Association Between Patient Factors and the Effectiveness of Wearable Trackers at Increasing the Number of Steps per Day Among Adults With Cardiometabolic Conditions: Meta-analysis of Individual Patient Data From Randomized Controlled Trials.

BACKGROUND: Current evidence supports the use of wearable trackers by people with cardiometabolic conditions. However, as the health benefits are small and confounded by heterogeneity, there remains uncertainty as to which patient groups are most helped by wearable trackers. OBJECTIVE: This study examined the effects of wearable trackers in patients with cardiometabolic conditions to identify subgroups of patients who most benefited and to understand interventional differences. METHODS: We obtained individual participant data from randomized controlled trials of wearable trackers that were conducted before December 2020 and measured steps per day as the primary outcome in participants with cardiometabolic conditions including diabetes, overweight or obesity, and cardiovascular disease. We used statistical models to account for clustering of participants within trials and heterogeneity across trials to estimate mean differences with the 95% CI. RESULTS: Individual participant data were obtained from 9 of 25 eligible randomized controlled trials, which included 1481 of 3178 (47%) total participants. The wearable trackers revealed that over the median duration of 12 weeks, steps per day increased by 1656 (95% CI 918-2395), a significant change. Greater increases in steps per day from interventions using wearable trackers were observed in men (interaction coefficient -668, 95% CI -1157 to -180), patients in age categories over 50 years (50-59 years: interaction coefficient 1175, 95% CI 377-1973; 60-69 years: interaction coefficient 981, 95% CI 222-1740; 70-90 years: interaction coefficient 1060, 95% CI 200-1920), White patients (interaction coefficient 995, 95% CI 360-1631), and patients with fewer comorbidities (interaction coefficient -517, 95% CI -1188 to -11) compared to women, those aged below 50, non-White patients, and patients with multimorbidity. In terms of interventional differences, only face-to-face delivery of the tracker impacted the effectiveness of the interventions by increasing steps per day. CONCLUSIONS: In patients with cardiometabolic conditions, interventions using wearable trackers to improve steps per day mostly benefited older White men without multimorbidity. TRIAL REGISTRATION: PROSPERO CRD42019143012; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=143012.

Coordination of Care Between Chiropractic and Behavioral Health Practitioners Within the US Department of Veterans Affairs Health Care System: A Report of 3 Patients With Pain and Mental Health Symptoms.

Objective: The purpose of this case series is to describe coordination of care between chiropractic and behavioral health practitioners within an integrated hospital-based system. Clinical Features: Three individuals presented to a US Veterans Affairs Health Care system with musculoskeletal complaints for chiropractic care. Each person demonstrated symptoms of depression or anxiety and in 2 cases indicated passive suicidal ideation. Intervention and Outcome: The chiropractors referred the patients to a mental health provider for co-management. Different approaches to mental health care were offered to each of these patients to meet their individual preferences and needs as part of an evidence informed approach. One patient underwent individual cognitive behavioral therapy; 1 patient responded well to individual cognitive behavioral therapy before transitioning to group-based pain skills, resiliency, and mindfulness therapy; and 1 patient required additional referral to Primary Care-Mental Health Integration for pharmacologic treatment. The 3 patients responded positively to interdisciplinary care and realized functional improvements and improved patient reported outcomes as assessed with the 11-point Numerical Pain Rating Scale and Neck or Back Bournemouth Questionnaire. Conclusion: This case series describes the recognition of mental health symptoms, referral to behavioral health providers, and the subsequent treatment approaches. This case series presents the first description of co-managed care for US veterans by a chiropractor and psychologist.

Best Practices for Chiropractic Management of Adult Patients With Mechanical Low Back Pain: A Clinical Practice Guideline for Chiropractors in the United States.

OBJECTIVE: The purpose of this paper was to update the previously published 2016 best-practice recommendations for chiropractic management of adults with mechanical low back pain (LBP) in the United States. METHODS: Two experienced health librarians conducted the literature searches for clinical practice guidelines and other relevant literature, and the investigators performed quality assessment of included studies. PubMed was searched from March 2015 to September 2021. A steering committee of 10 experts in chiropractic research, education, and practice used the most current relevant guidelines and publications to update care recommendations. A panel of 69 experts used a modified Delphi process to rate the recommendations. RESULTS: The literature search yielded 14 clinical practice guidelines, 10 systematic reviews, and 5 randomized controlled trials (all high quality). Sixty-nine members of the panel rated 38 recommendations. All but 1 statement achieved consensus in the first round, and the final statement reached consensus in the second round. Recommendations covered the clinical encounter from history, physical examination, and diagnostic considerations through informed consent, co-management, and treatment considerations for patients with mechanical LBP. CONCLUSION: This paper updates a previously published best-practice document for chiropractic management of adults with mechanical LBP.

The chiropractor's role in primary, secondary, and tertiary prevention of suicide: a clinical guide.

OBJECTIVE: To provide the practicing chiropractor foundational knowledge to enhance the understanding of relevant primary, secondary, and tertiary public health measures for suicide prevention. METHODS: A descriptive literature review was performed using keywords low back pain, neck pain, psychosocial, pain, public health, suicide, suicide risk factors, and suicide prevention. English language articles pertaining to suicide prevention and the chiropractic profession were retrieved and evaluated for relevance. Additional documents from the Centers for Disease Control, Veterans Health Administration, and the World Health Organization were reviewed. Key literature from the clinical social work and clinical psychology fields were provided by authorship team subject matter experts. CONCLUSION: No articles reported a position statement regarding suicide prevention specific to the chiropractic profession. Risk, modifiable, and protective factors associated with self-directed violence are important clinical considerations. A proactive approach to managing patients at-risk includes developing interprofessional and collaborative relationships with mental health care professionals.

OBJECTIF: Donner aux chiropraticiens en exercice les connaissances de base nécessaires pour leur permettre de mieux saisir les mesures de santé publique primaires, secondaires et tertiaires servant à prévenir le suicide. MÉTHODOLOGIE: On a fait une revue descriptive de la littérature à l'aide des mots-clés suivants : lombalgie, cervicalgie, psychosocial, douleur, santé publique, suicide, facteurs de risque de suicide et prévention du suicide. On a évalué la pertinence des articles en anglais portant sur la prévention du suicide et la profession de chiropraticien. On a examiné d'autres documents provenant de Centers for Disease Control, de la Veterans Health Administration et de l'Organisation mondiale de la santé. Des experts en la matière, membres du comité de rédaction, ont fourni des articles importants sur le travail social clinique et la psychologie clinique. CONCLUSION: Aucun article ne renferme d'énoncé de principe sur la prévention du suicide issu de professionnels de la chiropratique. Les facteurs de risque, les facteurs modifiables et les facteurs de protection associés à l'automutilation sont des aspects importants à examiner. La prise en charge des patients vulnérables d'une manière proactive consiste entre autres à établir et à entretenir des liens de collaboration avec les professionnels de la santé mentale.

Suicide prevention, public health, and the chiropractic profession: a call to action.

BACKGROUND: Suicide is a major public health concern that has wide-reaching implications on individuals, families, and society. Efforts to respond to a public health concern as a portal-of-entry provider can reduce morbidity and mortality of patients. The objective of this commentary is a call to action to initiate dialogue regarding suicide prevention and the role the chiropractic profession may play. DISCUSSION: This public health burden requires doctors of chiropractic to realize current strengths and recognize contemporaneous deficiencies in clinical, research, and policy environments. With this better understanding, only then can the chiropractic profession strive to enhance knowledge and promote clinical acumen to target and mitigate suicide risk to better serve the public. CONCLUSION: We implore the profession to transition from bystander to actively engaged in the culture of suicide prevention beholden to all aspects of the biopsychosocial healthcare model. The chiropractic profession's participation in suicide prevention improves the health and wellness of one's community while also impacting the broader public health arena.

Military Sexual Trauma and Chronic Pain in Veterans.

OBJECTIVE: Chronic pain rehabilitation warrants sensitivity to unique psychosocial factors, such as trauma history. In Veterans of the United States Armed Forces, military sexual trauma (MST) is a pervasive type of trauma associated with a host of physical and psychological sequelae. A growing literature suggests a relationship between history of MST and chronic pain. This study sought to clarify the relationship between MST and chronic pain among male and female Veterans and explore whether individual factors moderate this relationship. DESIGN: A baseline survey of 328 Veterans seeking care for chronic pain via behavioral pain treatments was conducted. RESULTS: MST was reported by 31.4% of the sample and uniquely predicted pain interference. A significant interaction was found between MST and age, such that younger Veterans with a history of MST reported greater pain interference than younger Veterans with no MST. CONCLUSION: Findings provide further evidence that the experience of MST may intensify the overall burden of chronic pain and suggest that younger Veterans with MST seem to be most vulnerable to impaired pain rehabilitation. Unique study contributions include a robust sample of women and men with elevated rates of MST and examination of MST-age relationships concurrent with chronic pain.

Higher Anxiety and Will to Live Are Associated With Poorer Adherence to Cardiac Rehabilitation.

PURPOSE: Cardiac rehabilitation (CR) session attendance and rates of completion remain suboptimal. Greater distress (ie, depression and anxiety) has been associated with both better and poorer adherence. Will to live (ie, desire, determination and effort to survive) has been associated with survival among cardiac patients and thus may be relevant for CR adherence. It was hypothesized that depression and anxiety would be negatively associated with adherence, and that will to live would moderate these relationships. METHODS: Sixty patients (mean age = 56.9 ± 10.8 yr; 38 males) entering outpatient CR completed self-report measures of will to live (Wish to Prolong Life Questionnaire) and distress (Hospital Anxiety and Depression Scale). Hierarchical regression analyses were performed to predict CR session attendance (%) and program completion (yes/no) from depression and anxiety, as well as the interaction of those variables with will to live. RESULTS: Neither depression nor anxiety was associated with CR adherence (Ps > .33). However, there was a significant interaction of will to live with anxiety in predicting attendance (ß= -0.31, P = .03, Model R = .19, P = .01), reflecting that anxiety predicted lower attendance only among patients reporting greater will to live. CONCLUSIONS: These data help clarify the complex relationship between distress and CR adherence. Findings suggest that higher anxiety is associated with poorer adherence, but only in combination with greater motivation for living. Patients higher in anxiety and will to live may benefit from additional strategies to make actionable behavioral change in the context of CR.

Perceived social support moderates the relationship between activities of daily living and depression after lower limb loss.

OBJECTIVE: This study examined the moderating influence of perceived social support on the prospective relationship between baseline levels of activities of daily living (ADL) and depressive symptoms during the 1st year following amputation. METHOD: Participants included 73 veterans with new/first unilateral lower extremity amputation due to vascular disease or diabetes. Baseline levels of perceived social support, ADL function, and mobility were assessed by retrospective recall 6 weeks after amputation. Depressive symptoms were measured at 6 weeks and 12 months following surgery. RESULTS: Perceived social support moderated the relationship between baseline ADL functioning and depressive symptoms at 12 months (ß = -0.27, p < .001) after controlling for 6-week depressive symptoms and sociodemographic and physical/functional variables. Lower levels of baseline ADL function were associated with depressive symptoms at 12 months among those who reported lower levels of perceived social support. CONCLUSION: These data allowed us to identify those participants with both low ADL function at baseline and low social support as being at higher risk for depression symptoms postamputation. The findings support the stress buffering hypothesis and suggest that perceived social support may be an important modifiable target of intervention among individuals with lower levels of functioning. (PsycINFO Database Record

Utility of Walk Tests in Evaluating Functional Status Among Participants in an Outpatient Cardiac Rehabilitation Program.

PURPOSE: Although walk tests are frequently used in cardiac rehabilitation (CR), no prior study has evaluated the capacity of these measures to predict peak oxygen uptake during exercise testing ((Equation is included in full-text article.)O2peak). This study evaluated the interrelationship of objective measures of exercise performance (walk and exercise testing) among patients entering CR as well as a novel measure of functional status assessment for use in CR. METHODS: Forty-nine patients (33 males) referred to an outpatient CR program were evaluated with objective measures of ambulatory functional status (peak oxygen uptake [(Equation is included in full-text article.)O2peak], 6-minute walk test [6MWT], and 60-ft walk test [60ftWT]). RESULTS: All measures of functional status were moderately to highly intercorrelated (r values from 0.50 to 0.88; P values < .05). The relationship among measures differed by sex, but not by age or diagnosis. Among men, results were generally consistent with the full sample. Among women, the magnitude of correlations was generally lower and there was no relationship between (Equation is included in full-text article.)O2peak and other measures. CONCLUSIONS: Measures of functional status, including (Equation is included in full-text article.)O2peak, 6MWT, and 60ftWT, were highly correlated among CR patients, suggesting the plausibility of using them interchangeably to fit the needs of the patient and testing environment. Among women, walk tests may not be appropriate substitutes for (Equation is included in full-text article.)O2peak. Because of the brevity of the 60ftWT, it may be particularly useful for measuring functional status in patients with greater symptoms and those with comorbidities limiting walking.

Irrational health beliefs predict adherence to cardiac rehabilitation: a pilot study.

OBJECTIVE: Cardiac rehabilitation (CR) is routinely prescribed for patients with cardiovascular disease (CVD), but data indicate that 20% to 50% of patients do not adhere to CR. Studies have focused on the impact of depression on CR adherence, but results have been equivocal. Irrational health beliefs are related to adherence among diabetes patients, but have not been examined among cardiac patients. This study examined depression and irrational health beliefs as predictors of CR adherence. METHOD: Sixty-one participants (30% female; mean age = 59.9 ± 11.8; 72% Caucasian), recruited at the outset of an outpatient CR program, completed a baseline questionnaire including measures of depression and irrational health beliefs. CR adherence was defined as the percentage of CR exercise sessions completed. Pearson correlations and analysis of variance determined demographic factors related to adherence. Hierarchical regression analyses examined irrational health beliefs and depression as predictors of CR adherence. RESULTS: Older age (p < .05) and higher income (p < .05) were associated with better CR adherence, but CR adherence was lower among African Americans than Caucasians (p < .01). Depression was not related to adherence (p = .78), but irrational health beliefs predicted CR adherence, after controlling for race/ethnicity, income, and age (ß = -.290, ΔR² = .074, ΔF[1,55] = 5.50, p < .05). CONCLUSIONS: Irrational health beliefs predicted CR adherence but depression did not. Thus, poorer adherence to CR was associated with endorsing beliefs that are not based in medical evidence.

Meta-analysis of efficacy of interventions for elevated depressive symptoms in adults diagnosed with cancer.

BACKGROUND: Cancer patients are at increased risk for depression compared with individuals with no cancer diagnosis, yet few interventions target depressed cancer patients. METHODS: Efficacy of psychotherapeutic and pharmacologic interventions for depression in cancer patients who met an entry threshold for depressive symptoms was examined by meta-analysis. Five electronic databases were systematically reviewed to identify randomized controlled trials meeting the selection criteria. Effect sizes were calculated using Hedges' g and were pooled to compare pre- and postrandomization depressive symptoms with a random effects model. Subgroup analyses tested moderators of effect sizes, such as comparison of different intervention modalities, with a mixed effects model. All statistical tests were two-sided. RESULTS: Ten randomized controlled trials (six psychotherapeutic and four pharmacologic studies) met the selection criteria; 1362 participants with mixed cancer types and stages had been randomly assigned to treatment groups. One outlier trial was removed from analyses. The random effects model showed interventions to be superior to control conditions on reducing depressive symptoms postintervention (Hedges' g = 0.43, 95% confidence interval = 0.30 to 0.56, P < .001). In the four psychotherapeutic trials with follow-up assessment, interventions were more effective than control conditions up to 12-18 months after patients were randomly assigned to treatment groups (P < .001). Although each approach was more effective than the control conditions in improving depressive symptoms (P < .001), subgroup analyses showed that cognitive behavioral therapy appeared more effective than problem-solving therapy (P = .01), but not more effective than pharmacologic intervention (P = .07). CONCLUSIONS: Our findings suggest that psychological and pharmacologic approaches can be targeted productively toward cancer patients with elevated depressive symptoms. Research is needed to maximize effectiveness, accessibility, and integration into clinical care of interventions for depressed cancer patients.