 43% of studies), with an average percent improvement across all studies and time points of 32% (range: 18-60%). CONCLUSIONS: Findings from this systematic review of practice-based, real-word research indicate that CIH therapies exert positive effects on various pain outcomes. Although all studies reported beneficial impacts on one or more pain outcomes, the heterogeneous nature of the studies limits our overall understanding of CIH as provided in clinical settings. Accordingly, we present numerous recommendations to improve publication reporting and guide future research. Our call to action is that future practice-based CIH research is needed, but it should be more expansive and conducted in association with a CIH scientific society with academic and health care members.

Acupuncture Therapy as an Evidence-Based Nonpharmacologic Strategy for Comprehensive Acute Pain Care: The Academic Consortium Pain Task Force White Paper Update.

BACKGROUND: A crisis in pain management persists, as does the epidemic of opioid overdose deaths, addiction, and diversion. Pain medicine is meeting these challenges by returning to its origins: the Bonica model of multidisciplinary pain care. The 2018 Academic Consortium White Paper detailed the historical context and magnitude of the pain crisis and the evidence base for nonpharmacologic strategies. More than 50% of chronic opioid use begins in the acute pain care setting. Acupuncture may be able to reduce this risk. OBJECTIVE: This article updates the evidence base for acupuncture therapy for acute pain with a review of systematic reviews and meta-analyses on postsurgical/perioperative pain with opioid sparing and acute nonsurgical/trauma pain, including acute pain in the emergency department. METHODS: To update reviews cited in the 2018 White Paper, electronic searches were conducted in PubMed, MEDLINE, CINAHL, and the Cochrane Central Register of Controlled Trials for "acupuncture" and "acupuncture therapy" and "acute pain," "surgery," "peri-operative," "trauma," "emergency department," "urgent care," "review(s) ," "systematic review," "meta-analysis," with additional manual review of titles, links, and reference lists. RESULTS: There are 22 systematic reviews, 17 with meta-analyses of acupuncture in acute pain settings, and a review for acute pain in the intensive care unit. There are additional studies of acupuncture in acute pain settings. CONCLUSION: The majority of reviews found acupuncture therapy to be an efficacious strategy for acute pain, with potential to avoid or reduce opioid reliance. Future multicenter trials are needed to clarify the dosage and generalizability of acupuncture for acute pain in the emergency department. With an extremely low risk profile, acupuncture therapy is an important strategy in comprehensive acute pain care.

Guideline-concordant utilization of magnetic resonance imaging in adults receiving chiropractic manipulative therapy vs other care for radicular low back pain: a retrospective cohort study.

BACKGROUND: Lumbar magnetic resonance imaging (LMRI) is often performed early in the course of care, which can be discordant with guidelines for non-serious low back pain. Our primary hypothesis was that adults receiving chiropractic spinal manipulative therapy (CSMT) for incident radicular low back pain (rLBP) would have reduced odds of early LMRI over 6-weeks' follow-up compared to those receiving other care (a range of medical care, excluding CSMT). As a secondary hypothesis, CSMT recipients were also expected to have reduced odds of LMRI over 6-months' and 1-years' follow-up. METHODS: A national 84-million-patient health records database including large academic healthcare organizations (TriNetX) was queried for adults age 20-70 with rLBP newly-diagnosed between January 31, 2012 and January 31, 2022. Receipt or non-receipt of CSMT determined cohort allocation. Patients with prior lumbar imaging and serious pathology within 90 days of diagnosis were excluded. Propensity score matching controlled for variables associated with LMRI utilization (e.g., demographics). Odds ratios (ORs) of LMRI over 6-weeks', 6-months', and 1-years' follow-up after rLBP diagnosis were calculated. RESULTS: After matching, there were 12,353 patients per cohort (mean age 50 years, 56% female), with a small but statistically significant reduction in odds of early LMRI in the CSMT compared to other care cohort over 6-weeks' follow-up (9%, 10%, OR [95% CI] 0.88 [0.81-0.96] P = 0.0046). There was a small but statistically significant increase in odds of LMRI among patients in the CSMT relative to the other care cohort over 6-months' (12%, 11%, OR [95% CI] 1.10 [1.02-1.19], P < 0.0174) and 1-years' follow-up (14%, 12%, OR [95% CI] 1.21 [1.13-1.31], P < 0.0001). CONCLUSIONS: These results suggest that patients receiving CSMT for newly-diagnosed rLBP are less likely to receive early LMRI than patients receiving other care. However, CSMT recipients have a small increase in odds of LMRI over the long-term. Both cohorts in this study had a relatively low rate of early LMRI, possibly because the data were derived from academic healthcare organizations. The relationship of these findings to other patient care outcomes and cost should be explored in a future randomized controlled trial. REGISTRATION: Open Science Framework ( https://osf.io/t9myp ).

Common and Dissociable Neural Activity After Mindfulness-Based Stress Reduction and Relaxation Response Programs.

OBJECTIVE: We investigated common and dissociable neural and psychological correlates of two widely used meditation-based stress reduction programs. METHODS: Participants were randomized to the Relaxation Response (RR; n = 18; 56% female) or the Mindfulness-Based Stress Reduction (MBSR; n = 16; 56% female) programs. Both programs use a "bodyscan" meditation; however, the RR program explicitly emphasizes physical relaxation during this practice, whereas the MBSR program emphasizes mindful awareness with no explicit relaxation instructions. After the programs, neural activity during the respective meditation was investigated using functional magnetic resonance imaging. RESULTS: Both programs were associated with reduced stress (for RR, from 14.1 ± 6.6 to 11.3 ± 5.5 [Cohen's d = 0.50; for MBSR, from 17.7 ± 5.7 to 11.9 ± 5.0 [Cohen's d = 1.02]). Conjunction analyses revealed functional coupling between ventromedial prefrontal regions and supplementary motor areas (p < .001). The disjunction analysis indicated that the RR bodyscan was associated with stronger functional connectivity of the right inferior frontal gyrus-an important hub of intentional inhibition and control-with supplementary motor areas (p < .001, family-wise error [FWE] rate corrected). The MBSR program was uniquely associated with improvements in self-compassion and rumination, and the within-group analysis of MBSR bodyscan revealed significant functional connectivity of the right anterior insula-an important hub of sensory awareness and salience-with pregenual anterior cingulate during bodyscan meditation compared with rest (p = .03, FWE corrected). CONCLUSIONS: The bodyscan exercises in each program were associated with both overlapping and differential functional coupling patterns, which were consistent with each program's theoretical foundation. These results may have implications for the differential effects of these programs for the treatment of diverse conditions.

Acceptability, Adaptation, and Clinical Outcomes of Acupuncture Provided in the Emergency Department: A Retrospective Pilot Study.

Objective: To evaluate acceptability and clinical outcomes of acupuncture on patient-reported pain and anxiety in an emergency department (ED). Design: Observational, retrospective pilot study. Setting: Abbott Northwestern Hospital ED, Minneapolis, MN. Methods: Retrospective data was used to identify patients receiving acupuncture in addition to standard medical care in the ED between 11/1/13 and 12/31/14. Feasibility was measured by quantifying the utilization of acupuncture in a novel setting and performing limited tests of its efficacy. Patient-reported pain and anxiety scores were collected by the acupuncturist using an 11-point (0-10) numeric rating scale before (pre) and immediately after (post) acupuncture. Efficacy outcomes were change in pain and anxiety scores. Results: During the study period, 436 patients were referred for acupuncture, 279 of whom were approached by the acupuncturist during their ED visit. Consent for acupuncture was obtained from 89% (248/279). A total of 182 patients, who had a pre-pain score >0 and non-missing anxiety scores, were included in analyses. Of the 52% (94/182) who did not have analgesics before or during the acupuncture session, the average decrease of 2.37 points (95% CI: 1.92, 2.83) was not different (p > 0.05) than the mean decrease of 2.68 points for those receiving analgesics (95% CI 2.21, 3.15). The average pre-anxiety score was 4.73 points (SD = 3.43) and the mean decrease was 2.27 points (95% CI: 1.89, 2.66). Conclusions: Results from this observational trial indicate that acupuncture was acceptable and effective for pain and anxiety reduction, in conjunction with standard medical care. These results will inform future randomized trials.

Vitamin D therapy in individuals with prehypertension or hypertension: the DAYLIGHT trial.

BACKGROUND: A large body of epidemiological and experimental evidence suggests that vitamin D deficiency may promote hypertension. This raises the possibility that vitamin D supplementation could be a simple intervention to reduce blood pressure, but data from prospective, randomized trials are limited. METHODS AND RESULTS: A double-blind, randomized, controlled trial was conducted at 4 sites in the United States. We enrolled 534 individuals 18 to 50 years of age with low vitamin D status (25-hydroxyvitamin D levels ≤25 ng/mL) and systolic blood pressure of 120 to 159 mm Hg. Participants were randomized to high-dose (4000 IU/d) versus low-dose (400 IU/d) oral vitamin D3 for 6 months. The primary end point was change in mean 24-hour systolic blood pressure. Secondary end points included change in ambulatory diastolic blood pressure and clinic systolic and diastolic blood pressures. The median age was 38 years, and 62% of participants were men. Forty-six percent of participants were white, and 48% were black. The median 25-hydroxyvitamin D level at baseline was 15.3 ng/mL. Four-hundred fifty-five participants (85%) had at least 1 follow-up blood pressure measurement; 383 participants (72%) completed the full 6-month study. At the end of the study, there was no significant difference in the primary end point (change in mean 24-hour systolic blood pressure, -0.8 versus -1.6 mm Hg in the high-dose and low-dose arms; P=0.71) or in any of the secondary end points. Furthermore, there was no evidence of association between change in 25-hydroxyvitamin D and change in 24-hour systolic blood pressure at 6 months (Spearman correlation coefficient, -0.05, P=0.34). Results were consistent across prespecified subgroups. CONCLUSIONS: Vitamin D supplementation did not reduce blood pressure in individuals with prehypertension or stage I hypertension and vitamin D deficiency. Our findings suggest that the association between vitamin D status and elevated blood pressure noted in observational studies is not causal. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT01240512.

Patients Receiving Integrative Medicine Effectiveness Registry (PRIMIER) of the BraveNet practice-based research network: study protocol.

BACKGROUND: Integrative medicine (IM) provides patient-centered care and addresses the full range of physical, emotional, mental, social, spiritual, and environmental influences that affect a person's health. IM is a "whole systems" approach that employs multiple modalities as opposed to an isolated complementary therapy. Thus, studying outcomes of IM is more challenging than evaluating an isolated intervention. Practice-based research networks (PBRNs) allow for clinicians/investigators at multiple diverse sites using common methodology to pool their data, increase participant sample size and increase generalizability of results. To conduct real-world, practice-based research, the Bravewell Collaborative founded BraveNet in 2007 as the first national integrative medicine PBRN. METHODS AND DESIGN: Patients Receiving Integrative Medicine Effectiveness Registry (PRIMIER) is a prospective, non-randomized, observational evaluation conducted at fourteen clinical sites. Participants receive a non-standardized, personalized, multimodal IM approach for various medical conditions. Using the REDCap electronic platform, an anticipated 10,000 study participants will complete patient-reported outcome measures including Patient Reported Outcomes Measurement Information System (PROMIS)-29, Perceived Stress Scale-4, and the Patient Activation Measure at baseline, 2, 4, 6, 12, 18 and 24 months. Extractions from participants' electronic health records include IM services received, as well as ICD diagnostic codes, and CPT billing codes associated with each IM visit. Repeated-measures analyses will be performed on data to assess change from baseline through 24 months with planned subgroup analyses to include specific clinical population and specific IM intervention or combinations. DISCUSSION: As the PRIMIER registry grows, we anticipate that our results would provide an indication of the promise of PBRN research efforts in IM. Analyses will incorporate a large sample of participants and an expected 10-year observation period and will provide the ability to evaluate the effect of IM on outcomes for specific clinical populations and specific IM interventions or combinations. As such, PRIMIER will serve as a national platform for future evaluations of IM best practices. TRIAL REGISTRATION: Clinical Trials.gov NCT01754038.

Development of a Health System-Based Nurse-Delivered Aromatherapy Program.

Healthcare systems are increasingly looking to integrate aromatherapy (essential oils) as a safe, low-cost, and nonpharmacologic option for patient care to reduce pain, nausea, and anxiety and to improve sleep. This article describes the development and implementation of a healthcare system-wide program of nurse-delivered essential oil therapeutic interventions to inpatients throughout an acute care setting. In addition, we provide lessons learned for nursing administrators interested in developing similar nurse-delivered aromatherapy programs.

Acupuncture provides short-term pain relief for patients in a total joint replacement program.

OBJECTIVE: Given the risks of opioid medications, nonpharmacological strategies should be considered for total joint replacement patients. We investigated acupuncture as an adjunct therapy for postsurgical pain management in a total joint replacement program by examining which total hip and knee replacement patients elected to receive acupuncture and the effect of acupuncture on short-term pain. DESIGN: A total joint replacement program using fast-track physiotherapy offered elective postsurgical acupuncture to all patients, at no additional cost, as an adjunct therapy to opioids for pain management. SETTING: The Joint Replacement Center at Abbott Northwestern Hospital, a 630-bed teaching and specialty hospital in Minneapolis, Minnesota from 2010 to 2012. SUBJECTS: Our sample included 2,500 admissions of total hip (THR) and total knee replacement (TKR) patients. METHODS: Self-reported pain was assessed before and after acupuncture using a 0-10 scale and categorized as none/mild (0-4) and moderate/severe pain (5-10). RESULTS: Seventy-five percent of admissions included acupuncture. Women (Odds Ratio: 1.48, 95% Confidence Interval (CI): 1.22, 1.81) had higher odds of receiving acupuncture compared to men, and nonwhite patients (Odds Ratio: 0.55, 95% CI: 0.39, 0.78) had lower odds of receiving acupuncture compared to white patients. Average short-term pain reduction was 1.91 points (95% CI: 1.83, 1.99), a 45% reduction from the mean prepain score. Forty-one percent of patients reported moderate/severe pain prior to receiving acupuncture, while only 15% indicated moderate/severe pain after acupuncture. CONCLUSIONS: Acupuncture may be a viable adjunct to pharmacological approaches for pain management after THR or TKR.

Perceptions of providers and administrators in the Veterans Health Administration regarding complementary and alternative medicine.

BACKGROUND: The integration of complementary and alternative medicine (CAM) therapies into a large organization such as the Veterans Health Administration (VHA) requires cultural change and deliberate planning to ensure feasibility and buy-in from staff and patients. At present, there is limited knowledge of VHA patient care providers' and administrators' viewpoints regarding CAM therapies and their implementation. OBJECTIVES: Our purpose was to qualitatively examine knowledge, attitudes, perceived value and perceived barriers, and/or facilitators to CAM program implementation among VHA providers and administrators at a large VHA facility. RESEARCH DESIGN: We are reporting the qualitative interview portion of a mixed-methods study. SUBJECTS: Twenty-eight participants (patient care providers or administrators) were purposely chosen to represent a spectrum of positions and services. Participants' experience with and exposure to CAM therapies varied. MEASURES: Individual interviews were conducted using a semi-structured format and were digitally recorded, transcribed, and coded for themes. RESULTS: Recurrent themes included: a range of knowledge about CAM; benefits for patients and staff; and factors that can be facilitators or barriers including evidence-based practice or perceived lack thereof, prevailing culture, leadership at all levels, and lack of position descriptions for CAM therapists. Participants rated massage, meditation, acupuncture, and yoga as priorities for promotion across the VHA. CONCLUSIONS: Despite perceived challenges, providers and administrators recognized the value of CAM and potential for expansion of CAM within the VHA. Interview results could inform the process of incorporating CAM into a plan for meeting VHA Strategic Goal One of personalized, proactive, patient-driven health care across the VHA.

The effectiveness of integrative medicine interventions on pain and anxiety in cardiovascular inpatients: a practice-based research evaluation.

BACKGROUND: Pain and anxiety occurring from cardiovascular disease are associated with long-term health risks. Integrative medicine (IM) therapies reduce pain and anxiety in small samples of hospitalized cardiovascular patients within randomized controlled trials; however, practice-based effectiveness research has been limited. The goal of the study is to evaluate the effectiveness of IM interventions (i.e., bodywork, mind-body and energy therapies, and traditional Chinese medicine) on pain and anxiety measures across a cardiovascular population. METHODS: Retrospective data obtained from medical records identified patients with a cardiovascular ICD-9 code admitted to a large Midwestern hospital between 7/1/2009 and 12/31/2012. Outcomes were changes in patient-reported pain and anxiety, rated before and after IM treatments based on a numeric scale (0-10). RESULTS: Of 57,295 hospital cardiovascular admissions, 6,589 (11.5%) included IM. After receiving IM therapy, patients averaged a 46.5% (p-value < 0.001) decrease in pain and a 54.8% (p-value < 0.001) decrease in anxiety. There was no difference between treatment modalities on pain reduction; however, mind-body and energy therapies (p-value < 0.01), traditional Chinese medicine (p-value < 0.05), and combination therapies (p-value < 0.01) were more effective at reducing anxiety than bodywork therapies. Each additional year of age reduced the odds of receiving any IM therapy by two percent (OR: 0.98, p-value < 0.01) and females had 96% (OR: 1.96, p-value < 0.01) higher odds of receiving any IM therapy compared to males. CONCLUSIONS: Cardiovascular inpatients reported statistically significant decreases in pain and anxiety following care with adjunctive IM interventions. This study underscores the potential for future practice-based research to investigate the best approach for incorporating these therapies into an acute care setting such that IM therapies are most appropriately provided to patient populations.

Effectiveness of Medical Music Therapy Practice: Integrative Research Using the Electronic Health Record: Rationale, Design, and Population Characteristics.

Background: Several clinical trials support the efficacy of music therapy (MT) for improving outcomes in hospitalized patients, but few studies have evaluated the real-world delivery and integration of MT across multiple medical centers. This article describes the rationale, design, and population characteristics of a retrospective study examining the delivery and integration of MT within a large health system. Methods: A retrospective electronic health record (EHR) review was conducted of hospitalized patients seen by and/or referred to MT between January 2017 and July 2020. MT was provided across ten medical centers, including an academic medical center, a freestanding cancer center, and eight community hospitals. Discrete demographic, clinical, and MT treatment and referral characteristics were extracted from the EHR, cleaned, and organized using regular expressions functions, and they were summarized using descriptive statistics. Results: The MT team (average 11.6 clinical fulltime equivalent staff/year) provided 14,261 sessions to 7378 patients across 9091 hospitalizations. Patients were predominantly female (63.7%), White (54.3%) or Black/African American (44.0%), 63.7 ± 18.5 years of age at admission, and insured under Medicare (51.1%), Medicaid (18.1%), or private insurance (14.2%). Patients' hospitalizations (median length of stay: 5 days) were primarily for cardiovascular (11.8%), respiratory (9.9%), or musculoskeletal (8.9%) conditions. Overall, 39.4% of patients' hospital admissions included a mental health diagnosis, and 15.4% were referred to palliative care. Patients were referred by physicians (34.7%), nurses (29.4%), or advanced practice providers (24.7%) for coping (32.0%), anxiety reduction (20.4%), or pain management (10.1%). Therapists provided sessions to patients discharged from medical/surgical (74.5%), oncology (18.4%), or intensive care (5.8%) units. Conclusions: This retrospective study indicates that MT can be integrated across a large health system for addressing the needs of socioeconomically diverse patients. However, future research is needed to assess MT's impact on health care utilization (i.e., length of stay and rates of readmission) and immediate patient-reported outcomes.

Acupuncture knowledge, attitudes, beliefs and health service needs after traumatic brain injury: a cross-sectional survey.

BACKGROUND: Acupuncture is a promising treatment for common symptoms after traumatic brain injury (TBI). Our objectives were to explore knowledge, attitudes and beliefs about acupuncture, identify health service needs and assess the perceived feasibility of weekly acupuncture visits among individuals with TBI. METHODS: We surveyed adults 18 years of age and older with TBI who received care at the University of Washington. Respondents were asked to complete 143 questions regarding acupuncture knowledge, attitudes and beliefs, injury-related symptoms and comorbidities, and to describe their interest in weekly acupuncture. RESULTS: Respondents (n = 136) reported a high degree of knowledge about acupuncture as a component of Traditional Chinese Medicine, needle use and safety, but were less knowledgeable regarding that the fact that most conditions require multiple acupuncture treatments to achieve optimal therapeutic benefit. Respondents were comfortable talking with healthcare providers about acupuncture (63.4%), open to acupuncture concurrent with conventional treatments (80.6%) and identified lack of insurance coverage as a barrier (50.8%). Beliefs varied, but respondents were generally receptive to using acupuncture as therapy. Unsurprisingly, respondents with a history of acupuncture (n = 60) had more acupuncture knowledge than those without such a history (n = 66) and were more likely to pursue acupuncture without insurance (60%), for serious health conditions (63.3%) or alongside conventional medical therapy (85.0%). Half of all respondents expressed interest in participating in weekly acupuncture for up to 12 months and would expect almost a 50% improvement in symptoms by participating. CONCLUSION: Adults with TBI were receptive and interested in participating in weekly acupuncture to address health concerns. These results provide support for exploring the integration of acupuncture into the care of individuals with TBI.

Fidelity to the acupuncture intervention protocol in the ACUpuncture In The EmergencY department for pain management (ACUITY) trial: Expanding the gold standard of STRICTA and CONSORT guidelines.

Background: Acupuncture shows promise as an effective nonpharmacologic option for reduction of acute pain in the emergency department (ED). Following CONSORT and STRICTA guidelines, randomized controlled trials (RCTs) generally report intervention details and acupoint options, but fidelity to acupuncture interventions, critical to reliability in intervention research, is rarely reported. Methods: ACUITY is an NCCIH-funded, multi-site feasibility RCT of acupuncture in 3 EDs (Cleveland, Nashville, and San Diego). ACUITY acupuncturists were trained in study design, responsive acupuncture manualization protocol, logistics and real-time recording of session details via REDCap forms created to track fidelity. Results: Across 3 recruiting sites, 79 participants received acupuncture: 51 % women, 43 % Black/African American, with heterogeneous acute pain sites at baseline: 32 % low back, 22 % extremity, 20 % abdominal, 10 % head. Pragmatically, participants were treated in ED common areas (52 %), private rooms (39 %), and semi-private rooms (9 %). Objective tracking found 98 % adherence to the six components of the acupuncture manualization protocol: staging, number of insertion points (M = 13.2, range 2-22), needle retention time (M = 23.5 min, range 4-52), session length (M = 40.3 min, range 20-66), whether general recommendations were provided and completion of the session form. Conclusion: To the best of our knowledge, this is the first RCT to assess and report fidelity to an acupuncture protocol. Fidelity monitoring will be fundamental for ACUITY2, which would be a future definitive, multi-site RCT. Furthermore, we recommend that fidelity to acupuncture interventions be added to CONSORT and STRICTA reporting guidelines in future RCTs. Protocol registration: The protocol of this study is registered at clinicaltrials.gov: NCT04880733.

Immediate Effects of Integrative Health and Medicine Modalities Among Outpatients With Moderate-To-Severe Symptoms.

Background: Patients seeking integrative health and medicine (IHM) modalities often present with multiple physical and psychological concerns. Research supports IHM's effectiveness for addressing symptoms over longer time periods. However, few studies have evaluated immediate outpatient effects. Objective: This study describes pre-encounter patient-reported outcome (PRO) clusters and examines the immediate clinical effectiveness of IHM modalities on pain, stress, and anxiety among outpatients with moderate-to-severe symptoms. Methods: A retrospective review was conducted of encounters among adults presenting to outpatient acupuncture, chiropractic, massage, integrative medicine consultation, or osteopathic manipulation treatment between January 2019 and July 2020. Encounters were included if patients reported pre-encounter pain, stress, or anxiety ≥4 on a numeric rating scale (NRS). Outcome analyses included random effects for patient and provider using a mixed model. Results: Across 7335 clinical encounters among 2530 unique patients (mean age: 49.14 years; 81.0% female; 75.9% White; 15.8% Black/African American), the most common pre-encounter PRO clusters were pain, stress, and anxiety ≥4 (32.4%); pain ≥4 only (31.3%); and stress and anxiety ≥4 (15.6%). Clinically meaningful single-encounter mean [95% CI] changes were observed across all modalities in pain (-2.50 [-2.83, -2.17]), stress (-3.22 [-3.62, -2.82]), and anxiety (-3.05 [-3.37, -2.73]). Conclusion: Patients presenting to outpatient IHM with moderate-to-severe symptoms most often presented with pain, stress, and anxiety ≥4 on the NRS. Multiple IHM modalities yielded clinically meaningful (≥2 unit) immediate reductions in these symptoms. Future research measuring immediate and longitudinal effectiveness is needed to optimize the triage and coordination of IHM modalities to meet patients' needs.