A proactive walking trial to reduce pain in Black Veterans

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Anticipated Impacts on Veterans Healthcare. This project will result in a non-pharmacological intervention to reduce pain and improve functioning among Veteran in VA care suffering from chronic musculoskeletal (MSK) pain, by increasing walking. The intervention will be administered by phone to reach patients who experience barriers to high quality chronic pain care. This intervention is specifically designed to address factors that contribute to MSK pain among black Veterans; however, we expect that it will also benefit non-black Veterans. Project Background. Chronic musculoskeletal (MSK) pain is one of the most common conditions among Veterans, affecting approximately 60% of those seen in VA primary care. Although perceived effectiveness of chronic pain treatment is low among all VA patients, black patients are less likely than whites to perceive their treatment as effective, and are more likely to experience functional limitations due to pain. There is growing consensus that chronic MSK pain is best addressed by a biopsychosocial approach that acknowledges the role of psychological and environmental factors, some of which differ by race. For example, blacks experience greater pain-related fear and lower self-efficacy in coping with pain (psychological contributors), and neighborhoods that make physical activity difficult (environmental contributors). However, there is a lack of effective interventions to improve pain treatment among minority patients, particularly those that target psychological and environmental contributors. Project Objective. Our long term goal is to improve the quality and equity of pain treatment in order to improve pain outcomes for all Veterans. The objective of this application is to test the effectiveness of a multi- component intervention that specifically targets known barriers to effective pain care among blacks Veterans with chronic MSK pain. Our primary hypothesis is that a telephone-delivered intervention, which emphasizes walking and incorporates Action Planning, Motivational Interviewing (MI) and Cognitive Behavioral Therapy (CBT) techniques, and the use of pedometers, will improve core chronic pain outcomes in black Veterans. Secondarily, we will determine whether our intervention also benefits non-black patients with MSK Project Methods. We propose a randomized trial to test the effectiveness of the intervention compared with usual care (UC) among 250 black and 250 non-black patients with chronic MSK pain. Patients from the Atlanta VAMC will be identified using data from the recently funded VA cohort study of Veterans with diagnoses of MSK pain in VA care. Patients will be screened by phone, and, if eligible, will be administered the full baseline survey. Eligible patients will be randomly assigned to the Usual Care (UC) or intervention condition (IC). Intervention participants will receive a pedometer-mediated walking intervention that will incorporate Action Planning and the use MI and CBT techniques. The intervention will be delivered in 6 telephone counseling sessions over three months. Patients in the UC condition will receive an informational brochure and a pedometer. The study is powered to find a difference between the IC and UC groups within the black and non- black groups. The primary outcome is chronic pain-related physical functioning, assessed by the revised Roland and Morris Disability Questionnaire, a measure recommended by the Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT). We will also examine whether the intervention improves other IMMPACT-recommended domains (pain intensity, emotional functioning, and ratings of overall improvement). Secondary objectives include examining potential mediators targeted by the intervention, exploring whether the intervention affects service utilization and use of opioid analgesics, and exploring whether the intervention reduces racial disparities in pain outcomes. Measures will be assessed by phone survey at baseline, 3 months, and 6 months. Data analysis of primary aims will follow intent-to-treat methodology.