The spectrum of therapeutic influences and integrative health care: classifying health care practices by mode of therapeutic action

Chiropractor interaction and treatment equivalence in a pilot randomized controlled trial: an observational analysis of clinical encounter video-recordings

Background

Chiropractic care is a complex health intervention composed of both treatment effects and non-specific, or placebo, effects. While doctor-patient interactions are a component of the non-specific effects of chiropractic, these effects are not evaluated in most clinical trials. This study aimed to: 1) develop an instrument to assess practitioner-patient interactions; 2) determine the equivalence of a chiropractor’s verbal interactions and treatment delivery for participants allocated to active or sham chiropractic groups; and 3) describe the perceptions of a treatment-masked evaluator and study participants regarding treatment group assignment.

Methods

We conducted an observational analysis of digital video-recordings derived from study visits conducted during a pilot randomized trial of conservative therapies for temporomandibular pain. A theory-based, iterative process developed the 13-item Chiropractor Interaction and Treatment Equivalence Instrument. A trained evaluator masked to treatment assignment coded video-recordings of clinical encounters between one chiropractor and multiple visits of 26 participants allocated to active or sham chiropractic treatment groups. Non-parametric statistics were calculated.

Results

The trial ran from January 2010 to October 2011. We analyzed 111 complete video-recordings (54 active, 57 sham). Chiropractor interactions differed between the treatment groups in 7 categories. Active participants received more interactions with clinical information (8 vs. 4) or explanations (3.5 vs. 1) than sham participants within the therapeutic domain. Active participants received more directions (63 vs. 58) and adjusting instrument thrusts (41.5 vs. 23) in the procedural domain and more optimistic (2.5 vs. 0) or neutral (7.5 vs. 5) outcome statements in the treatment effectiveness domain. Active participants recorded longer visit durations (13.5 vs. 10 minutes). The evaluator correctly identified 61% of active care video-recordings as active treatments but categorized only 31% of the sham treatments correctly. Following the first treatment, 82% of active and 11% of sham participants correctly identified their treatment group. At 2-months, 93% of active and 42% of sham participants correctly identified their group assignment.

Conclusions

Our findings show the feasibility of evaluating doctor-patient interactions in chiropractic clinical trials using video-recordings and standardized instrumentation. Clinical trial design and clinician training protocols should improve and assess the equivalence of doctor-patient interactions between treatment groups.

Trial registration

This trial was registered in ClinicalTrials.gov as NCT01021306 on 24 November 2009.

Attitudes and practices of massage therapists as related to conventional medicine

Introduction

Research into opinions about complementary and alternative medicine (CAM) has focused on conventional medical practitioners with little exploration of CAM practitioners’ views.

Purpose

To survey attitudes and practices of massage therapists toward conventional medicine.

Research Design

An anonymous online survey consisting of Likert-type scales, fill-in answers, and multiple-choice questions was used.

Participants

Members of the Associated Bodywork & Massage Professionals (ABMP), the largest massage therapy association in the US with over 77,000 members.

Main Outcome Measures

Participants were asked about their years of practice and training, choice of health care practitioners, sources for information about CAM and Western/allopathic medicine, client referral patterns, optimal treatment approaches for various medical conditions, and overall impressions of CAM and Western/ allopathic medicine.

Results

Analysis of n = 3,148 responses indicated that while 66.9% of respondents had a neutral or worse impression of Western/allopathic medicine, 64.3% use a conventional medicine practitioner as their primary health care provider, 61.9% have referred clients to a conventional medicine practitioner in the past six months, and 90.5% seek out information on Western/allopathic medicine. The mode response of the best treatment approach to various medical problems was a mix of Western/allopathic medicine and CAM.

Conclusions

This study suggests that despite the ambivalence of many massage therapists towards conventional medicine, many use it, encourage clients to do so, and see involvement of both as crucial to health.

The use of mixed methods for therapeutic massage research

Mixed methods research is the integration of quantitative and qualitative components in a research project. Whether you are reading or designing a mixed methods research project, it is important to be familiar with both qualitative and quantitative research methods and the specific purposes for which they are brought together in a study: triangulation, complementarity, expansion, initiation, or development. In addition, decisions need to be made about the sequencing and the priority or importance of each qualitative and quantitative component relative to the other components, and the point or points at which the various qualitative and quantitative components will be integrated.

Mixed methods research is increasingly being recognized for its ability to bring multiple points of view to a research project, taking advantage of the strengths of each of the quantitative and qualitative components to explain or resolve complex phenomena or results. This ability becomes critical when complex healing systems such as therapeutic massage are being studied. Complex healing systems may have multiple physiologic effects, often reflected in changes throughout the patient’s body. Additionally, the patient’s experience of the treatment may be an important outcome.

The integrated taxonomy of health care: classifying both complementary and biomedical practices using a uniform classification protocol

Background:

Since the late 1980s, several taxonomies have been developed to help map and describe the interrelationships of complementary and alternative medicine (CAM) modalities. In these taxonomies, several issues are often incompletely addressed:

A simple categorization process that clearly isolates a modality to a single conceptual category

Clear delineation of verticality—that is, a differentiation of scale being observed from individually applied techniques, through modalities (therapies), to whole medical systems

Recognition of CAM as part of the general field of health care

Methods:

Development of the Integrated Taxonomy of Health Care (ITHC) involved three stages:

Development of a precise, uniform health glossary

Analysis of the extant taxonomies

Use of an iterative process of classifying modalities and medical systems into categories until a failure to singularly classify a modality occurred, requiring a return to the glossary and adjustment of the classifying protocol

Results:

A full vertical taxonomy was developed that includes and clearly differentiates between techniques, modalities, domains (clusters of similar modalities), systems of health care (coordinated care system involving multiple modalities), and integrative health care.

Domains are the classical primary focus of taxonomies. The ITHC has eleven domains: chemical/substance-based work, device-based work, soft tissue–focused manipulation, skeletal manipulation, fitness/movement instruction, mind–body integration/classical somatics work, mental/emotional–based work, bio-energy work based on physical manipulation, bio-energy modulation, spiritual-based work, unique assessments. Modalities are assigned to the domains based on the primary mode of interaction with the client, according the literature of the practitioners.

Conclusions:

The ITHC has several strengths: little interpretation is used while successfully assigning modalities to single domains; the issue of taxonomic verticality is fully resolved; and the design fully integrates the complementary health care fields of biomedicine and CAM.

Pushed and Pulled

We used Self-Regulation Theory (SRT) to elaborate and describe cognitive and affective representations presumed to underlie CAM decisions in a sample of 55 men who were using CAM after having received conventional treatment for early-stage, localized prostate cancer. Positive representations of CAM were the strongest predictors of beliefs that CAM was necessary for one's health (a `pulling' effect toward CAM). Nonetheless, negative representations of conventional medicine made an important, though somewhat lesser contribution (a `pushing' effect away from conventional medicine and towards CAM). Our results also indicate preliminarily that affect may be more important than cognition in shaping CAM decisions.

Mapping patterns of complementary and alternative medicine use in cancer: an explorative cross-sectional study of individuals with reported positive "exceptional" experiences

Background

While the use of complementary and alternative medicine (CAM) among cancer patients is common and widespread, levels of commitment to CAM vary. "Committed" CAM use is important to investigate, as it may be associated with elevated risks and benefits, and may affect use of biomedically-oriented health care (BHC). Multiple methodological approaches were used to explore and map patterns of CAM use among individuals postulated to be committed users, voluntarily reporting exceptional experiences associated with CAM use after cancer diagnosis.

Method

The verbatim transcripts of thirty-eight unstructured interviews were analyzed in two steps. First, manifest content analysis was used to elucidate and map participants' use of CAM, based on the National Center for Complementary Medicine (NCCAM)'s classification system. Second, patterns of CAM use were explored statistically using principal component analysis.

Findings

The 38 participants reported using a total of 274 specific CAM (median = 4) consisting of 148 different therapeutic modalities. Most reported therapies could be categorized using the NCCAM taxonomy (n = 224). However, a significant number of CAM therapies were not consistent with this categorization (n = 50); consequently, we introduced two additional categories: Spiritual/health literature and Treatment centers. The two factors explaining the largest proportion of variation in CAM usage patterns were a) number of CAM modalities used and b) a category preference for Energy therapies over the categories Alternative Medical Systems and Treatment centers or vice versa.

Discussion

We found considerable heterogeneity in patterns of CAM use. By analyzing users' own descriptions of CAM in relation to the most commonly used predefined professional taxonomy, this study highlights discrepancies between user and professional conceptualizations of CAM not previously addressed. Beyond variations in users' reports of CAM, our findings indicate some patterns in CAM usage related to number of therapies used and preference for different CAM categories.