On the Job Training

By Sienna Shoup

In the wake of the national opioid crisis in the United States, primary care clinics are beginning to recognize the importance of non-pharmacologic care for patients with common musculoskeletal conditions such as low back pain. Integrating chiropractic care into healthcare clinics is an important step toward offering these more holistic approaches to pain management. However, clinics in lower-income neighborhoods often face financial and other barriers to offering this type of care. Partnerships between community health centers and local chiropractors in the communities is another option for increasing access to chiropractic care.

ACA member Eric Roseen, DC, MSc (pictured), recently received a five year $802,000 K23 Career Development Award from the National Center for Complementary and Integrative Health (NCCIH). This funding will support Dr. Roseen’s career development and research goal to develop strategies to improve availability of non-pharmacologic treatments in primary care settings.

Dr. Roseen is a chiropractor in Boston and an assistant professor of family medicine at the Boston University School of Medicine / Boston Medical Center. He currently investigates the management of common musculoskeletal conditions and has been involved with multiple clinical trials based at Boston Medical Center and in the Boston University Program for Integrative Medicine and Health Disparities. This new award will allow Dr. Roseen to develop strategies that help primary care clinics in low-income communities overcome obstacles to offering chiropractic care and other nonpharmacologic treatments to patients with musculoskeletal pain.

The lack of non-pharmacologic healthcare accessibility is familiar to Dr. Roseen, who was first exposed to the issue while working at a health clinic for lower-income adults in Portland, Ore. After moving to Boston, he volunteered at Rosie’s Place, a shelter for low-income women and those experiencing homelessness. Through those experiences Dr. Roseen saw first-hand that for many low-income adults it is easier to get access to pharmacologic pain management such as opioids than it is to get access to integrative therapies such as chiropractic care.

The American College of Physicians released a guideline in 2017 for low back pain management in primary care settings that recommends non-pharmacologic treatments before turning to higher risk options, including prescription opioids and surgery. The recommended treatments (e.g., spinal manipulation, heat, massage and acupuncture) are often unavailable or difficult to access in underserved communities. Through his research, Dr. Roseen is studying ways to help chiropractic care become more accessible for patients in such communities around Boston, in the hopes of treating pain while reducing reliance on pain medications.

“The lack of chiropractic care availability in low-income communities is an understudied area,” notes Dr. Roseen. “Community health centers are working with limited resources as they move forward in their goals to increase access for patients in these communities.”

Bringing Attention to an Understudied Problem

Dr. Roseen plans to speak with patients, primary care providers, clinic administrators, insurance companies, policymakers and other community stakeholders in low-income neighborhoods to identify and more comprehensively understand the barriers that prevent people from accessing conservative pain management care. He will try to answer questions such as:

• Is the treatment covered by insurance?
• Is it perceived as expensive?
• What are other perceptions of chiropractic care by providers and patients in these communities?
• Are these stakeholders aware of chiropractic care as an option for low back pain?
• Are there enough doctors of chiropractic (DCs) in these communities to meet the need?

Following that, he will create a multi-level implementation strategy addressing identified barriers to improve access to chiropractic care in three community health centers in the Boston area. By educating patients and providers, and developing resources within healthcare systems to make referrals easier, Dr. Roseen believes collaborative care between primary care providers and DCs in underserved communities can be improved.

The plan is to focus on health centers that do not currently have chiropractors available and determine how they can partner with chiropractors who already practice in the community. To enhance research capabilities, Dr. Roseen is obtaining advanced training in an emerging field called implementation science, where he hopes to use strategies to implement underutilized resources that will help address the problem. To gain expertise in this area, he is currently participating in the Training Institute on Dissemination and Implementation Research in Health (TIDIRH), an intensive and highly-competitive program funded by NIH’s Office of Behavioral and Social Sciences.

Over the duration of the project, Dr. Roseen will work closely with his mentors Robert Saper, MD, MPH, David Felson, MD, MPH, and Roni Evans, DC, PhD in Massachusetts and Minnesota. In addition to addressing the accessibility obstacles and highlighting an understudied issue, the funding will enable him to expand his knowledge and expertise in the fields of epidemiology, biostatistics, qualitative methods, health services research and implementation science.

Advice for Those with Research Aspirations

For those who may be looking to join the research field, Dr. Roseen offers some advice: He says that finding a mentor who will share knowledge, experience and skills is important. He also recommends talking with someone who has previous or current NIH funding. “This track-record of research support of a potential mentor can be as important as the topic of their research. I found it to be very important to have someone with this experience guide me when I was just getting  started,” he explains. “Research is done in teams, so joining a team that has experience receiving grants and publishing papers is one practical way to gain experience. Once you’ve found a mentor or a team to work with, NIH has a number of funding mechanisms to support your training and development. My research career started through support form an Administrative Supplement for Complementary Health Practitioner Research Experiences from NIH in 2014.”

In respect to training grants, the NIH/NCCIH evaluates the proposed research project, the background of the candidate, their mentorship team, and resources at the academic institution from which the applicant is applying. Applicants must also create a training plan for obtaining advanced expertise in areas and methods that are relevant to their project. More information about NIH/NCCIH Training and Development Awards is available online at https://nccih.nih.gov/training/opportunities.

Dr. Roseen has been an American Chiropractic Association (ACA) member for 12 years. As a student at the University of Western States, he served as the Student American Chiropractic Association (SACA) National Vice Chair, forming the Integrative Health Committee, and is currently a member of ACA’s Clinical Guideline Review Task Force.

Sienna Shoup is an associate in the ACA Communications Department.