Barriers and Facilitators to Implementing Bundled Acupuncture and Yoga Therapy to Treat Chronic Pain in Community Healthcare Settings: A Feasibility Pilot

Belinda J Anderson, Paul Meissner, Donna M Mah, Arya Nielsen, Steffany Moonaz, M Diane McKee, Benjamin Kligler, Mirta Milanes, Hernidia Guerra, Raymond Teets, Belinda J Anderson, Paul Meissner, Donna M Mah, Arya Nielsen, Steffany Moonaz, M Diane McKee, Benjamin Kligler, Mirta Milanes, Hernidia Guerra, Raymond Teets

Abstract

Objective: To identify factors associated with implementing bundled group acupuncture and yoga therapy (YT) to treat underserved patients with chronic pain in community health center (CHC) settings. This is not an implementation science study, but rather an organized approach for identification of barriers and facilitators to implementing these therapies as a precursor to a future implementation science study. Design: This study was part of a single-arm feasibility trial, which aimed to test the feasibility of bundling GA and YT for chronic pain in CHCs. Treatment outcomes were measured before and after the 10-week intervention period. Implementation feasibility was assessed through weekly research team meetings, weekly yoga provider meetings, monthly acupuncture provider meetings, and weekly provider surveys. Settings: The study was conducted in New York City at two Montefiore Medical Group (MMG) sites in the Bronx, and one Institute for Family Health (IFH) site in Harlem. Subjects: Participants in the feasibility trial were recruited from IFH and MMG sites, and needed to have had lower back, neck, or osteoarthritis pain for >3 months. Implementation stakeholders included the research team, providers of acupuncture and YT, referring providers, and CHC staff. Results: Implementation of these therapies was assessed using the Consolidated Framework for Implementation Research. We identified issues associated with scheduling, treatment fidelity, communication, the three-way disciplinary interaction of acupuncture, yoga, and biomedicine, space adaptation, site-specific logistical and operational requirements, and patient-provider language barriers. Issues varied as to their frequency and resolution difficulty. Conclusions: This feasibility trial identified implementation issues and resolution strategies that could be further explored in future implementation studies. Clinical Trial Registration No.: NCT04296344.

Keywords: acupuncture therapy; implementation; nonpharmacologic pain care; underserved setting; yoga therapy.

Conflict of interest statement

The authors declare that they have no competing interests.

References

    1. Fischer F, Lange K, Klose K, et al. . Barriers and strategies in guideline implementation—A scoping review. Healthcare (Basel) 2016;4:36
    1. Qaseem A, Wilt TJ, McLean RM, Forciea MA. Noninvasive treatments for acute, subacute, and chronic low back pain: A clinical practice guideline from the American College of Physicians. Ann Intern Med 2017;166:514–530
    1. Skelly AC, Chou R, Dettori JR, et al. . Noninvasive nonpharmacological treatment for chronic pain: A systematic review update. Comparative Effectiveness Review No. 227. AHRQ Publication No. 20-EHC009 2020. Online document at: , accessed April17, 2020
    1. Pain management—Leadership responsibilities for providing nonpharmacologic modalities for managing pain—LD.04.03.13 EP 2 2020. Online document at: , accessed April20, 2020
    1. . Drug overdose deaths 2020. Online document at: , accessed June20, 2020
    1. Hedegaard H, Miniño AM, Warner M. Drug overdose deaths in the United States, 1999-2018. NCHS Data Brief 2020:1–8
    1. Tick H, Nielsen A, Pelletier KR, et al. . Evidence-based nonpharmacologic strategies for comprehensive pain care: The Consortium Pain Task Force White Paper. Explore (NY) 2018;14:177–211
    1. Kennedy J, Roll JM, Schraudner T, et al. . Prevalence of persistent pain in the U.S. adult population: New data from the 2010 National Health Interview Survey. J Pain 2014;15:979–984
    1. Blackwell DL, Lucas JW, Clarke TC. Summary health statistics for U.S. adults: National Health Interview Survey, 2012. National Center for Health Statistics. Vital Health Stat 10 2014;1–161
    1. Reyes-Gibby CC, Aday L, Cleeland C. Impact of pain on self-rated health in the community-dwelling older adults. Pain 2002;95:75–82
    1. Institute of Medicine (IOM). Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington, DC: The National Academies Press, 2011
    1. Vickers AJ, Cronin AM, Maschino AC, et al. . Acupuncture for chronic pain: Individual patient data meta-analysis. Arch Intern Med 2012;172:1444–1453
    1. Vickers AJ, Linde K. Acupuncture for chronic pain. JAMA 2014;311:955–956
    1. Yuan QL, Wang P, Liu L, et al. . Acupuncture for musculoskeletal pain: A meta-analysis and meta-regression of sham-controlled randomized clinical trials. Sci Rep 2016;6:30675.
    1. Chou R, Deyo R, Friedly J, et al. . Nonpharmacologic therapies for low back pain: A systematic review for an American College of Physicians clinical practice guideline. Ann Intern Med 2017;166:493–505
    1. Liu L, Skinner M, McDonough S, et al. . Acupuncture for low back pain: An overview of systematic reviews. Evid Based Complement Alternat Med 2015;2015:328196.
    1. Tang S, Mo Z, Zhang R. Acupuncture for lumbar disc herniation: A systematic review and meta-analysis. Acupunct Med 2018;36:62–70
    1. Yuan Q-L, Guo T-M, Liu L, et al. . Traditional Chinese medicine for neck pain and low back pain: A systematic review and meta-analysis. PLoS One 2015;10:e0117146.
    1. National Center for Complementary and Integrative Health. Paying for complementary and integrative health approaches. Online document at: , accessed August24, 2020
    1. Trinh K, Graham N, Irnich D, Cameron ID. Acupuncture for neck disorders. Cochrane Dababase Syst Rev 2016;5:CD004870
    1. Vickers AJ, Vertosick EA, Lewith G, et al. . Acupuncture for chronic pain: Update of an individual patient data meta-analysis. J Pain 2018;19:455–474
    1. Berman BM, Lao L, Langenberg P, et al. . Effectiveness of acupuncture as adjunctive therapy in osteoarthritis of the knee: A randomized, controlled trial. Ann Intern Med 2004;141:901–910
    1. Kwon YD, Pittler MH, Ernst E. Acupuncture for peripheral joint osteoarthritis: A systematic review and meta-analysis. Rheumatology (Oxford) 2006;45:1331–1337
    1. Lin X, Huang K, Zhu G, et al. . The effects of acupuncture on chronic knee pain due to osteoarthritis: A meta-analysis. J Bone Joint Surg Am 2016;98:1578–1585
    1. Zhang Y, Bao F, Wang Y, Wu Z. Influence of acupuncture in treatment of knee osteoarthritis and cartilage repairing. Am J Transl Res 2016;8:3995–4002
    1. Manyanga T, Froese M, Zarychanski R, et al. . Pain management with acupuncture in osteoarthritis: A systematic review and meta-analysis. BMC Complement Altern Med 2014;14:312.
    1. Woods B, Manca A, Weatherly H, et al. . Cost-effectiveness of adjunct nonpharmacological interventions for osteoarthritis of the knee. PLoS One 2017;12:e0172749.
    1. Wieland LS, Skoetz N, Pilkington K, et al. . Yoga treatment for chronic non-specific low back pain. Cochrane Database Syst Rev 2017;2017:CD010671
    1. Li Y, Li S, Jiang J, Yuan S. Effects of yoga on patients with chronic nonspecific neck pain: A PRISMA systematic review and meta-analysis. Medicine (Baltimore) 2019;98:e14649.
    1. Kan L, Zhang J, Yang Y, Wang P. The effects of yoga on pain, mobility, and quality of life in patients with knee osteoarthritis: A systematic review. Evid Based Complement Alternat Med 2016;2016:6016532.
    1. Pure E, Terhorst L, Baker N. Movement and manual therapy for adults with arthritis: 2012 National Health Interview Survey. Complement Ther Med 2018;37:96–102
    1. Ward L, Stebbings S, Cherkin D, Baxter GD. Yoga for functional ability, pain and psychosocial outcomes in musculoskeletal conditions: A systematic review and metaanalysis. Musculoskeletal Care 2013;11:203–217
    1. Bussing A, Ostermann T, Ludtke R, Michalsen A. Effects of yoga interventions on pain and pain-associated disability: A meta-analysis. J Pain 2012;13:1–9
    1. Nguyen M, Ugarte C, Fuller I, et al. . Access to care for chronic pain: Racial and ethnic differences. J Pain 2005;6:301–314
    1. Grol-Prokopczyk H. Sociodemographic disparities in chronic pain, based on 12-year longitudinal data. Pain 2017;158:313–322
    1. Altekruse SF, Cosgrove CM, Altekruse WC, et al. . Socioeconomic risk factors for fatal opioid overdoses in the United States: Findings from the Mortality Disparities in American Communities Study (MDAC). PLoS One 2020;15:e0227966.
    1. McKee MD, Nielsen A, Anderson B, et al. . Individual vs. group delivery of acupuncture therapy for chronic musculoskeletal pain in urban primary care—A randomized trial. J Gen Intern Med 2020;35:1227–1237
    1. Kligler B, Buonora M, Gabison J, et al. . “I felt like it was God's hands putting the needles in”: A qualitative analysis of the experience of acupuncture for chronic pain in a low-income, ethnically diverse, and medically underserved patient population. J Altern Complement Med 2015;21:713–719
    1. Chuang E, Hashai N, Buonora M, et al. . “It's better in a group anyway”: Patient experiences of group and individual acupuncture. J Altern Complement Med 2018;24:336–342
    1. Moscoso DI, Goese D, Van Hyfte GJ, et al. . The impact of yoga in medically underserved populations: A mixed-methods study. Complement Ther Med 2019;43:201–207
    1. Nielsen A, Teets R, Moonaz S, et al. . Group Acupuncture Therapy with Yoga Therapy for chronic neck, low back and OA pain in safety net setting for an underserved population (GAPYOGA): Design and rationale for a feasibility pilot. Glob Adv Health Med 2020;9:1–10
    1. Kepner J, Devi NJ, Le Page J, et al. . The differences between yoga teacher training and yoga therapist training and the distinction between yoga teaching and yoga therapy. Int J Yoga Therap 2014;24:7–21
    1. Hsu CC, Sandford BA. The Delphi technique: Making sense of consensus. Pract Assess Res Eval 2007;12:1–8
    1. Nielsen A, Anderson B, Citkovitz C, et al. . Developing and employing a ‘responsive manualization’ in the ‘Acupuncture Approaches to Decrease Disparities in Outcomes of Pain Treatment’ comparative effectiveness study. Acupunct Med 2019;37:184–191
    1. Damschroder LJ, Aron DC, Keith RE, et al. . Fostering implementation of health services research findings into practice: A consolidated framework for advancing implementation science. Implement Sci 2009;4:50.
    1. Health Resources & Services Administration (HRSA). Federally qualified health centers. 2018. Online document at: , accessed April29, 2020
    1. Saper RB, Sherman KJ, Delitto A, et al. . Yoga teacher training manual. Supplement to: Yoga vs. physical therapy vs. education for chronic low back pain in predominantly minority populations: Study protocol for a randomized controlled trial. Trials 2014;15:67.
    1. Cramer H, Lauche R, Hohmann C, et al. . Randomized-controlled trial comparing yoga and home-based exercise for chronic neck pain. Clin J Pain 2013;29:216–223
    1. Moonaz SH, Bingham CO, 3rd, Wissow L, Bartlett SJ. Yoga in sedentary adults with arthritis: Effects of a randomized controlled pragmatic trial. J Rheumatol 2015;42:1194–1202
    1. Cheung C, Wyman JF, Bronas U, et al. . Managing knee osteoarthritis with yoga or aerobic/strengthening exercise programs in older adults: A pilot randomized controlled trial. Rheumatol Int 2016;37:389–398
    1. Moonaz S, Whitehead AM, Lawrence L, et al. . Yoga therapy dyads: A novel approach to chronic pain management in underserved populations. Explore (NY). 2020. [Epub ahead of print]; DOI: 10.1016/j.explore.2020.12.002
    1. Santiago Perez T, Pola AD, Crowe BM, et al. . The emerging healthcare professional: Certified yoga therapist (C-IAYT). Complement Ther Clin Pract 2020;39:101147.
    1. McKee MD, Kligler B, Fletcher J, et al. . Outcomes of acupuncture for chronic pain in urban primary care. J Am Board Fam Med 2013;26:692–700
    1. McKee MD, Kligler B, Blank AE, et al. . The ADDOPT study (Acupuncture to Decrease Disparities in Outcomes of Pain Treatment): Feasibility of offering acupuncture in the community health center setting. J Altern Complement Med 2012;18:839–843
    1. Kligler B, Nielsen A, Kohrrer C, et al. . Acupuncture therapy in a group setting for chronic pain. Pain Med 2018;19:393–403
    1. The Joint Commission. Clarification of the pain management standard. 2015. Online document at: , accessed May22, 2019
    1. . Decision memo for acupuncture for chronic low back pain (CAG-00452N). 2020. Online document at: , accessed January22, 2020
    1. Fuller J. The new medical model: A renewed challenge for biomedicine. CMAJ 2017;189:e640–e641
    1. Farre A, Rapley T. The new old (and old new) medical model: Four decades navigating the biomedical and psychosocial understandings of health and illness. Healthcare (Basel) 2017;5:88
    1. Ring M, Mahadevan R. Introduction to integrative medicine in the primary care setting. Prim Care 2017;44:203–215
    1. Anderson BJ, Jurawanichkul S, Kligler BE, et al. . Interdisciplinary relationship models for complementary and integrative health: Perspectives of Chinese medicine practitioners in the United States. J Altern Complement Med 2019;25:288–295
    1. Hullender Rubin L, Veleber S. Hospital-based acupuncture integration: Access, reimbursement, and implementation. J Altern Complement Med 2020;26:356–359

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