Gerontologist. 2018 (Mar 19); 58 (2): 376–387 ~ FULL TEXT
Stacie A. Salsbury, PhD, RN, Christine M. Goertz, DC, PhD, Robert D. Vining, DC,
Maria A. Hondras, DC, MPH, PhD, Andrew A. Andresen, MD, Cynthia R. Long, PhD,
Kevin J. Lyons, PhD, Lisa Z. Killinger, DC and Robert B. Wallace, MD, MS
Palmer Center for Chiropractic Research,
Palmer College of Chiropractic,
PURPOSE:   Older adults seek health care for low back pain from multiple providers who may not coordinate their treatments. This study evaluated the perceived feasibility of a patient-centered practice model for back pain, including facilitators for interprofessional collaboration between family medicine physicians and doctors of chiropractic.
DESIGN AND METHODS:   This qualitative evaluation was a component of a randomized controlled trial of 3 interdisciplinary models for back pain management: usual medical care; concurrent medical and chiropractic care; and collaborative medical and chiropractic care with interprofessional education, clinical record exchange, and team-based case management. Data collection included clinician interviews, chart abstractions, and fieldnotes analyzed with qualitative content analysis. An organizational-level framework for dissemination of health care interventions identified norms/attitudes, organizational structures and processes, resources, networks-linkages, and change agents that supported model implementation.
RESULTS:   Clinicians interviewed included 13 family medicine residents and 6 chiropractors. Clinicians were receptive to interprofessional education, noting the experience introduced them to new colleagues and the treatment approaches of the cooperating profession. Clinicians exchanged high volumes of clinical records, but found the logistics cumbersome. Team-based case management enhanced information flow, social support, and interaction between individual patients and the collaborating providers. Older patients were viewed positively as change agents for interprofessional collaboration between these provider groups.
IMPLICATIONS:   Family medicine residents and doctors of chiropractic viewed collaborative care as a useful practice model for older adults with back pain. Health care organizations adopting medical and chiropractic collaboration can tailor this general model to their specific setting to support implementation.
KEYWORDS:   Care coordination; Evaluation; Integrative medicine; Pain management; Patient-centered care; Teams/interdisciplinary/multidisciplinary
From the FULL TEXT Article:
Low back pain (LBP) is a common and costly musculoskeletal
complaint among older adults (Patel, Guralnik, Dansie, &
Turk, 2013; Weiner, Kim, Bonino, & Wang, 2006). Not
only is back pain a nagging reminder of the aging process
(Makris et al., 2015), older adults may be disabled by LBP,
experiencing restricted physical function, impaired activities
of daily living, increased medication use, and poor quality
of life (Docking et al., 2011; Gore, Sadosky, Stacey, Tai,
& Leslie, 2012; Makris, Fraenkel, Han, Leo-Summers, &
Gill, 2011; Weiner, Sakamoto, Perera, & Breuer, 2006).
Indeed, some researchers identify LBP and other musculoskeletal
complaints as significant threats to healthy aging
worldwide (Briggs et al., 2016).
Older patients may seek LBP treatment from multiple
health care professionals, at times concurrently, and with
little care coordination among clinicians (Lyons et al.,
2013; Weigel, Hockenberry, Bentler, Kaskie, & Wolinsky,
2012). Effective treatment for back pain can be elusive as
“what works” varies between patients and over episodes
(Borkan, Reis, Hermoni, & Biderman, 1995; Parsons et al.,
2012). However, patients with back pain often prefer to use
conservative, non-pharmacological therapies over medication
or surgery (Löckenhoff et al., 2013; McIntosh & Shaw,
2003; Ness, Cirillo, Weir, Nisly, & Wallace, 2005; Sherman
et al., 2004).
One innovative, conservative practice model for older
adults with LBP is collaborative care pairing medical doctors
(MDs) and doctors of chiropractic (DCs) (Goertz et al.,
2013; Lyons et al., 2013). Collaborative care for patients
with complex health conditions can improve patient outcomes
and satisfaction (Karlin & Karel, 2014; Scharlach,
Graham, & Berridge, 2015; Tracy, Bell, Nickell, Charles, &
Upshur, 2013). And yet, implementation of such interdisciplinary
models is challenging. Providers often demonstrate
limited knowledge of LBP diagnoses and treatment
(Buchbinder, Staples, & Jolley, 2009; Cayea, Perera, &
Weiner, 2006). Hundreds of treatments for LBP exist
(Haldeman & Dagenais, 2008), with guidelines endorsing
self-care, medication, physical therapy, exercise, spinal
manipulation, and other treatments (Chou et al., 2007).
Providers may not understand how to select or integrate
musculoskeletal treatments from other clinicians
with the services they offer (Frenkel & Borkan, 2003;
Penney et al., 2016).
Recent studies of nationally representative samples
of older adults demonstrate that chiropractic care has a
protective effect against declines in activities of daily living
and self-rated health (Weigel, Hockenberry, Bentler, &
Wolinsky, 2014; Weigel, Hockenberry, & Wolinsky, 2014),
comparable outcomes for functional health with medical
care (Weigel, Hockenberry, Bentler, & Wolinsky, 2013),
high satisfaction with care and health information (Weigel,
Hockenberry, & Wolinsky, 2014), and positive safety
profiles (Whedon, Mackenzie, Phillips, & Lurie, 2015).
However, few medical doctors and chiropractors work in
the same facility (Christensen, Hyland, Goertz, & Kollasch,
2015) and most report infrequent referrals with minimal
exchange of clinical information (Greene, Smith, Haas, &
Allareddy, 2007; Mainous, Gill, Zoller, & Wolman, 2000).
The purpose of this qualitative study was to evaluate multidisciplinary
practice for older adults with back pain by physicians
training in a family medicine residency program and
licensed chiropractors from the perspectives of these provider
groups. In this paper, we highlight the essential components of
a collaborative care model, describe the context for establishing
this interprofessional practice, and discuss the implications
of this model for implementation in real-world clinical settings.
Collaborative Care Model
The Collaborative Care for Older Adults with Back Pain
(COCOA) model (Goertz et al., 2013) was based upon a
provider-level framework for integrative medicine that
includes team functions (attitudes/knowledge), referral,
and clinical practice (Hsiao et al., 2006). We designed a collaborative
care model with three essential components to
enhance interdisciplinary communication between providers:
interprofessional education, clinical record exchange,
and team-based case management (Figure 1).
Interprofessional education was offered by an interdisciplinary
committee to supervised family medicine residents
(MDs or doctors of osteopathy [DO]) and licensed
DCs. Clinicians completed four, hour-long, lunchtime
workshops on professional scopes of practice, LBP management
in older adults, and interdisciplinary collaboration
(Table 1) and half-day job shadowing experiences at the
cooperating clinic (Riva et al., 2010). Five additional trainings
reinforced procedures, prevented intervention drift,
and strengthened collaborative processes.
Clinical record exchanges enhanced interdisciplinary
communication for clinicians working with different health
care facilities and record systems (Bailey et al., 2013).
A study-designed, secure, websystem using a Microsoft
SQL Server (Redmond, WA) facilitated record exchanges
of baseline evaluations (health history, medications,
examinations, and imaging), treatment summaries, and
status changes. Clinicians accessed records through the
websystem with a unique log-in and password and received
automated e-mails on record updates.
Team-based case management supported integrative
practice. Clinicians evaluated the participant, offered recommendations,
and completed telephone consultations
with the collaborating doctor to discuss patient history,
diagnoses, and treatment goals; treatment approaches; and
status changes. The clinicians supported this shared treatment
plan and treatment goals in subsequent interactions
with the patient (Parsons et al., 2012).
This evaluation was a component of a pragmatic,
pilot randomized controlled trial (ClinicalTrials.gov
NCT01312233) that compared three professional models
for back pain treatment (Figure 2). Our aims were to
evaluate the perceived feasibility of collaborative practice
by medical doctors and chiropractors, describe the context
of diffusion for this intervention, and identify model
facilitators for real-world implementation. Our research
approach included qualitative interviews with providers,
clinical record abstraction, and fieldnotes. The Institutional
Review Boards of Palmer College of Chiropractic and
Genesis Health System approved the study. Written consent
was obtained from participants. We published the trial protocol
(Goertz et al., 2013); patient outcomes will be presented
Setting and Participants
The settings were an unaffiliated family medicine residency
and a chiropractic research center located in one community.
Medical residents volunteered as providers for the
trial; from these, residency faculty selected five residents
from various years in the program to serve as collaborative
physicians. These residents shared an office that allowed
them to engage in team-based case management without
exposing residents assigned to patients in other groups to
this intervention. Nineteen other residents provided back
pain treatments without receiving the interprofessional
education. Four licensed chiropractors treated participants
in both chiropractic groups, with designated patients
receiving the collaborative care model. Five research fellows
also received the interprofessional education, but
delivered no chiropractic care. Clinicians were not the
usual primary care provider or chiropractor of most participants,
and therefore only treated patients for LBP.
No clinician received financial incentives to participate,
although all received light lunches during the noontime
Patient participants included adults aged 65 years or
older with a current LBP episode lasting at least 1 month
and rated as ≥4 on a 0–10 pain numerical rating scale (NRS)
at baseline. Patients were recruited from invitational letters
to residency patients in the target population and from the
community by direct mailers to households with an identified
member aged 65 years or older within a 35-mile radius
of the research center and through local media. Patients
ineligible for the trial if they received LBP treatment from
any provider in the previous 2 months. Enrolled patients
had a median age of 72 (6.2) years, with 61% male and
94% white. Most (84%) reported LBP duration of ≥1 year,
with baseline mean LBP rated as 5.8 on the NRS (Khorsan,
Coulter, Hawk, & Choate, 2008) and mean score of 7.5
on the 24-item Roland Morris Disability Questionnaire
(Roland & Morris, 1983).
Participants were randomized to one of three interventions
usual medical care (Med Care);
concurrent medical and chiropractic care (Dual Care); or
collaborative medical and chiropractic care (Shared Care).
received up to 12 weeks of individualized, guideline-based,
usual medical care (Chou et al., 2007). Participants
allocated to chiropractic also received up to 12 weeks of
individualized chiropractic care consistent with best practices
(Hawk, Schneider, Dougherty, Gleberzon, & Killinger,
2010). Shared Care participants received care guided by the
collaborative model. Evaluations and chiropractic services
were provided without cost; medical visits and therapies
(physical therapy, medications) were billed to the patient
or insurance. Treatment frequency was determined by the
Data were collected from qualitative interviews, clinical
record audits, and fieldnotes of the educational sessions
and model implementation challenges. The first author
compiled all fieldnotes and conducted voluntary interviews
with 19 clinicians, including 13/24 (54%) medical
or osteopathic doctors and 6/9 (67%) chiropractors after
trial participation. A structured interview asked clinicians
their perceptions of the feasibility of model components
for clinical practice settings. A service completed verbatim
transcriptions from digital audio-recordings.
Descriptive statistics for patient demographics and record
exchanges were calculated using SAS, version 9.2 (SAS
Institute, Cary, NC). Qualitative data were managed with
NVivo-9 software (QSR International, Doncaster, Victoria,
Australia). The first author, a qualitative researcher who
served as project manager of the trial, coded the transcripts
for key themes underlying model feasibility using
content analysis techniques (Hsieh & Shannon, 2005). Two
co-investigators (M. A. Hondras and R. D. Vining), DCs
with added expertise in clinical research and/or qualitative
methods, confirmed the coding results. Data interpretation
reflected the domains of the collaborative model, organized
with contextual factors from an implementation framework
for health care interventions (Mendel, Meredith,
Schoenbaum, Sherbourne, & Wells, 2008). This implementation
framework specifies factors that affect stakeholders’
willingness and ability to implement and sustain
new health care interventions (including norms/attitudes,
organizational structures/processes, and resources) as well
as influences and information sources for disseminating
such innovations (networks/linkages and media/change
agents) (Mendel et al., 2008). An online Supplementary
Material presents contextual factor domains, themes and
representative quotes identified by provider treatment
group, profession, and interview number. Quotes are
included from providers who received the interprofessional
training and practiced under the collaborative model, as
well as those who did not, offering the reader a range of
viewpoints about the barriers and facilitators of interdisciplinary
care for older adults with back pain.
Changing Provider Attitudes and Knowledge Through Interprofessional Education
The medical residents and chiropractors who participated in
the interprofessional education program reported changes
in their attitudes and knowledge of the collaborating discipline,
and in their perceptions of caring for older adults
who have back pain (Supplementary Material—Norms and
attitudes). As one medical doctor stated:
I really liked the interprofessional education sessions
and getting to do some of the shadowing and talking
with the chiropractic folks. I learned a lot about where
they were coming from and we had good discussions
about medical and chiropractic care and different kinds
of chiropractic treatment that I hadn’t had before.
(Shared Care MD-IN01)
Several physicians noted these sessions were their introduction
All that’s fascinating to me, especially when I can hear
clinical outcomes and how that benefited their patients.
That’s good because in medical school, they typically
do not teach what a chiropractor does. Certainly in our
medical journals we never have any overview of what a
(Shared Care DO-IN03)
Chiropractors noted these programs were among their first
opportunities to observe medical doctors as collaborating
It helped to open up doors a little bit…This experience
allowed…meeting somebody who’s doing this in the
field on a professional level and not just of the patient,
so that was enjoyable.
(Chiropractic research fellow, IN-19)
Shared Care clinicians participated in up to nine educational
sessions and all job shadowed for 3–5 hr. Topics
covered during the lunchtime workshops (Table 1) were
often mentioned as areas where provider attitudes and
knowledge had changed, including professional scopes
of practice, patient motivations and preferences for back
pain management, and communication strategies for
working with older adults. Treatment safety concerns for
older people with back pain largely centered on medications,
mobility issues, and comorbidities, particularly
after the medical doctors had learned more about spinal
With safety, I was worried about my patients taking
their medications the way they should. Big combinations
of medications and the wrong doses could potentially
hurt someone…I wouldn’t say that I ever worry
about chiropractic care causing a problem.
(Med/Dual Care DO-IN10)
The chiropractors noted that delivery of chiropractic care
to older adults sometimes required treatment modification
to optimize its safety:
You have to do technique modification, and you need
to take into account how much spinal and soft tissue
degeneration there is and their other comorbid conditions
that might impact their low back pain.
(Dual/Shared Care DC-IN15)
Fieldnotes and provider interviews noted attendance discrepancies
between provider groups. The institutional mission
of the research center allowed the chiropractors to
attend all educational sessions, whereas the patient care
demands of the residency led most medical doctors to omit
single training sessions or shorten attendance times:
On a logistical basis, getting out of clinic and rotations
either in time to get to [sessions] or the times when our
schedules ended up being blocked off and we had clinic
patients starting before those ended, that was stressful…
I always wish I could have stayed… arrange the scheduling
a little better between the clinics.
Recommendations for improving the interprofessional education
included shorter, more frequent sessions; hands-on
workshops for complex patients; and more information
about the effectiveness and safety of LBP treatments for
One clinician summarized:
I don’t know what kind of common forums we can participate
in, but more interaction would bridge that gap,
because it seemed to work well. We’re taking care of
the same community, same patients. It’s just a matter of
more interaction from the practitioners.
(Shared Care MD-IN09)
Organizational Structures and Processes to Support Collaboration
Organizational structures and processes are necessary infrastructures
to support collaboration. Core health care technologies
(Mendel et al., 2008), such as medical knowledge,
clinical routines, and treatment protocols, were commonly
mentioned in provider interviews as organizational features
that served as barriers or facilitators of interdisciplinary
communication and practice (Supplementary Material—
Organizational structures and processes). Disciplinary jargon
and clinical record content were areas where providers
negotiated common ground:
Content is probably okay…cut communication down
to a one-page treatment summary. I don’t have time
to read…I just want the pertinent.
(Shared Care DO-IN03)
We adapted a little bit…met in the middle…keeping it
simple, one page, bare bones, need to know, rule out
red flags and then one or two additional things that are
very telling that may have an impact on management
(Chiropractic research fellow, IN-17)
Clinicians also gained knowledge about the treatment protocols
of their collaborators:
It made me more familiar with techniques and strategies
and, you know, we all had the same common goal
so it was reassuring more than anything.
(Shared Care MD-IN09)
Chiropractors reported a better understanding of the
challenges family physicians have managing older adults
who have multiple comorbidities and medication use in
[The pharmacist’s] topics on the drug stuff…it was a
nice gesture to see…people who work in that realm of
healthcare also recognize that a lot of what they do has
a relatively limited evidence-base to draw upon.
(Dual/Shared Care DC-IN05)
The clinical record exchange was a challenging organizational
process to implement. Overall, the clinics shared
968 records, with most exchanged during the baseline
evaluation to support eligibility decisions. During active
care, the number of record exchanges differed modestly
between clinics. The medical clinic uploaded 110 records,
including 103 treatment and 7 phone call summaries and
no status change reports. The chiropractic clinic uploaded
150 records, including 86 treatment and 44 phone call
summaries. Chiropractors uploaded 20 status reports indicating
a participant had experienced a deterioration in
health. Fieldnotes documented several logistical challenges,
including multiple log-in screens and slow file uploads
that required a research nurse to format, upload, and print
records for medical providers. Chiropractors scanned and
uploaded records, a process taking 15–30 min. One medical
doctor called the record exchange process:
Impractical…the time commitment, the cumbersome
nature of the electronic forms…it could work in a traditional
practice, not a residency program.
(Shared Care MD-IN06)
A chiropractor concurred:
Not as feasible simply because of the paperwork…along
the lines of 20 pages scanned, uploaded, categorized
into a secure network that is not as efficient as a commercial
electronic medical records program would be.
(Chiropractic research fellow, IN-17)
Linking Providers and Patients for Better Back Health
Team-based case management served as a critical connection
for information flow, social support, and interaction
between patients and collaborating providers
(Supplementary Material—Networks and linkages).
One exemplar of case management is from an osteopathic
physician and a chiropractor who commented on
their shared treatment with a mutual patient who had a
personal goal to stop smoking, a known risk factor for
I was surprised at how effectively we worked together
on one patient for smoking cessation. Part of my challenge
is, I don’t see the patients as often as a chiropractic
doctor would. Even though we set goals and the patient
gets excited to achieve their goals, that extra reinforcement
when you see them more often really does help
the patient in a way I’m not able to. I was glad to see
that. I was able to reinforce your suggestions and you
were able to reinforce mine and ultimately the patient
did benefit; although this particular one did not quit
entirely, cutting down helps.
(Shared Care DO-IN03)
There was one case that comes to mind…our participant
was involved in smoking cessation and the medical
physician and I worked together on that with different
approaches, so I think we enhanced each other.
(Dual/Shared Care DC-IN16)
In contrast, clinicians who had not participated in interprofessional
education reported they would likely not refer
older patients for spinal manipulation because they had
not developed a working relationship with a chiropractor.
Another practice challenge was that the providers worked
in different settings:
Normally, people that are working together are in the
same building, and even in the same wing…trying to
get each other on the phone has been impossible.
(Dual/Shared Care DC-IN05)
And yet, the telephone consultations did offer clinicians a
positive space to talk about their patient’s preferences and
Whenever we got to brainstorm about a particular participant’s
condition, especially some of the comorbid
conditions, I thought that was good because I saw these
people more often and could gauge whether they were
getting better or worse…and pass on that information…
having access to people who can assess non-musculoskeletal
problems was good, especially with this group
that had so many comorbid conditions.
Finally, the patients themselves served as the best advocates
to these doctors who were just learning the possibilities of
The most prominent request was for a multi-disciplinary
approach. [Patients] wanted both practitioners to
be working at the same time, they didn’t want just one
or the other. They felt the combination had an added
benefit to them.
(Shared Care MD-IN09)
Most were very happy to have chiropractic care. I know
a lot of them didn’t think they would get much help
from the medical people. Some were given things like
gabapentin or anti-inflammatories that really helped
them a lot. They were glad for the collaborative care,
as I was. You know, I didn’t care who did what to make
them feel better. They’re patients. You just want them to
(Dual/Shared Care DC-IN15)
Table 2 offers some recommendations based on the provider
interviews (see Supplementary Material) for clinicians
and health care organizations considering implementing
collaborative practice between medical doctors and chiropractors
for older adults with back pain.
Recommendations From Provider Interviews for |
Implementing Collaborative Care for Older Adults With Back Pain
This qualitative study evaluated the perceived feasibility of
interprofessional practice for the management of LBP that
includes collaboration between family medicine physicians
and doctors of chiropractic, the health professionals who
most often treat older adults with this condition (Weigel
et al., 2012). This collaborative care model (COCOA)
included three essential components for enhancing interdisciplinary
communication and practice: interprofessional
education, clinical record exchanges, and team-based case
management (Goertz et al., 2013). Health care innovations,
such as interdisciplinary practice, require stakeholders to
adopt new attitudes and knowledge and organizations to
build and maintain networks between entities (Hsiao et al.,
2006; Mendel et al., 2008). Interprofessional education
provided a forum where medical doctors and chiropractors
learned about each providers’ treatment protocols, discovered
how to work together, and forged a shared commitment
to patient-centered care for older patients. Clinicians
were satisfied with the interprofessional education, with
many listing the opportunity to know the partnering providers
on a personal basis as a favorite feature of the model.
Alternative educational formats, such as preclinical training,
webinars, and continuing education offering credit for
both professions, also might be offered (Bednarz & Lisi,
2014; Wong et al., 2014). Targeted e-learning programs
similarly may improve clinicians’ skills managing back pain
in older adults (Weiner et al., 2014).
Organizational structures and processes, such as health
information systems, are vital supports of interprofessional
collaboration (Mendel et al., 2008). These providers successfully
shared over 900 clinical records, a vast improvement
over previous research showing limited information
exchange between primary care physicians and chiropractors
(Greene et al., 2007). Importantly, both provider
groups valued the content shared in these records, whereas
the medical doctors lacking record access expressed a preference
for the exchange of such health information between
providers rather than through patients. Operational efficiencies,
such as integrated clinical records and secure messaging
found in commercial electronic health records used
within a single health care organization (Chen, Garrido,
Chock, Okawa, & Liang, 2009), were not realized, a finding
with workload implications for clinicians both in facilities
with health information systems and those in solo or
small group practices. Until electronic health records are
exchanged securely and seamlessly between all settings,
medical doctors and chiropractors might continue sharing
patient care information through less “high-tech” means
such as mailed or faxed treatment summaries. Of note, we
did not share clinical records with patients. Health record
access, such as My HealtheVet (Woods et al., 2013) and
Patients Like Me (Wicks et al., 2010), improves patients’
understanding of their health conditions and perceptions of
patient–provider communication. Back pain advice has had
beneficial effects on fear avoidance behaviors and disability
measures (Burton, Waddell, Tillotson, & Summerton,
1999). Future studies might evaluate how patient access to
health records affects back pain outcomes.
Providers considered the older adults in this trial as
change agents who helped drive the introduction of collaborative
care in these settings (Mendel et al., 2008),
which does differ from our initial conceptual framework
which posited integrative medicine was a provider-driven
model (Goertz et al., 2013; Hsiao et al., 2006). We published
a case report from the trial to demonstrate how
patients and providers can collaborate for more patientcentered
approaches to LBP (Seidman, Vining, & Salsbury,
2015). Providers also noted more confidence when discussing
the management of back pain with their patients
(Supplementary Material and Table 2). Many studies have
noted that chronic pain patients, and those with back pain in
particular, do not experience patient-centered communication
(Borkan et al., 1995; Gulbrandsen, Madsen, Benth, &
Laerum, 2010; Walker, Holloway, & Sofaer, 1999). Our
previous research showed older adults wanted chiropractors
and primary care doctors to communicate both with
each other, and with them, about back pain, and to involve
patients in decision-making (Lyons et al., 2013). Thus, we
are encouraged by provider reports that they talked with
patients more about their spinal health and treatment
Integrative health care is difficult to achieve under the best
of circumstances (Frenkel & Borkan, 2003; Gucciardi, Espin,
Morganti, & Dorado, 2016; Sundberg, Halpin, Warenmark, &
Falkenberg, 2007) and may be more challenging across health
care organizations (Coulter, Ellison, Hilton, Rhodes, &
Ryan, 2008). Along a continuum for models of team-based
health care (Boon, Verhoef, O’Hara, & Findlay, 2004),
the COCOA model is classified as a collaborative model.
Higher level models, from coordinated to interdisciplinary
to integrative care, may require a shared physical space, in
addition to shared core values, patient-centered care, and
institutional support (Boon et al., 2004). Health care organizations
should realize that their older patients are interested
in a one-stop approach to management of their musculoskeletal
conditions and would value seeing their providers in
shared appointments (Lyons et al., 2013).
This study had its limitations. Our clinicians noted
that these older adults seemed more motivated to address
their back pain than patients who seek care outside clinical
trials. The family physicians were supervised residents,
the chiropractors were employed in a research center, and
neither clinician was the regular provider for participants.
An anticipated limitation from the outset of the project
was that residents would miss some presentations due to
patient care schedules. Thus, the model may be more challenging
to implement with providers working outside the
unique settings where this study took place, and in practices
where scheduling the time and personnel to support
collaboration may differ. Not all clinicians participated
in the interviews, which may suggest some response bias.
Lastly, much of the patient care provided in this study
was supported by a research grant, and we did not collect
data about the costs associated with interprofessional
education or model implementation. Older adults who are
paying or co-paying for care and organizations that might
have to invest capital to integrate these clinical practices
will need to consider any associated costs.
Although site-specific tailoring and additional research
on the implementation of this health care innovation is
suggested for other real-world settings (Mendel et al.,
2008), model components were feasible and transferrable
to interprofessional practice between family medicine
residents and chiropractors. The model supported interprofessional
education about back pain, a common condition
for which older adults seek health care from both
these provider groups. Clinical record exchanges between
the clinics were supported, and allowed for a modest
level of team-based case management between clinicians
working in two health systems with no history of interprofessional
cooperation, most of whom had reported no
previous experience collaborating with the other provider
type. The findings here might be most transferrable within
health care systems that employ both medical doctors and
chiropractors. Training programs that introduce medical,
osteopathic and chiropractic students to the approaches
and treatments of the other disciplines might also improve
interprofessional collaboration for older adults with back
The authors thank the older adults, providers, and study personnel
who participated in the COCOA Study. We are grateful to the clinicians
who presented at the interprofessional education sessions: Drs.
John Stites, Michael Tunning, and Michael Seidman. We appreciate
the contributions of Dr. Mark Jones on all aspects of this project.
The authors report no conflicts of interest.
This work was supported by the Health Resources and Services
Administration (R18HP15126) and the National Institutes of
Health National Center for Research Resources (C06-RR015433).
Bailey, J., Pope, R., Elliott, E., Wan, J., Waters, T., & Frisse, M.
Health information exchange reduces repeated diagnostic imaging for back pain.
Annals of Emergency Medicine, 62, 16–24. doi:10.1016/j.annemergmed.2013.01.006
Bednarz, E., & Lisi, A. (2014).
A survey of interprofessional education in chiropractic continuing education in the United States.
Journal of Chiropractic Education, 28, 152–156. doi:10.7899/JCE-13-17
Boon, H., Verhoef, M., O’Hara, D., & Findlay, B. (2004).
From parallel practice to integrative health care: A conceptual framework.
BMC Health Services Research, 4, 15. doi:10.1186/1472-6963-4-15
Borkan, J., Reis, S., Hermoni, D., & Biderman, A. (1995).
Talking about the pain: A patient-centered study of low back pain in primary care.
Social Science and Medicine, 40, 977–988. doi:10.1016/0277-9536(94)00156-N
Briggs, A., Cross, M., Hoy, D., Sánchez-Riera, L., Blyth, F., Woolf, A.,
& March, L. (2016).
Musculoskeletal health conditions represent a global threat to healthy aging: A report for the 2015 World
Health Organization World Report on Ageing and Health.
The Gerontologist, 56, S243–S255. doi:10.1093/geront/gnw002
Buchbinder, R., Staples, M., & Jolley, D. (2009).
Doctors with a special interest in back pain have poorer knowledge about how to treat back pain.
Spine, 34, 1218–1226. doi:10.1097/BRS.0b013e318195d688
Burton, A., Waddell, G., Tillotson, K., & Summerton, N. (1999).
Information and advice to patients with back pain can have a positive effect:
A randomized controlled trial of a novel educational booklet in primary care.
Spine, 24, 2484–2491. doi:10.1097/00007632-199912010-00010
Cayea, D., Perera, S., & Weiner, D. (2006).
Chronic low back pain in older adults: What physicians know, what they think they know, and what they should be taught.
Journal of the American Geriatrics Society, 54, 1772–1777. doi:10.1111/j.1532-5415.2006.00883.x
Chen, C., Garrido, T., Chock, D., Okawa, G., & Liang, L. (2009).
The Kaiser Permanente Electronic Health Record: Transforming and streamlining modalities of care.
Health Affairs, 28, 323–333. doi:10.1377/hlthaff.28.2.323
Chou R, Qaseem A, Snow V, Casey D, Cross JT Jr., Shekelle P, Owens DK:
Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline
from the American College of Physicians and the American Pain Society
Annals of Internal Medicine 2007 (Oct 2); 147 (7): 478–491
Christensen, M., Hyland, J., Goertz, C., & Kollasch, M. (2015).
Practice Analysis of Chiropractic 2015:
A project report, survey analysis, and summary of chiropractic practice in the United States.
Greely, CO: National Board of Chiropractic Examiners.
Coulter, I., Ellison, M., Hilton, L., Rhodes, H., & Ryan, G. (2008).
Hospital-based integrative medicine: A case study of the barriers and factors facilitating the creation of a center.
Santa Monica, CA: RAND Corporation.
Docking, R., Fleming, J., Brayne, C., Zhao, J., Macfarlane, G., &
Jones, G. (2011).
Epidemiology of back pain in older adults: Prevalence and risk factors for back pain onset.
Rheumatology, 50, 1645–1653. doi:10.1093/rheumatology/ker175
Frenkel, M., & Borkan, J. (2003).
An approach for integrating complementary-alternative medicine into primary care.
Family Practice, 20, 324–332. doi:10.1093/fampra/cmg315
Goertz, C., Salsbury, S., Vining, R., Long, C., Andresen, A., Jones, M.
et al. (2013).
Collaborative care for older adults with low back pain by family medicine physicians and doctors of chiropractic
(COCOA): Study protocol for a randomized controlled trial.
Trials, 14, 18. doi:10.1186/1745-6215-14-18
Gore M, Sadosky A, Stacey BR, Tai KS, Leslie D.
The Burden of Chronic Low Back Pain: Clinical Comorbidities, Treatment Patterns,
and Health Care Costs in Usual Care Settings
Spine (Phila Pa 1976). 2012 (May 15); 37 (11): E668–677
Greene, B., Smith, M., Haas, M., & Allareddy, V. (2007).
How often are physicians and chiropractors provided with patient information when accepting referrals?
Journal of Ambulatory Care Management, 30, 344–346. doi:10.1097/01. JAC.0000290403.89284.e0
Gucciardi, E., Espin, S., Morganti, A., & Dorado, L. (2016).
Exploring interprofessional collaboration during the integration of diabetes teams into primary care.
BMC Family Practice, 17, 1. doi:10.1186/s12875-016-0407-1
Gulbrandsen, P., Madsen, H., Benth, J., & Laerum, E. (2010).
Health care providers communicate less well with patients with chronic low back pain:
A study of encounters at a back pain clinic in Denmark.
Pain, 150, 458–461. doi:10.1016/j.pain.2010.05.024
Haldeman S, Dagenais S.
A Supermarket Approach to the Evidence-informed Management of Chronic Low Back Pain
Spine Journal 2008 (Jan); 8 (1): 1–7
Hawk C, Schneider M, Dougherty P, Gleberzon BJ, Killinger LZ.
Best Practices Recommendations for Chiropractic Care
for Older Adults: Results of a Consensus Process
J Manipulative Physiol Ther 2010 (Jul); 33 (6): 464–473
Hsiao, A., Ryan, G., Hays, R., Coulter, I., Andersen, R., & Wenger,
Variations in provider conceptions of integrative medicine.
Social Science and Medicine, 62, 2973–2987. doi:10.1016/j.socscimed.2005.11.056
Hsieh, H., & Shannon, S. (2005).
Three approaches to qualitative content analysis.
Qualitative Health Research, 15, 1277–1288. doi:10.1177/1049732305276687
Karlin, B., & Karel, M. (2014).
National integration of mental health providers in VA home-based primary care:
An innovative model for mental health care delivery with older adults.
The Gerontologist, 54, 868–879. doi:10.1093/geront/gnt142
Khorsan, R., Coulter, I., Hawk, C., & Choate, C. (2008).
Measures in chiropractic research: Choosing patient-based outcome assessments.
Journal of Manipulative and Physiological Therapeutics, 31, 355–375. doi:10.1016/j.jmpt.2008.04.007
Löckenhoff, C., Laucks, S., Port, A., Tung, J., Wethington, E., &
Reid, M. (2013).
Temporal horizons in pain management: Understanding the perspectives of physicians, physical therapists,
and their middle-aged and older adult patients.
The Gerontologist, 53, 850–860. doi:10.1093/geront/gns136
Lyons K, Salsbury S, Hondras M, Jones M, Andresen A, Goertz C.
Perspectives of Older Adults on Co-management of Low Back Pain by Doctors of Chiropractic
and Family Medicine Physicians: A Focus Group Study
BMC Complement Altern Med. 2013 (Sep 16); 13: 225
Mainous, A., Gill, J., Zoller, J., & Wolman, M. (2000).
Fragmentation of patient care between chiropractors and family physicians.
Archives of Family Medicine, 9, 446–450. doi:10.1001/archfami.9.5.446
Makris, U., Fraenkel, L., Han, L., Leo-Summers, L., & Gill, T.
Epidemiology of restricting back pain in communityliving older persons.
Journal of the American Geriatrics Society, 59, 610–614. doi:10.1111/j.1532-5415.2011.03329.x
Makris, U., Higashi, R., Marks, E., Fraenkel, L., Sale, J., Gill, T. et al.
Ageism, negative attitudes, and competing co-morbidities - why older adults may not seek care
for restricting back pain: A qualitative study.
BMC Geriatrics, 15, 39. doi:10.1186/s12877-015-0042-z
McIntosh, A., & Shaw, C. (2003).
Barriers to patient information provision in primary care: Patients’ and general practitioners’ experiences
and expectations of information for low back pain.
Health Expectations, 6, 19–29. doi:10.1046/j.1369-6513.2003.00197.x
Mendel, P., Meredith, L., Schoenbaum, M., Sherbourne, C., & Wells,
Interventions in organizational and community context: A framework for building evidence on dissemination and
implementation in health services research.
Administration and Policy in Mental Health and Mental Health Services Research, 35, 21–37.
Ness, J., Cirillo, D., Weir, D., Nisly, N., & Wallace, R. (2005).
Use of complementary medicine in older Americans: Results from the Health and Retirement Study.
The Gerontologist, 45, 516–524. doi:10.1093/geront/45.4.516
Parsons S, Harding G, Breen A, Foster N, Pincus T, Vogel S, et al.
Will Shared Decision Making Between Patients with Chronic Musculoskeletal Pain
and Physiotherapists, Osteopaths and Chiropractors Improve Patient Care?
Fam Pract. 2012 (Apr); 29 (2): 203–212
Patel, K., Guralnik, J., Dansie, E., & Turk, D. (2013).
Prevalence and impact of pain among older adults in the United States:
Findings from the 2011 National Health and Aging Trends Study.
Pain, 154, 2649–2657. doi:10.1016/j.pain.2013.07.029
Penney LS, Ritenbaugh C, Elder C, Schneider J, Deyo RA, DeBar LL.
Primary Care Physicians, Acupuncture and Chiropractic Clinicians,
and Chronic Pain Patients: A Qualitative Analysis of
Communication and Care Coordination Patterns
BMC Complement Altern Med. 2016 (Jan 25); 16: 30
Riva, J., Lam, J., Stanford, E., Moore, A., Endicott, A., & Krawchenko,
Interprofessional education through shadowing experiences in multi-disciplinary clinical settings.
Chiropractic & Osteopathy, 18, 31. doi:10.1186/1746-1340-18-31
Roland, M., & Morris, R. (1983).
A study of the natural history of back pain. Part I: Development of a reliable and sensitive measure of
disability in low-back pain.
Spine, 8, 141–144. doi:10.1097/00007632-198303000-00005
Scharlach, A., Graham, C., & Berridge, C. (2015).
An integrated model of co-ordinated community-based care.
The Gerontologist, 55, 677–687. doi:10.1093/geront/gnu075
Seidman M, Vining R, Salsbury S.
Collaborative Care for a Patient with Complex Low Back Pain
and Long-term Tobacco Use: A Case Report
J Can Chiropr Assoc. 2015 (Sep); 59 (3): 216–225
Sherman, KJ, Cherkin, DC, Connelly, MT, Erro, J, Savetsky, JB, Davis, RB et al.
Complementary and Alternative Medical Therapies for Chronic Low Back Pain:
What Treatments Are Patients Willing To Try?
BMC Complement Altern Med. 2004 (Jul 19); 4: 9
Sundberg, T., Halpin, J., Warenmark, A., & Falkenberg, T.
Towards a model for integrative medicine in Swedish primary care.
BMC Health Services Research, 7, 107. doi:10.1186/1472-6963-7-107
Tracy, C., Bell, S., Nickell, L., Charles, J., & Upshur, R. (2013).
The IMPACT clinic innovative model of interprofessional primary care for elderly patients with complex health care needs.
Canadian Family Physician, 59, e148–e155.
Walker, J., Holloway, I., & Sofaer, B. (1999).
In the system: The lived experience of chronic back pain from the perspectives of those seeking help from pain clinics.
Pain, 80, 621–628. doi:10.1016/S0304-3959(98)00254-1
Weigel, PAM, Hockenberry, JM, Bentler, SE, Kaskie, B, and Wolinsky, FD.
Chiropractic Episodes and the Co-occurrence of Chiropractic
and Health Services Use Among Older Medicare Beneficiaries
J Manipulative Physiol Ther 2012 (Mar); 35 (3): 168-175
Weigel, P., Hockenberry, J., Bentler, S., & Wolinsky, F. (2013).
Chiropractic use and changes in health among older Medicare beneficiaries: A comparative effectiveness observational study.
Journal of Manipulative and Physiological Therapeutics, 36, 572–584. doi:10.1016/j.jmpt.2013.08.008
Weigel P, Hockenberry J, Bentler S, Wolinsky F.
The Comparative Effect of Episodes of Chiropractic and Medical Treatment
on the Health of Older Adults
J Manipulative Physiol Ther 2014 (Mar); 37 (3): 143–154
Weigel, P., Hockenberry, J., & Wolinsky, F. (2014).
Chiropractic Use in the Medicare Population: Prevalence, Patterns, and Associations
With 1-year Changes in Health and Satisfaction With Care
J Manipulative Physiol Ther 2014 (Mar); 37 (8): 542-551
Weiner, D., Kim, Y., Bonino, P., & Wang, T. (2006).
Low back pain in older adults: Are we utilizing healthcare resources wisely?
Pain Medicine, 7, 143–150. doi:10.1111/j.1526-4637.2006.00112.x
Weiner, D., Morone, N., Spallek, H., Karp, J., Schneider, M., Washburn,
C. et al. (2014).
E-learning module on chronic low back pain in older adults: Evidence of effect on medical student o
bjective structured clinical examination performance.
Journal of the American Geriatrics Society, 62, 1161–1167. doi:10.1111/jgs.12871
Weiner, D., Sakamoto, S., Perera, S., & Breuer, P. (2006).
Chronic low back pain in older adults: Prevalence, reliability, and validity of physical examination findings.
Journal of the American Geriatrics Society, 54, 11–20. doi:10.1111/j.1532-5415.2005.00534.x
Whedon, J., Mackenzie, T., Phillips, R., & Lurie, J. (2015).
Risk of traumatic injury associated with chiropractic spinal manipulation in Medicare Part B beneficiaries aged 66–99.
Spine, 40, 264–270. doi:10.1097/BRS.0000000000000725
Wicks, P., Massagli, M., Frost, J., Brownstein, C., Okun, S., Vaughan,
T. et al. (2010).
Sharing health data for better outcomes on PatientsLikeMe.
Journal of Medical Internet Research, 12, e19. doi:10.2196/jmir.1549
Wong, J., Di Loreto, L., Kara, A., Yu, K., Mattia, A., Soave, D.
et al. (2014).
Assessing the change in attitudes, knowledge, and perspectives of medical students towards chiropractic
after an educational intervention.
Journal of Chiropractic Education, 28, 112–122. doi:10.7899/JCE-14–16
Woods, S. S., Schwartz, E., Tuepker, A., Press, N. A., Nazi, K. M., Turvey,
C. L. et al. (2013).
Patient experiences with full electronic access to health records and clinical notes through the My HealtheVet
Personal Health Record Pilot: Qualitative study.
Journal of Medical Internet Research, 15, e65. doi:10.2196/jmir.2356
Return to LOW BACK PAIN
Return to INTEGRATED HEALTH CARE