Interdisciplinary Practice Models for Older Adults With Back Pain

A Qualitative Evaluation

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; Robert B. Wallace, MD, MS


Gerontologist. 2018;58(2):376-387. 

In This Article

Abstract and Introduction


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.


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.