Bone-Density Testing Interval and Transition to Osteoporosis in Older Women. Gourlay ML, et al. N Engl J Med. 2012 Jan 19;366(3):225-33.
Background: Although bone mineral density (BMD) testing to screen for osteoporosis (BMD T score, -2.50 or lower) is recommended for women 65 years of age or older, there are few data to guide decisions about the interval between BMD tests. Methods: We studied 4957 women, 67 years of age or older, with normal BMD (T score at the femoral neck and total hip, -1.00 or higher) or osteopenia (T score, -1.01 to -2.49) and with no history of hip or clinical vertebral fracture or of treatment for osteoporosis, followed prospectively for up to 15 years. The BMD testing interval was defined as the estimated time for 10% of women to make the transition to osteoporosis before having a hip or clinical vertebral fracture, with adjustment for estrogen use and clinical risk factors. Transitions from normal BMD and from three subgroups of osteopenia (mild, moderate, and advanced) were analyzed with the use of parametric cumulative incidence models. Incident hip and clinical vertebral fractures and initiation of treatment with bisphosphonates, calcitonin, or raloxifene were treated as competing risks. Results: The estimated BMD testing interval was 16.8 years (95% confidence interval [CI], 11.5 to 24.6) for women with normal BMD, 17.3 years (95% CI, 13.9 to 21.5) for women with mild osteopenia, 4.7 years (95% CI, 4.2 to 5.2) for women with moderate osteopenia, and 1.1 years (95% CI, 1.0 to 1.3) for women with advanced osteopenia. Conclusions: Our data indicate that osteoporosis would develop in less than 10% of older, postmenopausal women during rescreening intervals of approximately 15 years for women with normal bone density or mild osteopenia, 5 years for women with moderate osteopenia, and 1 year for women with advanced osteopenia. (Funded by the National Institutes of Health.).
The Changing Face of Older Adult Substance Abuse. Reardon C. Social Work Today, 2012 Jan/Feb;12(1):8-11.
A surprising number of baby boomers are abusing drugs and alcohol into their older adult years. Asking about substance use is a necessary part of elder mental health assessment. Clinical, Epidemiologic, Histopathologic and Molecular Features of an Unexplained Dermopathy. Pearson ML, et al. PLoS ONE. 2012;7(1): e29908. doi:10.1371/journal.pone.0029908
Background: Morgellons is a poorly characterized constellation of symptoms, with the primary manifestations involving the skin. We conducted an investigation of this unexplained dermopathy to characterize the clinical and epidemiologic features and explore potential etiologies. Methods: A descriptive study was conducted among persons at least 13 years of age and enrolled in Kaiser Permanente Northern California (KPNC) during 2006–2008. A case was defined as the self-reported emergence of fibers or materials from the skin accompanied by skin lesions and/or disturbing skin sensations. We collected detailed epidemiologic data, performed clinical evaluations and geospatial analyses and analyzed materials collected from participants' skin. Results: We identified 115 case-patients. The prevalence was 3.65 (95% CI = 2.98, 4.40) cases per 100,000 enrollees. There was no clustering of cases within the 13-county KPNC catchment area (p = .113). Case-patients had a median age of 52 years (range: 17–93) and were primarily female (77%) and Caucasian (77%). Multi-system complaints were common; 70% reported chronic fatigue and 54% rated their overall health as fair or poor with mean Physical Component Scores and Mental Component Scores of 36.63 (SD = 12.9) and 35.45 (SD = 12.89), respectively. Cognitive deficits were detected in 59% of case-patients and 63% had evidence of clinically significant somatic complaints; 50% had drugs detected in hair samples and 78% reported exposure to solvents. Solar elastosis was the most common histopathologic abnormality (51% of biopsies); skin lesions were most consistent with arthropod bites or chronic excoriations. No parasites or mycobacteria were detected. Most materials collected from participants' skin were composed of cellulose, likely of cotton origin. Conclusions: This unexplained dermopathy was rare among this population of Northern California residents, but associated with significantly reduced health-related quality of life. No common underlying medical condition or infectious source was identified, similar to more commonly recognized conditions such as delusional infestation. Delayed and Forgone Care for Families with Chronic Conditions in High-Deductible Health Plans. Galbraith AA, et al. J Gen Intern Med. 2012 Jan 18. [Epub ahead of print]
Background: High-deductible health plans (HDHPs) are an increasingly common strategy to contain health care costs. Individuals with chronic conditions are at particular risk for increased out-of-pocket costs in HDHPs and resulting cost-related underuse of essential health care. Objective: To evaluate whether families with chronic conditions in HDHPs have higher rates of delayed or forgone care due to cost, compared with those in traditional health insurance plans. DESIGN: This mail and phone survey used multiple logistic regression to compare family-level rates of reporting delayed/forgone care in HDHPs vs. traditional plans. Participants: We selected families with children that had at least one member with a chronic condition. Families had employer-sponsored insurance in a Massachusetts health plan and >12 months of enrollment in an HDHP or a traditional plan. Main Measures: The primary outcome was report of any delayed or forgone care due to cost (acute care, emergency department visits, chronic care, checkups, or tests) for adults or children during the prior 12 months. Results: Respondents included 208 families in HDHPs and 370 in traditional plans. Membership in an HDHP and lower income were each independently associated with higher probability of delayed/forgone care due to cost. For adult family members, the predicted probability of delayed/forgone care due to cost was higher in HDHPs than in traditional plans [40.0% vs 15.1% among families with incomes <400% of the federal poverty level (FPL) and 16.0% vs 4.8% among those with incomes ≥400% FPL]. Similar associations were observed for children. Conclusions: Among families with chronic conditions, reporting of delayed/forgone care due to cost is higher for both adults and children in HDHPs than in traditional plans. Families with lower incomes are also at higher risk for delayed/forgone care.
Ideal Cardiovascular Health and Mortality from All Causes and Diseases of the Circulatory System among Adults in the United States. Ford ES, Greenlund KJ, Hong Y. Circulation. 2012 Feb 28;125(8):987-95.
Background: Recently, the American Heart Association (AHA) developed a set of seven ideal health metrics that will be used to measure progress towards their 2020 goals for cardiovascular health. The objective of the present study was to examine how well these metrics predicted mortality from all-causes and diseases of the circulatory system in a national sample of adults in the United States. Methods and Results: We used data from 7622 adults aged ≥20 years who participated in the National Health and Nutrition Examination Survey from 1999 to 2002 and whose mortality through 2006 was determined via linkage to the National Death Index. For the dietary and glycemic metrics, we used alternative measures. During a median follow-up of 5.8 years, 532 deaths (186 deaths from diseases of the circulatory system) occurred. About 1.5% of participants met none of the seven ideal cardiovascular health metrics, and 1.1% of participants met all seven metrics. The number of ideal metrics was significantly and inversely related to mortality from all-causes and diseases of the circulatory system. Compared to participants who met none of the ideal metrics, those meeting five or more metrics had a reduction of 78% (adjusted hazard ratio [aHR]: 0.22; 95% confidence interval [CI]: 0.10, 0.50) in the risk for all-cause mortality and 88% (aHR: 0.12; 95% CI: 0.03, 0.57) in the risk for mortality from diseases of the circulatory system. Conclusions: The number of ideal cardiovascular health metrics is a strong predictor of mortality from all-causes and diseases of the circulatory system.
Internet-Based Cognitive Behavior Therapy for Obsessive Compulsive Disorder: A Pilot Study. Andersson E, et al. BMC Psychiatry. 2011 Aug 3;11:125.
Background: Cognitive behavior therapy (CBT) is widely regarded as an effective treatment for obsessive compulsive disorder (OCD), but access to CBT therapists is limited. Internet-based CBT (ICBT) with therapist support is a way to increase access to CBT but has not been developed or tested for OCD. The aim of this study was to evaluate ICBT for OCD. Method: An open trial where patients (N = 23) received a 15-week ICBT program with therapist support consisting of psychoeducation, cognitive restructuring and exposure with response prevention. The primary outcome was the Yale-Brown Obsessive Compulsive Scale (Y-BOCS), which was assessed by a psychiatrist before and immediately after treatment. Secondary outcomes were self-rated measures of OCD symptoms, depressive symptoms, general functioning, anxiety and quality of life. All assessments were made at baseline and post-treatment. Results: All participants completed the primary outcome measure at all assessment points. There were reductions in OCD symptoms with a large within-group effect size (Cohen's d = 1.56). At post-treatment, 61% of participants had a clinically significant improvement and 43% no longer fulfilled the diagnostic criteria of OCD. The treatment also resulted in statistically significant improvements in self-rated OCD symptoms, general functioning and depression. Conclusions: ICBT with therapist support reduces OCD symptoms, depressive symptoms and improves general functioning. Randomized trials are needed to confirm the effectiveness of this new treatment format. Lifetime Risks of Cardiovascular Disease. Berry JD, et al. N Engl J Med. 2012 Jan 26;366(4):321-9.
Background: The lifetime risks of cardiovascular disease have not been reported across the age spectrum in black adults and white adults. Methods: We conducted a meta-analysis at the individual level using data from 18 cohort studies involving a total of 257,384 black men and women and white men and women whose risk factors for cardiovascular disease were measured at the ages of 45, 55, 65, and 75 years. Blood pressure, cholesterol level, smoking status, and diabetes status were used to stratify participants according to risk factors into five mutually exclusive categories. The remaining lifetime risks of cardiovascular events were estimated for participants in each category at each age, with death free of cardiovascular disease treated as a competing event. Results: We observed marked differences in the lifetime risks of cardiovascular disease across risk-factor strata. Among participants who were 55 years of age, those with an optimal risk-factor profile (total cholesterol level, <180 mg per deciliter [4.7 mmol per liter]; blood pressure, <120 mm Hg systolic and 80 mm Hg diastolic; nonsmoking status; and nondiabetic status) had substantially lower risks of death from cardiovascular disease through the age of 80 years than participants with two or more major risk factors (4.7% vs. 29.6% among men, 6.4% vs. 20.5% among women). Those with an optimal risk-factor profile also had lower lifetime risks of fatal coronary heart disease or nonfatal myocardial infarction (3.6% vs. 37.5% among men, <1% vs. 18.3% among women) and fatal or nonfatal stroke (2.3% vs. 8.3% among men, 5.3% vs. 10.7% among women). Similar trends within risk-factor strata were observed among blacks and whites and across diverse birth cohorts. Conclusions: Differences in risk-factor burden translate into marked differences in the lifetime risk of cardiovascular disease, and these differences are consistent across race and birth cohorts. (Funded by the National Heart, Lung, and Blood Institute.).
Risk of Acute Myocardial Infarction after Death of a Significant Person in One's Life: The Determinants of MI Onset Study. Mostofsky E, et al. Circulation. 2012 Jan 24;125(3):491-6.
Background: Acute psychological stress is associated with an abrupt increase in the risk of cardiovascular events. Intense grief in the days following the death of a significant person may trigger the onset of acute myocardial infarction (MI), but this relationship has not been systematically studied. Methods and Results: We conducted a case-crossover analysis of 1985 participants from the multicenter Determinants of MI Onset Study interviewed during index hospitalization for an acute MI between 1989 and 1994. We compared the observed number of deaths in the days preceding MI symptom onset to its expected frequency based on each patient's control information, defined as the occurrence of deaths in the period from 1 to 6 months prior to infarction. Among the 1985 subjects, 270 (13.6%) experienced the loss of a significant person in the prior six months, including 19 within 1 day of their MI. The incidence rate of acute MI onset was elevated 21.1 fold (95%CI 13.1 to 34.1) within 24 hours of the death of a significant person, and declined steadily on each subsequent day. The absolute risk of MI within 1 week of the death of a significant person is 1 excess MI per 1394 exposed individuals at low (5%) 10-year MI risk and 1 per 320 among individuals at high (20%) 10-year risk. Conclusions: Grief over the death of a significant person was associated with an acutely increased risk of MI in the subsequent days. The impact may be greatest among individuals at high cardiovascular risk.
Social and News Media Enable Estimation of Epidemiological Patterns Early in the 2010 Haitian Cholera Outbreak. Chunara R, Andrews JR, Brownstein JS. Am J Trop Med Hyg. 2012 Jan;86(1):39-45.
During infectious disease outbreaks, data collected through health institutions and official reporting structures may not be available for weeks, hindering early epidemiologic assessment. By contrast, data from informal media are typically available in near real-time and could provide earlier estimates of epidemic dynamics. We assessed correlation of volume of cholera-related HealthMap news media reports, Twitter postings, and government cholera cases reported in the first 100 days of the 2010 Haitian cholera outbreak. Trends in volume of informal sources significantly correlated in time with official case data and was available up to 2 weeks earlier. Estimates of the reproductive number ranged from 1.54 to 6.89 (informal sources) and 1.27 to 3.72 (official sources) during the initial outbreak growth period, and 1.04 to 1.51 (informal) and 1.06 to 1.73 (official) when Hurricane Tomas afflicted Haiti. Informal data can be used complementarily with official data in an outbreak setting to get timely estimates of disease dynamics.
Suffering in Silence: Reasons for Not Disclosing Depression in Primary Care. Bell RA, et al. Ann Fam Med. 2011 Sep-Oct;9(5):439-46.
Purpose: Depression symptoms are underreported by patients. We thus assessed individuals' reasons for not disclosing depression to their primary care physician. Methods: We conducted a follow-up telephone survey of 1,054 adults who had participated in the California Behavioral Risk Factor Survey System. Respondents were asked about reasons for nondisclosure of depressive symptoms to their primary care physician, depression-related beliefs, and demographic characteristics. Descriptive and inferential statistical procedures were used to characterize perceived obstacles to disclosure. Results: Of the respondents, 43% reported 1 or more reasons for nondisclosure. The most frequent reason was the concern that the physician would recommend antidepressants (22.9%; 95% confidence interval, 18.8%-27.5%). Reported reasons for nondisclosure of depression varied based on whether the respondent had a history of depression. For example, respondents with no depression history were more likely to believe that depression falls outside the purview of primary care (P=.040) and more likely to fret about being referred to a psychiatrist (P=.036). Respondents with clinically significant depressive symptoms rated 10 of 11 barriers to disclosure as more personally applicable than did those without symptoms (all P values =.014). Number of reported disclosure barriers was predicted by demographic characteristics (being female, Hispanic, of low socioeconomic status), depression beliefs (depression is stigmatizing and should be under one's control), symptom severity, and absence of a family history of depression. Conclusions: Many adults subscribe to beliefs likely to inhibit explicit requests for help from their primary care physician during a depressive episode. Interventions should be developed to encourage patients to disclose their depression symptoms and physicians to ask about depression.
Beyond the Lean Revolution: Achieving Successful and Sustainable Enterprise Transformation by Deborah J. Nightingale.
The Critical Thinking Tool Kit: Spark Your Team’s Creativity with 35 Problem Solving Activities by Marlene Caroselli.
Customer Service Management Training 101: Quick and Easy Techniques that Get Great Results by Renee Evenson.
Customer Service Training 101, 2nd ed. by Renee Evenson.
Delivering Knock Your Socks Off Service, 5th ed. by Performance Associates, Inc.
The Enemy of Engagement: Put an End to Workplace Frustration--And Get the Most from Your Employees by Mark Royal.
Fundamentals of Project Management, 4th ed. by Joseph Heagney.
Getting Things Done: The Art of Stress-Free Productivity by David Allen.
Improving the Performance of Government Employees: A Manager's Guide by Stewart Liff.
Leader as Coach: Strategies for Coaching and Developing Others by David B. Peterson.
A Manager’s Guide to Virtual Teams by Yael S. Zofi.
A Map of the Child: A Pediatrician’s Tour of the Body by Darshak Sanghavi.
Now, Discover Your Strengths by Marcus Buckingham.
The Origins of AIDS by Jacques Pepin.
True North: Discover Your Authentic Leadership by Bill George.
The Winning Attitude; Developing the Leaders around You; Becoming a Person of Influence by John Maxwell.
Absolute Risk of Suicide after First Hospital Contact in Mental Disorder. Nordentoft M, Mortensen PB, Pedersen CB. Arch Gen Psychiatry. 2011;68(10):1058-1064.
Context: Estimates of lifetime risk of suicide in mental disorders were based on selected samples with incomplete follow-up. Objective: To estimate, in a national cohort, the absolute risk of suicide within 36 years after the first psychiatric contact. Design: Prospective study of incident cases followed up for as long as 36 years. Median follow-up was 18 years. Setting: Individual data drawn from Danish longitudinal registers. Participants: A total of 176 347 persons born from January 1, 1955, through December 31, 1991, were followed up from their first contact with secondary mental health services after 15 years of age until death, emigration, disappearance, or the end of 2006. For each participant, 5 matched control individuals were included. Main Outcome Measures: Absolute risk of suicide in percentage of individuals up to 36 years after the first contact. Results: Among men, the absolute risk of suicide (95% confidence interval [CI]) was highest for bipolar disorder, (7.77%; 6.01%-10.05%), followed by unipolar affective disorder (6.67%; 5.72%-7.78%) and schizophrenia (6.55%; 5.85%-7.34%). Among women, the highest risk was found among women with schizophrenia (4.91%; 95% CI, 4.03%-5.98%), followed by bipolar disorder (4.78%; 3.48%-6.56%). In the nonpsychiatric population, the risk was 0.72% (95% CI, 0.61%-0.86%) for men and 0.26% (0.20%-0.35%) for women. Comorbid substance abuse and comorbid unipolar affective disorder significantly increased the risk. The co-occurrence of deliberate self-harm increased the risk approximately 2-fold. Men with bipolar disorder and deliberate self-harm had the highest risk (17.08%; 95% CI, 11.19%-26.07%). Conclusions: This is the first analysis of the absolute risk of suicide in a total national cohort of individuals followed up from the first psychiatric contact, and it represents, to our knowledge, the hitherto largest sample with the longest and most complete follow-up. Our estimates are lower than those most often cited, but they are still substantial and indicate the continuous need for prevention of suicide among people with mental disorders.
Chocolate Consumption and Cardiometabolic Disorders: Systematic Review and Meta-Analysis. Buitrago-Lopez A, et al. BMJ. 2011 Aug 26;343:d4488.
Objective: To evaluate the association of chocolate consumption with the risk of developing cardiometabolic disorders. Design: Systematic review and meta-analysis of randomised controlled trials and observational studies. Data Sources: Medline, Embase, Cochrane Library, PubMed, CINAHL, IPA, Web of Science, Scopus, Pascal, reference lists of relevant studies to October 2010, and email contact with authors. Study Selection: Randomised trials and cohort, case-control, and cross sectional studies carried out in human adults, in which the association between chocolate consumption and the risk of outcomes related to cardiometabolic disorders were reported. Data Extraction: Data were extracted by two independent investigators, and a consensus was reached with the involvement of a third. The primary outcome was cardiometabolic disorders, including cardiovascular disease (coronary heart disease and stroke), diabetes, and metabolic syndrome. A meta-analysis assessed the risk of developing cardiometabolic disorders by comparing the highest and lowest level of chocolate consumption. Results: From 4576 references seven studies met the inclusion criteria (including 114,009 participants). None of the studies was a randomised trial, six were cohort studies, and one a cross sectional study. Large variation was observed between these seven studies for measurement of chocolate consumption, methods, and outcomes evaluated. Five of the seven studies reported a beneficial association between higher levels of chocolate consumption and the risk of cardiometabolic disorders. The highest levels of chocolate consumption were associated with a 37% reduction in cardiovascular disease (relative risk 0.63 (95% confidence interval 0.44 to 0.90)) and a 29% reduction in stroke compared with the lowest levels. Conclusions: Based on observational evidence, levels of chocolate consumption seem to be associated with a substantial reduction in the risk of cardiometabolic disorders. Further experimental studies are required to confirm a potentially beneficial effect of chocolate consumption.
Incidence of Dementia and Cognitive Impairment, Not Dementia in the United States. Plassman BL, et al. Ann Neurol. 2011 Sep;70(3):418-26.
Objective: Estimates of incident dementia, and cognitive impairment, not dementia (CIND) (or the related mild cognitive impairment) are important for public health and clinical care policy. In this paper, we report US national incidence rates for dementia and CIND. Methods: Participants in the Aging, Demographic, and Memory Study (ADAMS) were evaluated for cognitive impairment using a comprehensive in-home assessment. A total of 456 individuals aged 72 years and older, who were not demented at baseline, were followed longitudinally from August 2001 to December 2009. An expert consensus panel assigned a diagnosis of normal cognition, CIND, or dementia and its subtypes. Using a population-weighted sample, we estimated the incidence of dementia, Alzheimer disease (AD), vascular dementia (VaD), and CIND by age. We also estimated the incidence of progression from CIND to dementia. RESULTS: The incidence of dementia was 33.3 (standard error [SE], 4.2) per 1,000 person-years and 22.9 (SE, 2.9) per 1,000 person-years for AD. The incidence of CIND was 60.4 (SE, 7.2) cases per 1,000 person-years. An estimated 120.3 (SE, 16.9) individuals per 1,000 person-years progressed from CIND to dementia. Over a 5.9-year period, about 3.4 million individuals aged 72 and older in the United States developed incident dementia, of whom approximately 2.3 million developed AD, and about 637,000 developed VaD. Over this same period, almost 4.8 million individuals developed incident CIND. Interpretation: The incidence of CIND is greater than the incidence of dementia, and those with CIND are at high risk of progressing to dementia, making CIND a potentially valuable target for treatments aimed at slowing cognitive decline.
Patients and Populations: Public Health in Medical Education. All the articles in the October 2011 supplement of the American Journal of Preventive Medicine are available for free. Access them at
http://www.ajpmonline.org/supplements.
Perceived Impact of the Disclosure of a Schizophrenia Diagnosis. Pandya A, et al. Community Ment Health J. 2011 Dec;47(6):613-21.
Stigma against those with schizophrenia has demonstrated deleterious effects. However, less is known about the experience of individuals who disclose this diagnosis and how such disclosures differ by social situations. This study examines diagnosis disclosure in different contexts. A convenience sample of 258 adults with schizophrenia recruited via the internet and e-mail lists completed an online survey. Subjects were more open about their diagnosis with doctors, parents and friends than with employers or police. Those who report very good current mental health or who had fewer types of relationships were more open overall. Although reactions to disclosure varied, many report worse treatment by police and better treatment by parents after disclosure. Many also experienced worse treatment for medical problems after disclosing their schizophrenia diagnosis. These results support targeted anti-stigma interventions. It also suggests that stigma must be understood through individual experience in specific contexts rather than as a unitary experience.
Sustaining Clinical Programs during Difficult Economic Times: A Case Series from the Hospital Elder Life Program. Steelfisher GK, et al. J Am Geriatr Soc. 2011 Oct;59(10):1873-82.
OBJECTIVES: To explore strategies used by clinical programs to justify operations to decision-makers using the example of the Hospital Elder Life Program (HELP), an evidence-based, cost-effective program to improve care for hospitalized older adults. DESIGN: Qualitative study design using 62 in-depth, semistructured interviews conducted with HELP staff members and hospital administrators between September 2008 and August 2009. SETTING: Nineteen HELP sites in hospitals across the United States and Canada that had been recruiting patients for at least 6 months. PARTICIPANTS: HELP staff and hospital administrators. MEASUREMENTS: Participant experiences sustaining the program in the face of actual or perceived financial threats, with a focus on factors they believe are effective in justifying the program to decision-makers in the hospital or health system. RESULTS: Using the constant comparative method, a standard qualitative analysis technique, three major themes were identified across interviews. Each focuses on a strategy for successfully justifying the program and securing funds for continued operations: interact meaningfully with decision-makers, including formal presentations that showcase operational successes and informal means that highlight the benefits of HELP to the hospital or health system; document day-to-day, operational successes in metrics that resonate with decision-maker priorities; and garner support from influential hospital staff that feed into administrative decision-making, particularly nurses and physicians. CONCLUSION: As clinical programs face financially challenging times, it is important to find effective ways to justify their operations to decision-makers. Strategies described here may help clinically effective and cost-effective programs sustain themselves and thus may help improve care in their institutions.
The Wrong Tool for the Job: Diabetes Public Health Programs and Practice Guidelines. Sarkar U, et al. Am J Public Health. 2011 Oct;101(10):1871-3.
We surveyed state diabetes programs to determine whether they develop and disseminate diabetes guidelines. We found they largely disseminate clinical practice guidelines developed from subspecialty organizations, do not prioritize among the many recommendations contained in diabetes guidelines, and have not adapted guidelines to focus on population rather than individual health. An opportunity exists for state diabetes control programs to better align guidelines with public health goals.
Yoga for Chronic Low Back Pain: A Randomized Trial. Tilbrook HE, et al. Ann Intern Med. 2011 Nov 1;155(9):569-78.
Background: Previous studies indicate that yoga may be an effective treatment for chronic or recurrent low back pain. Objective: To compare the effectiveness of yoga and usual care for chronic or recurrent low back pain. Design: Parallel-group, randomized, controlled trial using computer-generated randomization conducted from April 2007 to March 2010. Outcomes were assessed by postal questionnaire. (International Standard Randomised Controlled Trial Number Register: ISRCTN 81079604) Setting: 13 non-National Health Service premises in the United Kingdom. Patients: 313 adults with chronic or recurrent low back pain. Intervention: Yoga (n = 156) or usual care (n = 157). All participants received a back pain education booklet. The intervention group was offered a 12-class, gradually progressing yoga program delivered by 12 teachers over 3 months. Measurements: Scores on the Roland-Morris Disability Questionnaire (RMDQ) at 3 (primary outcome), 6, and 12 (secondary outcomes) months; pain, pain self-efficacy, and general health measures at 3, 6, and 12 months (secondary outcomes). Results: 93 (60%) patients offered yoga attended at least 3 of the first 6 sessions and at least 3 other sessions. The yoga group had better back function at 3, 6, and 12 months than the usual care group. The adjusted mean RMDQ score was 2.17 points (95% CI, 1.03 to 3.31 points) lower in the yoga group at 3 months, 1.48 points (CI, 0.33 to 2.62 points) lower at 6 months, and 1.57 points (CI, 0.42 to 2.71 points) lower at 12 months. The yoga and usual care groups had similar back pain and general health scores at 3, 6, and 12 months, and the yoga group had higher pain self-efficacy scores at 3 and 6 months but not at 12 months. Two of the 157 usual care participants and 12 of the 156 yoga participants reported adverse events, mostly increased pain. Limitation: There were missing data for the primary outcome (yoga group, n = 21; usual care group, n = 18) and differential missing data (more in the yoga group) for secondary outcomes. Conclusion: Offering a 12-week yoga program to adults with chronic or recurrent low back pain led to greater improvements in back function than did usual care. Primary Funding Source: Arthritis Research UK.