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

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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.