Karen J Sherman

• Kaiser Permanente Washington Health Research Institute

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 ParticipantsVeterans diagnosed with cLBP at a VA medical center enrolled in a randomize...

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 20-70 years with CLBP (N = 297), we examined b...

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-car...

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...

Objective: To investigate whether indirect effects via psychological mechanisms explain the effects of physical therapy (PT) or yoga, versus education, on back-related outcomes. Design: Mediation analyses using data from a randomized controlled trial of PT, yoga, and education interventions for chronic low back pain. Methods: Primary outcomes...

Background: To describe characteristics of patients, providers, and clinics associated with opioid or non-opioid pain medication prescribing patterns for patients who received lower spine imaging in primary care clinics. Methods: In these secondary analyses of the Lumbar Imaging with Reporting of Epidemiology (LIRE) study, a randomized controlle...

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...

Background 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 under...

Objective: To evaluate the effect of inserting epidemiologic information into lumbar spine imaging reports on subsequent non-surgical and surgical procedures involving the thoracolumbosacral spine and sacroiliac (SI) joints. Design: Analysis of secondary outcomes from the Lumbar Imaging with Reporting of Epidemiology (LIRE) pragmatic stepped-wed...

Background: Information on the prevalence of common imaging findings among patients without back pain in spine imaging reports might affect pain medication prescribing for patients with back pain. Prior research on inserting this text suggested a small reduction in opioid prescribing. Objective: To evaluate the effect of epidemiologic informatio...

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 tri...

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 in...

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 feder...

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 dis...

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...

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 cla...

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...

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 contro...

OBJECTIVES: To optimally select chronic pain patients for different treatments, as it is of interest to identify patient characteristics that might moderate treatment effect. Our aim was to evaluate the impact of possible moderators on the effect of acupuncture treatment using a large data set. METHODS: We used data from an individual patient data...

Objectives: To optimally select chronic pain patients for different treatments, as it is of interest to identify patient characteristics that might moderate treatment effect. Our aim was to evaluate the impact of possible moderators on the effect of acupuncture treatment using a large data set. Methods: We used data from an individual patient da...

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 dat...

Background: The STarT Back strategy for categorizing and treating patients with low back pain (LBP) improved patients' function while reducing costs in England. Objective: This trial evaluated the effect of implementing an adaptation of this approach in a US setting. Design: The Matching Appropriate Treatments to Consumer Healthcare needs (MAT...

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) s...

Perspective: Acupuncture is effective for the treatment of chronic musculosketal, 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.

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 prima...

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 g...

Study design: Economic evaluation alongside a randomized trial of cognitive-behavioral therapy (CBT) and mindfulness-based stress reduction (MBSR) versus usual care alone (UC) for chronic low-back pain (CLBP). Objective: Determine the one-year cost-effectiveness of CBT and MBSR compared to UC. Summary of background data: CLBP is expensive in t...

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....

The need for effective treatment options for chronic low back pain has spurred interest in “mind-body” approaches including cognitive behavioral therapy (CBT) and mindfulness-based stress reduction (MBSR). We previously reported that, compared with usual care, MBSR and CBT reduced functional limitations and pain bothersomeness for up to 1 year amon...

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 in...

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 following acupuncture, using a large individual patient dataset from high quality randomized trials of acupuncture for chronic pain. The available individual patient dataset...

Background: Patient expectations may be associated with outcomes of complementary and alternative medicine (CAM) treatments for chronic pain. However, a psychometrically sound measure of such expectations is needed. Objectives: The purpose of this study was to develop and evaluate a questionnaire to assess individuals' expectations regarding out...

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: demog...

Background Despite numerous options for treating back pain and the increasing healthcare resources devoted to this problem, the prevalence and impact of back pain-related disability has not improved. It is now recognized that psychosocial factors, as well as physical factors, are important predictors of poor outcomes for back pain. A promising new...

In Reply Drs Gatchel and Licciardone comment that “not all participants attended all group sessions, but it was not stated whether the techniques taught were implemented daily or practiced at home.” In our study, 88.6% of participants attended at least 1 session. Less than 100% session attendance is typical in studies of psychosocial interventions...

Cognitive-behavioral therapy (CBT) is believed to improve chronic pain problems by decreasing patient catastrophizing and increasing patient self-efficacy for managing pain. Mindfulness-based stress reduction (MBSR) is believed to benefit chronic pain patients by increasing mindfulness and pain acceptance. However, little is known about how these t...

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...

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, cl...

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...

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 non-pharmacological treatments. To determine the optimal dose of massage for neck pain. Two-phase randomized trial for persons with chronic non-specific...

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. Prospective inception cohort study. Primary care settings of three integrated healt...

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 outc...

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 examin...

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:...

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 b...

Background Positive patient expectations are often believed to be associated with greater benefits from complementary and alternative medicine (CAM) treatments. However, clinical studies of CAM treatments for chronic pain have not consistently supported this assumption, possibly because of differences in definitions and measures of expectations. Th...

This article explores the role of hope in participants’ assessments of their expectations, experiences and treatment outcomes. Data analysis focused on semi-structured, open-ended interviews with 44 participants, interviewed 3-5 times each over the course of a study evaluating Traditional Chinese Medicine (TCM) for Temporomandibular Disorders (TMD,...

Background Evidence suggests yoga is a safe and effective intervention for the management of physical and psychosocial symptoms associated with musculoskeletal conditions. However, heterogeneity in the components and reporting of clinical yoga trials impedes both the generalization of study results and the replication of study protocols. The aim of...

Background The self-reported health and functional status of persons with back pain in the United States have declined in recent years, despite greatly increased medical expenditures due to this problem. Although patient psychosocial factors such as pain-related beliefs, thoughts and coping behaviors have been demonstrated to affect how well patien...

Background Vitamin and mineral supplement use after a breast cancer diagnosis is common and controversial. Dosages used and the timing of initiation and/or discontinuation of supplements have not been clearly described. Methods We prospectively examined changes in use of 17 vitamin/mineral supplements in the first six months following breast cance...

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 exami...

Little is known about the reliability of different methods of survey administration in low back pain trials. This analysis was designed to determine the reliability of responses to self-administered paper surveys compared to computer assisted telephone interviews (CATI) for the primary outcomes of pain intensity and back-related function, and secon...

In a recent individual patient data meta-analysis, acupuncture was found to be superior to both sham and non-sham controls in patients with chronic pain. In this paper we identify variations in types of sham and non-sham controls used and analyze their impact on the effect size of acupuncture. Based on literature searches of acupuncture trials invo...

Purpose: This trial was designed to evaluate the optimal dose of massage for individuals with chronic neck pain. Methods: We recruited 228 individuals with chronic nonspecific neck pain from an integrated health care system and the general population, and randomized them to 5 groups receiving various doses of massage (a 4-week course consisting...

Background: Chronic low back pain causes substantial morbidity and cost to society while disproportionately impacting low-income and minority adults. Several randomized controlled trials show yoga is an effective treatment. However, the comparative effectiveness of yoga and physical therapy, a common mainstream treatment for chronic low back pain,...

Background Chronic low back pain causes substantial morbidity and cost to society while disproportionately impacting low-income and minority adults. Several randomized controlled trials show yoga is an effective treatment. However, the comparative effectiveness of yoga and physical therapy, a common mainstream treatment for chronic low back pain, i...

No consistent relationship exists between pre-treatment expectations and therapeutic benefit from various complementary and alternative medicine (CAM) therapies in clinical trials. However, many different expectancy measures have been used in those studies, with no validated questionnaires clearly focused on CAM and pain. We undertook cognitive int...

Context: Studies suggest that yoga is effective for moderate to severe chronic low back pain (cLBP) in diverse predominantly lower socioeconomic status populations. However, little is known about factors associated with benefit from the yoga intervention. Objective: Identify factors at baseline independently associated with greater efficacy amon...

Objective: To explore factors that influence satisfaction with yoga as a treatment for chronic low back pain (cLBP) in a predominantly minority population participating in a dosing research study. Information on treatment satisfaction is related to adherence and may give useful insights into patients' experience with treatment. Methods: Study parti...

SYR 2013 Accepted Poster abstracts.

Objective: Evidence suggests yoga may result in clinically relevant improvements in pain and functional outcomes across a range of musculoskeletal conditions including rheumatoid arthritis, osteoarthritis, and fibromyalgia. The aim of the current study was to develop a set of standardized core components for yoga therapy in clinical intervention tr...

In September 2012 the Acupuncture Trialists' Collaboration published the results of an individual patient data meta-analysis of almost 18 000 patients in high quality randomised trials. The results favoured acupuncture. Although there was little argument about the findings in the scientific press, a controversy played out in blog posts and the lay...

Although yoga is an effective treatment for chronic low back pain, little is known about the mechanisms responsible for its benefits. In a trial comparing yoga to intensive stretching and self-care, we explored whether physical (hours of back exercise/week), cognitive (fear avoidance, body awareness, and self-efficacy), affective (psychological dis...

Background. Previous studies have demonstrated that once-weekly yoga classes are effective for chronic low back pain (cLBP) in white adults with high socioeconomic status. The comparative effectiveness of twice-weekly classes and generalizability to racially diverse low income populations are unknown. Methods. We conducted a 12-week randomized, par...

Background Some researchers think that patients with higher expectations for CAM therapies experience better outcomes and that enthusiastic providers can enhance treatment outcomes. This is in contrast to evidence suggesting conventional medical providers often reorient patient expectations to better match what providers believe to be realistic. Ho...

Conceptual model of factors influencing patient expectations.

Background Although acupuncture is widely used for chronic pain, there remains considerable controversy as to its value. We aimed to determine the effect size of acupuncture for 4 chronic pain conditions: back and neck pain, osteoarthritis, chronic headache, and shoulder pain. Methods We conducted a systematic review to identify randomized control...

Differences in the effectiveness of diverse healthcare providers to promote health behavior change and successful diabetes self-care have received little attention. Because training in naturopathic medicine (NM) emphasizes a patient-centered approach, health promotion, and routine use of clinical counseling on wellness and prevention, naturopathic...

The full text of the focus group interview guide. (DOC)

Background: Health care costs associated with use of complementary and alternative medicine (CAM) by patients with spine problems have not been studied in a national sample. Objectives: To estimate the total and spine-specific medical expenditures among CAM and non-CAM users with spine problems. Research design: Analysis of the 2002-2008 Medic...

Objectives: Complementary and alternative medicine (CAM) providers are becoming more integrated into the United States health care system. Because patients self-select CAM use, risk adjustment is needed to make the groups more comparable when analyzing utilization. This study examined how the choice of risk adjustment method affects assessment of...

Little guidance is available to assist researchers in developing treatment protocols for research on yoga for health concerns. Because yoga is a complex multifactorial mind-body discipline historically developed for nonmedical purposes, numerous decisions must be made in order to thoughtfully develop such protocols. In this paper, a systematic appr...

Background Despite the growing popularity of massage, its effectiveness for treating neck pain remains unclear, largely because of the poor quality of research. A major deficiency of previous studies has been their use of low “doses” of massage that massage therapists consider inadequate. Unfortunately, the number of minutes per massage session, se...

This report summarizes the current evidence on the effects of yoga interventions on various components of mental and physical health, by focussing on the evidence described in review articles. Collectively, these reviews suggest a number of areas where yoga may well be beneficial, but more research is required for virtually all of them to firmly es...

Background: Although acupuncture is widely used for chronic pain, there remains considerable controversy as to its value. We aimed to determine the effect size of acupuncture for 4 chronic pain conditions: back and neck pain, osteoarthritis, chronic headache, and shoulder pain. Methods: We conducted a systematic review to identify randomized con...

Purpose Little is known about the reliability of different forms of survey administration in CAM trials of low back pain. This analysis was designed to determine the reliability of responses to self-administered paper surveys and computer assisted telephone administered interviews for pain intensity and the Roland Morris Disability Questionnaire am...

Purpose To test the hypothesis that people with inadequately controlled Type 2 diabetes (T2D) interested in adjunc-tive naturopathic care (ANC) may differ in their current self-care behavior and motivation for behavior change compared to those with less interest. We also aimed to measure CAM use and satisfaction with health care. Methods Patients w...

Background Although acupuncture is widely used for chronic pain, there remains considerable controversy as to its value. We aimed to determine the effect size of acupuncture for 4 chronic pain conditions: back and neck pain, osteoarthritis, chronic headache, and shoulder pain. Methods We conducted a systematic review to identify randomized controll...

Purpose Minority groups experience significant barriers to participation in clinical trials. Little is known about characteristics of treatment adherence among low income minority populations in CAM trials. This analysis aims to identify factors associated with class attendance, a major component of treatment adherence, in participants engaged in a...

Purpose We conducted a one-year prospective cohort study to determine the promise and feasibility of a randomized clinical trial of adjunctive naturopathic care (ANC) for type 2 diabetes (T2D). Methods 40 patients from Group Health Cooperative (GHC), a large integrated healthcare system in Washington State, with existing T2D and hemoglobin A1c valu...

Modern clinical-research practice favors placebo controls over usual-care controls whenever a credible placebo exists. An unrecognized consequence of this preference is that clinicians are more limited in their ability to provide the benefits of the non-specific healing effects of placebos in clinical practice. We examined the issues in choosing be...

Several small, uncontrolled studies have found improvements in self-care behaviors and reductions in clinical risk in persons with type 2 diabetes who received care from licensed naturopathic physicians. To extend these findings and determine the feasibility and promise of a randomized clinical trial, we conducted a prospective study to measure the...