Self-Administered Acupressure for Veterans with Chronic Back Pain: A Multisite Evaluation of Effectiveness and Implementation

背景：据估计，在退伍军人健康中心接受护理的900万退伍军人中，约有一半 管理(VHA)有慢性疼痛，其中慢性下腰痛(CLBP)是主要类型。退伍军人与 CLBP是医疗保健的高利用率者，正在经历医疗保健的戏剧性转变--从医疗方法 从依赖阿片类药物止痛到生物心理社会方法，在其中证据- 基于基础的、风险较低的非药物选择受到青睐。非药理学干预，包括 补充和综合卫生(CIH)治疗，现在是一线护理。因此，退伍军人 需要能够获得这些治疗，但它们提供起来很复杂，很难在现实世界中提供 设置。因此，CLBP的非药物治疗不仅需要有效，而且需要低成本， 易于管理，易于访问，退伍军人及其提供者可以接受。 意义：我们的长期目标是通过以下方式改善CLBP退伍军人的慢性疼痛管理 使用现有结构将有效的自控穴位干预集成到VHA中 支持以退伍军人为中心的关爱。拟议中的项目是关键的第一步。它从以下方面直接解决优先事项 寻求为慢性疼痛提供更多非阿片类药物选择的VA、HSR&D和CARA立法， 包括针灸等CIH治疗。 创新和影响：该项目利用VHA内独特的基础设施进行测试和交付 可在全系统范围内推广的干预措施。自我穴位按摩是一种理想的干预方法 测试使用现有的VHA支持结构进行CIH治疗，整个卫生系统。自行管理 穴位按压是一种很有前途的VHA替代疗法，因为它的风险很低，而且可以在家中进行。 任何时候都可以。除了提供可以为退伍军人管理局下腰痛临床实践指南提供依据的证据外， 关于CLBP自我穴位按压的有效性，本项目还将介绍如何开始 在VHA实施这种治疗，这将支持最近的CIH指令，该指令概述了如何 整合退伍军人的CIH治疗。 具体目标：目标1：确定为期6周的自我穴位按压方案对疼痛的有效性 干预后的干扰、残疾、疲劳和睡眠，以及[10周的持续影响]和2) 评估对退伍军人CLBP实施自我穴位按压的支持和障碍。 方法：将在退伍军人事务部的三个地点进行类型1有效性-实施混合研究：ANN Arbor VA医疗中心、托莱多社区门诊和弗林特社区门诊 诊所。将有300名退伍军人从这些地点的提供者那里招募，并通过 整个健康系统，这是一项旨在教退伍军人如何自我管理健康方面的倡议。 随机进入刺激穴位按压组的参与者将与参与者进行比较 随机分为等待名单对照组和实施因素将进行定量测量和 从质量上讲。这项工作由传播框架指导，吸引利益相关者参与，衡量保真度， 考虑现场特点，评估促进者和实施障碍。 下一步/实施：本研究对自拟穴位推拿的知识库做出贡献 作为一种治疗慢性阻塞性肺疾病症状的方法，将研究的状态扩展到疗效研究之外。它填补了一个空白 关于有效性和如何最好地实施自我穴位按压的知识。这个项目将 提供关键信息，以提高访问患者首选的非阿片类疼痛的能力 治疗。如果自我管理的穴位按摩有效，下一步将是测试实施情况 不同地区的几个退伍军人事务部站点，更全面地检查促进者和障碍，考虑到 全国各地退伍军人的地理和文化差异。

Background: It is estimated that about half of the 9 million Veterans who receive care at Veterans Health Administration (VHA) have chronic pain, of which chronic low back pain (CLBP) is a major type. Veterans with CLBP are high healthcare utilizers and are experiencing a dramatic shift in care – from a medical approach that relied on medications like opioids for pain management to a biopsychosocial approach in which evidence - based, lower risk non-pharmacological options are favored. Non-pharmacological interventions, which include complementary and integrative health (CIH) treatments, are now a first line of care. Consequently, Veterans need to be able to access these treatments, but they are complex to deliver and difficult to provide in real-world settings. Thus, non-pharmacological treatments for CLBP need to not only be effective, but also low cost, easy-to-administer, accessible, and acceptable to Veterans and to their providers. Significance: Our long-term goal is to improve chronic pain management for Veterans with CLBP by integrating an effective self-administered acupressure intervention into VHA using current structures that support Veteran-centered care. The proposed project is a crucial first step. It directly addresses priorities from VA, HSR&D, and CARA legislation that seek to provide greater access to non-opioid options for chronic pain, including CIH treatments like acupressure. Innovation and Impact: This project leverages the unique infrastructure within VHA to test and deliver interventions that could have system-wide uptake. Self-administered acupressure is an ideal intervention to test using the existing VHA support structure for CIH treatments, the Whole Health System. Self-administered acupressure is a promising candidate for uptake at VHA given its low risk and ability to be performed at home at any time. In addition to providing evidence that can inform VA clinical practice guidelines for low back pain on effectiveness of self-administered acupressure for CLBP, this project will also inform on how to begin to implement this treatment at VHA, which would support the recent CIH Directive that outlines processes for how to integrate CIH treatments for Veterans. Specific Aims: Aim 1: Determine effectiveness of a 6-week self-administered acupressure protocol on pain interference, disability, fatigue, and sleep post intervention, and [sustained effects at 10 weeks] and 2) Evaluate supports and barriers for implementation of self -administered acupressure to Veterans with CLBP. Methodology: A Type 1 effectiveness-implementation hybrid study will be conducted at three VA sites: Ann Arbor VA Medical Center, Toledo Community-Based Outpatient Clinic, and Flint Community-Based Outpatient Clinic. There will be 300 Veterans recruited from providers at these sites and through classes offered through the Whole Health System, an initiative designed to teach Veterans how to self-manage aspects of their health. Participants who are randomized into the stimulating acupressure arm will be compared to participants randomized into a wait list control group and implementation factors will be measured quantitatively and qualitatively. This work is guided by dissemination frameworks, engaging stakeholders, measuring fidelity, considering site characteristics, and assessing facilitators and barriers to implementation. Next Steps/Implementation: This study contributes to the knowledge base of self -administered acupressure as a treatment for symptoms in CLBP, extending the state of the research beyond efficacy studies. It fills a gap in knowledge about effectiveness and how to best implement self-administered acupressure. This project will provide critical information that can increase the ability to access a patient-preferred, non-opioid pain treatment. If self-administered acupressure is effective, next steps would be to test implementation across several VA sites in different regions and more comprehensively examine facilitators and barriers considering geographical and cultural differences in Veterans across the country.