Characterizing Therapeutic Pluralism Policies in Latin America: A Qualitative Content Analysis.

Introduction: The 1978 Alma Ata Declaration initiated international recognition of non-biomedical healing systems and their relevance for primary health. World Health Assembly (WHA) resolutions have called for the study and inclusion of traditional and complementary medicine (T&CM) into national health systems through policy development. The increased public, political, and scholarly attention given to T&CM has focused on clinical efficacy, cost-effectiveness, mechanisms of action, consumer demand, and supply-side regulation. Although >50% of WHO member states have T&CM policies, scant research has focused on these policies and their public health implications. This paper defines a novel term "therapeutic pluralism," and it aims at characterizing related policies in Latin America. Methods: A qualitative content analysis of Latin American therapeutic pluralism policies was performed. Policies' characteristics and the reported social, political, and economic forces that have made possible their development were assessed. Pre-defined policy features were categorized on an MS-Excel; in-depth text analyses were conducted in NVivo. Analyses followed the steps described by Bengtsson: decontextualization, recontextualization, categorization, and compilation. Results: Seventy-four (74) policy documents from 16 of the 20 sovereign Latin American countries were included. Mechanisms for policy enactment included: Constitution, National Law, National Policy, National Healthcare Model, National Program Guideline, Specific Regulatory Norms, and Supporting Legislation, Policies, and Norms. We propose a four-category typology of policy approaches in Latin America: Health Services-centered, Model of Care-based, Participatory, and Indigenous People-focused. Common themes countries used when justifying developing these policies included: benefits to the health system, legal and political mandates, supply and demand, and culture and identity. Social forces these policies referenced as influencing their development included: pluralism, self-determination and autonomy, anticapitalism and decolonization, safeguarding cultural identity, bridging cultural barriers, and sustainability. Conclusion: Policy approaches to therapeutic pluralism in Latin America go beyond integrating non-biomedical interventions into health services; they offer perspectives for transforming health systems. Characterizing these approaches has implications for policy development, implementation, evaluation, international collaboration, the development of technical cooperation tools and frameworks, and research.

Yoga Versus Education for Veterans with Chronic Low Back Pain: a Randomized Controlled Trial.

BACKGROUND: Yoga is effective for chronic low back pain (cLBP) in civilians but understudied among Veterans. OBJECTIVE: Determine whether yoga is more effective than an educational book for improving disability and pain among Veterans with cLBP. DESIGN, SETTING, AND PARTICIPANTS: Veterans diagnosed with cLBP at a VA medical center enrolled in a randomized controlled trial from March to December of 2015. INTERVENTIONS: Twelve weekly hatha yoga classes or education using The Back Pain Helpbook. MEASURES: Co-primary outcomes were changes from baseline at 12 weeks in back-related disability on the modified Roland Morris Disability Questionnaire and pain on the Defense & Veterans Pain Rating Scale. Secondary outcomes were global improvement, patient satisfaction, pain medication use, and post-traumatic stress symptoms. An intention-to-treat approach was used in primary analyses. RESULTS: One hundred twenty Veterans (mean age, 55.5 [SD = 16.9]; 11 [9%] women; mean number of chronic conditions, 5.5) were randomized to yoga (n = 62) and education (n = 58). At 12 weeks, reductions in back-related disability in yoga (mean difference [MD] = - 3.50, 95% CI: - 5.03, - 1.97) were not significantly different than education (MD = - 2.55, 95% CI: - 4.10, - 0.99; between-group difference: - 0.95 [95% CI: - 3.14, 1.23], p = 0.39). For pain, there was no significant difference between yoga (MD = - 1.01, 95% CI: - 1.67, - 0.35) and education (MD = - 0.81, 95% CI: - 1.36, - 0.27; between-group difference: - 0.20, 95% CI: - 1.06, 0.66, p = 0.65). More yoga than education participants reported being very much or extremely improved (39% vs 19%, OR = 3.71, 95% CI: 1.37, 10.02, p = 0.01) and very satisfied with treatment (60% vs 31%, OR = 4.28, 95% CI: 1.70, 10.77, p = 0.002). No differences in pain medication use or post-traumatic stress symptoms were observed at 12 weeks. No serious adverse events were reported in either group. CONCLUSION: Twelve weekly yoga classes were not more effective than an education intervention for improving pain or disability outcomes among mostly older male Veterans with cLBP and multiple comorbid health conditions. GOV IDENTIFIER: NCT02224183.

Beyond the pain: A qualitative study exploring the physical therapy experience in patients with chronic low back pain.

BACKGROUND: Chronic low back pain (cLBP) is a complex condition that is physically and psychologically debilitating, with vulnerable populations experiencing more severe outcomes. Physical therapy (PT) includes evidence-based treatments that can reduce disability, however the experience of PT can vary amongst different populations. Empirical evidence is largely based on majority samples that are predominantly white with high educational attainment. Little is known regarding how people from vulnerable groups (e.g. low income and racial minority) experience physical therapy treatment for low back pain. OBJECTIVE: To describe the experience of physical therapy in a predominantly low-income and minority population with cLBP. METHODS: This qualitative study was embedded within a randomized controlled trial for patients with cLBP in urban, underserved communities. We used a convenience sample to interview 12 participants from the 102 who participated in the PT arm of the trial and then performed thematic analysis to describe their experience. RESULTS: Three major themes emerged: 1) Empowerment through education and exercise; 2) Interconnectedness to providers and other patients; and 3) Improvements in pain, body mechanics, and mood. Divergent cases were few however centered around a lack of improvement in pain or an absence of connection with the therapist. Within the first theme a prevailing sub-theme emerged that aligned with Bandura's theory of self-efficacy: 1) Mastery of experience; 2) Verbal persuasion; 3) Vicarious experience; and 4) Physiological state. CONCLUSIONS: Our participants' insight highlighted the value of cognitive-emotional and interpersonal dimensions of PT. These may be particularly important components of PT in populations that have experienced systemic distrust in providers and disparities in services. Future work could use Bandura's model of self-efficacy to build a PT intervention comprised of fear-based movement exercises, interconnectedness, a strong therapeutic alliance, and mindfulness techniques.

"In Class We Were All One." A Qualitative Exploration of Yoga and Educational Interventions for Predominantly Low-Income and Minority Adults with Chronic Low Back Pain.

Introduction: Chronic low back pain (cLBP) can be physically and psychologically debilitating and disproportionally afflicts vulnerable populations. Yoga and education are increasingly common interventions for cLBP yet are understudied in low-income and minority adults. The objective of this qualitative study was to understand the yoga and self-care experience of adults with cLBP from urban, underserved communities who were enrolled in a randomized controlled trial that included these treatments. Methods: We interviewed 26 (18 yoga and 8 education) participants. Interviews were transcribed verbatim and analyzed using thematic analysis with codes developed inductively from data. Results: Participants from both yoga and education groups reported initial apprehension and ambivalence toward their respective intervention. However, physical and psychological benefits were noted, mainly in the form of improved pain self-management. Communal support and camaraderie reported by the yoga group was absent and desired by education participants. Social factors impeding the ability to sustain yoga practice included transportation, access, and cost, whereas education participants described literacy and language challenges and a general lack of motivation to read the book. Conclusion: Yoga and education are viable treatments for adults with cLBP who live in underserved neighborhoods. However, social stigma and socioeconomic barriers may hinder their uptake. Communal support in group-based nonpharmacological treatments is valued and may contribute to participation and clinical outcomes. ClinicalTrials.gov Identifier: NCT01343927.

Do Physical Therapy and Yoga Improve Pain and Disability through Psychological Mechanisms? A Causal Mediation Analysis of Adults with Chronic Low Back Pain.

OBJECTIVE: To investigate whether indirect effects via psychological mechanisms explain the effects of physical therapy (PT) or yoga versus education on back-related outcomes. DESIGN: Mediation analyses using data from a randomized controlled trial of PT, yoga, and education interventions for chronic low back pain. METHODS: Primary outcomes were changes in back-related pain on the 11-point numeric rating scale and disability on the modified 23-point Roland-Morris Disability Questionnaire, measured at 52 weeks after randomization. Hypothesized mediators were 12-week changes in pain self-efficacy, fear-avoidance beliefs, depression, anxiety, perceived stress, and sleep quality. We used causal mediation analysis to estimate the total effect, direct effect, indirect effect, and proportion mediated. RESULTS: We analyzed data from 230 adults (mean age = 46.2 years, 69.6% female, 79.6% non-White). In the PT-versus-education model, when the mediator was perceived stress, the total effect on disability was 2.6 points (95% confidence interval [CI]: 0.3, 4.9) and decomposed into a direct effect of 1.7 points (95% CI: -0.4, 3.8) and an indirect effect 0.9 points (95% CI: 0.1, 2.0; proportion mediated, 34%). No other psychological construct was a significant mediator. CONCLUSION: Improvements in perceived stress mediated improvements in disability after PT treatment compared to education. Other psychological outcomes did not mediate the effect of yoga or PT on pain or disability outcomes compared to education. J Orthop Sports Phys Ther 2022;52(7):470-483. Epub: 18 May 2022. doi:10.2519/jospt.2022.10813.

Changes in Pain Self-Efficacy, Coping Skills, and Fear-Avoidance Beliefs in a Randomized Controlled Trial of Yoga, Physical Therapy, and Education for Chronic Low Back Pain.

OBJECTIVE: We evaluated exercise interventions for cognitive appraisal of chronic low back pain (cLBP) in an underserved population. METHODS: We conducted a secondary analysis of the Back to Health Trial, showing yoga to be noninferior to physical therapy (PT) for pain and function outcomes among adults with cLBP (n = 320) recruited from primary care clinics with predominantly low-income patients. Participants were randomized to 12 weeks of yoga, PT, or education. Cognitive appraisal was assessed with the Pain Self-Efficacy Questionnaire (PSEQ), Coping Strategies Questionnaire (CSQ), and Fear-Avoidance Beliefs Questionnaire (FABQ). Using multiple imputation and linear regression, we estimated within- and between-group changes in cognitive appraisal at 12 and 52 weeks, with baseline and the education group as references. RESULTS: Participants (mean age = 46 years) were majority female (64%) and majority Black (57%), and 54% had an annual household income <$30,000. All three groups showed improvements in PSEQ (range 0-60) at 12 weeks (yoga, mean difference [MD] = 7.0, 95% confidence interval [CI]: 4.9, 9.0; PT, MD = 6.9, 95% CI: 4.7 to 9.1; and education, MD = 3.4, 95% CI: 0.54 to 6.3), with yoga and PT improvements being clinically meaningful. At 12 weeks, improvements in catastrophizing (CSQ, range 0-36) were largest in the yoga and PT groups (MD = -3.0, 95% CI: -4.4 to -1.6; MD = -2.7, 95% CI: -4.2 to -1.2, respectively). Changes in FABQ were small. No statistically significant between-group differences were observed on PSEQ, CSQ, or FABQ at either time point. Many of the changes observed at 12 weeks were sustained at 52 weeks. CONCLUSION: All three interventions were associated with improvements in self-efficacy and catastrophizing among low-income, racially diverse adults with cLBP. TRIAL REGISTRATION: ClinicalTrials.gov identifier NCT01343927.

Can Yoga or Physical Therapy for Chronic Low Back Pain Improve Depression and Anxiety Among Adults From a Racially Diverse, Low-Income Community? A Secondary Analysis of a Randomized Controlled Trial.

OBJECTIVE: To determine and compare the effect of yoga, physical therapy (PT), and education on depressive and anxious symptoms in patients with chronic low back pain (CLBP). DESIGN: Secondary analysis of a randomized controlled trial. SETTING: Academic safety net hospital and 7 community health centers. PARTICIPANTS: A total of 320 adults with CLBP. INTERVENTION: Yoga classes, PT sessions, or an educational book. OUTCOME MEASURE: Depression and anxiety were measured using the Patient Health Questionnaire and Generalized Anxiety Disorder 7-item Scale, respectively, at baseline, 12, and 52 weeks. We identified baseline and midtreatment (6-wk) factors associated with clinically meaningful improvements in depressive (≥3 points) or anxious (≥2 points) symptoms at 12 weeks. RESULTS: Participants (female=64%; mean age, 46.0±10.7 years) were predominantly non-White (82%), low-income (<$30,000/year, 59%), and had not received a college degree (71%). Most participants had mild or worse depressive (60%) and anxious (50%) symptoms. At 12 weeks, yoga and PT participants experienced modest within-group improvements in depressive symptoms (mean difference [MD]=-1.23 [95% CI, -2.18 to -0.28]; MD=-1.01 [95% CI, -2.05 to -0.03], respectively). Compared with the education group, 12-week differences were not statistically significant, although trends favored yoga (MD=-0.71 [95% CI, -2.22 to 0.81]) and PT (MD= -0.32 [95% CI, -1.82 to 1.18]). At 12 weeks, improvements in anxious symptoms were only found in participants who had mild or moderate anxiety at baseline. Independent of treatment arm, participants who had 30% or greater improvement in pain or function midtreatment were more likely to have a clinically meaningful improvement in depressive symptoms (odds ratio [OR], 1.82 [95% CI, 1.03-3.22]; OR, 1.79 [95% CI, 1.06-3.04], respectively). CONCLUSIONS: In our secondary analysis we found that depression and anxiety, common in this sample of underserved adults with CLBP, may improve modestly with PT and yoga. However, effects were not superior to education. Improvements in pain and function are associated with a decrease in depressive symptoms. More research is needed to optimize the integration of physical and psychological well-being in PT and yoga.

Doctors of chiropractic working with or within integrated healthcare delivery systems: a scoping review protocol.

INTRODUCTION: Back and neck pain are the leading causes of disability worldwide. Doctors of chiropractic (DCs) are trained to manage these common conditions and can provide non-pharmacological treatment aligned with international clinical practice guidelines. Although DCs practice in over 90 countries, chiropractic care is rarely available within integrated healthcare delivery systems. A lack of DCs in private practice, particularly in low-income communities, may also limit access to chiropractic care. Improving collaboration between medical providers and community-based DCs, or embedding DCs in medical settings such as hospitals or community health centres, will improve access to evidence-based care for musculoskeletal conditions. METHODS AND ANALYSES: This scoping review will map studies of DCs working with or within integrated healthcare delivery systems. We will use the recommended six-step approach for scoping reviews. We will search three electronic data bases including Medline, Embase and Web of Science. Two investigators will independently review all titles and abstracts to identify relevant records, screen the full-text articles of potentially admissible records, and systematically extract data from selected articles. We will include studies published in English from 1998 to 2020 describing medical settings that have established formal relationships with community-based DCs (eg, shared medical record) or where DCs practice in medical settings. Data extraction and reporting will be guided by the Proctor Conceptual Model for Implementation Research, which has three domains: clinical intervention, implementation strategies and outcome measurement. Stakeholders from diverse clinical fields will offer feedback on the implications of our findings via a web-based survey. ETHICS AND DISSEMINATION: Ethics approval will not be obtained for this review of published and publicly accessible data, but will be obtained for the web-based survey. Our results will be disseminated through conference presentations and a peer-reviewed publication. Our findings will inform implementation strategies that support the adoption of chiropractic care within integrated healthcare delivery systems.

Which Chronic Low Back Pain Patients Respond Favorably to Yoga, Physical Therapy, and a Self-care Book? Responder Analyses from a Randomized Controlled Trial.

PURPOSE: To identify baseline characteristics of adults with chronic low back pain (cLBP) that predict response (i.e., a clinically important improvement) and/or modify treatment effect across three nonpharmacologic interventions. DESIGN: Secondary analysis of a randomized controlled trial. SETTING: Academic safety net hospital and seven federally qualified community health centers. SUBJECTS: Adults with cLBP (N = 299). METHODS: We report patient characteristics that were predictors of response and/or modified treatment effect across three 12-week treatments: yoga, physical therapy [PT], and a self-care book. Using preselected characteristics, we used logistic regression to identify predictors of "response," defined as a ≥30% improvement in the Roland Morris Disability Questionnaire. Then, using "response" as our outcome, we identified baseline characteristics that were treatment effect modifiers by testing for statistical interaction (P < 0.05) across two comparisons: 1) yoga-or-PT vs self-care and 2) yoga vs PT. RESULTS: Overall, 39% (116/299) of participants were responders, with more responders in the yoga-or-PT group (42%) than the self-care (23%) group. There was no difference in proportion responding to yoga (48%) vs PT (37%, odds ratio [OR] = 1.5, 95% confidence interval = 0.88 - 2.6). Predictors of response included having more than a high school education, a higher income, employment, few depressive symptoms, lower perceived stress, few work-related fear avoidance beliefs, high pain self-efficacy, and being a nonsmoker. Effect modifiers included use of pain medication and fear avoidance beliefs related to physical activity (both P = 0.02 for interaction). When comparing yoga or PT with self-care, a greater proportion were responders among those using pain meds (OR = 5.3), which differed from those not taking pain meds (OR = 0.94) at baseline. We also found greater treatment response among those with lower (OR = 7.0), but not high (OR = 1.3), fear avoidance beliefs around physical activity. CONCLUSIONS: Our findings revealed important subgroups for whom referral to yoga or PT may improve cLBP outcomes.

Changes in Perceived Stress After Yoga, Physical Therapy, and Education Interventions for Chronic Low Back Pain: A Secondary Analysis of a Randomized Controlled Trial.

OBJECTIVE: Perceived stress and musculoskeletal pain are common, especially in low-income populations. Studies evaluating treatments to reduce stress in patients with chronic pain are lacking. We aimed to quantify the effect of two evidence-based interventions for chronic low back pain (cLBP), yoga and physical therapy (PT), on perceived stress in adults with cLBP. METHODS: We used data from an assessor-blinded, parallel-group randomized controlled trial, which recruited predominantly low-income and racially diverse adults with cLBP. Participants (N = 320) were randomly assigned to 12 weeks of yoga, PT, or back pain education. We compared changes in the 10-item Perceived Stress Scale (PSS-10) from baseline to 12- and 52-week follow-up among yoga and PT participants with those receiving education. Subanalyses were conducted for participants with elevated pre-intervention perceived stress (PSS-10 score ≥17). We conducted sensitivity analyses using various imputation methods to account for potential biases in our estimates due to missing data. RESULTS: Among 248 participants (mean age = 46.4 years, 80% nonwhite) completing all three surveys, yoga and PT showed greater reductions in PSS-10 scores compared with education at 12 weeks (mean between-group difference = -2.6, 95% confidence interval [CI] = -4.5 to -0.66, and mean between-group difference = -2.4, 95% CI = -4.4 to -0.48, respectively). This effect was stronger among participants with elevated pre-intervention perceived stress. Between-group effects had attenuated by 52 weeks. Results were similar in sensitivity analyses. CONCLUSIONS: Yoga and PT were more effective than back pain education for reducing perceived stress among low-income adults with cLBP.

Association of Initial Provider Type on Opioid Fills for Individuals With Neck Pain.

OBJECTIVE: To determine whether the initial care provider for neck pain was associated with opioid use for individuals with neck pain. DESIGN: Retrospective cohort study. SETTING: Marketscan research databases. PARTICIPANTS: Patients (N=427,966) with new-onset neck pain from 2010-2014. MAIN OUTCOME MEASURES: Opioid use was defined using retail pharmacy fills. We performed logistic regression analysis to assess the association between initial provider and opioid use. Adjusted odds ratios (ORs) with 95% confidence intervals (CIs) were calculated using bootstrapping logistic models. We performed propensity score matching as a robustness check on our findings. RESULTS: Compared to patients with neck pain who saw a primary health care provider, patients with neck pain who initially saw a conservative therapist were 72%-91% less likely to fill an opioid prescription in the first 30 days, and between 41%-87% less likely to continue filling prescriptions for 1 year. People with neck pain who initially saw emergency medicine physicians had the highest odds of opioid use during the first 30 days (OR, 3.58; 95% CI, 3.47-3.69; P<.001). CONCLUSIONS: A patient's initial clinical contact for neck pain may be an important opportunity to influence subsequent opioid use. Understanding more about the roles that conservative therapists play in the treatment of neck pain may be key in unlocking new ways to lessen the burden of opioid use in the United States.

Enhancing yoga participation: A qualitative investigation of barriers and facilitators to yoga among predominantly racial/ethnic minority, low-income adults.

Yoga is underutilized among racial/ethnic minorities and low-income populations. To enhance participation among these demographic groups and to inform a future clinical trial, we conducted a qualitative formative investigation, informed by the Social Contextual Model of health behavior change, to identify barriers and facilitators to yoga that could impact study participation. We recruited twenty-four racially/ethnically diverse adults, with and without prior yoga experience, from a low-income, urban housing community to participate in either an individual interview or focus group. A thematic data analysis approach was employed. Barriers to yoga engagement included the perception that yoga lacks physicality and weight loss benefits, fear of injury, lack of ability/self-efficacy to perform the practices, preference for other physical activities, and scheduling difficulties. Facilitators of yoga engagement included a quality yoga instructor who provides individualized instruction, beginner level classes, and promotional messaging that highlights the potential benefits of yoga, such as stress reduction.

Yoga, Physical Therapy, or Education for Chronic Low Back Pain: A Randomized Noninferiority Trial.

BACKGROUND: Yoga is effective for mild to moderate chronic low back pain (cLBP), but its comparative effectiveness with physical therapy (PT) is unknown. Moreover, little is known about yoga's effectiveness in underserved patients with more severe functional disability and pain. OBJECTIVE: To determine whether yoga is noninferior to PT for cLBP. DESIGN: 12-week, single-blind, 3-group randomized noninferiority trial and subsequent 40-week maintenance phase. (ClinicalTrials.gov: NCT01343927). SETTING: Academic safety-net hospital and 7 affiliated community health centers. PARTICIPANTS: 320 predominantly low-income, racially diverse adults with nonspecific cLBP. INTERVENTION: Participants received 12 weekly yoga classes, 15 PT visits, or an educational book and newsletters. The maintenance phase compared yoga drop-in classes versus home practice and PT booster sessions versus home practice. MEASUREMENTS: Primary outcomes were back-related function, measured by the Roland Morris Disability Questionnaire (RMDQ), and pain, measured by an 11-point scale, at 12 weeks. Prespecified noninferiority margins were 1.5 (RMDQ) and 1.0 (pain). Secondary outcomes included pain medication use, global improvement, satisfaction with intervention, and health-related quality of life. RESULTS: One-sided 95% lower confidence limits were 0.83 (RMDQ) and 0.97 (pain), demonstrating noninferiority of yoga to PT. However, yoga was not superior to education for either outcome. Yoga and PT were similar for most secondary outcomes. Yoga and PT participants were 21 and 22 percentage points less likely, respectively, than education participants to use pain medication at 12 weeks. Improvements in yoga and PT groups were maintained at 1 year with no differences between maintenance strategies. Frequency of adverse events, mostly mild self-limited joint and back pain, did not differ between the yoga and PT groups. LIMITATIONS: Participants were not blinded to treatment assignment. The PT group had disproportionate loss to follow-up. CONCLUSION: A manualized yoga program for nonspecific cLBP was noninferior to PT for function and pain. PRIMARY FUNDING SOURCE: National Center for Complementary and Integrative Health of the National Institutes of Health.

Yoga versus education for Veterans with chronic low back pain: study protocol for a randomized controlled trial.

BACKGROUND: Chronic low back pain is the most frequent pain condition in Veterans and causes substantial suffering, decreased functional capacity, and lower quality of life. Symptoms of post-traumatic stress, depression, and mild traumatic brain injury are highly prevalent in Veterans with back pain. Yoga for low back pain has been demonstrated to be effective for civilians in randomized controlled trials. However, it is unknown if results from previously published trials generalize to military populations. METHODS/DESIGN: This study is a parallel randomized controlled trial comparing yoga to education for 120 Veterans with chronic low back pain. Participants are Veterans ≥18 years old with low back pain present on at least half the days in the past six months and a self-reported average pain intensity in the previous week of ≥4 on a 0-10 scale. The 24-week study has an initial 12-week intervention period, where participants are randomized equally into (1) a standardized weekly group yoga class with home practice or (2) education delivered with a self-care book. Primary outcome measures are change at 12 weeks in low back pain intensity measured by the Defense and Veterans Pain Rating Scale (0-10) and back-related function using the 23-point Roland Morris Disability Questionnaire. In the subsequent 12-week follow-up period, yoga participants are encouraged to continue home yoga practice and education participants continue following recommendations from the book. Qualitative interviews with Veterans in the yoga group and their partners explore the impact of chronic low back pain and yoga on family relationships. We also assess cost-effectiveness from three perspectives: the Veteran, the Veterans Health Administration, and society using electronic medical records, self-reported cost data, and study records. DISCUSSION: This study will help determine if yoga can become an effective treatment for Veterans with chronic low back pain and psychological comorbidities. TRIAL REGISTRATION: ClinicalTrials.gov: NCT02224183.

"We're all in this together": A qualitative study of predominantly low income minority participants in a yoga trial for chronic low back pain.

OBJECTIVE: To explore the experiences of low-income minority adults taking part in a yoga dosing trial for chronic low back pain. DESIGN: Individual semi-structured interviews were conducted with nineteen participants recruited from a randomized yoga dosing trial for predominantly low-income minority adults with chronic low back pain. Interviews discussed the impact of yoga on low back pain and emotions; other perceived advantages or disadvantages of the intervention; and facilitators and barriers to practicing yoga. Interviews were audio taped and transcribed, coded using ATLAS.ti software, and analyzed with inductive and deductive thematic analysis methods. SETTING: Boston Medical Center, Boston, MA, USA. RESULTS: Participants viewed yoga as a means of pain relief and attributed improved mood, greater ability to manage stress, and enhanced relaxation to yoga. Overall, participants felt empowered to self-manage their pain. Some found yoga to be helpful in being mindful of their emotions and accepting of their pain. Trust in the yoga instructors was a commonly cited facilitator for yoga class attendance. Lack of time, motivation, and fear of injury were reported barriers to yoga practice. CONCLUSIONS: Yoga is a multidimensional treatment for low back pain that has the potential to favorably impact health in a predominantly low-income minority population.

Integrative Medicine in a Preventive Medicine Residency: A Program for the Urban Underserved.

The Preventive Medicine Residency Program collaborated with the Department of Family Medicine's Program for Integrative Medicine and Health Disparities at Boston Medical Center to create a new rotation for preventive medicine residents starting in autumn 2012. Residents participated in integrative medicine group visits and consults, completed an online curriculum in dietary supplements, and participated in seminars all in the context of an urban safety net hospital. This collaboration was made possible by a federal Health Resources and Services Administration grant for integrative medicine in preventive medicine residencies and helped meet a need of the program to increase residents' exposure to clinical preventive medicine and integrative health clinical skills and principles. The collaboration has resulted in a required rotation for all residents that continues after the grant period and has fostered additional collaborations related to integrative medicine across the programs.

Preference and Expectation for Treatment Assignment in a Randomized Controlled Trial of Once- vs Twice-weekly Yoga for Chronic Low Back Pain.

BACKGROUND: In studies involving nonpharmacological complementary and alternative medicine interventions, participant blinding is very difficult. Participant expectations may affect perceived benefit of therapy. In studies of yoga as treatment for chronic low back pain, little is known about the relationship between patient expectations and preferences on outcomes. This study was designed to identify baseline predictors of preference and to determine if expectations and preferences for different doses of yoga affect back-related function and low back pain intensity. METHODS: This was a secondary data analysis of a 12-week randomized controlled trial comparing once-weekly vs twice-weekly yoga for treatment of chronic low back pain in 93 adults from a predominantly low-income minority population. At baseline, participants were asked about back function, back pain, treatment expectations, and treatment preferences. We created a variable "concordance" to describe the matching of participant preference to randomized treatment. Our outcome variables were change in back function and pain intensity after 12 weeks of yoga instruction. We performed logistic regression to identify predictors of preference for once- or twice-weekly yoga instruction. We created linear regression models to identify independent associations between expectations, preference, concordance, and outcomes. RESULTS: Worse back function at baseline was associated with 20% higher odds of preferring twice-weekly yoga (OR 1.2, CI 1.1, 1.3). Individuals with higher expectation scores for twice-weekly yoga had 90% higher odds of preferring twice-weekly vs once-weekly yoga (OR 1.9, CI 1.3, 2.7). Individuals with higher expectation scores for once-weekly yoga had 40% less odds of preferring twice-weekly yoga (OR 0.6, CI 0.5, 0.9). After controlling for baseline characteristics, we found no statistically significant relationship between treatment outcomes, preference, expectation scores, or concordance. CONCLUSION: In a population of predominantly low-income minority participants with chronic low back pain, worse back function was associated with preference for more frequent yoga classes. Those who preferred more yoga classes had higher expectations for those classes. Twelve-week change in back pain intensity and back function were not affected by dosing preference, expectation score, or concordance. More research is needed to better measure and quantify preference, expectations, and their relationship to outcomes in yoga research.

Antecedentes: En estudios que incluyen intervenciones complementarias no farmacológicas y de medicina alternativa es muy difícil realizar estas de manera ciega para los participantes. Las expectativas de los participantes pueden afectar el beneficio percibido de la terapia. En estudios del yoga como tratamiento del dolor lumbar crónico, se sabe poco de la relación entre las expectativas del paciente y las preferencias sobre los resultados. Este estudio se diseñó para identificar los predictores iniciales de preferencia y para determinar si las expectativas y preferencias para dosis diferentes de yoga afectaban la funcionalidad relativa a la espalda y la intensidad de dolor lumbar.Métodos: Este fue un análisis de datos secundarios de un ensayo aleatorio controlado de 12 semanas que comparó yoga una vez a la semana frente a dos veces a la semana para el tratamiento del dolor lumbar crónico en 93 adultos de una población minoritaria predominantemente de ingresos bajos. En el momento inicial, se les preguntó a los participantes sobre el dolor y la funcionalidad de sus espaldas, las expectativas del tratamiento y las preferencias del mismo. Creamos una "concordancia" variable para describir la correspondencia entre las preferencias del paciente y el tratamiento aleatorizado. Nuestras variables de resultados fueron el cambio de la funcionalidad de la espalda y la intensidad del dolor después de 12 semanas de sesiones de yoga. Realizamos una regresión logística para identificar los predictores de preferencias para las sesiones semanales o bisemanales de yoga. Creamos modelos de regresión lineal para identificar las asociaciones independientes entre expectativas, preferencias, concordancia y resultados.Resultados: Una peor funcionalidad de la espalda en el inicio se asoció con un 20% de mayor probabilidad de preferir yoga dos veces a la semana (TP 1,2, IC 1,1, 1,3). Los individuos con mayores escalas de expectativas de yoga dos veces a la semana tuvieron un 90% más de probabilidades de preferir yoga dos veces a la semana que una vez a la semana (TP 1,9, IC 1,3, 2,7). Los individuos con mayores escalas de expectativas de yoga una vez a la semana tuvieron un 40% menos de probabilidades de preferir yoga dos veces a la semana (TP 0,6, IC 0,5, 0,9). Después de controlar las características iniciales, no hallamos relación estadísticamente significativa entre los resultados del tratamiento, preferencias, escalas de expectativas o concordancia.Conclusión: En una población de participantes de minorías predominantemente con bajos ingresos con dolor lumbar crónico, se asoció una peor funcionalidad de la espalda con la preferencia por una mayor frecuencia de clases de yoga. Aquellos que prefirieron más clases de yoga tenían más expectativas para esas clases. El cambio de doce semanas en la intensidad del dolor de espalda y la funcionalidad de la misma no se vio afectado por la preferencia de dosis, escala de expectativas o concordancia. Se necesita realizar más investigaciones para medir mejor y cuantificar las preferencias, las expectativas y su relación con los resultados en la investigación del yoga.