Perspectives of older adults on co-management of low back pain by doctors of chiropractic and family medicine physicians: a focus group study

Low back pain (LBP) is a leading cause of disability and disease burden [1, 2]. People age 65 years and older report a 25% monthly LBP prevalence rate [3, 4] with recurrent or debilitating LBP common in older populations [4‐6]. Chronic LBP is linked to difficulties with activities of daily living (ADLs) [7, 8], depression [4, 7, 9, 10], sleep problems [7, 9], and decreased performance on physical function [7, 11] and neuropsychological tests [11]. An estimated 2.3% of annual physician visits in the U.S. are for LBP [3]. Persons with LBP and other spine conditions have increased healthcare expenditures for medications, spinal imaging, injections and surgery [3, 4, 9, 12‐14]. Medicare charges among older adults with back disorders have demonstrated significant increases for patient visits, imaging and spinal injections [12, 15] without translation to better health outcomes for LBP patients [13‐15].

Patients with unresolved pain may pair conventional healthcare with complementary and alternative medicine (CAM) [16‐19]. Chiropractic is among the most widely used CAM therapies [16, 17, 20, 21], including by older adults [22‐26]. Patients who use medical care and chiropractic together believe the combination helps their condition more than either alone [21]. And yet, co-occurring medical and chiropractic care is uncommon among older patients, ranging from 5-11% [23] to 33% [27]. Medical doctors (MDs) and doctors of chiropractic (DCs) make few formal referrals to each other and rarely share health records, suggesting little care coordination between these providers [28‐30]. While patients of all ages might benefit from improved co-management of their pain and other medical conditions [31‐33], interprofessional collaboration between healthcare providers is particularly important for older adults due to the high rates of chronic disease, multimorbidity and disability [32, 34‐36], polypharmacy [37, 38], and healthcare received from multiple providers [39] in this patient population.

The purpose of this focus group study was to explore the perspectives of older adults toward LBP collaborative care by MDs and DCs. Researchers have conducted focus groups to understand patients’ LBP experiences [40, 41] and primary care preferences [42, 43] and to design interventions for musculoskeletal disease [44‐47]. However, researchers have not explored the patient perspective on LBP collaborative care. In this paper, we describe older adults’ LBP healthcare seeking experiences, expectations for collaborative care provided by family medicine MDs and DCs, and insights into implementation barriers and facilitators. We incorporated the recommendations from these focus groups into the design of an interdisciplinary model and training plan for DCs and MDs providing co-managed LBP care to older people that was subsequently tested in a pragmatic randomized controlled trial [48].

Genesis Health System and Palmer College of Chiropractic institutional review boards provided ethics approval for this study. Focus group methodology allowed the researchers to gather a diverse range of perceptions of older adults who shared the experience of LBP through structured, moderated group discussions [49]. As we could identify no previous studies assessing patient preferences for LBP co-management by MDs and DCs, we could not anticipate which topics might be most important for older adults with this condition. We selected focus groups as a method that would allow for a dynamic data collection process in which group members might immediately discuss new topics introduced by fellow participants while statements offered by one individual might trigger the recollections of other members. We modified standard focus group techniques for use with older adults by using smaller groups and shorter time periods for data collection [50].

We recruited participants by letter from patient lists at a family medicine clinic and chiropractic academic health center and through flyers at two senior centers (SC) and three senior housing (SH) sites. Community-dwelling adults who were 65 years or older and self-reported LBP in the past year were eligible. Participants read and spoke English, heard well enough to join a discussion, and were willing to talk about LBP in a group. Participants provided written consent and completed a demographic survey. Sessions were held in conference rooms and lasted about one hour. Participants received a small gift and snacks for their contributions, but received no monetary compensation.

Table 1 provides the key focus group questions. An interdisciplinary steering committee developed the interview based on a literature review, discussions, and a theory of integrative medicine [51]. The lead author (KJL) facilitated most sessions while assistant moderators (SAS, MAH) documented the interview process in fieldnotes and asked follow-up questions. During the introduction to each session, the moderators instructed participants on the aims and methods of focus groups. The moderators emphasized that participants need not agree with one another, that diverse perspectives on LBP care were welcomed, and that the goal of the discussion was not to achieve consensus on the topics under discussion, but, rather, to generate new information based on the participants’ own experiences. The moderating team guided the interviews back to the main topic of discussion when irrelevant subjects arose or when a single group member dominated the conversation. The lead moderators also took care to ask the group if they had similar experiences, probed for differing opinions and invited quieter group members to offer their own perspectives to the conversation. Overall, the groups listened intently to the discussions, did not appear hesitant to discuss conflicting opinions, and offered supportive comments to participants who expressed emotional concerns. The moderating team presented an oral overview of key themes discussed at the end of the session to confirm initial session findings with participants [52]. Participants then added to or clarified points of the discussion. The moderating team debriefed after each session to identify key topics and format changes to elicit feedback from subsequent groups on emerging themes. Focus group sessions continued until thematic saturation was reached [52, 53]. A transcriptionist transcribed the digitally-recorded sessions verbatim that an assistant moderator had compared to the recordings to establish accuracy [53].

Transcriptions were analyzed using content analysis [54]. The lead author (KJL), a social scientist with expertise in interprofessional collaboration, summarized the themes for each focus group and the overall set of groups [49]. The assistant moderators are a gerontological nurse with experience in interdisciplinary teams and qualitative methods (SAS) and a doctor of chiropractic with expertise in LBP in older adults (MAH). The assistant moderators completed a peer review process to affirm the dependability of the initial coding by reading the transcripts and group summaries independently, confirming and expanding the thematic codebook, and classifying themes into discrete domains [53, 54]. We organized our analysis at the group level, rather than at the level of the individual. The analytic team organized the themes into data tables and identified which groups discussed each of the themes to identify similarities and differences in the topics generated in discussion across the four different settings from which we recruited participants. Data tables include a checkmark whenever a group discussed a topic. In some cases, many participants may have discussed a topic, while in others only one participant may have introduced an idea. In our results, we use the terms ‘most’ or ‘many’ when the majority of participants or the focus groups discussed a particular theme, ‘some’ when half of the groups identified a topic, and ‘few’ when themes were discussed by one or two participants in less than half of the groups.

While previous research has evaluated collaborative models for primary care [43, 55, 56], this study is among the first to assess older adults’ preferences for LBP co-management by MDs and DCs in primary care settings. The dynamics of collaboration between healthcare providers may vary widely, as identified by Boon and colleagues [57, 58], who have developed a seven model conceptual framework of team-oriented health care delivery. In this study, our participants largely described models of LBP treatment that may be best described as parallel practice with some consultative practice [58]. For example, most participants sought pain relief from both MDs and DCs, but no participant had experienced MD-DC collaborative care for LBP in which their providers shared health information or coordinated their care in any way. Nonetheless, our participants considered MD-DC collaboration a feasible treatment model. These older adults emphasized honest and respectful communication between health professionals for LBP co-management success. Participants also stressed the importance of providers’ direct, honest, and consistent communication with older adults suggesting any co-management model must embrace a patient-centered care approach, a finding that echoes other studies of patient preferences for doctor-patient communication [31, 43, 44, 59‐61].

Older adults were interested in talking with doctors about their diagnoses, prognosis and treatment options, as other research in primary care settings has shown [18, 61, 62]. A recent study found the quality of communication between LBP patients and 3 professional subgroups (MD, DC, and physical therapy) were worse the longer the patient had LBP and in older patients [63]. Physicians demonstrate low confidence and knowledge scores toward evaluation and treatment of LBP in elderly people [64]. While comparative studies for DCs are unavailable, chiropractic students are less knowledgeable about primary care, other than musculoskeletal conditions, than medical students [65]. Our findings suggest a MD-DC team approach may fill the knowledge and skill gaps of each provider, as primary care patients desire competent clinicians who know when to seek assistance from other professionals [66]. Intensive training and practice in communication skills may benefit health professionals who work with older adults and patients using CAM [61, 67, 68]. Healthcare providers should develop communication skills that assist patients with LBP to set realistic expectations about their treatment options, understand their potential outcomes, and engage in an active role in their therapeutic process [69].

Barriers to LBP co-management identified by these participants included financial costs, scheduling and transportation issues, and side effects from medication or chiropractic treatment, similar to other studies [42, 43, 61]. Participants thought some providers would be unwilling to engage in collaborative practice, a finding noted in other studies that have explored combining conventional and complementary approaches to healthcare [42, 51]. Participants viewed information sharing between doctors through provider referral, communication by telephone or in shared practice settings, or via computer-mediated health record exchange as an essential facilitator of LBP co-management. Previous studies of interdisciplinary practice by MDs and DCs revealed little concurrent care, referral or record sharing by these providers [23, 27‐30] suggesting the need for pragmatic co-management models to guide such practice innovations.

Through this focus group study, we improved our model of collaborative care for older adults with back pain and the interprofessional context in which this model was tested [48]. Our results also have implications for clinical practice. These participants were uneasy about pain medicine because of potential side effects, a finding expressed by other primary care and CAM patients in other studies [18, 43, 70]. Some participants refused to take pain medicine and chose to “live with pain”. One preliminary study demonstrated structural brain changes in older adults with chronic LBP [71], suggesting elders’ decisions to “live with pain” may be detrimental not only to their quality of life [4, 7, 9] but their cognitive status as well [71]. Health providers who co-manage LBP in older adults should be aware of their concerns regarding medication safety, the preferences of many elders for minimal medication use for pain relief, and the need to ascertain whether their patients are using their medications as prescribed.

This focus group study demonstrated an interest among older adults with back pain in co-management models by medical doctors and doctors of chiropractic. Older adults viewed collaboration between these providers as a potentially advantageous approach for back problems. Participants thought the combination of medical treatments and chiropractic adjustments might best achieve their goals for pain relief for low back conditions and improved physical function.

Older adults identified financial costs, scheduling and transportation issues, side effects from medication or chiropractic treatment, duplicate testing, and providers’ willingness to engage in collaborative care models as potential barriers to low back pain co-management. Facilitators of back pain treatment provided jointly by medical doctors and doctors of chiropractic included a collegial approach between providers, referral and consultation relationships, health record sharing, and co-located clinics. Patient-centered communication that included respect for the older adult as the expert in his or her own body, an openness to discussing chronic pain and diagnoses, refraining from blaming back pain on the patient’s age, and an individualized approach to treatment were considered key components of LBP collaborative care.