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Hohenschurz-Schmidt DJ, Cherkin D, Rice AS, Dworkin RH, Turk DC, McDermott MP, Bair MJ, DeBar LL, Edwards RR, Farrar JT, Kerns RD, Markman JD, Rowbotham MC, Sherman KJ, Wasan AD, Cowan P, Desjardins P, Ferguson M, Freeman R, Gewandter JS, Gilron I, Grol-Prokopczyk H, Hertz SH, Iyengar S, Kamp C, Karp BI, Kleykamp BA, Loeser JD, Mackey S, Malamut R, McNicol E, Patel KV, Sandbrink F, Schmader K, Simon L, Steiner DJ, Veasley C, Vollert J. Research objectives and general considerations for pragmatic clinical trials of pain treatments: IMMPACT statement. Pain 2023; 164:1457-1472. [PMID: 36943273 PMCID: PMC10281023 DOI: 10.1097/j.pain.0000000000002888] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 01/09/2023] [Accepted: 01/12/2023] [Indexed: 03/23/2023]
Abstract
ABSTRACT Many questions regarding the clinical management of people experiencing pain and related health policy decision-making may best be answered by pragmatic controlled trials. To generate clinically relevant and widely applicable findings, such trials aim to reproduce elements of routine clinical care or are embedded within clinical workflows. In contrast with traditional efficacy trials, pragmatic trials are intended to address a broader set of external validity questions critical for stakeholders (clinicians, healthcare leaders, policymakers, insurers, and patients) in considering the adoption and use of evidence-based treatments in daily clinical care. This article summarizes methodological considerations for pragmatic trials, mainly concerning methods of fundamental importance to the internal validity of trials. The relationship between these methods and common pragmatic trials methods and goals is considered, recognizing that the resulting trial designs are highly dependent on the specific research question under investigation. The basis of this statement was an Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT) systematic review of methods and a consensus meeting. The meeting was organized by the Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks (ACTTION) public-private partnership. The consensus process was informed by expert presentations, panel and consensus discussions, and a preparatory systematic review. In the context of pragmatic trials of pain treatments, we present fundamental considerations for the planning phase of pragmatic trials, including the specification of trial objectives, the selection of adequate designs, and methods to enhance internal validity while maintaining the ability to answer pragmatic research questions.
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Affiliation(s)
- David J. Hohenschurz-Schmidt
- Pain Research, Department of Surgery & Cancer, Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Dan Cherkin
- Department of Family Medicine, University of Washington and Kaiser Permanente Washington Health Research Institute, Seattle, WA, United States
| | - Andrew S.C. Rice
- Pain Research, Department of Surgery & Cancer, Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Robert H. Dworkin
- Department of Anesthesiology and Perioperative Medicine, University of Rochester Medical Center, Rochester, NY, United States
| | - Dennis C. Turk
- Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, United States
| | - Michael P. McDermott
- Department of Biostatistics and Computational Biology, University of Rochester, Rochester, NY, United States
| | - Matthew J. Bair
- VA Center for Health Information and Communication, Regenstrief Institute, and Indiana University School of Medicine, Indianapolis, IN, United States
| | - Lynn L. DeBar
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, United States
| | | | - John T. Farrar
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, PA, United States
| | - Robert D. Kerns
- Departments of Psychiatry, Neurology and Psychology, Yale University, New Haven, CT, United States
| | - John D. Markman
- Neuromedicine Pain Management and Translational Pain Research, University of Rochester School of Medicine and Dentistry, Rochester, NY, United States
| | - Michael C. Rowbotham
- Department of Anesthesia, University of California San Francisco School of Medicine, San Francisco, CA, United States
| | - Karen J. Sherman
- Kaiser Permanente Washington Health Research Institute and Department of Epidemiology, University of Washington, Seattle WA, United States
| | - Ajay D. Wasan
- Departments of Anesthesiology & Perioperative Medicine, and Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Penney Cowan
- American Chronic Pain Association, Rocklin, CA, United States
| | - Paul Desjardins
- Department of Diagnostic Sciences, School of Dental Medicine, Rutgers University, Newark, NJ, United States
| | - McKenzie Ferguson
- Department of Pharmacy Practice, Southern Illinois University Edwardsville, Edwardsville, IL, United States
| | - Roy Freeman
- Department of Neurology, Harvard Medical School, Boston, MA, United States
| | - Jennifer S. Gewandter
- Department of Anesthesiology and Perioperative, University of Rochester, Rochester, NY, United States
| | - Ian Gilron
- Departments of Anesthesiology & Perioperative Medicine, Biomedical & Molecular Sciences, Centre for Neuroscience Studies, and School of Policy Studies, Queen's University, Kingston, ON, Canada
| | - Hanna Grol-Prokopczyk
- Department of Sociology, University at Buffalo, State University of New York, Buffalo NY, United States
| | - Sharon H. Hertz
- Hertz and Fields Consulting, Inc, Silver Spring, MD, United States
| | | | - Cornelia Kamp
- Center for Health and Technology (CHeT), Clinical Materials Services Unit (CMSU), University of Rochester Medical Center, Rochester, NY, United States
| | | | - Bethea A. Kleykamp
- Department of Anesthesiology and Perioperative Medicine, University of Rochester Medical Center, Rochester, NY, United States
| | - John D. Loeser
- Departments of Neurological Surgery and Anesthesia and Pain Medicine, University of Washington, Seattle, WA, United States
| | - Sean Mackey
- Department of Anesthesiology, Perioperative, and Pain Medicine, Neurosciences and Neurology, Stanford University School of Medicine, Palo Alto, CA, United States
| | | | - Ewan McNicol
- Department of Pharmacy Practice, Massachusetts College of Pharmacy and Health Sciences, Boston, MA, United States
| | - Kushang V. Patel
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, United States
| | - Friedhelm Sandbrink
- Department of Neurology, Washington DC Veterans Affairs Medical Center, Washington, DC, United States
- Department of Neurology, George Washington University, Washington, DC, United States
| | - Kenneth Schmader
- Department of Medicine-Geriatrics, Center for the Study of Aging, Duke University Medical Center, and Geriatrics Research Education and Clinical Center, Durham VA Medical Center, Durham, NC, United States
| | - Lee Simon
- SDG, LLC, Cambridge, MA, United States
| | | | - Christin Veasley
- Chronic Pain Research Alliance, North Kingstown, RI, United States
| | - Jan Vollert
- Pain Research, Department of Surgery and Cancer, Imperial College London, London, United Kingdom
- Division of Neurological Pain Research and Therapy, Department of Neurology, University Hospital of Schleswig-Holstein, Campus Kiel, Germany
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital Muenster, Muenster, Germany
- Neurophysiology, Mannheim Center of Translational Neuroscience (MCTN), Medical Faculty Mannheim, Heidelberg University, Heidelberg, Germany
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Chen JA, Anderson ML, Cherkin DC, Balderson BH, Cook AJ, Sherman KJ, Turner JA. Moderators and Nonspecific Predictors of Treatment Benefits in a Randomized Trial of Mindfulness-Based Stress Reduction vs Cognitive-Behavioral Therapy vs Usual Care for Chronic Low Back Pain. J Pain 2023; 24:282-303. [PMID: 36180008 PMCID: PMC9898119 DOI: 10.1016/j.jpain.2022.09.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Revised: 09/12/2022] [Accepted: 09/15/2022] [Indexed: 02/06/2023]
Abstract
Both mindfulness-based stress reduction (MBSR) and cognitive-behavioral therapy (CBT) are effective for chronic low back pain (CLBP), but little is known regarding who might benefit more from one than the other. Using data from a randomized trial comparing MBSR, CBT, and usual care (UC) for adults aged 20 to 70 years with CLBP (N = 297), we examined baseline characteristics that moderated treatment effects or were associated with improvement regardless of treatment. Outcomes included 8-week function (modified Roland Disability Questionnaire), pain bothersomeness (0-10 numerical rating scale), and depression (Patient Health Questionnaire-8). There were differences in the effects of CBT versus MBSR on pain based on participant gender (P = .03) and baseline depressive symptoms (P = .01), but the only statistically significant moderator after Bonferroni correction was the nonjudging dimension of mindfulness. Scores on this measure moderated the effects of CBT versus MBSR on both function (P = .001) and pain (P = .04). Pain control beliefs (P <.001) and lower anxiety (P < .001) predicted improvement regardless of treatment. Replication of these findings is needed to guide treatment decision-making for CLBP. TRIAL REGISTRATION: The trial and analysis plan were preregistered in ClinicalTrials.gov (Identifier: NCT01467843). PERSPECTIVE: Although few potential moderators and nonspecific predictors of benefits from CBT or MBSR for CLBP were statistically significant after adjustment for multiple comparisons, these findings suggest potentially fruitful directions for confirmatory research while providing reassurance that patients could reasonably expect to benefit from either treatment.
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Affiliation(s)
- Jessica A Chen
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, Washington; Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Healthcare System, Seattle, Washington.
| | - Melissa L Anderson
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | - Daniel C Cherkin
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | | | - Andrea J Cook
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | - Karen J Sherman
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | - Judith A Turner
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, Washington; Department of Rehabilitation Medicine, University of Washington School of Medicine, Seattle, Washington
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Roseen EJ, Pinheiro A, Lemaster CM, Plumb D, Wang S, Elwy AR, Streeter CC, Lynch S, Groessl E, Sherman KJ, Weinberg J, Saper RB. Yoga Versus Education for Veterans with Chronic Low Back Pain: a Randomized Controlled Trial. J Gen Intern Med 2023:10.1007/s11606-023-08037-2. [PMID: 36650329 PMCID: PMC10361953 DOI: 10.1007/s11606-023-08037-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Accepted: 12/30/2022] [Indexed: 01/19/2023]
Abstract
BACKGROUND Yoga is effective for chronic low back pain (cLBP) in civilians but understudied among Veterans. OBJECTIVE Determine whether yoga is more effective than an educational book for improving disability and pain among Veterans with cLBP. DESIGN, SETTING, AND PARTICIPANTS Veterans diagnosed with cLBP at a VA medical center enrolled in a randomized controlled trial from March to December of 2015. INTERVENTIONS Twelve weekly hatha yoga classes or education using The Back Pain Helpbook. MEASURES Co-primary outcomes were changes from baseline at 12 weeks in back-related disability on the modified Roland Morris Disability Questionnaire and pain on the Defense & Veterans Pain Rating Scale. Secondary outcomes were global improvement, patient satisfaction, pain medication use, and post-traumatic stress symptoms. An intention-to-treat approach was used in primary analyses. RESULTS One hundred twenty Veterans (mean age, 55.5 [SD = 16.9]; 11 [9%] women; mean number of chronic conditions, 5.5) were randomized to yoga (n = 62) and education (n = 58). At 12 weeks, reductions in back-related disability in yoga (mean difference [MD] = - 3.50, 95% CI: - 5.03, - 1.97) were not significantly different than education (MD = - 2.55, 95% CI: - 4.10, - 0.99; between-group difference: - 0.95 [95% CI: - 3.14, 1.23], p = 0.39). For pain, there was no significant difference between yoga (MD = - 1.01, 95% CI: - 1.67, - 0.35) and education (MD = - 0.81, 95% CI: - 1.36, - 0.27; between-group difference: - 0.20, 95% CI: - 1.06, 0.66, p = 0.65). More yoga than education participants reported being very much or extremely improved (39% vs 19%, OR = 3.71, 95% CI: 1.37, 10.02, p = 0.01) and very satisfied with treatment (60% vs 31%, OR = 4.28, 95% CI: 1.70, 10.77, p = 0.002). No differences in pain medication use or post-traumatic stress symptoms were observed at 12 weeks. No serious adverse events were reported in either group. CONCLUSION Twelve weekly yoga classes were not more effective than an education intervention for improving pain or disability outcomes among mostly older male Veterans with cLBP and multiple comorbid health conditions. GOV IDENTIFIER NCT02224183.
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Affiliation(s)
- Eric J Roseen
- Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine and Boston Medical Center, Boston University Medical Campus, 801 Massachusetts Ave, Second Floor, Boston, MA, 02131, USA. .,Department of Physical Medicine and Rehabilitation and New England Geriatric Research Education and Clinical Center, VA Boston Healthcare System, Boston, MA, USA.
| | - Adlin Pinheiro
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA
| | - Chelsey M Lemaster
- Department of Family Medicine, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA.,Department of Surgery, University of Arizona College of Medicine, Tucson, AZ, USA
| | - Dorothy Plumb
- Department of Family Medicine, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
| | - Shihwe Wang
- Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA, USA
| | - A Rani Elwy
- Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA, USA.,Department of Psychiatry and Human Behavior, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Chris C Streeter
- Department of Psychiatry and Neurology, Boston University School of Medicine, Boston, MA, USA.,Department of Psychiatry, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA, USA
| | - Susan Lynch
- There & Back Again, Inc., Wakefield, MA, USA
| | - Erik Groessl
- Herbert Wertheim School of Public Health, University of California San Diego and VA San Diego Health Care System, San Diego, CA, USA
| | - Karen J Sherman
- Kaiser Permanente Washington Health Research Institute, Seattle WA and Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - Janice Weinberg
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA
| | - Robert B Saper
- Department of Wellness and Preventive Medicine, Cleveland Clinic, Cleveland, OH, USA
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Joyce C, Kelly KC, Gurnani S, Sherman KJ, Roseen EJ, Saper RB. "In Class We Were All One." A Qualitative Exploration of Yoga and Educational Interventions for Predominantly Low-Income and Minority Adults with Chronic Low Back Pain. J Integr Complement Med 2022; 28:870-877. [PMID: 35914101 PMCID: PMC9835301 DOI: 10.1089/jicm.2022.0557] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Introduction: Chronic low back pain (cLBP) can be physically and psychologically debilitating and disproportionally afflicts vulnerable populations. Yoga and education are increasingly common interventions for cLBP yet are understudied in low-income and minority adults. The objective of this qualitative study was to understand the yoga and self-care experience of adults with cLBP from urban, underserved communities who were enrolled in a randomized controlled trial that included these treatments. Methods: We interviewed 26 (18 yoga and 8 education) participants. Interviews were transcribed verbatim and analyzed using thematic analysis with codes developed inductively from data. Results: Participants from both yoga and education groups reported initial apprehension and ambivalence toward their respective intervention. However, physical and psychological benefits were noted, mainly in the form of improved pain self-management. Communal support and camaraderie reported by the yoga group was absent and desired by education participants. Social factors impeding the ability to sustain yoga practice included transportation, access, and cost, whereas education participants described literacy and language challenges and a general lack of motivation to read the book. Conclusion: Yoga and education are viable treatments for adults with cLBP who live in underserved neighborhoods. However, social stigma and socioeconomic barriers may hinder their uptake. Communal support in group-based nonpharmacological treatments is valued and may contribute to participation and clinical outcomes. ClinicalTrials.gov Identifier: NCT01343927.
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Affiliation(s)
- Christopher Joyce
- School of Physical Therapy, Massachusetts College of Pharmacy and Health Sciences, Worcester, MA, USA
| | | | | | - Karen J. Sherman
- Kaiser Permanente Washington Health Research Institute, Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - Eric J. Roseen
- Department of Family Medicine, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
- Department of Rehabilitation Science, MGH Institute of Health Professions, Boston, MA, USA
| | - Robert B. Saper
- Department of Wellness and Preventive Medicine, Cleveland Clinic, Cleveland, OH, USA
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Gold LS, Cody RF, Tan WK, Marcum ZA, Meier EN, Sherman KJ, James KT, Griffith B, Avins AL, Kallmes DF, Suri P, Friedly JL, Heagerty PJ, Deyo RA, Luetmer PH, Rundell SD, Haynor DR, Jarvik JG. Osteoporosis identification among previously undiagnosed individuals with vertebral fractures. Osteoporos Int 2022; 33:1925-1935. [PMID: 35654855 PMCID: PMC10120403 DOI: 10.1007/s00198-022-06450-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 05/22/2022] [Indexed: 11/28/2022]
Abstract
UNLABELLED Because osteoporosis is under-recognized in patients with vertebral fractures, we evaluated characteristics associated with osteoporosis identification. Most patients with vertebral fractures did not receive evaluation or treatment for osteoporosis. Black, younger, and male participants were particularly unlikely to have had recognized osteoporosis, which could increase their risk of negative outcomes. INTRODUCTION Vertebral fractures may be identified on imaging but fail to prompt evaluation for osteoporosis. Our objective was to evaluate characteristics associated with clinical osteoporosis recognition in patients who had vertebral fractures detected on their thoracolumbar spine imaging reports. METHODS We prospectively identified individuals who received imaging of the lower spine at primary care clinics in 4 large healthcare systems who were eligible for osteoporosis screening and lacked indications of osteoporosis diagnoses or treatments in the prior year. We evaluated characteristics of participants with identified vertebral fractures that were associated with recognition of osteoporosis (diagnosis code in the health record; receipt of bone mineral density scans; and/or prescriptions for anti-osteoporotic medications). We used mixed models to estimate adjusted odds ratios (ORs) and 95% confidence intervals (95% CIs). RESULTS A total of 114,005 participants (47% female; mean age 65 (interquartile range: 57-72) years) were evaluated. Of the 8579 (7%) participants with vertebral fractures identified, 3784 (44%) had recognition of osteoporosis within the subsequent year. In adjusted regressions, Black participants (OR (95% CI): 0.74 (0.57, 0.97)), younger participants (age 50-60: 0.48 (0.42, 0.54); age 61-64: 0.70 (0.60, 0.81)), and males (0.39 (0.35, 0.43)) were less likely to have recognized osteoporosis compared to white participants, adults aged 65 + years, or females. CONCLUSION Individuals with identified vertebral fractures commonly did not have recognition of osteoporosis within a year, particularly those who were younger, Black, or male. Providers and healthcare systems should consider efforts to improve evaluation of osteoporosis in patients with vertebral fractures.
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Affiliation(s)
- L S Gold
- Department of Radiology, School of Medicine, University of Washington, 4333 Brooklyn Ave NE Box 359558, Seattle, WA, 98195-9558, USA.
- Clinical Learning, Evidence, and Research Center, University of Washington, Seattle, WA, USA.
| | - R F Cody
- Department of Radiology, School of Medicine, University of Washington, 4333 Brooklyn Ave NE Box 359558, Seattle, WA, 98195-9558, USA
| | - W K Tan
- Clinical Learning, Evidence, and Research Center, University of Washington, Seattle, WA, USA
- Department of Biostatistics, University of Washington, Seattle, WA, USA
- Flatiron Health, Inc, New York, NY, USA
| | - Z A Marcum
- Department of Pharmacy, School of Pharmacy, University of Washington, Seattle, WA, USA
| | - E N Meier
- Department of Biostatistics, University of Washington, Seattle, WA, USA
| | - K J Sherman
- Kaiser Permanente Washington, Seattle, WA, USA
| | - K T James
- Department of Radiology, School of Medicine, University of Washington, 4333 Brooklyn Ave NE Box 359558, Seattle, WA, 98195-9558, USA
- Clinical Learning, Evidence, and Research Center, University of Washington, Seattle, WA, USA
| | - B Griffith
- Department of Radiology, Henry Ford Hospital, Detroit, MI, USA
| | - A L Avins
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - D F Kallmes
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - P Suri
- Clinical Learning, Evidence, and Research Center, University of Washington, Seattle, WA, USA
- Rehabilitation Care Services, VA Puget Sound Health Care System, Seattle, WA, USA
| | - J L Friedly
- Clinical Learning, Evidence, and Research Center, University of Washington, Seattle, WA, USA
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA, USA
| | - P J Heagerty
- Clinical Learning, Evidence, and Research Center, University of Washington, Seattle, WA, USA
- Department of Biostatistics, University of Washington, Seattle, WA, USA
| | - R A Deyo
- Departments of Family Medicine and Internal Medicine, Oregon Health & Science University, Portland, OR, USA
| | - P H Luetmer
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - S D Rundell
- Clinical Learning, Evidence, and Research Center, University of Washington, Seattle, WA, USA
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA, USA
| | - D R Haynor
- Department of Radiology, School of Medicine, University of Washington, 4333 Brooklyn Ave NE Box 359558, Seattle, WA, 98195-9558, USA
| | - J G Jarvik
- Department of Radiology, School of Medicine, University of Washington, 4333 Brooklyn Ave NE Box 359558, Seattle, WA, 98195-9558, USA
- Clinical Learning, Evidence, and Research Center, University of Washington, Seattle, WA, USA
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Jones SMW, Sherman KJ, Bermet Z, Palazzo LG, Lewis CC. An experimental study to inform adoption of mindfulness-based stress reduction in chronic low back pain. Implement Sci Commun 2022; 3:87. [PMID: 35933438 PMCID: PMC9356436 DOI: 10.1186/s43058-022-00335-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 07/29/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Chronic low back pain is a common and sometimes disabling condition, and mindfulness-based stress reduction is recommended as a first line of therapy. This study tested whether different descriptions of mindfulness training altered based on influential intervention characteristics increased adoption intentions. METHODS People with chronic low back pain (n = 452) were randomized to review one of four mindfulness training descriptions in an online survey using a 2 × 2 factorial design. The first factor was evidence strength and quality with relative advantage (ER). The second factor was adaptability, trialability, complexity, and design quality and packaging (AD). Each factor had two levels: a description of standardized mindfulness training that described each intervention characteristic and a patient-centered description emphasizing flexibility and patient testimonials. The primary outcomes were intentions to try mindfulness training and practice mindfulness at home. Using structural equation modeling with a bootstrapped distribution, we tested six mediators, three of which are Theory of Planned Behavior predictors of intention-self-efficacy, norms, and attitudes- and the other three are predictors of adoption-feasibility, appropriateness, and acceptability. RESULTS Overall, the mindfulness training descriptions were not associated with an increase in intentions compared to the classic vignette (11/12 p's > 0.05). Most descriptions were unrelated to mediators except the classic ER with patient-centered AD was associated with higher self-efficacy/control and feasibility (p's ≤ 0.05; standardized effect range: 0.111-0.125). Self-efficacy/control (training standardized coefficient: 0.531, home: 0.686), norms (training: 0.303, home: 0.256), and attitudes (training: 0.316, home: 0.293) were all positively associated with intentions to adopt mindfulness training and home practice. Feasibility (training: 0.185; home: 0.293) and acceptability (training: 0.639; home: 0.554) were positively related to intentions to adopt mindfulness training. Appropriateness was related to intentions to adopt home practice (0.187) but not mindfulness training (0.100). None of the indirect effects from experimental group to intentions was significant (all p's > 0.05). CONCLUSIONS Self-efficacy/control and acceptability may be key mediators for increasing patient adoption of mindfulness. Because experimental manipulation did not substantially change intentions to adopt mindfulness, the presentation and delivery of MBSR may need to be tailored to the individual patient's needs rather than a specific format for chronic low back pain.
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Affiliation(s)
- Salene M. W. Jones
- grid.270240.30000 0001 2180 1622Fred Hutchinson Cancer Research Center, 1100 Fairview Ave N, Seattle, WA 98109 USA ,grid.488833.c0000 0004 0615 7519Kaiser Permanente Washington Health Research Institute, Seattle, USA
| | - Karen J. Sherman
- grid.270240.30000 0001 2180 1622Fred Hutchinson Cancer Research Center, 1100 Fairview Ave N, Seattle, WA 98109 USA ,grid.488833.c0000 0004 0615 7519Kaiser Permanente Washington Health Research Institute, Seattle, USA
| | - Zoe Bermet
- grid.270240.30000 0001 2180 1622Fred Hutchinson Cancer Research Center, 1100 Fairview Ave N, Seattle, WA 98109 USA ,grid.488833.c0000 0004 0615 7519Kaiser Permanente Washington Health Research Institute, Seattle, USA
| | - Lorella G. Palazzo
- grid.270240.30000 0001 2180 1622Fred Hutchinson Cancer Research Center, 1100 Fairview Ave N, Seattle, WA 98109 USA ,grid.488833.c0000 0004 0615 7519Kaiser Permanente Washington Health Research Institute, Seattle, USA
| | - Cara C. Lewis
- grid.270240.30000 0001 2180 1622Fred Hutchinson Cancer Research Center, 1100 Fairview Ave N, Seattle, WA 98109 USA ,grid.488833.c0000 0004 0615 7519Kaiser Permanente Washington Health Research Institute, Seattle, USA
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7
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Sherman KJ, Wellman RD, Jones SM, Lewis CC. Interest in Mindfulness Training for Chronic Low-Back Pain: Results from a Vignette-driven, Web-based Survey of Patients. J Integr Complement Med 2022; 28:484-496. [PMID: 35352963 PMCID: PMC9232229 DOI: 10.1089/jicm.2021.0427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Objectives: Mindfulness-based stress reduction (MBSR) has been found effective for improving chronic low-back pain (cLBP). However, little data exist regarding how attractive this technique is to Americans as a therapy for cLBP. Design: Survey of randomly selected persons with cLBP. Settings/Location: Respondents were recruited from Kaiser Permanente Washington and one-time surveys were completed online. Patients: Adults 18-80 years of age with cLBP. Surveys: The study was conducted between December 2019 and August 2020. Outcome measures: The survey described an evidence-based classic MBSR course and then asked respondents about their sociodemographic characteristics, their current back pain, previous back pain treatments, behavioral risk factors for back pain, and four outcomes indicative of intention to engage in MBSR. Results: Four-hundred fifty-seven respondents completed the survey. Respondents were primarily women, white, educated, and with back pain for more than 5 years. About half had previously used a mind-body therapy for their pain. Overall, they reported moderate to high intention to try mindfulness classes and practice at home (median of 5 with 50% of the observations between 4 and 6, and 5.7, 50% of the observations between 4.3 and 6.3, respectively, on a 7-point scale). They reported a willingness to spend a median of 3 h/week learning mindfulness and 3.5 h/week practicing mindfulness techniques (for both outcomes, 50% of the respondents reported between 2 and 5 h). Few patient characteristics predicted intention to engage in MBSR, with no variable predicting all outcomes. The magnitude of the effect associated with significant predictors was small. Conclusion: Classic MBSR appealed to many survey respondents, in that they reported high interest in learning MBSR and intention to practice at home. The amount of time they reported being willing to spend learning MBSR and practicing at home is consistent with the time commitment in the original course.
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Affiliation(s)
- Karen J. Sherman
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington, USA.,Department of Epidemiology, University of Washington, Seattle, Washington, USA.,Address correspondence to: Karen J. Sherman, PhD, Kaiser Permanente Washington Health Research Institute, 1730 Minor Avenue, Suite 1600, Seattle, WA 98101, USA
| | - Robert D. Wellman
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington, USA
| | | | - Cara C. Lewis
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington, USA
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8
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Selfe TK, Montgomery C, Klatt M, Wen S, Sherman KJ, Innes KE. An Exploratory Randomized Controlled Trial of a 12-Week Yoga Versus Educational Film Program for the Management of Restless Legs Syndrome: Feasibility and Acceptability. Journal of Integrative and Complementary Medicine 2022; 28:309-319. [PMID: 35426733 PMCID: PMC9051873 DOI: 10.1089/jicm.2021.0182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Objectives: The primary objectives of this pilot trial were to assess the study feasibility and acceptability of the 12-week yoga and educational film programs for the management of restless legs syndrome (RLS) in preparation for a future randomized controlled trial (RCT). Materials and Methods: This pilot, parallel-arm, randomized feasibility trial was conducted at two sites, Morgantown, WV and Columbus, OH. Yoga group participants attended 75-min Iyengar yoga classes, twice weekly for 4 weeks, then once a week for 8 weeks (16 total classes), and completed a 30-min homework routine on nonclass days. Educational film group participants attended once weekly, 75-min classes (12 total classes), which included information on RLS and other sleep disorders, RLS management including sleep hygiene practices, and complementary therapies. Feasibility and acceptability outcomes included program satisfaction and recruitment, retention, and adherence rates. In addition, participants were asked their preferences regarding three yoga class schedule scenarios for a future study. Attendance, yoga, and treatment logs were collected weekly. Program evaluation and yoga scheduling questionnaires were collected at week 12. Results: Forty-one adults with moderate to severe RLS were randomized to a 12-week yoga (n = 19) or educational film (n = 22) program. Thirty participants (73%) completed the program. Yoga and education group participants attended an average of 13.0 ± 0.84 (81%) and 10.3 ± 0.3 classes (85%), respectively. Participants from both groups indicated satisfaction with the study. All yoga group respondents to the program evaluation reported they would likely (n = 6) or very likely (n = 7) continue yoga practice; 86.7% of education group respondents (13 of 15) indicated that they were likely (n = 7) or very likely (n = 6) to make lasting changes based on what they had learned. The preferred schedule for a future study was a 16-week study with once-weekly yoga classes. Conclusions: The findings of this study suggest that a larger RCT comparing yoga with an educational film group for the management of RLS is feasible. Trial registration: Clinicaltrials.gov: NCT03570515; 02/01/2017.
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Affiliation(s)
- Terry Kit Selfe
- Academic Research Consulting & Services, Health Science Center Libraries, University of Florida, Gainesville, FL, USA
| | - Caitlin Montgomery
- Department of Epidemiology, School of Public Health, West Virginia University, Morgantown, WV, USA
| | - Maryanna Klatt
- Department of Family and Community Medicine, College of Medicine, The Ohio State University, Columbus, OH, USA
| | - Sijin Wen
- Department of Biostatistics, School of Public Health, West Virginia University, Morgantown, WV, USA
| | - Karen J. Sherman
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - Kim E. Innes
- Department of Epidemiology, School of Public Health, West Virginia University, Morgantown, WV, USA
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9
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Zhang YQ, Jiao RM, Witt CM, Lao L, Liu JP, Thabane L, Sherman KJ, Cummings M, Richards DP, Kim EKA, Kim TH, Lee MS, Wechsler ME, Brinkhaus B, Mao JJ, Smith CA, Gang WJ, Liu BY, Liu ZS, Liu Y, Zheng H, Wu JN, Carrasco-Labra A, Bhandari M, Devereaux PJ, Jing XH, Guyatt G. How to design high quality acupuncture trials-a consensus informed by evidence. BMJ 2022; 376:e067476. [PMID: 35354583 PMCID: PMC8965655 DOI: 10.1136/bmj-2021-067476] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
An international panel including patients, clinicians, researchers, acupuncture and surgery trialists, statisticians, and experts in clinical epidemiology and methodology have developed new guidance for randomised controlled trials in acupuncture. It addresses the most prevalent and critical concerns of current acupuncture trials and will help funding agencies, trial registers, and journal editors to evaluate the relevance, importance, and quality of submitted trial proposals and completed trials
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Affiliation(s)
- Yu-Qing Zhang
- Institute of Acupuncture and Moxibustion, China Academy of Chinese Medical Sciences, Beijing, China
- CEBIM (Center for Evidence-Based Integrative Medicine)-Clarity Collaboration, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Nottingham Ningbo GRADE Centre, University of Nottingham Ningbo, China
| | - Rui-Min Jiao
- Institute of Acupuncture and Moxibustion, China Academy of Chinese Medical Sciences, Beijing, China
- China Center for Evidence-Based Traditional Chinese Medicine, China Academy of Chinese Medical Sciences, Beijing, China
| | - Claudia M Witt
- Institute for Complementary and Integrative Medicine, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Lixing Lao
- Virginia University of Integrative Medicine, Fairfax, VA, USA
| | - Jian-Ping Liu
- Center for Evidence-Based Chinese Medicine, Beijing University of Chinese Medicine, Beijing, China
- Institute for Excellence in Evidence-Based Chinese Medicine, Beijing University of Chinese Medicine, Beijing, China
| | - Lehana Thabane
- Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Karen J Sherman
- Kaiser Permanente Washington Health Research Institute, Seattle WA, USA
- Department of Epidemiology, University of Washington, Seattle WA, USA
| | | | - Dawn P Richards
- Patient and Public Engagement, Clinical Trials Ontario, Toronto, ON, Canada
| | - Eun-Kyung Anna Kim
- Department of Western Medicine, Virginia University of Integrative Medicine, Fairfax, VA, USA
| | - Tae-Hun Kim
- Korean Medicine Clinical Trial Center, Seoul, Republic of Korea
- Korean Medicine Hospital, Seoul, Republic of Korea
- Kyung Hee University, Seoul, Republic of Korea
| | - Myeong Soo Lee
- Clinical Medicine Division, Korea Institute of Oriental Medicine, Daejeon, Republic of Korea
- Korean Convergence Medicine, University of Science and Technology, Daejeon, Republic of Korea
| | | | - Benno Brinkhaus
- Institute of Social Medicine, Epidemiology and Health Economics, Charité Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Jun J Mao
- Integrative Medicine Service, Memorial Sloan Kettering Cancer Center, Bendheim Integrative Medicine Center, New York, NY USA
| | - Caroline A Smith
- Translational Health Research Institute, Western Sydney University, Penrith, New South Wales, Australia
| | - Wei-Juan Gang
- Institute of Acupuncture and Moxibustion, China Academy of Chinese Medical Sciences, Beijing, China
- China Center for Evidence-Based Traditional Chinese Medicine, China Academy of Chinese Medical Sciences, Beijing, China
| | - Bao-Yan Liu
- China Academy of Chinese Medical Sciences, Beijing, China
| | - Zhi-Shun Liu
- Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Yan Liu
- Key Laboratory of Chinese Internal Medicine of Ministry of Education, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Hui Zheng
- School of Acupuncture-Moxibustion and Tuina/The Third Affiliated Hospital, Chengdu University of Traditional Chinese Medicine, Sichuan, China
| | - Jia-Ni Wu
- Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Alonso Carrasco-Labra
- Center for Integrative Global Oral Health, School of Dental Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Mohit Bhandari
- Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Philip J Devereaux
- Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Xiang-Hong Jing
- Institute of Acupuncture and Moxibustion, China Academy of Chinese Medical Sciences, Beijing, China
- China Center for Evidence-Based Traditional Chinese Medicine, China Academy of Chinese Medical Sciences, Beijing, China
| | - Gordon Guyatt
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
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10
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Jones SMW, Sherman KJ, Bermet Z, Palazzo LG, Lewis CC. Theory of Planned Behavior and Mindfulness Intentions in Chronic Low Back Pain. Mindfulness (N Y) 2022; 13:3145-3152. [PMID: 36408120 PMCID: PMC9648996 DOI: 10.1007/s12671-022-02022-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/01/2022] [Indexed: 11/12/2022]
Abstract
Objectives Theory of planned of behavior (TPB) constructs have been linked to health behavior intentions. Intentions to try mindfulness-based stress reduction (MBSR), a first-line therapy for chronic low back pain (cLBP), have been less studied. This study aimed to identify which TPB constructs could inform strategies to improve adoption of MBSR. Methods People with cLBP (n = 457) read a description of MBSR then completed survey items assessing TPB constructs: attitudes, norms, self-efficacy, perceived control, and intentions to try MBSR training. Results Structural equation modeling showed self-efficacy/control (coefficient: 0.564), norms (0.245), and attitudes (0.131) were all positively associated with intentions to try mindfulness trainings. Conclusions Results suggest self-efficacy/control may be the most strongly related TPB construct with intentions to try MBSR. Dissemination of MBSR for cLBP could focus on adapting the intervention to increase accessibility and improving available resources to overcome logistical barriers (online formats, drop-in classes). Supplementary Information The online version contains supplementary material available at 10.1007/s12671-022-02022-2.
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Affiliation(s)
- Salene M. W. Jones
- Fred Hutchinson Cancer Research Center, Kaiser Permanente Washington Health Research Institute, University of Washington, 1100 Fairview Ave N, Seattle, WA 98109 USA
| | - Karen J. Sherman
- Fred Hutchinson Cancer Research Center, Kaiser Permanente Washington Health Research Institute, University of Washington, 1100 Fairview Ave N, Seattle, WA 98109 USA
| | - Zoe Bermet
- University of Washington, Seattle, WA USA
| | - Lorella G. Palazzo
- Fred Hutchinson Cancer Research Center, Kaiser Permanente Washington Health Research Institute, University of Washington, 1100 Fairview Ave N, Seattle, WA 98109 USA
| | - Cara C. Lewis
- Fred Hutchinson Cancer Research Center, Kaiser Permanente Washington Health Research Institute, University of Washington, 1100 Fairview Ave N, Seattle, WA 98109 USA
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11
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Marshall A, Joyce CT, Tseng B, Gerlovin H, Yeh GY, Sherman KJ, Saper RB, Roseen EJ. Changes in Pain Self-Efficacy, Coping Skills, and Fear-Avoidance Beliefs in a Randomized Controlled Trial of Yoga, Physical Therapy, and Education for Chronic Low Back Pain. Pain Med 2021; 23:834-843. [PMID: 34698869 PMCID: PMC8992579 DOI: 10.1093/pm/pnab318] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 09/16/2021] [Accepted: 10/03/2021] [Indexed: 11/13/2022]
Abstract
OBJECTIVE We evaluated exercise interventions for cognitive appraisal of chronic low back pain (cLBP) in an underserved population. METHODS We conducted a secondary analysis of the Back to Health Trial, showing yoga to be noninferior to physical therapy (PT) for pain and function outcomes among adults with cLBP (n = 320) recruited from primary care clinics with predominantly low-income patients. Participants were randomized to 12 weeks of yoga, PT, or education. Cognitive appraisal was assessed with the Pain Self-Efficacy Questionnaire (PSEQ), Coping Strategies Questionnaire (CSQ), and Fear-Avoidance Beliefs Questionnaire (FABQ). Using multiple imputation and linear regression, we estimated within- and between-group changes in cognitive appraisal at 12 and 52 weeks, with baseline and the education group as references. RESULTS Participants (mean age = 46 years) were majority female (64%) and majority Black (57%), and 54% had an annual household income <$30,000. All three groups showed improvements in PSEQ (range 0-60) at 12 weeks (yoga, mean difference [MD] = 7.0, 95% confidence interval [CI]: 4.9, 9.0; PT, MD = 6.9, 95% CI: 4.7 to 9.1; and education, MD = 3.4, 95% CI: 0.54 to 6.3), with yoga and PT improvements being clinically meaningful. At 12 weeks, improvements in catastrophizing (CSQ, range 0-36) were largest in the yoga and PT groups (MD = -3.0, 95% CI: -4.4 to -1.6; MD = -2.7, 95% CI: -4.2 to -1.2, respectively). Changes in FABQ were small. No statistically significant between-group differences were observed on PSEQ, CSQ, or FABQ at either time point. Many of the changes observed at 12 weeks were sustained at 52 weeks. CONCLUSION All three interventions were associated with improvements in self-efficacy and catastrophizing among low-income, racially diverse adults with cLBP. TRIAL REGISTRATION ClinicalTrials.gov identifier NCT01343927.
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Affiliation(s)
- Allison Marshall
- Tufts University School of Medicine, Boston, Massachusetts,Department of Family Medicine, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts
| | - Christopher T Joyce
- School of Physical Therapy, Massachusetts College of Pharmacy and Health Sciences, Worcester, Massachusetts
| | - Bryan Tseng
- Department of Family Medicine, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts
| | - Hanna Gerlovin
- Massachusetts Veterans Epidemiology, Research and Information Center (MAVERIC), US Department of Veterans Affairs, VA Boston Healthcare System, Boston, Massachusetts
| | - Gloria Y Yeh
- Division of General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
| | - Karen J Sherman
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington,Department of Epidemiology, University of Washington, Seattle, Washington
| | - Robert B Saper
- Department of Family Medicine, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts
| | - Eric J Roseen
- Department of Family Medicine, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts,Department of Rehabilitation Science, MGH Institute of Health Professions, Boston, Massachusetts, USA,Correspondence to: Eric J. Roseen, DC, MSc, Department of Family Medicine, Boston Medical Center, One Boston Medical Center Place, Dowling 5 South, Boston, MA 02118, USA. Tel: 617.414.4464; Fax: 617.414.3345; E-mail:
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12
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Colgan DD, Green K, Eddy A, Brems C, Sherman KJ, Cramer H, Oken B, Christopher M. Translation, Cross-Cultural Adaptation, and Psychometric Validation of the English Version of the Postural Awareness Scale. Pain Med 2021; 22:2686-2699. [PMID: 34240200 DOI: 10.1093/pm/pnab200] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
PURPOSE The Postural Awareness Scale (PAS) was developed among a sample of German speakers to measure self-reported awareness of body posture. The first aim of this study was to conduct an English translation and cross-cultural adaptation of the PAS. The second aim was to assess psychometric properties of the English version of the PAS. METHODS Forward and backward translations were conducted. The translated scale was then pretested in a small sample of English-speaking adults (n = 30), followed by cognitive interviews. Finally, consensus of the translated scale was achieved among an expert committee (n = 5), resulting in the Postural Awareness Scale-English Version (PAS-E). Psychometric properties of the PAS-E were investigated among a sample of individuals with chronic pain (n = 301) by evaluating factor structure, reliability, and construct validity. Analyses of variance were conducted to calculate differences in PAS-E scores between specific subgroups (pain conditions, sex, and history of mindfulness practice). Linear regression analyses investigated whether the scores on the PAS-E predicted levels of pain, stress, and mood. RESULTS The results obtained from an exploratory factor analysis showed a two-factor solution and were supported by a confirmatory factor analysis. The scale demonstrated good internal consistency and satisfactory construct validity. No significant differences related to sex at birth or pain duration were found. CONCLUSION PAS-E demonstrated good psychometric properties, and therefore, can and should be used both for research and clinical practice.
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Affiliation(s)
- Dana Dharmakaya Colgan
- Neurology Department, Oregon Health & Science University, 3181 Sam Jackson Park Road, Portland, OR, 97239
| | - Kaylie Green
- Pacific University, School of Graduate Psychology, Forest Grove, OR
| | - Ashley Eddy
- Pacific University, School of Graduate Psychology, Forest Grove, OR
| | - Christiane Brems
- Stanford University School of Medicine, Department of Psychiatry and Behavioral Science, Palo Alto, CA
| | - Karen J Sherman
- Kaiser Permanente Washington Health Research Institute, Seattle, WA
| | - Holger Cramer
- University of Duisburg-Essen, Evang. Kliniken Essen-Mitte, Department of Internal and Internal Medicine, Essen, Germany
| | - Barry Oken
- Neurology Department, Oregon Health & Science University, Portland, OR
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13
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Bresnahan BW, Jarvik JG, Meier EN, James KT, Gold LS, Rundell SD, Turner JA, Suri P, Luetmer PH, Friedly JL, Sherman KJ, Heagerty PJ, Kallmes DF, Avins AL, Griffith BD, Kessler LG. Expected Organizational Costs for Inserting Prevalence Information Into Lumbar Spine Imaging Reports. J Am Coll Radiol 2021; 18:1415-1422. [PMID: 34216559 DOI: 10.1016/j.jacr.2021.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 05/27/2021] [Accepted: 06/07/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Modifying physician behavior to more closely align with guideline-based care can be challenging. Few effective strategies resulting in appropriate spine-related health care have been reported. The Lumbar Imaging With Reporting of Epidemiology (LIRE) intervention did not result in reductions in spine care but did in opioid prescriptions written. OBJECTIVES To estimate organizational resource needs and costs associated with implementing a pragmatic, decision support-type intervention that inserted age- and modality-matched prevalence information for common lumbar spine imaging findings, using site-based resource use data from the LIRE trial. RESEARCH DESIGN Time and cost estimation associated with implementing the LIRE intervention in a health organization. SUBJECTS Providers and patients assessed in the LIRE trial. MEASURES Expected personnel costs required to implement the LIRE intervention. RESULTS Annual salaries were converted to daily average per person costs, ranging from $400 to $2,200 per day (base case) for personnel (range: $300-$2,600). Estimated total average cost for implementing LIRE was $5,009 (range: $2,651-$12,020), including conducting pilot testing with providers. Costs associated with a small amount of time for a radiologist (6-12 hours) and imaging-ordering providers (1-8 hours each) account for approximately 75% of the estimated total cost. CONCLUSIONS The process of implementing an intervention for lumbar spine imaging reports containing age- and modality-appropriate epidemiological benchmarks for common imaging findings required radiologists, imaging-ordering providers, information technology specialists, and limited testing and monitoring. The LIRE intervention seems to be a relatively low-cost, evidence-based, complementary tool that can be easily integrated into the reporting of spine imaging.
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Affiliation(s)
- Brian W Bresnahan
- Department of Radiology, University of Washington, Seattle, Washington; Department of Health Services, University of Washington, Seattle, Washington; Comparative Effectiveness, Cost, and Outcomes Research Center, University of Washington, Seattle, Washington.
| | - Jeffrey G Jarvik
- Department of Radiology, University of Washington, Seattle, Washington; Department of Neurological Surgery, University of Washington, Seattle, Washington; Department of Health Services, University of Washington, Seattle, Washington; Comparative Effectiveness, Cost, and Outcomes Research Center, University of Washington, Seattle, Washington
| | - Eric N Meier
- Department of Biostatistics, University of Washington, Seattle, Washington
| | - Kathryn T James
- Department of Radiology, University of Washington, Seattle, Washington; Comparative Effectiveness, Cost, and Outcomes Research Center, University of Washington, Seattle, Washington
| | - Laura S Gold
- Department of Radiology, University of Washington, Seattle, Washington; Comparative Effectiveness, Cost, and Outcomes Research Center, University of Washington, Seattle, Washington
| | - Sean D Rundell
- Comparative Effectiveness, Cost, and Outcomes Research Center, University of Washington, Seattle, Washington; Department of Rehabilitation Medicine, University of Washington, Seattle, Washington
| | - Judith A Turner
- Comparative Effectiveness, Cost, and Outcomes Research Center, University of Washington, Seattle, Washington; Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington; Department of Rehabilitation Medicine, University of Washington, Seattle, Washington
| | - Pradeep Suri
- Rehabilitation Care Services, VA Puget Sound Health Care System, Seattle, Washington; Department of Rehabilitation Medicine, University of Washington, Seattle, Washington
| | | | - Janna L Friedly
- Comparative Effectiveness, Cost, and Outcomes Research Center, University of Washington, Seattle, Washington; Department of Rehabilitation Medicine, University of Washington, Seattle, Washington
| | | | - Patrick J Heagerty
- Department of Biostatistics, University of Washington, Seattle, Washington
| | | | - Andrew L Avins
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Brent D Griffith
- Diagnostic Radiology, Henry Ford Hospital, Henry Ford Health System, Detroit, Michigan
| | - Larry G Kessler
- Department of Health Services, University of Washington, Seattle, Washington
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14
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Chubak J, Hawkes R, Dudzik C, Ziebell RA, Sherman KJ. Letter: The Choice of Control Conditions in Animal-Assisted Intervention Research. Integr Cancer Ther 2021; 20:15347354211025626. [PMID: 34166147 PMCID: PMC8236761 DOI: 10.1177/15347354211025626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Jessica Chubak
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - Rene Hawkes
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - Christi Dudzik
- Seattle Children's Hospital and Regional Medical Center, Seattle, WA, USA.,Healing Paws, Inc., Woodinville, WA, USA
| | - Rebecca A Ziebell
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - Karen J Sherman
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
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15
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Suri P, Meier EN, Gold LS, Marcum ZA, Johnston SK, James KT, Bresnahan BW, O'Reilly M, Turner JA, Kallmes DF, Sherman KJ, Deyo RA, Luetmer PH, Avins AL, Griffith B, Heagerty PJ, Rundell SD, Jarvik JG, Friedly JL. Providing Epidemiological Data in Lumbar Spine Imaging Reports Did Not Affect Subsequent Utilization of Spine Procedures: Secondary Outcomes from a Stepped-Wedge Randomized Controlled Trial. Pain Med 2021; 22:1272-1280. [PMID: 33595635 DOI: 10.1093/pm/pnab065] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
OBJECTIVE To evaluate the effect of inserting epidemiological information into lumbar spine imaging reports on subsequent nonsurgical and surgical procedures involving the thoracolumbosacral spine and sacroiliac joints. DESIGN Analysis of secondary outcomes from the Lumbar Imaging with Reporting of Epidemiology (LIRE) pragmatic stepped-wedge randomized trial. SETTING Primary care clinics within four integrated health care systems in the United States. SUBJECTS 238,886 patients ≥18 years of age who received lumbar diagnostic imaging between 2013 and 2016. METHODS Clinics were randomized to receive text containing age- and modality-specific epidemiological benchmarks indicating the prevalence of common spine imaging findings in people without low back pain, inserted into lumbar spine imaging reports (the "LIRE intervention"). The study outcomes were receiving 1) any nonsurgical lumbosacral or sacroiliac spine procedure (lumbosacral epidural steroid injection, facet joint injection, or facet joint radiofrequency ablation; or sacroiliac joint injection) or 2) any surgical procedure involving the lumbar, sacral, or thoracic spine (decompression surgery or spinal fusion or other spine surgery). RESULTS The LIRE intervention was not significantly associated with subsequent utilization of nonsurgical lumbosacral or sacroiliac spine procedures (odds ratio [OR] = 1.01, 95% confidence interval [CI] 0.93-1.09; P = 0.79) or any surgical procedure (OR = 0.99, 95 CI 0.91-1.07; P = 0.74) involving the lumbar, sacral, or thoracic spine. The intervention was also not significantly associated with any individual spine procedure. CONCLUSIONS Inserting epidemiological text into spine imaging reports had no effect on nonsurgical or surgical procedure utilization among patients receiving lumbar diagnostic imaging.
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Affiliation(s)
- Pradeep Suri
- Clinical Learning, Evidence, and Research Center, University of Washington, Seattle, Washington, USA.,Department of Rehabilitation Medicine, University of Washington, Seattle, Washington, USA.,Seattle Epidemiologic Research and Information Center, VA Puget Sound Health Care System, Seattle, Washington, USA.,Rehabilitation Care Services, VA Puget Sound Health Care System, Seattle, Washington, USA
| | - Eric N Meier
- Clinical Learning, Evidence, and Research Center, University of Washington, Seattle, Washington, USA.,Department of Biostatistics, University of Washington, Seattle, Washington, USA
| | - Laura S Gold
- Clinical Learning, Evidence, and Research Center, University of Washington, Seattle, Washington, USA.,Department of Radiology, School of Medicine, University of Washington, Seattle, Washington, USA
| | - Zachary A Marcum
- Department of Pharmacy, School of Pharmacy, University of Washington, Seattle, Washington, USA
| | - Sandra K Johnston
- Clinical Learning, Evidence, and Research Center, University of Washington, Seattle, Washington, USA.,Department of Radiology, School of Medicine, University of Washington, Seattle, Washington, USA
| | - Kathryn T James
- Clinical Learning, Evidence, and Research Center, University of Washington, Seattle, Washington, USA.,Department of Radiology, School of Medicine, University of Washington, Seattle, Washington, USA
| | - Brian W Bresnahan
- Department of Radiology, School of Medicine, University of Washington, Seattle, Washington, USA
| | - Michael O'Reilly
- Clinical Learning, Evidence, and Research Center, University of Washington, Seattle, Washington, USA.,Department of Radiology, School of Medicine, University of Washington, Seattle, Washington, USA
| | - Judith A Turner
- Clinical Learning, Evidence, and Research Center, University of Washington, Seattle, Washington, USA.,Department of Rehabilitation Medicine, University of Washington, Seattle, Washington, USA.,Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington, USA
| | - David F Kallmes
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Richard A Deyo
- Departments of Family Medicine and Internal Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | | | - Andrew L Avins
- Division of Research (ALA), Kaiser Permanente Northern California, Oakland, California, USA
| | - Brent Griffith
- Department of Radiology, Henry Ford Hospital, Detroit, Michigan, USA
| | - Patrick J Heagerty
- Clinical Learning, Evidence, and Research Center, University of Washington, Seattle, Washington, USA.,Department of Biostatistics, University of Washington, Seattle, Washington, USA
| | - Sean D Rundell
- Clinical Learning, Evidence, and Research Center, University of Washington, Seattle, Washington, USA.,Department of Rehabilitation Medicine, University of Washington, Seattle, Washington, USA
| | - Jeffrey G Jarvik
- Clinical Learning, Evidence, and Research Center, University of Washington, Seattle, Washington, USA.,Department of Radiology, School of Medicine, University of Washington, Seattle, Washington, USA.,Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Janna L Friedly
- Clinical Learning, Evidence, and Research Center, University of Washington, Seattle, Washington, USA.,Department of Rehabilitation Medicine, University of Washington, Seattle, Washington, USA
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16
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Nielsen A, Ocker L, Majd I, Draisin JA, Taromina K, Maggenti MT, Long J, Nolting M, Sherman KJ. Acupuncture Intervention Protocol: Consensus Process for a Pragmatic Randomized Controlled Trial of Acupuncture for Management of Chronic Low Back Pain in Older Adults: An NIH HEAL Initiative Funded Project. Glob Adv Health Med 2021; 10:21649561211007091. [PMID: 34104574 PMCID: PMC8161858 DOI: 10.1177/21649561211007091] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 02/09/2021] [Accepted: 03/12/2021] [Indexed: 12/13/2022] Open
Abstract
Objective The aim of this article is to describe the consensus process used to develop an acupuncture intervention protocol for an NIH-funded pragmatic randomized controlled trial (PRCT) of acupuncture for the management of chronic low back (cLBP) in older adults (BackInAction). Background CLBP is among leading causes of disability worldwide: almost 33% of US adults 65 and older experience LBP. Acupuncture is effective for cLBP but there is no specific data on older adults. The National Institutes for Health (NIH) funded a PRCT of acupuncture needling for this population. An essential trial milestone was development of a consensus intervention protocol. Methods An Acupuncture Advisory Panel (AAP) was formed with nine members: two physician-acupuncturists, six licensed acupuncturists representing diverse work backgrounds, and an acupuncture researcher. We used a modified Delphi process that included provision of acupuncture trial data, survey data describing how each expert treats cLBP, three conference calls, and between-call email discussion. Results Lively and professional discussions led to a consensus intervention protocol for the BackInAction trial that included steps/staging of care, recommendations for parameters of care session length, number of needle insertion sites, insertion depths, needle retention times, recommended types of needles, both local and distal areas of the body to be treated, acupuncture point options, auricular point options, self-care options, and minimum number of sessions considered ideal. Conclusion Using a modified Delphi process, an expert AAP created a consensus intervention protocol for the PRCT of acupuncture needling for cLBP in patients 65 and older.
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Affiliation(s)
- Arya Nielsen
- Department of Family Medicine & Community Health, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Laura Ocker
- Multnomah County, Integrated Clinical Services, Portland, Oregon
| | - Iman Majd
- Department of Family Medicine, University of Washington, Seattle, Washington
| | - Jeff A Draisin
- Institute for Health and Healing, San Francisco, California
| | | | | | | | | | - Karen J Sherman
- Kaiser Permanente Washington Health Research Institute; Department of Epidemiology, University of Washington, Seattle, Washington
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Roseen EJ, Purtle J, Zhang W, Miller DW, Schwartz AW, Ramanadhan S, Sherman KJ. The Intersection of Dissemination Research and Acupuncture: Applications for Chronic Low Back Pain. Glob Adv Health Med 2021; 10:2164956120980694. [PMID: 34104573 PMCID: PMC8150432 DOI: 10.1177/2164956120980694] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 11/05/2020] [Accepted: 11/23/2020] [Indexed: 12/29/2022] Open
Abstract
Dissemination research is the study of distributing information and intervention materials to a specific clinical practice or public health audience. Acupuncture, a healthcare practice involving the stimulation of certain body points, often with thin needles, is considered an evidence-based treatment for low back pain (LBP), but is underutilized in the United States. Body: We will use the example of acupuncture for LBP to identify opportunities to leverage dissemination research to increase utilization of acupuncture. Deficits in the awareness or knowledge of acupuncture may limit its adoption by patients and other stakeholders. Thus, we summarize methods to gather data on stakeholder awareness and knowledge of acupuncture for LBP, i.e., audience research. Engaging multiple stakeholder audiences (e.g., health system leaders, primary care providers, patients), is needed to generate knowledge on promising dissemination strategies for each audience. Audience segmentation is important for identifying population subgroups for whom adoption of acupuncture may require a more intensive or tailored dissemination strategy. To illustrate potential audience ‘segments’, our research discussion focused on developing dissemination strategies by age (i.e., older adults – those age 65 years or older, and younger adults – those under age 65 ). This decision was prompted by Medicare’s recent policy covering acupuncture for chronic LBP. We leverage current knowledge of barriers and facilitators of acupuncture use to discuss how further tailoring of dissemination strategies might optimize adoption of acupuncture in both groups of adults. Experimental study designs could then be used to compare the effectiveness of such strategies to increase awareness, knowledge, or adoption of acupuncture. Conclusions: Conducting dissemination research may improve awareness and knowledge of acupuncture, and ultimately the adoption of acupuncture in biomedical settings. We anticipate that the concepts highlighted in this manuscript will also be helpful for those disseminating information about other complementary and integrative health approaches.
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Affiliation(s)
- Eric J Roseen
- Department of Family Medicine, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts.,Department of Rehabilitation Science, MGH Institute of Health Professions, Boston, Massachusetts.,New England Geriatric Research, Education, and Clinical Center, VA Boston Healthcare System, Boston, Massachusetts
| | - Jonathan Purtle
- Department of Health Management and Policy, Dornsife School of Public Health, Drexel University, Philadelphia, Pennsylvania
| | - Weijun Zhang
- Department of Medicine, UCLA Center for East-West Medicine, Los Angeles, California.,Division of General Internal Medicine and Health Service Research, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - David W Miller
- Department of Pediatrics, Connor Integrative Health Network, University Hospitals, Rainbow Babies and Children's Hospital, Cleveland, Ohio
| | - Andrea Wershof Schwartz
- New England Geriatric Research, Education, and Clinical Center, VA Boston Healthcare System, Boston, Massachusetts.,Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Shoba Ramanadhan
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Karen J Sherman
- Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington, Seattle, Washington.,Department of Epidemiology, University of Washington, Seattle, Washington
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18
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Berlowitz J, Hall DL, Joyce C, Fredman L, Sherman KJ, Saper RB, Roseen EJ. Changes in Perceived Stress After Yoga, Physical Therapy, and Education Interventions for Chronic Low Back Pain: A Secondary Analysis of a Randomized Controlled Trial. Pain Med 2021; 21:2529-2537. [PMID: 32500130 DOI: 10.1093/pm/pnaa150] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
OBJECTIVE Perceived stress and musculoskeletal pain are common, especially in low-income populations. Studies evaluating treatments to reduce stress in patients with chronic pain are lacking. We aimed to quantify the effect of two evidence-based interventions for chronic low back pain (cLBP), yoga and physical therapy (PT), on perceived stress in adults with cLBP. METHODS We used data from an assessor-blinded, parallel-group randomized controlled trial, which recruited predominantly low-income and racially diverse adults with cLBP. Participants (N = 320) were randomly assigned to 12 weeks of yoga, PT, or back pain education. We compared changes in the 10-item Perceived Stress Scale (PSS-10) from baseline to 12- and 52-week follow-up among yoga and PT participants with those receiving education. Subanalyses were conducted for participants with elevated pre-intervention perceived stress (PSS-10 score ≥17). We conducted sensitivity analyses using various imputation methods to account for potential biases in our estimates due to missing data. RESULTS Among 248 participants (mean age = 46.4 years, 80% nonwhite) completing all three surveys, yoga and PT showed greater reductions in PSS-10 scores compared with education at 12 weeks (mean between-group difference = -2.6, 95% confidence interval [CI] = -4.5 to -0.66, and mean between-group difference = -2.4, 95% CI = -4.4 to -0.48, respectively). This effect was stronger among participants with elevated pre-intervention perceived stress. Between-group effects had attenuated by 52 weeks. Results were similar in sensitivity analyses. CONCLUSIONS Yoga and PT were more effective than back pain education for reducing perceived stress among low-income adults with cLBP.
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Affiliation(s)
- Jonathan Berlowitz
- Department of Family Medicine, Boston Medical Center and Boston University School of Medicine, Boston, Massachusetts
| | - Daniel L Hall
- Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts.,Health Policy Research Center, Massachusetts General Hospital, Boston, Massachusetts
| | - Christopher Joyce
- Department of Rehabilitation Science, Massachusetts General Hospital Institute of Health Professions, Boston, Massachusetts.,School of Physical Therapy, Massachusetts College of Pharmacy and Health Sciences, Worcester, Massachusetts
| | - Lisa Fredman
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts
| | - Karen J Sherman
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington.,Department of Epidemiology, University of Washington, Seattle, Washington, USA
| | - Robert B Saper
- Department of Family Medicine, Boston Medical Center and Boston University School of Medicine, Boston, Massachusetts
| | - Eric J Roseen
- Department of Family Medicine, Boston Medical Center and Boston University School of Medicine, Boston, Massachusetts.,Department of Rehabilitation Science, Massachusetts General Hospital Institute of Health Professions, Boston, Massachusetts
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19
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Roseen EJ, Gerlovin H, Felson DT, Delitto A, Sherman KJ, Saper RB. Which Chronic Low Back Pain Patients Respond Favorably to Yoga, Physical Therapy, and a Self-care Book? Responder Analyses from a Randomized Controlled Trial. Pain Med 2021; 22:165-180. [PMID: 32662833 PMCID: PMC7861465 DOI: 10.1093/pm/pnaa153] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
PURPOSE To identify baseline characteristics of adults with chronic low back pain (cLBP) that predict response (i.e., a clinically important improvement) and/or modify treatment effect across three nonpharmacologic interventions. DESIGN Secondary analysis of a randomized controlled trial. SETTING Academic safety net hospital and seven federally qualified community health centers. SUBJECTS Adults with cLBP (N = 299). METHODS We report patient characteristics that were predictors of response and/or modified treatment effect across three 12-week treatments: yoga, physical therapy [PT], and a self-care book. Using preselected characteristics, we used logistic regression to identify predictors of "response," defined as a ≥30% improvement in the Roland Morris Disability Questionnaire. Then, using "response" as our outcome, we identified baseline characteristics that were treatment effect modifiers by testing for statistical interaction (P < 0.05) across two comparisons: 1) yoga-or-PT vs self-care and 2) yoga vs PT. RESULTS Overall, 39% (116/299) of participants were responders, with more responders in the yoga-or-PT group (42%) than the self-care (23%) group. There was no difference in proportion responding to yoga (48%) vs PT (37%, odds ratio [OR] = 1.5, 95% confidence interval = 0.88 - 2.6). Predictors of response included having more than a high school education, a higher income, employment, few depressive symptoms, lower perceived stress, few work-related fear avoidance beliefs, high pain self-efficacy, and being a nonsmoker. Effect modifiers included use of pain medication and fear avoidance beliefs related to physical activity (both P = 0.02 for interaction). When comparing yoga or PT with self-care, a greater proportion were responders among those using pain meds (OR = 5.3), which differed from those not taking pain meds (OR = 0.94) at baseline. We also found greater treatment response among those with lower (OR = 7.0), but not high (OR = 1.3), fear avoidance beliefs around physical activity. CONCLUSIONS Our findings revealed important subgroups for whom referral to yoga or PT may improve cLBP outcomes.
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Affiliation(s)
- Eric J Roseen
- Department of Family Medicine, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts, USA
- Department of Rehabilitation Science, Massachusetts General Hospital Institute of Health Professions, Boston, Massachusetts, USA
| | - Hanna Gerlovin
- Slone Epidemiology Center, Boston University School of Medicine, Boston, Massachusetts, USA
| | - David T Felson
- Clinical Epidemiology Research and Training Unit, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Anthony Delitto
- School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Karen J Sherman
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington, USA
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
| | - Robert B Saper
- Department of Family Medicine, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts, USA
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20
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Vickers AJ, Vertosick EA, Lewith G, MacPherson H, Foster NE, Sherman KJ, Irnich D, Witt CM, Linde K. Do the effects of acupuncture vary between acupuncturists? Analysis of the Acupuncture Trialists' Collaboration individual patient data meta-analysis. Acupunct Med 2020; 39:309-317. [PMID: 33300369 DOI: 10.1177/0964528420959089] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES The degree to which the effects of acupuncture treatment vary between acupuncturists is unknown. We used a large individual patient dataset of trials of acupuncture for chronic pain to assess practitioner heterogeneity. METHODS Individual patient data linked to identifiable acupuncturists were drawn from a dataset of 39 high-quality trials of acupuncture, where the comparators were either sham acupuncture or non-acupuncture controls, such as standard care or waitlist. Heterogeneity among acupuncturists was assessed by meta-analysis. RESULTS A total of 1206 acupuncturists in 13 trials were included. Statistically significant heterogeneity was found in trials with sham-control groups (p < 0.0001) and non-acupuncture control groups (p <0.0001). However, the degree of heterogeneity was very small, with the observed distribution of treatment effects virtually overlapping that expected by chance. For instance, for non-acupuncture-controlled trials, the proportion of acupuncturists with effect sizes half a standard deviation greater or less than average was expected to be 34%, but was observed to be 37%. A limitation is that the trials included a relatively limited range of acupuncturists, mainly physician-acupuncturists. DISCUSSION Although differences in effects between acupuncturists were greater than expected by chance, the degree of variation was small. This suggests that most chronic pain patients in clinical practice would have similar results to those reported in high-quality trials; comparably, we did not find evidence to suggest that greater standardization of acupuncture practice would improve outcomes. Further research needs to be conducted exploring variability using a sample of acupuncturists with a broader range of practice styles, training and experience.
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Affiliation(s)
| | | | | | | | | | - Karen J Sherman
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - Dominik Irnich
- Ludwig-Maximilians-Universität München (LMU Munich), Munich, Germany
| | - Claudia M Witt
- University Hospital Zurich, University of Zurich, Zurich, Switzerland.,Charite - Universitätsmedizin Berlin, Berlin, Germany.,University of Maryland School of Medicine, Baltimore, MD, USA
| | - Klaus Linde
- Technical University Munich, Munich, Germany
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21
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Jarvik JG, Meier EN, James KT, Gold LS, Tan KW, Kessler LG, Suri P, Kallmes DF, Cherkin DC, Deyo RA, Sherman KJ, Halabi SS, Comstock BA, Luetmer PH, Avins AL, Rundell SD, Griffith B, Friedly JL, Lavallee DC, Stephens KA, Turner JA, Bresnahan BW, Heagerty PJ. The Effect of Including Benchmark Prevalence Data of Common Imaging Findings in Spine Image Reports on Health Care Utilization Among Adults Undergoing Spine Imaging: A Stepped-Wedge Randomized Clinical Trial. JAMA Netw Open 2020; 3:e2015713. [PMID: 32886121 PMCID: PMC7489827 DOI: 10.1001/jamanetworkopen.2020.15713] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
IMPORTANCE Lumbar spine imaging frequently reveals findings that may seem alarming but are likely unrelated to pain. Prior work has suggested that inserting data on the prevalence of imaging findings among asymptomatic individuals into spine imaging reports may reduce unnecessary subsequent interventions. OBJECTIVE To evaluate the impact of including benchmark prevalence data in routine spinal imaging reports on subsequent spine-related health care utilization and opioid prescriptions. DESIGN, SETTING, AND PARTICIPANTS This stepped-wedge, pragmatic randomized clinical trial included 250 401 adult participants receiving care from 98 primary care clinics at 4 large health systems in the United States. Participants had imaging of their backs between October 2013 and September 2016 without having had spine imaging in the prior year. Data analysis was conducted from November 2018 to October 2019. INTERVENTIONS Either standard lumbar spine imaging reports (control group) or reports containing age-appropriate prevalence data for common imaging findings in individuals without back pain (intervention group). MAIN OUTCOMES AND MEASURES Health care utilization was measured in spine-related relative value units (RVUs) within 365 days of index imaging. The number of subsequent opioid prescriptions written by a primary care clinician was a secondary outcome, and prespecified subgroup analyses examined results by imaging modality. RESULTS We enrolled 250 401 participants (of whom 238 886 [95.4%] met eligibility for this analysis, with 137 373 [57.5%] women and 105 497 [44.2%] aged >60 years) from 3278 primary care clinicians. A total of 117 455 patients (49.2%) were randomized to the control group, and 121 431 patients (50.8%) were randomized to the intervention group. There was no significant difference in cumulative spine-related RVUs comparing intervention and control conditions through 365 days. The adjusted median (interquartile range) RVU for the control group was 3.56 (2.71-5.12) compared with 3.53 (2.68-5.08) for the intervention group (difference, -0.7%; 95% CI, -2.9% to 1.5%; P = .54). Rates of subsequent RVUs did not differ between groups by specific clinical findings in the report but did differ by type of index imaging (eg, computed tomography: difference, -29.3%; 95% CI, -42.1% to -13.5%; magnetic resonance imaging: difference, -3.4%; 95% CI, -8.3% to 1.8%). We observed a small but significant decrease in the likelihood of opioid prescribing from a study clinician within 1 year of the intervention (odds ratio, 0.95; 95% CI, 0.91 to 1.00; P = .04). CONCLUSIONS AND RELEVANCE In this study, inserting benchmark prevalence information in lumbar spine imaging reports did not decrease subsequent spine-related RVUs but did reduce subsequent opioid prescriptions. The intervention text is simple, inexpensive, and easily implemented. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02015455.
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Affiliation(s)
- Jeffrey G. Jarvik
- Department of Radiology, University of Washington, Seattle
- Department of Neurological Surgery, University of Washington, Seattle
- Department of Health Services, University of Washington, Seattle
- Comparative Effectiveness, Cost, and Outcomes Research Center, University of Washington, Seattle
| | - Eric N. Meier
- Department of Biostatistics, University of Washington, Seattle
- Center for Biomedical Statistics, University of Washington, Seattle
| | - Kathryn T. James
- Department of Radiology, University of Washington, Seattle
- Comparative Effectiveness, Cost, and Outcomes Research Center, University of Washington, Seattle
| | - Laura S. Gold
- Department of Radiology, University of Washington, Seattle
- Comparative Effectiveness, Cost, and Outcomes Research Center, University of Washington, Seattle
| | - Katherine W. Tan
- Department of Biostatistics, University of Washington, Seattle
- Center for Biomedical Statistics, University of Washington, Seattle
- Flatiron Health, New York, New York
| | - Larry G. Kessler
- Department of Health Services, University of Washington, Seattle
| | - Pradeep Suri
- Rehabilitation Care Services, VA Puget Sound Health Care System, Seattle, Washington
- Department of Rehabilitation Medicine, University of Washington, Seattle
| | | | | | - Richard A. Deyo
- Departments of Family Medicine and Internal Medicine, Oregon Health and Science University, Portland
| | | | - Safwan S. Halabi
- Department of Radiology, Henry Ford Hospital, Detroit, Michigan
- Department of Radiology, Stanford University School of Medicine, Palo Alto, California
| | - Bryan A. Comstock
- Department of Biostatistics, University of Washington, Seattle
- Center for Biomedical Statistics, University of Washington, Seattle
| | | | - Andrew L. Avins
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Sean D. Rundell
- Comparative Effectiveness, Cost, and Outcomes Research Center, University of Washington, Seattle
- Department of Rehabilitation Medicine, University of Washington, Seattle
| | - Brent Griffith
- Department of Radiology, Henry Ford Hospital, Detroit, Michigan
| | - Janna L. Friedly
- Comparative Effectiveness, Cost, and Outcomes Research Center, University of Washington, Seattle
- Department of Rehabilitation Medicine, University of Washington, Seattle
| | | | - Kari A. Stephens
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle
| | - Judith A. Turner
- Comparative Effectiveness, Cost, and Outcomes Research Center, University of Washington, Seattle
- Department of Rehabilitation Medicine, University of Washington, Seattle
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle
| | - Brian W. Bresnahan
- Department of Radiology, University of Washington, Seattle
- Comparative Effectiveness, Cost, and Outcomes Research Center, University of Washington, Seattle
| | - Patrick J. Heagerty
- Department of Biostatistics, University of Washington, Seattle
- Center for Biomedical Statistics, University of Washington, Seattle
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22
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Foster NE, Vertosick EA, Lewith G, Linde K, MacPherson H, Sherman KJ, Witt CM, Vickers AJ. Identifying patients with chronic pain who respond to acupuncture: results from an individual patient data meta-analysis. Acupunct Med 2020; 39:83-90. [PMID: 32571096 DOI: 10.1177/0964528420920303] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND In a recent individual patient data meta-analysis, acupuncture was found to be superior to sham and non-sham controls in patients with chronic pain. It has been suggested that a subgroup of patients has an exceptional response to acupuncture. We hypothesized the presence of exceptional acupuncture responders would lead to a different distribution of pain scores in acupuncture versus control groups, with the former being skewed to the right. METHODS This individual patient data meta-analysis included 39 high-quality randomized trials of acupuncture for chronic headache, migraine, osteoarthritis, low back pain, neck pain and shoulder pain published before December 2015 (n = 20,827). In all, 25 involved sham acupuncture controls (n = 7097) and 25 non-acupuncture controls (n = 16,041). We analyzed the distribution of change scores and calculated the difference in the skewness statistic-which assesses asymmetry in the data distribution-between acupuncture and either sham or non-acupuncture control groups. We then entered the difference in skewness along with standard error into a meta-analysis. FINDINGS Control groups were more right-skewed than acupuncture groups, although this difference was very small. The difference in skew was 0.124 for non-acupuncture-controlled trials (p = 0.047) and 0.141 for sham-controlled trials (p = 0.029). In a pre-specified sensitivity analysis excluding three trials with outlying results known a priori, the difference in skew between acupuncture and sham was no longer statistically significant (p = 0.2). CONCLUSION We did not find evidence to support the notion that there are exceptional acupuncture responders. The challenge remains to identify features of chronic pain patients that can be used to distinguish those that have a good response to acupuncture treatment.
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Affiliation(s)
- Nadine E Foster
- Primary Care Centre Versus Arthritis, School of Primary, Community and Social Care, Keele University, Staffordshire, UK
| | | | - George Lewith
- Faculty of Medicine, Primary Care and Population Sciences, University of Southampton, Southampton, UK
| | - Klaus Linde
- Institute of General Practice, Technische Universität München, Munich, Germany
| | | | - Karen J Sherman
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - Claudia M Witt
- Institute for Complementary and Integrative Medicine, University Hospital Zurich, Zurich, Switzerland.,Institute for Social Medicine, Epidemiology and Health Economics, Charité-Universitätsmedizin, Berlin, Germany
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23
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Lee TL, Sherman KJ, Hawkes RJ, Phelan EA, Turner JA. The Benefits of T'ai Chi for Older Adults with Chronic Back Pain: A Qualitative Study. J Altern Complement Med 2020; 26:456-462. [PMID: 32379976 DOI: 10.1089/acm.2019.0455] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Objective: To determine the perceived benefits of t'ai chi in older adults with chronic low-back pain (cLBP). Design: A qualitative analysis from a randomized controlled feasibility trial. Subjects: Eighteen participants (65+ years old) with cLBP of at least moderate intensity. Intervention: A 36-week intervention beginning with twice weekly classes for 12 weeks, weekly classes for 6 weeks, biweekly classes for 6 weeks, and monthly classes for 12 weeks. Participants were asked to practice at home on nonclass days and videos were provided to assist in that process. Outcome Measures: Participants in the focus groups were asked to provide feedback on their experiences with the study as well as the benefits of their t'ai chi practice. We used demographic and class attendance data to describe the sample. Results: Regarding the benefits of t'ai chi practice, five major themes were identified: functional benefits, pain reduction/pain relief, psychospiritual benefits, the importance of social support in learning t'ai chi, and the integration of t'ai chi into daily activities. The most common functional benefits were improvements in balance, flexibility, leg strength, and posture. Some reported pain reduction or pain relief, but others did not. Increased relaxation, mindfulness, and a sense of connectedness were subthemes that emerged from psychospiritual benefits. Social support benefits included motivation to attend class and group support while learning a new skill. Finally, improved body awareness allowed participants to integrate t'ai chi skills into their daily activities. Conclusions: This qualitative analysis demonstrates the multifaceted benefits of t'ai chi for older adults living with cLBP.
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Affiliation(s)
- Tamsin L Lee
- Department of Child, Family and Population Health Nursing, University of Washington, Seattle, WA, USA
| | - Karen J Sherman
- Kaiser Permanente WA Health Research Institute, Seattle, WA, USA.,Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - Rene J Hawkes
- Kaiser Permanente WA Health Research Institute, Seattle, WA, USA
| | - Elizabeth A Phelan
- Department of Medicine and Health Services, University of Washington, Seattle, WA, USA
| | - Judith A Turner
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA, USA.,Department of Rehabilitation Medicine, University of Washington School of Medicine, Seattle, WA, USA
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24
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Hsu C, Evers S, Balderson BH, Sherman KJ, Foster NE, Estlin K, Levine M, Cherkin D. Adaptation and Implementation of the STarT Back Risk Stratification Strategy in a US Health Care Organization: A Process Evaluation. Pain Med 2020; 20:1105-1119. [PMID: 30272177 DOI: 10.1093/pm/pny170] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To support implementation of effective treatments for back pain that can be delivered to a range of people, we summarize learnings from our process evaluation of the MATCH trial's implementation of an adaptation of the STarT Back risk-stratified care model. DESIGN Our logic model-driven evaluation focused primarily on qualitative data sources. SETTING This study took place in a US-based health care delivery system that had adapted and implemented the STarT Back stratified care approach. This was the first formal test of the strategy in a US setting. METHODS Data collection included observation of implementation activities, staff/provider interviews, and post-training evaluation questionnaires. Data were analyzed using thematic analysis of qualitative data and descriptive statistics for questionnaire data. RESULTS We found that both primary care teams and physical therapists at intervention clinics gave the training high scores on evaluation questionnaires and reported in the interviews that they found the training engaging and useful. However, there was significant variation in the extent to which the risk stratification strategy was incorporated into care. Some primary care providers reported that the intervention changed their conversations with patients and increased their confidence in working with patients with back pain. Providers using the STarT Back tool did not change referral rates for recommended matched treatments. CONCLUSIONS These insights provide guidance for future efforts to adapt and implement the STarT Back strategy and other complex practice change interventions. They emphasize the need for primary care-based interventions to minimize complexity and the need for ongoing monitoring and feedback.
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Affiliation(s)
- Clarissa Hsu
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington, USA
| | - Sarah Evers
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington, USA
| | - Benjamin H Balderson
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington, USA
| | - Karen J Sherman
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington, USA
| | - Nadine E Foster
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences, Keele University, Keele, Staffordshire, UK
| | - Katherin Estlin
- Open Door Fortuna Community Health Center, Fortuna, California
| | | | - Dan Cherkin
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington, USA
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25
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Sherman KJ. The Trials and Tribulations of Selecting Comparison Groups in Randomized Trials of Nonpharmacological Complementary and Integrative Health Interventions. J Altern Complement Med 2020; 26:449-455. [PMID: 32167801 DOI: 10.1089/acm.2019.0460] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Editor's Note: For over two decades, JACM Editorial Board member Karen Sherman, PhD has been among the most respected clinical trialists in complementary and integrative health research. The epidemiologist and Senior Researcher at Kaiser Permanente Washington Health Research Institute has focused on pain conditions and has led or been part of teams exploring the roles of such therapies as yoga, acupuncture, mind-body and manual therapies. In this Invited Commentary, Sherman shares wisdom gleaned from the process: trial designs, principles for selecting controls, benefits and liabilities of placebo and sham controls, attention controls, usual care controls, and more. She also discusses the effects of comparison groups on sample sizes, comparison groups for mechanistic studies, and other comparison groups' considerations. This commentary should prove a useful primer wherever research methods in complementary and integrative health are taught. We are pleased to offer it here through JACM. -John Weeks, Editor-in-Chief, JACM (johnweeks-integrator.com).
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Affiliation(s)
- Karen J Sherman
- Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington, Seattle, WA, USA.,Department of Epidemiology, University of Washington, Seattle, WA, USA
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Sherman KJ, Wellman RD, Hawkes RJ, Phelan EA, Lee T, Turner JA. T'ai Chi for Chronic Low Back Pain in Older Adults: A Feasibility Trial. J Altern Complement Med 2020; 26:176-189. [PMID: 32013530 DOI: 10.1089/acm.2019.0438] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Objectives: T'ai chi (TC) has been found effective for improving chronic low back pain (cLBP). However, such studies did not include adults over 65 years of age. This study was designed to evaluate the feasibility and acceptability of TC in this population compared with Health Education (HE) and with Usual Care (UC). Design: Feasibility randomized controlled trial. Settings/Location: Participants were recruited from Kaiser Permanente Washington and classes took place in a Kaiser facility. Patients: Adults 65 years of age and older with cLBP. Interventions: Twenty-eight participants were randomized to 12 weeks of TC followed by a 24-week tapered TC program, 12 were assigned to a 12-week HE intervention and 17 were assigned to UC only. Outcome Measures: Feasibility and acceptability were determined by recruitment, retention and 12-, 26-, and 52-week follow-up rates, instructor adherence to protocol, class attendance, TC home practice, class satisfaction, and adverse events. Results: Fifty-seven participants were enrolled in two cohorts of 28 and 29 during two 4-month recruitment periods. Questionnaire follow-up completion rates ranged between 88% and 93%. Two major class protocol deviations were noted in TC and none in HE. Sixty-two percent of TC participants versus 50% of HE participants attended at least 70% of the classes during the 12-week initial intervention period. Weekly rates of TC home practice were high among class attendees (median of 4.2 days) at 12 weeks, with fewer people practicing at 26 and 52 weeks. By 52 weeks, 70% of TC participants reported practicing the week before, with a median of 3 days per week and 15 min/session. TC participants rated the helpfulness of their classes significantly higher than did HE participants, but the groups were similarly likely to recommend the classes. Conclusion: The TC intervention is feasible in this population, while the HE group requires modifications in delivery.
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Affiliation(s)
- Karen J Sherman
- Kaiser Permanente Washington Health Research Institute, Seattle, WA.,Department of Epidemiology, University of Washington, Seattle, WA
| | - Robert D Wellman
- Kaiser Permanente Washington Health Research Institute, Seattle, WA
| | - Rene J Hawkes
- Kaiser Permanente Washington Health Research Institute, Seattle, WA
| | - Elizabeth A Phelan
- Department of Medicine and Health Services, University of Washington, Seattle, WA
| | - Tamsin Lee
- Department of Child, Family and Population Health Nursing, University of Washington, Seattle, WA
| | - Judith A Turner
- Department of Psychiatry and Behavioral Sciences and Rehabilitation Medicine, University of Washington, Seattle, WA
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Roseen EJ, Gerlovin H, Femia A, Cho J, Bertisch S, Redline S, Sherman KJ, Saper R. Yoga, Physical Therapy, and Back Pain Education for Sleep Quality in Low-Income Racially Diverse Adults with Chronic Low Back Pain: a Secondary Analysis of a Randomized Controlled Trial. J Gen Intern Med 2020; 35:167-176. [PMID: 31667747 PMCID: PMC6957649 DOI: 10.1007/s11606-019-05329-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Revised: 05/23/2019] [Accepted: 08/13/2019] [Indexed: 12/29/2022]
Abstract
BACKGROUND Poor sleep is common among adults with chronic low back pain (cLBP), but the influence of cLBP treatments, such as yoga and physical therapy (PT), on sleep quality is under studied. OBJECTIVE Evaluate the effectiveness of yoga and PT for improving sleep quality in adults with cLBP. DESIGN Secondary analysis of a randomized controlled trial. SETTING Academic safety-net hospital and 7 affiliated community health centers. PARTICIPANTS A total of 320 adults with cLBP. INTERVENTION Twelve weekly yoga classes, 1-on-1 PT sessions, or an educational book. MAIN MEASURES Sleep quality was measured using the Pittsburgh Sleep Quality Index (PSQI) global score (0-21) at baseline, 12 weeks, and 52 weeks. Additionally, we also evaluated how the proportion of participants who achieved a clinically meaningful improvement in sleep quality (> 3-point reduction in PSQI) at 12 weeks varied by changes in pain and physical function at 6 weeks. KEY RESULTS Among participants (mean age = 46.0, 64% female, 82% non-white), nearly all (92%) reported poor sleep quality (PSQI > 5) at baseline. At 12 weeks, modest improvements in sleep quality were observed among the yoga (PSQI mean difference [MD] = - 1.19, 95% confidence interval [CI] - 1.82, - 0.55) and PT (PSQI MD = - 0.91, 95% CI - 1.61, - 0.20) groups. Participants who reported a ≥ 30% improvement in pain or physical function at 6 weeks, compared with those who improved < 10%, were more likely to be a sleep quality responder at 12 weeks (odds ratio [OR] = 3.51, 95% CI 1.73, 7.11 and OR = 2.16, 95% CI 1.18, 3.95, respectively). Results were similar at 52 weeks. CONCLUSION In a sample of adults with cLBP, virtually all with poor sleep quality prior to intervention, modest but statistically significant improvements in sleep quality were observed with both yoga and PT. Irrespective of treatment, clinically important sleep improvements at the end of the intervention were associated with mid-intervention pain and physical function improvements. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01343927.
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Affiliation(s)
- Eric J. Roseen
- Department of Family Medicine, Boston University School of Medicine and Boston Medical Center, Boston, MA USA
- Department of Rehabilitation Sciences, Massachusetts General Hospital Institute of Health Professions, Boston, MA USA
| | - Hanna Gerlovin
- Slone Epidemiology Center, Boston University School of Medicine, Boston, MA USA
| | - Alexandra Femia
- Department of Family Medicine, Boston University School of Medicine and Boston Medical Center, Boston, MA USA
| | - Jae Cho
- Department of Family Medicine, Boston University School of Medicine and Boston Medical Center, Boston, MA USA
| | - Suzanne Bertisch
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Boston, MA USA
- Division of Sleep Medicine, Harvard Medical School, Boston, MA USA
| | - Susan Redline
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Boston, MA USA
- Division of Sleep Medicine, Harvard Medical School, Boston, MA USA
| | - Karen J. Sherman
- Kaiser Permanente Washington Health Research Institute, Seattle, WA USA
- Department of Epidemiology, University of Washington, Seattle, WA USA
| | - Robert Saper
- Department of Family Medicine, Boston University School of Medicine and Boston Medical Center, Boston, MA USA
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Thakral M, Walker RL, Saunders K, Shortreed SM, Dublin S, Parchman M, Hansen RN, Ludman E, Sherman KJ, Von Korff M. Impact of Opioid Dose Reduction and Risk Mitigation Initiatives on Chronic Opioid Therapy Patients at Higher Risk for Opioid-Related Adverse Outcomes. Pain Med 2019; 19:2450-2458. [PMID: 29220525 DOI: 10.1093/pm/pnx293] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Objective We aimed to determine if opioid risk reduction initiatives including dose reduction and risk mitigation strategies for chronic noncancer pain patients receiving chronic opioid therapy (COT) had a differential impact on average daily opioid doses of COT patients at higher risk for opioid-related adverse outcomes compared with lower-risk patients. Design Interrupted time series. Setting Group Health Cooperative (GH), a health care delivery system and insurance within Washington State, between 2006 and 2014. Population GH enrollees on COT defined as receiving a supply of 70 or more days of opioids within 90 days using electronic pharmacy data for filled prescriptions. Methods We compared the average daily morphine equivalent doses (MED) of COT patients with and without each of the following higher-risk characteristics: mental disorders, substance use disorders, sedative use, and male gender. Results In all four pairwise comparisons, the higher-risk subgroup had a higher average daily MED than the lower-risk subgroup across the study period. Adjusted for covariates, modest differences in the annual rate of reduction in average daily MED were noted between higher- and lower-risk subgroups in three pairwise comparisons: those with mental disorders vs without (-8.2 mg/y vs -5.2 mg/y, P = 0.005), with sedative use vs without (-9.2 mg/y vs -5.8 mg/y, P = 0.004); mg), in men vs women (-8.8 mg/y vs -5.9 mg/y, P = 0.01). Conclusion Using clinical policy initiatives in a health care system, dose reductions were achieved among COT patients at higher risk for opioid-related adverse outcomes that were at least as large as those among lower-risk patients.
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Affiliation(s)
- Manu Thakral
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington.,Department of Psychosocial and Community Health, School of Nursing
| | - Rod L Walker
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | - Kathleen Saunders
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | - Susan M Shortreed
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington.,Department of Biostatistics
| | - Sascha Dublin
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington.,Department of Epidemiology
| | - Michael Parchman
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | - Ryan N Hansen
- School of Pharmacy, University of Washington, Seattle, Washington, USA
| | - Evette Ludman
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | - Karen J Sherman
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington.,Department of Epidemiology
| | - Michael Von Korff
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
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Huhdanpaa HT, Tan WK, Rundell SD, Suri P, Chokshi FH, Comstock BA, Heagerty PJ, James KT, Avins AL, Nedeljkovic SS, Nerenz DR, Kallmes DF, Luetmer PH, Sherman KJ, Organ NL, Griffith B, Langlotz CP, Carrell D, Hassanpour S, Jarvik JG. Using Natural Language Processing of Free-Text Radiology Reports to Identify Type 1 Modic Endplate Changes. J Digit Imaging 2019; 31:84-90. [PMID: 28808792 DOI: 10.1007/s10278-017-0013-3] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Electronic medical record (EMR) systems provide easy access to radiology reports and offer great potential to support quality improvement efforts and clinical research. Harnessing the full potential of the EMR requires scalable approaches such as natural language processing (NLP) to convert text into variables used for evaluation or analysis. Our goal was to determine the feasibility of using NLP to identify patients with Type 1 Modic endplate changes using clinical reports of magnetic resonance (MR) imaging examinations of the spine. Identifying patients with Type 1 Modic change who may be eligible for clinical trials is important as these findings may be important targets for intervention. Four annotators identified all reports that contained Type 1 Modic change, using N = 458 randomly selected lumbar spine MR reports. We then implemented a rule-based NLP algorithm in Java using regular expressions. The prevalence of Type 1 Modic change in the annotated dataset was 10%. Results were recall (sensitivity) 35/50 = 0.70 (95% confidence interval (C.I.) 0.52-0.82), specificity 404/408 = 0.99 (0.97-1.0), precision (positive predictive value) 35/39 = 0.90 (0.75-0.97), negative predictive value 404/419 = 0.96 (0.94-0.98), and F1-score 0.79 (0.43-1.0). Our evaluation shows the efficacy of rule-based NLP approach for identifying patients with Type 1 Modic change if the emphasis is on identifying only relevant cases with low concern regarding false negatives. As expected, our results show that specificity is higher than recall. This is due to the inherent difficulty of eliciting all possible keywords given the enormous variability of lumbar spine reporting, which decreases recall, while availability of good negation algorithms improves specificity.
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Affiliation(s)
| | - W Katherine Tan
- Department of Biostatistics, University of Washington, Seattle, WA, USA.,Center for Biomedical Statistics, University of Washington, Seattle, WA, USA
| | - Sean D Rundell
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA, USA.,Comparative Effectiveness, Cost and Outcomes Research Center, University of Washington, Seattle, WA, USA
| | - Pradeep Suri
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA, USA.,Comparative Effectiveness, Cost and Outcomes Research Center, University of Washington, Seattle, WA, USA.,Division of Rehabilitation Care Services, Seattle Epidemiologic Research and Information Center, VA Puget Sound Health Care System, Seattle, WA, USA
| | - Falgun H Chokshi
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - Bryan A Comstock
- Department of Biostatistics, University of Washington, Seattle, WA, USA.,Center for Biomedical Statistics, University of Washington, Seattle, WA, USA
| | - Patrick J Heagerty
- Department of Biostatistics, University of Washington, Seattle, WA, USA.,Center for Biomedical Statistics, University of Washington, Seattle, WA, USA
| | - Kathryn T James
- Comparative Effectiveness, Cost and Outcomes Research Center, University of Washington, Seattle, WA, USA.,Department of Radiology, University of Washington, Box 359728, 325 Ninth Ave., Seattle, WA, 98104-2499, USA
| | - Andrew L Avins
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Srdjan S Nedeljkovic
- Department of Anesthesiology, Perioperative and Pain Medicine, Harvard Vanguard Medical Associates, Brigham and Women's Hospital and Spine Unit, Boston, MA, USA
| | - David R Nerenz
- Henry Ford Hospital, Neuroscience Institute, Detroit, MI, USA
| | | | | | - Karen J Sherman
- Kaiser Permanente of Washington Research Institute, Seattle, WA, USA
| | - Nancy L Organ
- Department of Biostatistics, University of Washington, Seattle, WA, USA.,Center for Biomedical Statistics, University of Washington, Seattle, WA, USA
| | - Brent Griffith
- Department of Radiology, Henry Ford Hospital, Detroit, MI, USA
| | | | - David Carrell
- Kaiser Permanente of Washington Research Institute, Seattle, WA, USA
| | - Saeed Hassanpour
- Department of Biomedical Data Science, Dartmouth College, Lebanon, NH, USA
| | - Jeffrey G Jarvik
- Comparative Effectiveness, Cost and Outcomes Research Center, University of Washington, Seattle, WA, USA. .,Department of Radiology, University of Washington, Box 359728, 325 Ninth Ave., Seattle, WA, 98104-2499, USA. .,Department of Neurological Surgery, University of Washington, Seattle, WA, USA. .,Department of Health Services, University of Washington, Seattle, WA, USA.
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Bradley R, Booth-LaForce C, Hanes D, Scott C, Sherman KJ, Lin YS, Zwickey H. Design of a Multidisciplinary Training Program in Complementary and Integrative Health Clinical Research: Building Research Across Interdisciplinary Gaps. J Altern Complement Med 2019; 25:509-516. [PMID: 30758218 DOI: 10.1089/acm.2018.0454] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Despite wide use by the public, limited evidence is available for many complementary and integrative health (CIH) practices. Thus, clinical researchers knowledgeable about CIH disciplines are necessary to study the efficacy and effectiveness of CIH practices to benefit the public health. To partially address the need for clinical researchers versed in CIH, the authors of this study report the design of an interprofessional clinical research training program focused on CIH, the Building Research across Interdisciplinary Gaps (BRIDG) program, supported by a 5-year T90/R90 grant from the National Center for Complementary and Integrative Health. The T90-supported arm of the program trains doctoral-level CIH providers in clinical research at the research-intensive University of Washington. The R90-supported arm of the program trains researchers with conventional backgrounds in the practices of CIH at the clinic-intensive National University of Natural Medicine. The "Translational Science Spectrum" provides a common conceptual framework for both programs. Specific program elements include: individualized didactic training in clinical research and CIH disciplines; placement with clinical research mentors; placement with clinical mentors in CIH disciplines; shared and independent research project development; and interdisciplinary experiences through seminars and retreats. Program evaluation includes annual completion of the Clinical Research Appraisal Inventory (CRAI), which queries confidence in research skills and methods and periodic evaluation of training elements using the Supplemental Kellogg Logic-World Health Organization model, which emphasizes relevance, adequacy, efficiency, effectiveness, process, impact, equity, and sustainability. The BRIDG program exemplifies a new standard in interprofessional clinical research training, made possible through strong collaboration between disparate research- and clinically intensive institutions.
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Affiliation(s)
- Ryan Bradley
- 1 Helfgott Research Institute, National University of Natural Medicine, Portland, OR.,2 Department of Pharmaceutics, University of Washington, Seattle, WA.,3 Department of Family Medicine and Public Health, University of California, San Diego, CA
| | | | - Doug Hanes
- 1 Helfgott Research Institute, National University of Natural Medicine, Portland, OR
| | - Craig Scott
- 5 Department of Biomedical Informatics and Medical Education, and University of Washington, Seattle, WA
| | - Karen J Sherman
- 7 Department of Epidemiology, University of Washington, Seattle, WA.,6 Kaiser Permanente Washington Health Research Institute, Seattle, WA
| | - Yvonne S Lin
- 2 Department of Pharmaceutics, University of Washington, Seattle, WA
| | - Heather Zwickey
- 1 Helfgott Research Institute, National University of Natural Medicine, Portland, OR
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Tan WK, Hassanpour S, Heagerty PJ, Rundell SD, Suri P, Huhdanpaa HT, James K, Carrell DS, Langlotz CP, Organ NL, Meier EN, Sherman KJ, Kallmes DF, Luetmer PH, Griffith B, Nerenz DR, Jarvik JG. Comparison of Natural Language Processing Rules-based and Machine-learning Systems to Identify Lumbar Spine Imaging Findings Related to Low Back Pain. Acad Radiol 2018; 25:1422-1432. [PMID: 29605561 DOI: 10.1016/j.acra.2018.03.008] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Revised: 03/09/2018] [Accepted: 03/09/2018] [Indexed: 12/28/2022]
Abstract
RATIONALE AND OBJECTIVES To evaluate a natural language processing (NLP) system built with open-source tools for identification of lumbar spine imaging findings related to low back pain on magnetic resonance and x-ray radiology reports from four health systems. MATERIALS AND METHODS We used a limited data set (de-identified except for dates) sampled from lumbar spine imaging reports of a prospectively assembled cohort of adults. From N = 178,333 reports, we randomly selected N = 871 to form a reference-standard dataset, consisting of N = 413 x-ray reports and N = 458 MR reports. Using standardized criteria, four spine experts annotated the presence of 26 findings, where 71 reports were annotated by all four experts and 800 were each annotated by two experts. We calculated inter-rater agreement and finding prevalence from annotated data. We randomly split the annotated data into development (80%) and testing (20%) sets. We developed an NLP system from both rule-based and machine-learned models. We validated the system using accuracy metrics such as sensitivity, specificity, and area under the receiver operating characteristic curve (AUC). RESULTS The multirater annotated dataset achieved inter-rater agreement of Cohen's kappa > 0.60 (substantial agreement) for 25 of 26 findings, with finding prevalence ranging from 3% to 89%. In the testing sample, rule-based and machine-learned predictions both had comparable average specificity (0.97 and 0.95, respectively). The machine-learned approach had a higher average sensitivity (0.94, compared to 0.83 for rules-based), and a higher overall AUC (0.98, compared to 0.90 for rules-based). CONCLUSIONS Our NLP system performed well in identifying the 26 lumbar spine findings, as benchmarked by reference-standard annotation by medical experts. Machine-learned models provided substantial gains in model sensitivity with slight loss of specificity, and overall higher AUC.
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Dublin S, Walker RL, Shortreed SM, Ludman EJ, Sherman KJ, Hansen RN, Thakral M, Saunders K, Parchman ML, Von Korff M. Impact of initiatives to reduce prescription opioid risks on medically attended injuries in people using chronic opioid therapy. Pharmacoepidemiol Drug Saf 2018; 28:90-96. [PMID: 30375121 DOI: 10.1002/pds.4678] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Revised: 08/16/2018] [Accepted: 09/17/2018] [Indexed: 11/06/2022]
Abstract
PURPOSE The purpose of the study is to determine whether initiatives to improve the safety of opioid prescribing decreased injuries in people using chronic opioid therapy (COT). METHODS We conducted an interrupted time series analysis using data from Group Health (GH), an integrated health care delivery system in the United States. In 2007, GH implemented initiatives which substantially reduced daily opioid dose and increased patient monitoring. Among GH members age 18 or older receiving COT between 2006 and 2014, we compared injury rates for patients in GH's integrated group practice (IGP; exposed to the initiatives) vs patients cared for by contracted providers (not exposed). Injuries were identified using a validated algorithm. We calculated injury incidence during the baseline (preintervention) period from 2006 to 2007; the dose reduction period, 2008 to 2010; and the risk stratification and monitoring period, 2010 to 2014. Using modified Poisson regression, we estimated adjusted relative risks (RRs) representing the relative change per year in injury rates. RESULTS Among 21 853 people receiving COT in the IGP and 8260 in contracted care, there were 2679 injuries during follow-up. The baseline injury rate was 1.0% per calendar quarter in the IGP and 0.9% in contracted care. Risk reduction initiatives did not decrease injury rates: Within the IGP, the RR in the dose reduction period was 1.01 (95% CI, 0.95-1.07) and in the risk stratification and monitoring period, 0.99 (95% CI, 0.95-1.04). Injury trends did not differ between the two care settings. CONCLUSIONS Risk reduction initiatives did not decrease injuries in people using COT.
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Affiliation(s)
- Sascha Dublin
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA.,Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - Rod L Walker
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - Susan M Shortreed
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA.,Department of Biostatistics, University of Washington, Seattle, WA, USA
| | - Evette J Ludman
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - Karen J Sherman
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - Ryan N Hansen
- Departments of Pharmacy and Health Services, University of Washington, Seattle, WA, USA
| | - Manu Thakral
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - Kathleen Saunders
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - Michael L Parchman
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - Michael Von Korff
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
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Von Korff M, Saunders K, Dublin S, Walker RL, Thakral M, Sherman KJ, Ludman EJ, Hansen RN, Parchman M, Shortreed SM. Impact of Chronic Opioid Therapy Risk Reduction Initiatives on Opioid Overdose. J Pain 2018; 20:108-117. [PMID: 30189248 DOI: 10.1016/j.jpain.2018.08.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/24/2018] [Revised: 07/30/2018] [Accepted: 08/14/2018] [Indexed: 12/29/2022]
Abstract
We assessed the effects of opioid dose and risk reduction initiatives on opioid overdose rates among patients on chronic opioid therapy (COT). Using an interrupted time series design, we compared trends in overdose rates. We compared patients on COT in settings that implemented a COT dose reduction initiative and then a COT risk stratification/monitoring initiative to similar patients on COT from control settings. From 2006 to 2014, 31,142 patients on COT (22,673 intervention, 8,469 control) experienced 311 fatal or nonfatal opioid overdoses. In primary analyses, changes in opioid overdose rates among patients on COT did not differ significantly between intervention and control settings with the implementation of either dose reduction or risk stratification/monitoring. In planned secondary analyses, overdose rates decreased significantly (17% per year) during the dose reduction initiative among patients on COT in intervention settings (relative annual change, 0.83; 95% confidence interval, 0.70-0.99), but not in control settings (0.98. 95% confidence interval, 0.70-1.39). We conclude that overdose rates among patients on COT were not decreased by risk stratification and monitoring initiatives. Results were inconsistent for COT dose reduction, with no significant difference between intervention and control settings (primary hypothesis test), but a significant decrease in overdose rates within the intervention setting during dose reduction (secondary hypothesis test). PERSPECTIVE: Risk stratification/monitoring interventions among patients on COT did not decrease opioid overdose rates. The effects of COT dose reduction on opioid overdose rates were inconsistent. Greater decreases in COT dose, a larger control group, or both may have been needed to identify conclusive reductions in opioid overdose rates.
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Affiliation(s)
- Michael Von Korff
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington.
| | - Kathleen Saunders
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | - Sascha Dublin
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington; Departments of Epidemiology, University of Washington, Seattle, Washington
| | - Rod L Walker
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | - Manu Thakral
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington; Departments of Psychosocial and Community Health, School of Nursing, University of Washington, Seattle, Washington
| | - Karen J Sherman
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | - Evette J Ludman
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | - Ryan N Hansen
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington; Departments of Pharmacy and Health Services, University of Washington, Seattle, Washington
| | - Michael Parchman
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | - Susan M Shortreed
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington; Departments of Biostatistics, University of Washington, Seattle, Washington
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Evers S, Hsu C, Sherman KJ, Balderson B, Hawkes R, Brewer G, La Porte AM, Yeoman J, Cherkin D. Patient Perspectives on Communication with Primary Care Physicians about Chronic Low Back Pain. Perm J 2018; 21:16-177. [PMID: 29035178 DOI: 10.7812/tpp/16-177] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVES Chronic low back pain (CLBP) is a common health problem with challenges for providing satisfactory care. This study was undertaken to identify opportunities to improve key aspects of physicians' communications with CLBP-affected patients. METHODS A series of 3 focus groups, each with 7 to 11 patients with CLBP, were recruited from primary care settings and grouped by risk level of reduced function resulting from back pain, to elicit perspectives about interactions with their primary care physicians. Analysis of focus group transcripts used an iterative process based on a thematic approach and a priori concepts. RESULTS A total of 28 patients participated in the focus groups. Patient comments about communicating with physicians around CLBP fit into themes of listening and empathy, validating pain experiences, conducting effective CLBP assessment, providing clear diagnosis and information, and collaboratively working on treatment. Patients shared that physicians can foster positive interactions with CLBP-affected patients by sharing personal experiences of chronic pain, being truthful about not having all the answers and being clear about how patients can benefit from referrals, reviewing the patient's previous treatments before beginning conversations about treatment options, providing follow-up instructions, giving patients a diagnosis beyond "chronic pain," and explaining the role of imaging in their care. CONCLUSION This study provides specific steps that physicians in the US can take to improve physician-patient interactions during primary care visits pertaining to CLBP. The findings could inform physician training, development of educational materials for patients, and future research.
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Affiliation(s)
- Sarah Evers
- Research Associate at Kaiser Permanente Washington Health Research Institute in Seattle.
| | - Clarissa Hsu
- Assistant Investigator at Kaiser Permanente Washington Health Research Institute in Seattle.
| | - Karen J Sherman
- Scientific Investigator at Kaiser Permanente Washington Health Research Institute in Seattle.
| | - Ben Balderson
- Research Associate at Kaiser Permanente Washington Health Research Institute and a Psychologist for Kaiser Permanente Washington-Behavioral Health in Seattle.
| | - Rene Hawkes
- Project Manager at Kaiser Permanente Washington Health Research Institute in Seattle.
| | - Georgie Brewer
- Patient Partner at Kaiser Permanente Washington Health Research Institute in Seattle.
| | - Anne-Marie La Porte
- Patient Partner at Kaiser Permanente Washington Health Research Institute in Seattle.
| | - John Yeoman
- Patient Partner at Kaiser Permanente Washington Health Research Institute in Seattle.
| | - Dan Cherkin
- Emeritus Senior Scientific Investigator at Kaiser Permanente Washington Health Research Institute in Seattle.
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Rundell SD, Sherman KJ, Heagerty PJ, Mock CN, Dettori NJ, Comstock BA, Avins AL, Nedeljkovic SS, Nerenz DR, Jarvik JG. Predictors of Persistent Disability and Back Pain in Older Adults with a New Episode of Care for Back Pain. Pain Med 2018; 18:1049-1062. [PMID: 27688311 DOI: 10.1093/pm/pnw236] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Objective To identify predictors of persistent disability and back pain in older adults. Design Prospective cohort study. Setting Back pain outcomes using longitudinal data registry. Subjects Five thousand two hundred twenty adults age 65 years and older with a new primary care visit for back pain. Methods Baseline measurements included: demographics, health, and back pain characteristics. We abstracted imaging findings from 348 radiology reports. The primary outcomes were the Roland-Morris Disability Questionnaire (RMDQ) and back pain intensity. We defined persistent disability as RMDQ of 4/24 or higher at both six and 12 months and persistent back pain as pain 3/10 or higher at both six and 12 months. Results There were 2,498 of 4,143 (60.3%) participants with persistent disability, and 2,099 of 4,144 (50.7%) had persistent back pain. Adjusted analyses showed the following characteristics most strongly predictive of persistent disability and persistent back pain: sex, race, worse baseline clinical characteristics of back pain, leg pain, back-related disability and duration of symptoms, smoking, anxiety symptoms, depressive symptoms, a history of falls, greater number of comorbidities, knee osteoarthritis, wide-spread pain syndromes, and an index diagnosis of lumbar spinal stenosis. Within the imaging data subset, central spinal stenosis was not associated with disability or pain. Conclusion We found that many predictors in older adults were similar to those for younger populations.
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Affiliation(s)
- Sean D Rundell
- Department of Rehabilitation Medicine.,Comparative Effectiveness, Cost, and Outcomes Research Center
| | | | | | - Charles N Mock
- Department of Epidemiology, University of Washington and Harborview Injury Prevention Research Center, Seattle, Washington
| | | | | | - Andrew L Avins
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Srdjan S Nedeljkovic
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, and Spine Unit, Harvard Vanguard Medical Associates, Boston, MA
| | - David R Nerenz
- Henry Ford Hospital, Neuroscience Institute, Detroit, MI, USA
| | - Jeffrey G Jarvik
- Comparative Effectiveness, Cost, and Outcomes Research Center.,Department of Radiology, Neurological Surgery, Orthopedic Surgery and Sports Medicine, Health Services and Pharmacy, University of Washington, Seattle, Washington
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Vickers AJ, Vertosick EA, Lewith G, MacPherson H, Foster NE, Sherman KJ, Irnich D, Witt CM, Linde K. Acupuncture for Chronic Pain: Update of an Individual Patient Data Meta-Analysis. J Pain 2017; 19:455-474. [PMID: 29198932 DOI: 10.1016/j.jpain.2017.11.005] [Citation(s) in RCA: 381] [Impact Index Per Article: 54.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Revised: 10/27/2017] [Accepted: 11/06/2017] [Indexed: 12/23/2022]
Abstract
Despite wide use in clinical practice, acupuncture remains a controversial treatment for chronic pain. Our objective was to update an individual patient data meta-analysis to determine the effect size of acupuncture for 4 chronic pain conditions. We searched MEDLINE and the Cochrane Central Registry of Controlled Trials randomized trials published up until December 31, 2015. We included randomized trials of acupuncture needling versus either sham acupuncture or no acupuncture control for nonspecific musculoskeletal pain, osteoarthritis, chronic headache, or shoulder pain. Trials were only included if allocation concealment was unambiguously determined to be adequate. Raw data were obtained from study authors and entered into an individual patient data meta-analysis. The main outcome measures were pain and function. An additional 13 trials were identified, with data received for a total of 20,827 patients from 39 trials. Acupuncture was superior to sham as well as no acupuncture control for each pain condition (all P < .001) with differences between groups close to .5 SDs compared with no acupuncture control and close to .2 SDs compared with sham. We also found clear evidence that the effects of acupuncture persist over time with only a small decrease, approximately 15%, in treatment effect at 1 year. In secondary analyses, we found no obvious association between trial outcome and characteristics of acupuncture treatment, but effect sizes of acupuncture were associated with the type of control group, with smaller effects sizes for sham controlled trials that used a penetrating needle for sham, and for trials that had high intensity of intervention in the control arm. We conclude that acupuncture is effective for the treatment of chronic pain, with treatment effects persisting over time. Although factors in addition to the specific effects of needling at correct acupuncture point locations are important contributors to the treatment effect, decreases in pain after acupuncture cannot be explained solely in terms of placebo effects. Variations in the effect size of acupuncture in different trials are driven predominantly by differences in treatments received by the control group rather than by differences in the characteristics of acupuncture treatment. PERSPECTIVE Acupuncture is effective for the treatment of chronic musculoskeletal, headache, and osteoarthritis pain. Treatment effects of acupuncture persist over time and cannot be explained solely in terms of placebo effects. Referral for a course of acupuncture treatment is a reasonable option for a patient with chronic pain.
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Affiliation(s)
| | | | - George Lewith
- University of Southampton, Southampton, United Kingdom (deceased)
| | | | | | - Karen J Sherman
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | | | - Claudia M Witt
- University Hospital Zurich, University of Zurich, Zurich, Switzerland; Charite-Universitätsmedizin, Berlin, Germany; University of Maryland School of Medicine, Baltimore, Maryland
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Thakral M, Walker RL, Saunders K, Shortreed SM, Parchman M, Hansen RN, Ludman E, Sherman KJ, Dublin S, Von Korff M. Comparing Pain and Depressive Symptoms of Chronic Opioid Therapy Patients Receiving Dose Reduction and Risk Mitigation Initiatives With Usual Care. J Pain 2017; 19:111-120. [PMID: 29038060 DOI: 10.1016/j.jpain.2017.09.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Revised: 08/30/2017] [Accepted: 09/30/2017] [Indexed: 01/30/2023]
Abstract
Dose reduction and risk mitigation initiatives have been recommended to reduce opioid-related risks among patients receiving chronic opioid therapy (COT), but questions remain over whether these initiatives worsen pain control and quality of life. In 2014 to 2015, we interviewed 1,588 adult COT patients within a health care system in Washington State and compared those who received dose reduction and risk mitigation initiatives in primary care clinics (intervention) with patients in comparable health care settings without initiatives (control). The primary outcomes were pain assessed using the pain, enjoyment, and general activity (PEG) scale, a 3-item scale to assess global pain intensity and interference, with secondary measures including depression (Patient Health Questionnaire-8 scale). Generalized estimating equations for linear regression models were used to estimate differences in mean scores between intervention and control sites. Estimated differences, adjusted for patient characteristics and weighted for nonresponse, between patients at intervention and control clinics were not clinically significant for the PEG (-.03, 95% confidence interval = -.25 to .19) or Patient Health Questionnaire-8 (-.64, 95% confidence interval = -1.19 to -.08). We found no evidence that COT patients in clinics with dose reduction and risk mitigation initiatives had clinically meaningful differences in pain intensity, interference with activities and enjoyment of life, or depressive symptoms compared with control health care settings. PERSPECTIVE This article evaluates the effect of dose reduction and risk mitigation initiatives, such as those recently recommended by the Centers for Disease Control and Prevention, to reduce risks associated with COT on global pain and interference, depressive symptoms, and perceived pain relief and bothersomeness of side effects.
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Affiliation(s)
- Manu Thakral
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington; Department of Psychosocial and Community Health, School of Nursing, University of Washington, Seattle, Washington.
| | - Rod L Walker
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | - Kathleen Saunders
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | - Susan M Shortreed
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington; Department of Biostatistics, University of Washington, Seattle, Washington
| | - Michael Parchman
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | - Ryan N Hansen
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington; Departments of Pharmacy and Health Services, University of Washington, Seattle, Washington
| | - Evette Ludman
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | - Karen J Sherman
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington; Department of Epidemiology, University of Washington, Seattle, Washington
| | - Sascha Dublin
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington; Department of Epidemiology, University of Washington, Seattle, Washington
| | - Michael Von Korff
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
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Saper RB, Lemaster C, Delitto A, Sherman KJ, Herman PM, Sadikova E, Stevans J, Keosaian JE, Cerrada CJ, Femia AL, Roseen EJ, Gardiner P, Gergen Barnett K, Faulkner C, Weinberg J. Yoga, Physical Therapy, or Education for Chronic Low Back Pain: A Randomized Noninferiority Trial. Ann Intern Med 2017; 167. [PMID: 28631003 PMCID: PMC6392183 DOI: 10.7326/m16-2579] [Citation(s) in RCA: 110] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Yoga is effective for mild to moderate chronic low back pain (cLBP), but its comparative effectiveness with physical therapy (PT) is unknown. Moreover, little is known about yoga's effectiveness in underserved patients with more severe functional disability and pain. OBJECTIVE To determine whether yoga is noninferior to PT for cLBP. DESIGN 12-week, single-blind, 3-group randomized noninferiority trial and subsequent 40-week maintenance phase. (ClinicalTrials.gov: NCT01343927). SETTING Academic safety-net hospital and 7 affiliated community health centers. PARTICIPANTS 320 predominantly low-income, racially diverse adults with nonspecific cLBP. INTERVENTION Participants received 12 weekly yoga classes, 15 PT visits, or an educational book and newsletters. The maintenance phase compared yoga drop-in classes versus home practice and PT booster sessions versus home practice. MEASUREMENTS Primary outcomes were back-related function, measured by the Roland Morris Disability Questionnaire (RMDQ), and pain, measured by an 11-point scale, at 12 weeks. Prespecified noninferiority margins were 1.5 (RMDQ) and 1.0 (pain). Secondary outcomes included pain medication use, global improvement, satisfaction with intervention, and health-related quality of life. RESULTS One-sided 95% lower confidence limits were 0.83 (RMDQ) and 0.97 (pain), demonstrating noninferiority of yoga to PT. However, yoga was not superior to education for either outcome. Yoga and PT were similar for most secondary outcomes. Yoga and PT participants were 21 and 22 percentage points less likely, respectively, than education participants to use pain medication at 12 weeks. Improvements in yoga and PT groups were maintained at 1 year with no differences between maintenance strategies. Frequency of adverse events, mostly mild self-limited joint and back pain, did not differ between the yoga and PT groups. LIMITATIONS Participants were not blinded to treatment assignment. The PT group had disproportionate loss to follow-up. CONCLUSION A manualized yoga program for nonspecific cLBP was noninferior to PT for function and pain. PRIMARY FUNDING SOURCE National Center for Complementary and Integrative Health of the National Institutes of Health.
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Affiliation(s)
- Robert B Saper
- From Boston University School of Medicine, Boston Medical Center, Harvard Medical School, and Boston University School of Public Health, Boston, Massachusetts; University of Pittsburgh School of Health and Rehabilitation Sciences, Pittsburgh, Pennsylvania; Group Health Research Institute and University of Washington, Seattle, Washington; and RAND Corporation, Santa Monica, California
| | - Chelsey Lemaster
- From Boston University School of Medicine, Boston Medical Center, Harvard Medical School, and Boston University School of Public Health, Boston, Massachusetts; University of Pittsburgh School of Health and Rehabilitation Sciences, Pittsburgh, Pennsylvania; Group Health Research Institute and University of Washington, Seattle, Washington; and RAND Corporation, Santa Monica, California
| | - Anthony Delitto
- From Boston University School of Medicine, Boston Medical Center, Harvard Medical School, and Boston University School of Public Health, Boston, Massachusetts; University of Pittsburgh School of Health and Rehabilitation Sciences, Pittsburgh, Pennsylvania; Group Health Research Institute and University of Washington, Seattle, Washington; and RAND Corporation, Santa Monica, California
| | - Karen J Sherman
- From Boston University School of Medicine, Boston Medical Center, Harvard Medical School, and Boston University School of Public Health, Boston, Massachusetts; University of Pittsburgh School of Health and Rehabilitation Sciences, Pittsburgh, Pennsylvania; Group Health Research Institute and University of Washington, Seattle, Washington; and RAND Corporation, Santa Monica, California
| | - Patricia M Herman
- From Boston University School of Medicine, Boston Medical Center, Harvard Medical School, and Boston University School of Public Health, Boston, Massachusetts; University of Pittsburgh School of Health and Rehabilitation Sciences, Pittsburgh, Pennsylvania; Group Health Research Institute and University of Washington, Seattle, Washington; and RAND Corporation, Santa Monica, California
| | - Ekaterina Sadikova
- From Boston University School of Medicine, Boston Medical Center, Harvard Medical School, and Boston University School of Public Health, Boston, Massachusetts; University of Pittsburgh School of Health and Rehabilitation Sciences, Pittsburgh, Pennsylvania; Group Health Research Institute and University of Washington, Seattle, Washington; and RAND Corporation, Santa Monica, California
| | - Joel Stevans
- From Boston University School of Medicine, Boston Medical Center, Harvard Medical School, and Boston University School of Public Health, Boston, Massachusetts; University of Pittsburgh School of Health and Rehabilitation Sciences, Pittsburgh, Pennsylvania; Group Health Research Institute and University of Washington, Seattle, Washington; and RAND Corporation, Santa Monica, California
| | - Julia E Keosaian
- From Boston University School of Medicine, Boston Medical Center, Harvard Medical School, and Boston University School of Public Health, Boston, Massachusetts; University of Pittsburgh School of Health and Rehabilitation Sciences, Pittsburgh, Pennsylvania; Group Health Research Institute and University of Washington, Seattle, Washington; and RAND Corporation, Santa Monica, California
| | - Christian J Cerrada
- From Boston University School of Medicine, Boston Medical Center, Harvard Medical School, and Boston University School of Public Health, Boston, Massachusetts; University of Pittsburgh School of Health and Rehabilitation Sciences, Pittsburgh, Pennsylvania; Group Health Research Institute and University of Washington, Seattle, Washington; and RAND Corporation, Santa Monica, California
| | - Alexandra L Femia
- From Boston University School of Medicine, Boston Medical Center, Harvard Medical School, and Boston University School of Public Health, Boston, Massachusetts; University of Pittsburgh School of Health and Rehabilitation Sciences, Pittsburgh, Pennsylvania; Group Health Research Institute and University of Washington, Seattle, Washington; and RAND Corporation, Santa Monica, California
| | - Eric J Roseen
- From Boston University School of Medicine, Boston Medical Center, Harvard Medical School, and Boston University School of Public Health, Boston, Massachusetts; University of Pittsburgh School of Health and Rehabilitation Sciences, Pittsburgh, Pennsylvania; Group Health Research Institute and University of Washington, Seattle, Washington; and RAND Corporation, Santa Monica, California
| | - Paula Gardiner
- From Boston University School of Medicine, Boston Medical Center, Harvard Medical School, and Boston University School of Public Health, Boston, Massachusetts; University of Pittsburgh School of Health and Rehabilitation Sciences, Pittsburgh, Pennsylvania; Group Health Research Institute and University of Washington, Seattle, Washington; and RAND Corporation, Santa Monica, California
| | - Katherine Gergen Barnett
- From Boston University School of Medicine, Boston Medical Center, Harvard Medical School, and Boston University School of Public Health, Boston, Massachusetts; University of Pittsburgh School of Health and Rehabilitation Sciences, Pittsburgh, Pennsylvania; Group Health Research Institute and University of Washington, Seattle, Washington; and RAND Corporation, Santa Monica, California
| | - Carol Faulkner
- From Boston University School of Medicine, Boston Medical Center, Harvard Medical School, and Boston University School of Public Health, Boston, Massachusetts; University of Pittsburgh School of Health and Rehabilitation Sciences, Pittsburgh, Pennsylvania; Group Health Research Institute and University of Washington, Seattle, Washington; and RAND Corporation, Santa Monica, California
| | - Janice Weinberg
- From Boston University School of Medicine, Boston Medical Center, Harvard Medical School, and Boston University School of Public Health, Boston, Massachusetts; University of Pittsburgh School of Health and Rehabilitation Sciences, Pittsburgh, Pennsylvania; Group Health Research Institute and University of Washington, Seattle, Washington; and RAND Corporation, Santa Monica, California
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MacPherson H, Vertosick EA, Foster NE, Lewith G, Linde K, Sherman KJ, Witt CM, Vickers AJ. The persistence of the effects of acupuncture after a course of treatment: a meta-analysis of patients with chronic pain. Pain 2017; 158:784-793. [PMID: 27764035 PMCID: PMC5393924 DOI: 10.1097/j.pain.0000000000000747] [Citation(s) in RCA: 101] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
There is uncertainty regarding how long the effects of acupuncture treatment persist after a course of treatment. We aimed to determine the trajectory of pain scores over time after acupuncture, using a large individual patient data set from high-quality randomized trials of acupuncture for chronic pain. The available individual patient data set included 29 trials and 17,922 patients. The chronic pain conditions included musculoskeletal pain (low back, neck, and shoulder), osteoarthritis of the knee, and headache/migraine. We used meta-analytic techniques to determine the trajectory of posttreatment pain scores. Data on longer term follow-up were available for 20 trials, including 6376 patients. In trials comparing acupuncture to no acupuncture control (wait-list, usual care, etc), effect sizes diminished by a nonsignificant 0.011 SD per 3 months (95% confidence interval: -0.014 to 0.037, P = 0.4) after treatment ended. The central estimate suggests that approximately 90% of the benefit of acupuncture relative to controls would be sustained at 12 months. For trials comparing acupuncture to sham, we observed a reduction in effect size of 0.025 SD per 3 months (95% confidence interval: 0.000-0.050, P = 0.050), suggesting approximately a 50% diminution at 12 months. The effects of a course of acupuncture treatment for patients with chronic pain do not seem to decrease importantly over 12 months. Patients can generally be reassured that treatment effects persist. Studies of the cost-effectiveness of acupuncture should take our findings into account when considering the time horizon of acupuncture effects. Further research should measure longer term outcomes of acupuncture.
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Affiliation(s)
- H MacPherson
- Department of Health Sciences, University of York, UK
| | - EA Vertosick
- Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - NE Foster
- Research Institute for Primary Care and Health Sciences, Keele University, UK
| | - G Lewith
- University of Southampton, Southampton, UK
| | - K Linde
- Institute of General Practice, Technische Universität München, Germany
| | - KJ Sherman
- Group Health Research Institute, Seattle, WA, USA
| | - CM Witt
- Institute for Complementary and Integrative Medicine, University of Zurich and University Hospital Zurich, Zurich, Switzerland
- Institute for Social Medicine, Epidemiology and Health Economics, Charité - Universitätsmedizin, Berlin, Germany
- Center for Integrative Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - AJ Vickers
- Memorial Sloan-Kettering Cancer Center, New York, NY, USA
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40
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Cherkin DC, Anderson ML, Sherman KJ, Balderson BH, Cook AJ, Hansen KE, Turner JA. Two-Year Follow-up of a Randomized Clinical Trial of Mindfulness-Based Stress Reduction vs Cognitive Behavioral Therapy or Usual Care for Chronic Low Back Pain. JAMA 2017; 317:642-644. [PMID: 28196244 DOI: 10.1001/jama.2016.17814] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
| | | | | | | | - Andrea J Cook
- Group Health Research Institute, Seattle, Washington
| | | | - Judith A Turner
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle
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Affiliation(s)
| | | | - Judith A Turner
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle
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Saper RB, Lemaster CM, Elwy AR, Paris R, Herman PM, Plumb DN, Sherman KJ, Groessl EJ, Lynch S, Wang S, Weinberg J. Yoga versus education for Veterans with chronic low back pain: study protocol for a randomized controlled trial. Trials 2016; 17:224. [PMID: 27129472 PMCID: PMC4850721 DOI: 10.1186/s13063-016-1321-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Accepted: 04/01/2016] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Chronic low back pain is the most frequent pain condition in Veterans and causes substantial suffering, decreased functional capacity, and lower quality of life. Symptoms of post-traumatic stress, depression, and mild traumatic brain injury are highly prevalent in Veterans with back pain. Yoga for low back pain has been demonstrated to be effective for civilians in randomized controlled trials. However, it is unknown if results from previously published trials generalize to military populations. METHODS/DESIGN This study is a parallel randomized controlled trial comparing yoga to education for 120 Veterans with chronic low back pain. Participants are Veterans ≥18 years old with low back pain present on at least half the days in the past six months and a self-reported average pain intensity in the previous week of ≥4 on a 0-10 scale. The 24-week study has an initial 12-week intervention period, where participants are randomized equally into (1) a standardized weekly group yoga class with home practice or (2) education delivered with a self-care book. Primary outcome measures are change at 12 weeks in low back pain intensity measured by the Defense and Veterans Pain Rating Scale (0-10) and back-related function using the 23-point Roland Morris Disability Questionnaire. In the subsequent 12-week follow-up period, yoga participants are encouraged to continue home yoga practice and education participants continue following recommendations from the book. Qualitative interviews with Veterans in the yoga group and their partners explore the impact of chronic low back pain and yoga on family relationships. We also assess cost-effectiveness from three perspectives: the Veteran, the Veterans Health Administration, and society using electronic medical records, self-reported cost data, and study records. DISCUSSION This study will help determine if yoga can become an effective treatment for Veterans with chronic low back pain and psychological comorbidities. TRIAL REGISTRATION ClinicalTrials.gov: NCT02224183.
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Affiliation(s)
- Robert B. Saper
- />Department of Family Medicine, Boston University School of Medicine and Boston Medical Center, Boston, MA USA
| | - Chelsey M. Lemaster
- />Department of Family Medicine, Boston University School of Medicine and Boston Medical Center, Boston, MA USA
| | - A. Rani Elwy
- />Center for Information Dissemination and Education Resources, VA Boston Healthcare System, Boston, MA USA
- />Department of Health Policy and Management, Boston University School of Public Health, Boston, MA USA
| | - Ruth Paris
- />Boston University School of Social Work, Boston, MA USA
| | | | - Dorothy N. Plumb
- />Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA USA
| | - Karen J. Sherman
- />Group Health Research Institute, Seattle, WA USA
- />Department of Epidemiology, University of Washington, Seattle, WA USA
| | - Erik J. Groessl
- />VA San Diego Healthcare System, San Diego, CA USA
- />Department of Family and Preventive Medicine, University of California San Diego School of Medicine, San Diego, CA USA
| | - Susan Lynch
- />There & Back Again, Inc., Wakefield, MA USA
| | - Shihwe Wang
- />Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA USA
| | - Janice Weinberg
- />Department of Biostatistics, Boston University School of Public Health, Boston, MA USA
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Cherkin DC, Sherman KJ, Balderson BH, Cook AJ, Anderson ML, Hawkes RJ, Hansen KE, Turner JA. Effect of Mindfulness-Based Stress Reduction vs Cognitive Behavioral Therapy or Usual Care on Back Pain and Functional Limitations in Adults With Chronic Low Back Pain: A Randomized Clinical Trial. JAMA 2016; 315:1240-9. [PMID: 27002445 PMCID: PMC4914381 DOI: 10.1001/jama.2016.2323] [Citation(s) in RCA: 375] [Impact Index Per Article: 46.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
IMPORTANCE Mindfulness-based stress reduction (MBSR) has not been rigorously evaluated for young and middle-aged adults with chronic low back pain. OBJECTIVE To evaluate the effectiveness for chronic low back pain of MBSR vs cognitive behavioral therapy (CBT) or usual care. DESIGN, SETTING, AND PARTICIPANTS Randomized, interviewer-blind, clinical trial in an integrated health care system in Washington State of 342 adults aged 20 to 70 years with chronic low back pain enrolled between September 2012 and April 2014 and randomly assigned to receive MBSR (n = 116), CBT (n = 113), or usual care (n = 113). INTERVENTIONS CBT (training to change pain-related thoughts and behaviors) and MBSR (training in mindfulness meditation and yoga) were delivered in 8 weekly 2-hour groups. Usual care included whatever care participants received. MAIN OUTCOMES AND MEASURES Coprimary outcomes were the percentages of participants with clinically meaningful (≥30%) improvement from baseline in functional limitations (modified Roland Disability Questionnaire [RDQ]; range, 0-23) and in self-reported back pain bothersomeness (scale, 0-10) at 26 weeks. Outcomes were also assessed at 4, 8, and 52 weeks. RESULTS There were 342 randomized participants, the mean (SD) [range] age was 49.3 (12.3) [20-70] years, 224 (65.7%) were women, mean duration of back pain was 7.3 years (range, 3 months-50 years), 123 (53.7%) attended 6 or more of the 8 sessions, 294 (86.0%) completed the study at 26 weeks, and 290 (84.8%) completed the study at 52 weeks. In intent-to-treat analyses at 26 weeks, the percentage of participants with clinically meaningful improvement on the RDQ was higher for those who received MBSR (60.5%) and CBT (57.7%) than for usual care (44.1%) (overall P = .04; relative risk [RR] for MBSR vs usual care, 1.37 [95% CI, 1.06-1.77]; RR for MBSR vs CBT, 0.95 [95% CI, 0.77-1.18]; and RR for CBT vs usual care, 1.31 [95% CI, 1.01-1.69]). The percentage of participants with clinically meaningful improvement in pain bothersomeness at 26 weeks was 43.6% in the MBSR group and 44.9% in the CBT group, vs 26.6% in the usual care group (overall P = .01; RR for MBSR vs usual care, 1.64 [95% CI, 1.15-2.34]; RR for MBSR vs CBT, 1.03 [95% CI, 0.78-1.36]; and RR for CBT vs usual care, 1.69 [95% CI, 1.18-2.41]). Findings for MBSR persisted with little change at 52 weeks for both primary outcomes. CONCLUSIONS AND RELEVANCE Among adults with chronic low back pain, treatment with MBSR or CBT, compared with usual care, resulted in greater improvement in back pain and functional limitations at 26 weeks, with no significant differences in outcomes between MBSR and CBT. These findings suggest that MBSR may be an effective treatment option for patients with chronic low back pain. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01467843.
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Affiliation(s)
- Daniel C. Cherkin
- Corresponding author. Group Health Research Institute; 1730 Minor Avenue, Suite 1600, Seattle, WA 98101; ; (206) 287-2875
| | - Karen J. Sherman
- Group Health Research Institute; Department of Epidemiology, University of Washington
| | | | - Andrea J. Cook
- Group Health Research Institute; Department of Biostatistics, University of Washington
| | | | - Rene J. Hawkes
- Group Health Research Institute, University of Washington
| | | | - Judith A. Turner
- Departments of Psychiatry and Behavioral Sciences and Rehabilitation Medicine, University of Washington
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Keosaian JE, Lemaster CM, Dresner D, Godersky ME, Paris R, Sherman KJ, Saper RB. "We're all in this together": A qualitative study of predominantly low income minority participants in a yoga trial for chronic low back pain. Complement Ther Med 2015; 24:34-9. [PMID: 26860799 DOI: 10.1016/j.ctim.2015.11.007] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2015] [Revised: 11/23/2015] [Accepted: 11/28/2015] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE To explore the experiences of low-income minority adults taking part in a yoga dosing trial for chronic low back pain. DESIGN Individual semi-structured interviews were conducted with nineteen participants recruited from a randomized yoga dosing trial for predominantly low-income minority adults with chronic low back pain. Interviews discussed the impact of yoga on low back pain and emotions; other perceived advantages or disadvantages of the intervention; and facilitators and barriers to practicing yoga. Interviews were audio taped and transcribed, coded using ATLAS.ti software, and analyzed with inductive and deductive thematic analysis methods. SETTING Boston Medical Center, Boston, MA, USA. RESULTS Participants viewed yoga as a means of pain relief and attributed improved mood, greater ability to manage stress, and enhanced relaxation to yoga. Overall, participants felt empowered to self-manage their pain. Some found yoga to be helpful in being mindful of their emotions and accepting of their pain. Trust in the yoga instructors was a commonly cited facilitator for yoga class attendance. Lack of time, motivation, and fear of injury were reported barriers to yoga practice. CONCLUSIONS Yoga is a multidimensional treatment for low back pain that has the potential to favorably impact health in a predominantly low-income minority population.
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Affiliation(s)
- Julia E Keosaian
- Department of Family Medicine, Boston Medical Center and Boston University School of Medicine, Boston, MA, USA.
| | - Chelsey M Lemaster
- Department of Family Medicine, Boston Medical Center and Boston University School of Medicine, Boston, MA, USA
| | - Danielle Dresner
- Department of Family Medicine, Boston Medical Center and Boston University School of Medicine, Boston, MA, USA
| | - Margo E Godersky
- Department of Family Medicine, Boston Medical Center and Boston University School of Medicine, Boston, MA, USA
| | - Ruth Paris
- Boston University School of Social Work, Boston, MA, USA
| | - Karen J Sherman
- Group Health Research Institute, Group Health Cooperative, WA and Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - Robert B Saper
- Department of Family Medicine, Boston Medical Center and Boston University School of Medicine, Boston, MA, USA
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Cook AJ, Wellman RD, Cherkin DC, Kahn JR, Sherman KJ. Randomized clinical trial assessing whether additional massage treatments for chronic neck pain improve 12- and 26-week outcomes. Spine J 2015; 15:2206-15. [PMID: 26096474 PMCID: PMC4596391 DOI: 10.1016/j.spinee.2015.06.049] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2014] [Revised: 05/18/2015] [Accepted: 06/12/2015] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT This is the first study to systematically evaluate the value of a longer treatment period for massage. We provide a framework of how to conceptualize an optimal dose in this challenging setting of nonpharmacologic treatments. PURPOSE The aim was to determine the optimal dose of massage for neck pain. STUDY DESIGN/SETTING Two-phase randomized trial for persons with chronic nonspecific neck pain. Primary randomization to one of five groups receiving 4 weeks of massage (30 minutes 2x/or 3x/wk or 60 minutes 1x, 2x, or 3x/wk). Booster randomization of participants to receive an additional six massages, 60 minutes 1x/wk, or no additional massage. PATIENT SAMPLE A total of 179 participants from Group Health and the general population of Seattle, WA, USA recruited between June 2010 and August 2011 were included. OUTCOME MEASURES Primary outcomes self-reported neck-related dysfunction (Neck Disability Index) and pain (0-10 scale) were assessed at baseline, 12, and 26 weeks. Clinically meaningful improvement was defined as greater than or equal to 5-point decrease in dysfunction and greater than or equal to 30% decrease in pain from baseline. METHODS Clinically meaningful improvement for each primary outcome with both follow-up times was analyzed using adjusted modified Poisson generalized estimating equations (GEEs). Secondary analyses for the continuous outcomes used linear GEEs. RESULTS There were no observed differences by primary treatment group at 12 or 26 weeks. Those receiving booster dose had improvements in both dysfunction and pain at 12 weeks (dysfunction: relative risk [RR]=1.56 [1.08-2.25], p=.018; pain: RR=1.25 [0.98-1.61], p=.077), but those were nonsignificant at 26 weeks (dysfunction: RR=1.22 [0.85-1.74]; pain: RR=1.09 [0.82-1.43]). Subgroup analysis by primary and booster treatments found the booster dose only effective among those initially randomized to one of the 60-minute massage groups. CONCLUSIONS "Booster" doses for those initially receiving 60 minutes of massage should be incorporated into future trials of massage for chronic neck pain.
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Affiliation(s)
- Andrea J Cook
- Group Health Research Institute, 1730 Minor Ave, Suite 1600, Seattle, WA 98101, USA; Department of Biostatistics, University of Washington, 1959 NE Pacific Street, Health Sciences Building F-600, Box 357232, Seattle, WA 98195, USA.
| | - Robert D Wellman
- Group Health Research Institute, 1730 Minor Ave, Suite 1600, Seattle, WA 98101, USA
| | - Daniel C Cherkin
- Group Health Research Institute, 1730 Minor Ave, Suite 1600, Seattle, WA 98101, USA
| | - Janet R Kahn
- Department of Psychiatry, University of Vermont College of Medicine, 1 South Prospect Street, MS 446AR6, Burlington, VT 05401, USA
| | - Karen J Sherman
- Group Health Research Institute, 1730 Minor Ave, Suite 1600, Seattle, WA 98101, USA; Department of Epidemiology, University of Washington, 1959 NE Pacific Street, Health Sciences Building F-250, Box 357236, Seattle, WA 98195, USA
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Rundell SD, Sherman KJ, Heagerty PJ, Mock CN, Jarvik JG. The clinical course of pain and function in older adults with a new primary care visit for back pain. J Am Geriatr Soc 2015; 63:524-30. [PMID: 25754841 DOI: 10.1111/jgs.13241] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To report the clinical course of older adults presenting for a new primary care visit for back pain, no healthcare visit for back pain within the prior 6 months, by describing pain intensity, disability, pain interference, and resolution of back pain over 12 months. DESIGN Prospective inception cohort study. SETTING Primary care settings of three integrated healthcare systems in the United States that participated in the Back pain Outcomes using Longitudinal Data (BOLD) registry. PARTICIPANTS Five thousand two hundred eleven (99.5%) of the 5,239 adults aged 65 and older who had reached their 12-month follow-up date. MEASUREMENTS Baseline demographic characteristics, EQ-5D score, duration of back pain, expectation for recovery, depression, and anxiety. Participant-reported outcomes of back-related disability (Roland Morris Disability Questionnaire), numerical pain rating scale, pain interference, and resolution of back pain were collected at baseline and 3, 6, and 12 months. RESULTS Most improvement occurred within the first 3 months. The number and proportion with 30% improvement in back pain increased from 1,950 (42.3%) at 3 months to 1,994 (44.8%) by 12 months, and 1,331 (28.8%) and 1,576 (35.4%) had 30% improvement in disability at 3 and 12 months. Only 23.0% reported that their back pain had resolved at 12 months. Improvements in disability and interference with activity over 12 months differed according to age, duration of back pain, symptoms of depression and anxiety, and expectation for recovery. CONCLUSION The majority of older adults in primary care practice settings presenting with a new visit for back pain have persistent symptoms, disability, and interference over 12 months of follow-up. Future research is needed to identify risk factors for persistent symptoms and effective interventions.
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Affiliation(s)
- Sean D Rundell
- Department of Rehabilitation Medicine, University of Washington, Seattle, Washington; Department of Comparative Effectiveness, Cost, and Outcomes Research Center, University of Washington, Seattle, Washington
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Tran HH, Weinberg J, Sherman KJ, Saper RB. Preference and Expectation for Treatment Assignment in a Randomized Controlled Trial of Once- vs Twice-weekly Yoga for Chronic Low Back Pain. Glob Adv Health Med 2015; 4:34-9. [PMID: 25694850 PMCID: PMC4311555 DOI: 10.7453/gahmj.2014.066] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Background: In studies involving nonpharmacological complementary and alternative medicine interventions, participant blinding is very difficult. Participant expectations may affect perceived benefit of therapy. In studies of yoga as treatment for chronic low back pain, little is known about the relationship between patient expectations and preferences on outcomes. This study was designed to identify baseline predictors of preference and to determine if expectations and preferences for different doses of yoga affect back-related function and low back pain intensity. Methods: This was a secondary data analysis of a 12-week randomized controlled trial comparing once-weekly vs twice-weekly yoga for treatment of chronic low back pain in 93 adults from a predominantly low-income minority population. At baseline, participants were asked about back function, back pain, treatment expectations, and treatment preferences. We created a variable “concordance” to describe the matching of participant preference to randomized treatment. Our outcome variables were change in back function and pain intensity after 12 weeks of yoga instruction. We performed logistic regression to identify predictors of preference for once- or twice-weekly yoga instruction. We created linear regression models to identify independent associations between expectations, preference, concordance, and outcomes. Results: Worse back function at baseline was associated with 20% higher odds of preferring twice-weekly yoga (OR 1.2, CI 1.1, 1.3). Individuals with higher expectation scores for twice-weekly yoga had 90% higher odds of preferring twice-weekly vs once-weekly yoga (OR 1.9, CI 1.3, 2.7). Individuals with higher expectation scores for once-weekly yoga had 40% less odds of preferring twice-weekly yoga (OR 0.6, CI 0.5, 0.9). After controlling for baseline characteristics, we found no statistically significant relationship between treatment outcomes, preference, expectation scores, or concordance. Conclusion: In a population of predominantly low-income minority participants with chronic low back pain, worse back function was associated with preference for more frequent yoga classes. Those who preferred more yoga classes had higher expectations for those classes. Twelve-week change in back pain intensity and back function were not affected by dosing preference, expectation score, or concordance. More research is needed to better measure and quantify preference, expectations, and their relationship to outcomes in yoga research.
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Affiliation(s)
- Huong H Tran
- Department of Family Medicine, Boston University School of Medicine and Boston Medical Center, Massachusetts (Dr Tran), United States
| | - Janice Weinberg
- Department of Biostatistics, Boston University School of Public Health, Massachusetts (Dr Weinberg), United States
| | - Karen J Sherman
- Group Health Research Institute, Group Health Cooperative, Seattle, Washington and Department of Epidemiology, University of Washington, Seattle (Dr Sherman), United States
| | - Robert B Saper
- Department of Family Medicine, Boston University School of Medicine and Boston Medical Center, Massachusetts (Dr Saper), United States
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Eaves ER, Sherman KJ, Ritenbaugh C, Hsu C, Nichter M, Turner JA, Cherkin DC. A qualitative study of changes in expectations over time among patients with chronic low back pain seeking four CAM therapies. BMC Complement Altern Med 2015; 15:12. [PMID: 25652396 PMCID: PMC4322442 DOI: 10.1186/s12906-015-0531-9] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/13/2014] [Accepted: 01/16/2015] [Indexed: 12/04/2022]
Abstract
BACKGROUND The relationship between patient expectations about a treatment and the treatment outcomes, particularly for Complementary and Alternative Medicine (CAM) therapies, is not well understood. Using qualitative data from a larger study to develop a valid expectancy questionnaire for use with participants starting new CAM therapies, we examined how participants' expectations of treatment changed over the course of a therapy. METHODS We conducted semi-structured qualitative interviews with 64 participants initiating one of four CAM therapies (yoga, chiropractic, acupuncture, massage) for chronic low back pain. Participants just starting treatment were interviewed up to three times over a period of 3 months. Interviews were transcribed verbatim and analyzed using a qualitative mixed methods approach incorporating immersion/crystallization and matrix analysis for a decontexualization and recontextualization approach to understand changes in thematic emphasis over time. RESULTS Pre-treatment expectations consisted of conjecture about whether or not the CAM therapy could relieve pain and improve participation in meaningful activities. Expectations tended to shift over the course of treatment to be more inclusive of broader lifestyle factors, the need for long-term pain management strategies and attention to long-term quality of life and wellness. Although a shift toward greater acceptance of chronic pain and the need for strategies to keep pain from flaring was observed across participants regardless of therapy, participants varied in their assessments of whether increased awareness of the need for ongoing self-care and maintenance strategies was considered a "positive outcome". Regardless of how participants evaluated the outcome of treatment, participants from all four therapies reported increased awareness, acceptance of the chronic nature of pain, and attention to the need to take responsibility for their own health. CONCLUSIONS The shift in treatment expectations to greater acceptance of pain and the need for continued self-care suggests that future research should explore how CAM practitioners can capitalize on these shifts to encourage feelings of empowerment rather than disappointment surrounding realizations of the need for continued engagement with self-care.
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Affiliation(s)
- Emery R Eaves
- Department of Family and Community Medicine & School of Anthropology, University of Arizona, Tucson, AZ, USA.
| | | | - Cheryl Ritenbaugh
- Department of Family and Community Medicine & School of Anthropology, University of Arizona, Tucson, AZ, USA.
| | | | - Mark Nichter
- Department of Family and Community Medicine & School of Anthropology, University of Arizona, Tucson, AZ, USA.
| | - Judith A Turner
- Department of Psychiatry & Behavioral Sciences and Department of Rehabilitation Medicine, University of Washington School of Medicine, Seattle, WA, USA.
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Rundell SD, Sherman KJ, Heagerty PJ, Mock C, Jarvik JG. Patient-reported outcomes associated with use of physical therapist services by older adults with a new visit for back pain. Phys Ther 2015; 95:190-201. [PMID: 25278334 PMCID: PMC5396148 DOI: 10.2522/ptj.20140132] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Accepted: 09/24/2014] [Indexed: 11/17/2022]
Abstract
BACKGROUND Among older adults, it is not clear how different types or amounts of physical therapy may be associated with improvements in back pain and function. OBJECTIVE The study objective was to investigate the association between types or amounts of physical therapist services and 1-year outcomes among older adults with back pain. DESIGN This was a prospective cohort study. METHODS A total of 3,771 older adults who were enrolled in a cohort study and who had a new primary care visit for back pain participated. Physical therapy use was ascertained from electronic health records. The following patient-reported outcomes were collected over 12 months: back-related disability (Roland-Morris Disability Questionnaire) and back and leg pain intensity (11-point numerical rating scale). Marginal structural models were used to estimate average effects of different amounts of physical therapy use on disability and pain for all types of physical therapy and for active, passive, and manual physical therapy. RESULTS A total of 1,285 participants (34.1%) received some physical therapy. There was no statistically significant gradient in relationships between physical therapy use and back-related disability score. The use of passive or manual therapy was not consistently associated with pain outcomes. Higher amounts of active physical therapy were associated with decreased back and leg pain and increased odds of clinically meaningful improvements in back and leg pain relative to results obtained with no active physical therapy. LIMITATIONS The fact that few participants had high amounts of physical therapy use limited precision and the ability to test for nonlinear relationships for the amount of use. CONCLUSIONS Higher amounts of active physical therapy were most consistently related to the greatest improvements in pain intensity; however, as with all observational studies, the results must be interpreted with caution.
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Affiliation(s)
- Sean D Rundell
- S.D. Rundell, PT, DPT, PhD, Department of Rehabilitation Medicine and Comparative Effectiveness, Cost, and Outcomes Research Center, University of Washington, Seattle, Washington. Mailing address: University of Washington, Box 359455, 4333 Brooklyn Ave NE, Seattle, WA 98105 (USA).
| | - Karen J Sherman
- K.J. Sherman, PhD, MPH, Department of Epidemiology, University of Washington, and Group Health Research Institute, Seattle, Washington
| | - Patrick J Heagerty
- P.J. Heagerty, PhD, Center for Biomedical Statistics, Department of Biostatistics, University of Washington
| | - Charles Mock
- C. Mock, MD, PhD, MPH, Department of Epidemiology, University of Washington, and Harborview Injury Prevention Research Center, Seattle, Washington
| | - Jeffrey G Jarvik
- J.G. Jarvik, MD, MPH, Comparative Effectiveness, Cost, and Outcomes Research Center and Department of Radiology, Neurological Surgery, Health Services, Orthopedic Surgery and Sports Medicine, and Pharmacy, University of Washington
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Abstract
Background: Non-surgical techniques for treating scoliosis frequently focus on realigning the spine, typically by muscular relaxation or muscular or ligamentous stretching. However, such treatments, which include physical therapeutic, chiropractic, and bracing techniques, are inconsistently supported by current evidence. In this study, we assess the possible benefits of asymmetrical strengthening of truncal muscles on the convex side of the scoliotic curve through a single yoga pose, the side plank pose, in idiopathic and degenerative scoliosis. Methods: Twenty-five patients with idiopathic or degenerative scoliosis and primary curves measuring 6 to 120 degrees by the Cobb method had spinal radiographs and were then taught the side plank pose. After 1 week performing the pose with convexity downward for 10 to 20 seconds, they were instructed to maintain the posture once daily for as long as possible on that one side only. A second series of spinal radiographs was taken 3 to 22 months later. Pre- and post-yoga Cobb measurements were compared. Results: The mean self-reported practice of the yoga pose was 1.5 minutes per day, 6.1 days per week, for a mean follow-up period of 6.8 months. Among all patients, a significant improvement in the Cobb angle of the primary scoliotic curve of 32.0% was found. Among 19 compliant patients, the mean improvement rose to 40.9%. Improvements did not differ significantly among adolescent idiopathic and degenerative subtypes (49.6% and 38.4%, respectively). Conclusions: Asymmetrically strengthening the convex side of the primary curve with daily practice of the side plank pose held for as long as possible for an average of 6.8 months significantly reduced the angle of primary scoliotic curves. These results warrant further testing.
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Affiliation(s)
- Loren M Fishman
- Columbia College of Physicians and Surgeons New York (Dr Fishman), United States
| | - Erik J Groessl
- University of California San Diego, VA San Diego Healthcare System (Dr Groessl), United States
| | - Karen J Sherman
- Karen J. Sherman, PhD, MPH, Group Health Research Institute, Seattle, Washington, United States
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