Compassion Meditation for Distressed Older Veterans: A Feasibility Study

OBJECTIVES

Older Veterans are at elevated risk for psychological distress and may encounter barriers to accessing mental health services. Compassion Meditation (CM) promotes positive emotions and outcomes among distressed individuals; thus, we conducted a preliminary feasibility study of CM among distressed older Veterans.

METHODS

Participants included 25 Veterans aged 55+ (M = 69.0, SD = 10.6) with anxiety and/or depressive symptoms, recruited from primary care, mostly male (76.0%), and White (60.0%). CM consisted of 10 groups, which were transitioned from in-person to telehealth due to COVID-19. Feasibility indices included rates of intervention initiation and completion, and attendance. Participants completed measures of symptom severity and well-being pre- and post-intervention.

RESULTS

Of 25 enrolled participants, 88.0% (n = 22) attended at least one session, and 52% (n = 13) completed the intervention (attended six or more sessions). Among intervention completers, the average number of sessions attended was 9.46. Seven Veterans withdrew from intervention due to difficulties engaging via telehealth.

CONCLUSIONS

These findings support the feasibility of CM training in older Veterans with psychological distress, though dropouts highlighted potential need for additional strategies to facilitate telehealth participation.

CLINICAL IMPLICATIONS

Older Veterans appear amenable to meditation-based practices, provided they are easy to access.

Self-administered acupressure for veterans with chronic back pain: Study design and methodology of a type 1 hybrid effectiveness implementation randomized controlled trial

BACKGROUND

Chronic low back pain is prevalent and disabling in Veterans, but effective pain management is challenging. Clinical practice guidelines emphasize multimodal pain management including evidence-based complementary and integrative health treatments such as acupressure as a first line of care. Unfortunately, the ability to replicate interventions, cost, resources, and limited access are implementation barriers. Self-administered acupressure has shown positive effects on pain and can be practiced anywhere with little to no side effects.

METHODS/DESIGN

The aims of this Type 1 hybrid effectiveness implementation randomized controlled trial are 1) to determine effectiveness of a self-administered acupressure protocol at improving pain interference and secondary outcomes of fatigue, sleep quality, and disability in 300 Veterans with chronic low back pain, and 2) evaluate implementation barriers and facilitators to scale-up acupressure utilization within Veterans Health Administration (VHA). Participants randomized to the intervention will receive instruction on acupressure application using an app that facilitates daily practice for 6 weeks. During weeks 6 through 10, participants will discontinue acupressure to determine sustainability of effects. Participants randomized to waitlist control will continue their usual care for pain management and receive study materials at the end of the study period. Outcomes will be collected at baseline and at 6- and 10-weeks post baseline. The primary outcome is pain interference, measured by the PROMIS pain interference scale. Using established frameworks and a mixed methods approach, we will evaluate intervention implementation.

DISCUSSION

If acupressure is effective, we will tailor strategies to support implementation in the VHA based on study findings.

TRIAL REGISTRATION NUMBER

NCT05423145.

Complementary/integrative healthcare utilization in US Gulf-War era veterans: Descriptive analyses based on deployment history, combat exposure, and Gulf War Illness

Complementary and integrative health (CIH) approaches have gained empirical support and are increasingly being utilized among veterans to treat a myriad of conditions. A cluster of medically unexplained chronic symptoms including fatigue, headaches, joint pain, indigestion, insomnia, dizziness, respiratory disorders, and memory problems, often referred to as Gulf War Illness (GWI) prominently affect US Gulf War era (GWE) veterans, yet little is known about CIH use within this population. Using data collected as part of a larger study (n = 1153), we examined the influence of demographic characteristics, military experiences, and symptom severity on CIH utilization, and utilization differences between GWE veterans with and without GWI. Over half of the sample (58.5%) used at least one CIH modality in the past six months. Women veterans, white veterans, and veterans with higher levels of education were more likely to use CIH. GWE veterans with a GWI diagnosis and higher GWI symptom severity were more likely to use at least one CIH treatment in the past six months. Over three quarters (82.7%) of veterans who endorsed using CIH to treat GWI symptoms reported that it was helpful for their symptoms. Almost three quarters (71.5%) of veterans indicated that they would use at least one CIH approach if it was available at VA. Results provide a deeper understanding of the likelihood and characteristics of veterans utilizing CIH to treat health and GWI symptoms and may inform expansion of CIH modalities for GWE veterans, particularly those with GWI.

The relationship between capacity and utilization of nonpharmacologic therapies in the US Military Health System

Background

Nonpharmacologic therapies (NPTs) are recommended as first-line treatments for pain, however the impact of expanding professional capacity to deliver these therapies on use has not been extensively studied. We sought to examine whether an effort by the US Military Health System (MHS) to improve access to NPTs by expanding professional capacity increased NPT utilization in a cohort at higher risk for pain – Army soldiers returning from deployment.

Methods

Our study involved secondary analysis of MHS workforce data derived from the Defense Medical Human Resources System Internet (DMHRSi), and healthcare utilization data obtained from two ambulatory record systems of the Military Health System (MHS) for a sample of 863,855 Army soldiers previously deployed to Iraq or Afghanistan over a 10-year period (2008–2017). We measured clinical provider capacity in three occupational groups responsible for pain management at 130 military treatment facilities (MTFs): physical therapy, chiropractic, and behavioral health, measured annually as full-time equivalence per 100,000 patients served at each MTF. Utilization in both direct and purchased care settings was measured as annual mean NPT users per 1000 sample members and mean encounters per NPT user. Generalized estimating equation models estimated the associations of facility-level occupational capacity measures and facility-level utilization NPT measures.

Results

In 2008, nearly all MTFs had some physical therapist and behavioral health provider capacity, but less than half had any chiropractor capacity. The largest increase in capacity from 2008 to 2017 was for chiropractors (89%) followed by behavioral health providers (77%) and physical therapists (37%). Models indicated that increased capacity of physical therapists and chiropractors were associated with significantly increased utilization of six out of seven NPTs. Acupuncture initiation was associated with capacity increases in each occupation. Increased professional capacity in MTFs was associated with limited but positive effects on NPT utilization in purchased care.

Conclusions

Increasing occupational capacity in three professions responsible for delivering NPTs at MTFs were associated with growing utilization of seven NPTs in this Army sample. Despite increasing capacity in MTFs, some positive associations between MTF capacity and purchased care utilization suggest an unmet need for NPTs. Future research should examine if these changes lead to greater receipt of guideline-concordant pain management.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07700-4.

Use of complementary and integrative health in cancer pain management among patients undergoing cancer treatments: a qualitative descriptive study

BACKGROUND

Pain is a common symptom in patients undergoing cancer treatment. Despite recommendations for the stronger integration of complementary and integrative health (CIH) in cancer pain management, little is known about the individual experience of using this approach for cancer pain, particularly in certain populations such as African Americans.

OBJECTIVE

This study aimed to describe the experiences of using CIH for pain in African American and White patients with cancer undergoing cancer treatments.

METHODS

A secondary analysis of qualitative descriptive data from a subsample of patients with cancer in a parent study of their illness concerns was employed. Atlas.ti 8.0 was used for data management and qualitative analysis. Counts of participant-endorsed themes were tabulated to discern differences in themes by group.

RESULTS

Of 32 participants (16 African American, 16 White), 22 reported CIH usage for cancer pain management, with equal distribution between groups (11 each). Three themes emerged: Approach to, Reasons for, and Barriers to CIH Use. Psychological approaches were most common (n = 15). Nutritional, physical, and combination approaches were less common and more often employed by White participants. Reasons for CIH use were to reduce opioid consumption or for an opioid adjuvant. Personal limitations and access issues contributed to Barriers to CIH use.

CONCLUSIONS

Both African American and White patients used CIH for pain management while undergoing cancer treatments. However, some preferential differences in CIH approaches by race surfaced. Further research into these differences may uncover new ways of addressing disparities in cancer pain management with CIH.

Development of observational rating scales for evaluating patient-centered communication within a whole health approach to care

CONTEXT

Teaching and evaluating patient-centered communication (PCC) skills that incorporate holistic approaches are increasingly relevant.

OBJECTIVE

This study describes the development of the Observational Whole Health Measure (OWHM) for evaluating the extent to which primary care providers in the Veterans Health Administration engaged in PCC in the context of a holistic approach to care known as "Whole Health."

DESIGN AND SETTING

Observational rating scales were created based on content from a national whole health clinical education program in the VA and refined from audio recordings of patient-provider interactions in primary care clinical encounters. Unpaired t-tests and Cohen's d were conducted to measure overall quality of what really matters and whole health goal setting and plan development.

PARTICIPANTS

65 clinical encounters across 8 providers before and after participating in the training were included for analysis.

INTERVENTION

The intervention used for creating rating scales is a 2.5 day whole health clinical education program designed to teach providers PCC skills to identify what matters most for the patients and develop a patient-centered health plan that incorporates integrative health approaches to care.

MAIN OUTCOME MEASURE

Quality scores (0-4) were used to measure number of instances and extent to which providers explored what matters most to patients, dimensions of whole health, and development of a whole health plan tailored to patient's goals.

RESULTS

We developed the Observational Whole Health Measure (OWHM) that captures changes in provider communication. Significant differences in overall quality of whole health goal setting and plan development were detected between pre- and post-encounters, demonstrating a sensitivity to change. With the rise of integrative health approaches being adopted across clinical settings, the observational rating scales created in this study are likely to have increasing relevance.

Comparing scientific worldviews between allopathic medical degree and East Asian medicine degree students utilizing the thinking about science survey instrument (TSSI)

BACKGROUND

Integrative medicine has become a new healthcare model due to the growing evidence base for complementary and integrative therapies. However, some question whether complementary and integrative therapies can truly be integrated with biomedicine due to differences in underlying paradigms and theoretical bases. This study aimed to explore differences in scientific worldviews between students studying East Asian medicine and those completing an allopathic medical degree using the validated Thinking about Science Survey Instrument (TSSI).

METHODS

122 medical students from Albert Einstein College of Medicine (Einstein) and 48 East Asian medicine students from the Pacific College of Health and Science (Pacific College) participated in this study. Participants completed the TSSI, a 60-item Likert-scale instrument that quantitatively measures the sociocultural resistance to, and support for science. Item and category means were compared between each group using an independent sample t-test.

RESULTS

Distinct differences were seen between the two groups of students with regard to age, gender distribution and prior education. Einstein students were generally supportive of science and Pacific College students were generally supportive of/positively neutral to science. Einstein students more strongly affirmed the relationship of science in relation to the categories of Epistemology, Public Health, Emotion and Aesthetics, the Economy, and Public Policy. Pacific College students more strongly affirmed the relationship between science and the category Race and Gender. There were no differences in the categories of Environment and Resource, Science for All, and Religion and Morality.

CONCLUSION

This study suggests that there are differences underlying the scientific worldviews of Einstein and Pacific College students, particularly with regard to Epistemology and Public Health. Such differences may be related to the different theoretical knowledge bases and ways of viewing health within the two disciplines. Despite demographic and educational differences between the two groups their overall scientific worldviews were similar with neither group expressing disparate views. This suggests that both groups may be receptive to the value of other paradigms. Providing courses that focus on different therapeutic approaches and paradigms during medical training may foster interprofessional understanding and collaborative practice between health professionals of different medical disciplines.

Effective recruitment strategies in an exercise trial for patients with fibromyalgia

BACKGROUND

Recruitment of fibromyalgia populations into long-term clinical trials involving exercise interventions is a challenge. We evaluated the cost and randomization yields of various recruitment methods used for a fibromyalgia trial in an urban setting. We also investigated differences in participant characteristics and exercise intervention adherence based on recruitment source.

METHODS

We recruited individuals with fibromyalgia in the greater Boston area to a randomized controlled trial (RCT) using six recruitment strategies: newspaper advertisements, web advertisements, flyers, clinic referrals, direct mailing to patients in a clinic database, and word of mouth. We used the American College of Rheumatology 1990 and 2010 diagnostic criteria to screen and enroll participants. During an initial phone call to an interested participant, the study staff asked how they heard about the study. In this study, we compared the cost and yield of the six recruitment strategies as well as baseline characteristics, adherence, and attendance rates of participants across strategies.

RESULTS

Our recruitment resulted in 651 prescreens, 272 screening visits, and 226 randomized participants. Advertisements in a local commuter newspaper were most effective, providing 113 of 226 randomizations, albeit high cost ($212 per randomized participant). Low-cost recruitment strategies included clinical referrals and web advertisements, but they only provided 32 and 16 randomizations. Community-based strategies including advertisement and flyers recruited a more racially diverse participant sample than clinic referrals and mailing or calling patients. There was no evidence of difference in adherence among participants recruited from various strategies.

CONCLUSIONS

Newspaper advertisement was the most effective and most expensive method per randomized participant for recruiting large numbers of individuals with fibromyalgia in an urban setting. Community-based strategies recruited a more racially diverse cohort than clinic-based strategies.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01420640 . Registered on 19 August 2011.

The integration of yoga in physical therapy clinical practice

Health professionals are beginning to use yoga as a treatment modality. However, evidence explaining physical therapists' integration of yoga in clinical practice is lacking.

OBJECTIVE

The purpose of this study was to explore how, why, and with whom physical therapists integrate yoga into clinical practice.

DESIGN

This study is a secondary analysis of qualitative data collected during a larger multi-methods study. Thematic analysis of 13 interviews was conducted.

RESULTS

Analysis indicated four themes, and six subthemes. Facilitating yoga in clinical practice and yoga training themes; including evaluation of outcomes, billing, terminology, and safety subthemes describe how physical therapists are using yoga in clinical practice. The perceived client outcomes theme, including physical and psychosocial outcomes explain why physical therapists use yoga in practice. The yoga with clinical populations theme addresses with whom physical therapists are using yoga.

CONCLUSION

Physical therapists are using yoga with individuals with various health conditions to improve their physical and mental health. Findings support the need for physical therapists to increase their assessment and documentation of functional outcomes associated with client's yoga participation. Documentation could contribute to evidence-based literature related to how, why, and with whom physical therapists are using yoga. Documented outcomes could also provide rationale for yoga to receive classification as a reimbursable complementary and integrative health approach. Future research involving a larger, diverse sample (e.g., physical therapists with varying levels of education and yoga training) focused on how, why, and with whom physical therapists integrate yoga into clinical practice is recommended.

Tele-Integrative Medicine to Support Rehabilitative Care

Complementary and integrative health (CIH) modalities have therapeutic value in the multidisciplinary rehabilitation of chronic pain patients. Evidence of such has been seen with the Whole Health Model at the (Veterans Affairs) VA Healthcare system. CIH therapies, including yoga, tai chi, mindfulness meditation, hypnosis, self-massage, and acupressure, are significantly effective for managing chronic pain with little to no negative effects, and can be easily incorporated into telemedicine care with great potential benefit. The future of wellness in telemedicine is evolving with great potential, and needs further attention to addressing barriers of care.

How can we improve specialist health services for children with multi-referrals? Parent reported experience

Background

Children with combined mental and somatic conditions pose a challenge to specialized health services. These cases are often characterized by multi-referrals, frequent use of health services, poor clinical and cost effectiveness, and a lack of coordination and consistency in the care. Reorganizing the health services offered to these children seems warranted. Patient reported experiences give important evidence for evaluating and developing health services. The aim of the present descriptive study was to explore how to improve specialist health services for children with multiple referrals for somatic and mental health conditions. Based on parent reported experiences of health services, we attempted to identify key areas of improvement.

Methods

As part of a larger, ongoing project; “Transitioning patients’ Trajectories”, we asked parents of children with multiple referrals to both somatic and mental health departments to provide their experiences with the services their children received. Parents/guardians of 250 children aged 6–12 years with multi-referrals to the Departments of Pediatrics and Child and Adolescent Mental Health at Haukeland University Hospital between 2013 and 2015 were invited. Their experience was collected through a 14 items questionnaire based on a generic questionnaire supplied with questions from parents and health personnel. Possible associations between overall experience and possible predictors were analyzed using bivariate regression.

Results

Of the 250 parents invited, 148 (59%) responded. Mean scores on single items ranged from 3.18 to 4.42 on a 1–5 scale, where five is the best possible experience. In the multiple regression model, perception of wait time (r = .56, CI = .44–.69 / β = 0.16, CI = .05–.28), accommodation of consultations (r = .71, CI = .62–.80 / β = 0.25, CI = .06–.45 / β = 0.27, CI = .09–.44), providing adequate information about the following treatment (r = .66, CI = .55–.77 / β = 0.26, CI = .09–.43), and collaboration between different departments at the hospital (r = .68, CI = .57–.78 / β = 0.20, CI = -.01–.40) were all statistically significantly associated with parents overall experience of care.

Conclusions

The study support tailored interdisciplinary innovations targeting wait time, accommodation of consultations, communication regarding the following treatment and collaboration within specialist health services for children with multi-referrals to somatic and mental specialist health care services.

HIV Stigma and Older Men's Psychological Well-Being: Do Coping Resources Differ for Gay/Bisexual and Straight Men?

OBJECTIVES

This study investigated whether sexual orientation moderated the mediation effects of coping resources (i.e., spirituality and complementary and integrative health [CIH] use) in the relationship between HIV stigma and psychological well-being (PWB) among older men with HIV (MWH).

METHOD

Data from the Research of Older Adults with HIV (ROAH) study was used (N = 640, Age 50+). Structural equation modeling (SEM) was employed to examine a coping resource mediation model. We used a multiple-group procedure to test moderation effects by sexual orientation.

RESULTS

HIV stigma was negatively associated with spirituality and PWB. HIV stigma accounted for a significant amount of variance in PWB, with significant indirect effects via spirituality, indicating a partial mediation. Chi-square difference tests supported the hypothesis that this mediation effect was moderated by sexual orientation. CIH use was not statistically significant.

DISCUSSION

HIV stigma's negative relationship with PWB was salient in both groups. Spirituality's buffer between HIV stigma and PWB was stronger in older gay/bisexual MWH compared to their heterosexual counterparts. With respect to HIV stigma, older gay/bisexual MWH exhibited a "crisis competence" in coping with stigma, perhaps through overcoming past homophobia related to their sexual minority status (i.e., homophobia).

The Integrative Migraine Pain Alleviation through Chiropractic Therapy (IMPACT) trial: Study rationale, design and intervention validation

Introduction

Approximately 15% of the US population experiences migraine, with women afflicted three times as often as men. While medications are often used as first-line treatments, up to 50% of people with migraine pursue complementary and integrative medicine. One promising non-pharmacological approach for migraine is chiropractic care, due to the co-occurrence of migraine disease and musculoskeletal tension and pain. To date, no large-scale trials have evaluated the impact of a comprehensive model of chiropractic care on migraine.

Methods

The Integrative Migraine Pain Alleviation through Chiropractic Therapy (IMPACT) study is a two-arm pilot pragmatic randomized clinical trial evaluating a multimodal chiropractic care intervention plus enhanced usual care (UC) vs. enhanced UC alone for adult women with episodic migraine. A total of 60 women aged 20–55 who meet criteria for episodic migraine will be randomly assigned to an evidence-informed, musculoskeletal focused multimodal chiropractic care (10 sessions over 14 weeks) plus enhanced UC vs. enhanced UC alone. Enhanced UC includes conventional care, migraine education materials, and biweekly check-in phone calls. Study specific aims include: 1) Determine safety and feasibility of the study design; 2) Provide preliminary data on the effectiveness of chiropractic care on migraine frequency, severity, duration and medication use; and 3) Provide preliminary estimates of the effects of chiropractic care on disability, health-related quality of life, and psychosocial well-being.

Discussion

Findings will be used to inform the design of a full-scale trial evaluating chiropractic care for women with episodic migraines.

Yoga for veterans with chronic low back pain: Design and methods of a randomized clinical trial

Chronic low back pain (CLBP) afflicts millions of people worldwide, with particularly high prevalence in military veterans. Many treatment options exist for CLBP, but most have limited effectiveness and some have significant side effects. In general populations with CLBP, yoga has been shown to improve health outcomes with few side effects. However, yoga has not been adequately studied in military veteran populations. In the current paper we will describe the design and methods of a randomized clinical trial aimed at examining whether yoga can effectively reduce disability and pain in US military veterans with CLBP. A total of 144 US military veterans with CLBP will be randomized to either yoga or a delayed treatment comparison group. The yoga intervention will consist of 2× weekly yoga classes for 12weeks, complemented by regular home practice guided by a manual. The delayed treatment group will receive the same intervention after six months. The primary outcome is the change in back pain-related disability measured with the Roland-Morris Disability Questionnaire at baseline and 12-weeks. Secondary outcomes include pain intensity, pain interference, depression, anxiety, fatigue/energy, quality of life, self-efficacy, sleep quality, and medication usage. Additional process and/or mediational factors will be measured to examine dose response and effect mechanisms. Assessments will be conducted at baseline, 6-weeks, 12-weeks, and 6-months. All randomized participants will be included in intention-to-treat analyses. Study results will provide much needed evidence on the feasibility and effectiveness of yoga as a therapeutic modality for the treatment of CLBP in US military veterans.