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 pain is best addressed
by a biopsychosocial approach that acknowledges the role of psychological
and environmental contributors to pain, some of which differ by race and hence
contribute to disparities. 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
The 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 black
Veterans with chronic MSK pain. The primary hypothesis is that a telephonedelivered 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.
The investigators propose a randomized trial to test the effectiveness of the
intervention compared with usual care (UC) among 250 black and 250 nonblack
patients with chronic MSK pain. Patients from the Atlanta VAMC will
be identified using administrative data. Patients will be screened by phone,
and, if eligible, will be mailed the baseline survey to complete and mail back.
Eligible patients who complete the baseline survey 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 of 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 mail and phone survey at baseline, 3 months, and 6 months. Data
analysis of primary aims will follow intent-to-treat methodology.
None at this time.
The work proposed is expected to result in a non-pharmacological intervention,
delivered by telephone, designed to reduce pain and improve functioning
among black patients with MSK pain, by promoting walking.
- Bhimani RH, Cross LJ, Taylor BC, Meis LA, Fu SS, Allen KD, Krein SL, Do T, Kerns RD, Burgess DJ. Taking ACTION to reduce pain: ACTION study rationale, design and protocol of a randomized trial of a proactive telephone-based coaching intervention for chronic musculoskeletal pain among African Americans. BMC musculoskeletal disorders. 2017 Jan 13; 18(1):15.