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Open Access Research article

A path analysis of the effects of the doctor-patient encounter and expectancy in an open-label randomized trial of spinal manipulation for the care of low back pain

Mitchell Haas1*, Darcy Vavrek1, Moni B Neradilek2 and Nayak Polissar2

Author Affiliations

1 Center for Outcomes Studies, University of Western States, 2900 NE 132nd Ave., Portland, OR, USA

2 The Mountain-Whisper-Light Statistics, 1827 23rd Ave. East, Seattle, WA, USA

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BMC Complementary and Alternative Medicine 2014, 14:16  doi:10.1186/1472-6882-14-16

Published: 13 January 2014

Abstract

Background

The doctor-patient encounter (DPE) and associated patient expectations are potential confounders in open-label randomized trials of treatment efficacy. It is therefore important to evaluate the effects of the DPE on study outcomes.

Methods

Four hundred participants with chronic low back pain (LBP) were randomized to four dose groups: 0, 6, 12, or 18 sessions of spinal manipulation from a chiropractor. Participants were treated three times per week for six weeks. They received light massage control at visits when manipulation was not scheduled. Treating chiropractors were instructed to have equal enthusiasm for both interventions. A path analysis was conducted to determine the effects of dose, patient expectations of treatment success, and DPE on LBP intensity (100-point scale) at the end of care (6 weeks) and primary endpoint (12 weeks). Direct, indirect, and total standardized effects (βtotal) were computed. Expectations and DPE were evaluated on Likert scales. The DPE was assessed as patient-rated perception of chiropractor enthusiasm, confidence, comfort with care, and time spent.

Results

The DPE was successfully balanced across groups, as were baseline expectations. The principal finding was that the magnitude of the effects of DPE on LBP at 6 and 12 weeks (|β|total = 0.22 and 0.15, p < .05) were comparable to the effects of dose of manipulation at those times (|β|total = 0.11 and 0.12, p < .05). In addition, baseline expectations had no notable effect on follow-up LBP. Subsequent expectations were affected by LBP, DPE, and dose (p < .05).

Conclusions

The DPE can have a relatively important effect on outcomes in open-label randomized trials of treatment efficacy. Therefore, attempts should be made to balance the DPE across treatment groups and report degree of success in study publications. We balanced the DPE across groups with minimal training of treatment providers.

Trial registration

ClinicalTrials.gov NCT00376350

Keywords:
Statistical model; Chronic low back pain; Spinal manipulation; Chiropractic; Randomized controlled trial; Doctor-patient interaction; Expectations