July 28, 2011

Group Health findings on alternative therapies can guide patient-centered care

Daniel C. Cherkin, PhD, and Karen J. Sherman, PhD, MPH, made headlines this week with their latest research on massage for back pain. Here, they reflect on their decade of investigating complementary and alternative medicine therapies, which have raised tantalizing questions for ongoing research and surfaced insights that conventional health care providers and systems can put into practice—today.

In a decade of rigorous research on complementary and alternative medicine (CAM) therapies, Daniel C. Cherkin, PhD, and Karen J. Sherman, PhD, MPH, have made many intriguing discoveries, including these:

  • “Structural” massage, aimed at the underlying causes of back pain, eased pain and improved function—but no better than did Swedish massage, which is aimed at general relaxation.
  • Acupuncture decreased chronic low back pain—but no better than did a treatment that didn’t penetrate the skin with a needle and wasn’t tailored to the individual.
  • And massage lessened anxiety—but no better than did simple relaxation in a darkened room with soothing music.

Drs. Cherkin and Sherman, both senior investigators at GHRI, discuss what this body of work, considered collectively, might mean.

“The mind and body are intricately and inextricably connected,” Dr. Cherkin says. “For instance, the same parts of the brain are involved in both depression and physical pain.” He notes that their studies tend to involve people suffering persistently from conditions with no identified cause, such as chronic nonspecific musculoskeletal pain.

“These conditions don’t fit the acute-care paradigm of ‘diagnosis plus treatment equals cure,’ and few physicians feel confident about treating them,” he adds. That’s one reason why people with these conditions are seeking more CAM therapies.

“We’ve found that various CAM therapies—including massage, acupuncture, and yoga—provide around as much benefit as reported for other effective treatments, such as medication, but with fewer side effects,” Dr. Sherman explains. With CAM, about three in five patients tend to get better, versus about two in five with usual care.

“That difference might not sound like much,” adds Dr. Cherkin, “but it matters for the one in five people who wouldn’t have gotten better otherwise.”

“Still, no one can say for certain precisely how any CAM therapy works,” Dr. Sherman says. In her research with Dr. Cherkin, higher-tech and more specific CAM techniques have proven no more effective than lower-tech and less-specific versions. Examples: massage and simple relaxation worked equally well for anxiety; and acupuncture and poking pressure points without penetrating skin worked equally well for back pain.

“Looking forward, we hope to answer questions that our research raises,” Dr. Cherkin says. “For example, which effects of CAM therapies—specific, nonspecific, or both—are responsible for promoting people’s ability to play an active role in their own healing?”

It may take years before such questions yield definitive answers. In the meantime, Drs. Cherkin and Sherman have worked with Clarissa Hsu, PhD, a research associate at GHRI’s Center for Community Health and Evaluation, and June BlueSpruce, MPH, a research interventionist, to learn from some fellow experts: patients. They explored comments from participants in five of their randomized controlled trials of six different CAM treatments for back pain.

Trial participants valued a range of positive outcomes of CAM, which standard quantitative outcome measures didn’t capture. Answering open-ended questions, participants most often described these CAM benefits: more options and hope; better ability to relax; positive changes in emotional states; increased body awareness; changes in thinking that helped them cope better with pain; greater sense of well-being; improvement in physical conditions unrelated to back pain; more energy; and becoming more activated as patients.

“Conventional health care providers and systems can put these insights into practice now,” Dr. Cherkin says. “We have no strong evidence that any particular treatment is very effective for pain that has no identified cause. But we do have evidence that nonspecific care experiences can improve the outcomes of care. So one way for clinicians to practice evidence-based medicine would be to optimize the nonspecific effects of their patients’ health care experiences.”

In other words, the key may be to take the time to listen to patients, promote healing environments, and strengthen a continuous patient-clinician relationship, as the patient-centered medical home aims to do. Dr. Cherkin is serving until 2014 on the National Advisory Council for Complementary and Alternative Medicine. He has studied back pain for all 26 years that he has worked at Group Health, and he will serve on the organization's new Back Pain Initiative.

“I hope to help put these ideas into practice here,” he says.

By Rebecca Hughes

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