chronic pain

Grand Rounds February 20, 2026: Applying Mind-Body Skills for Pain Using a Whole Health Telehealth Intervention (RAMP): Early Progress and Lessons Learned (Diana Burgess, PhD; Roni Evans, DC, MS, PhD; Katie Hadlandsmyth, PhD)

Posted on by Sophia Ramirez

Speakers

Diana Burgess, PhD
Professor of Medicine,
University of Minnesota
Director, VA Advanced Fellowship Program in Health Systems Research, Center for Care Delivery and Outcomes Research (CCDOR),
Minneapolis Veterans Affairs Healthcare System
Director, QUERI Complementary and Integrative Health Evaluation Center (CIHEC),
Veterans Affairs Healthcare System

Roni Evans, DC, MS, PhD
Research Professor
Director, Integrative Health & Wellbeing Research Program
Earl E. Bakken Center for Spirituality & Healing,
University of Minnesota

Katie Hadlandsmyth, PhD
Associate Professor
College of Nursing
University of Iowa

Keywords

Chronic Pain; Whole-Health; Biopsychosocial; Veterans Administration (VA); Rural Populations

Key Points

  • Rural Veterans exist at the intersection of 2 populations that are disproportionately affected by chronic pain. Compared to urban Veterans, rural Veterans are less likely to receive comprehensive and specialty pain care; are more likely to be prescribed opioid medication; and utilize pain self-management strategies at lower rates. The Veterans Administration (VA) serves 2.7 million rural veterans.
  • Seeking to improve pain management and reduce opioid use among rural patients, VA researchers developed the Rural Veterans Applying Mind Body Skills for Pain (RAMP) intervention. RAMP addresses pain as a biopsychosocial condition, providing rural VA patients with the opportunities and resources to enhance their capabilities and motivations to engage in helpful pain self-management behaviors.
  • A pilot study found that the intervention met milestones for enrollment, satisfaction, and fidelity. The researchers concluded that a full-scale randomized trial of a complementary and integrative health telehealth program for rural VA patients with chronic pain is feasible and can meet pain self-management needs. Their intervention and study processes have been refined to increase engagement and data collection.
  • In March 2026, the team will begin enrollment for a Type II randomized hybrid-effectiveness implementation trial.

Discussion Themes

The team emphasized the need for “resilient interventions” that can withstand external disruptions, such as natural disasters and VA workforce restructuring.

Relationship-building with high-level and local stakeholders was essential for navigating the VA’s complex and dynamic organizational structure. The researchers detailed their strategy for managing stakeholder panels, which included roughly 21 core members (i.e., patients and community advisors) and 10 internal VA stakeholders.

Grand Rounds September 6, 2024: Conventional, Complementary, and Integrative Pain Therapies in a Military Population with Chronic Musculoskeletal Pain: Results of a Pragmatic Clinical Trial Using SMART Design (Ardith Z. Doorenbos, PhD, RN; Diane M. Flynn, MD, MPH)

Posted on by Sophia Ramirez

Speakers

Ardith Z. Doorenbos, PhD, RN
Professor
Department of Biobehavioral Nursing Science
College of Nursing
University of Illinois, Chicago

Diane M. Flynn, MD, MPH
Primary Care Pain Management Advisor
Interdisciplinary Pain Management Center
Madigan Army Medical Center
Tacoma, WA

Keywords

Chronic Pain; Military; Rehabilitative Care; Pain Therapies; SMART Design

Key Points

  • Physical and occupational therapies are standard rehabilitative care (SRC) for chronic pain, and a growing body of evidence supports complementary and integrative health (CIH) therapies (such as acupuncture, chiropractic, yoga and massage).
  • Few studies have explored the optimal duration, sequence and combination of SRC and CIH to manage chronic pain.
  • The study team investigated the effectiveness of starting treatment for pain with SRC versus CIH therapies. Their primary outcome was the Pain Impact Scores of active-duty service members with chronic pain.
  • Their study design, a Sequential Multiple Assignment Randomized Trial (SMART) Design, randomized participants to CIH or SRC for three weeks each. At that point, participants who were improving continued on in their assigned treatment arm, while those who were not improving were randomized to either the other treatment arm or a combination arm.
  • Compared to baseline pain levels, both groups improved significantly up to six months out. After three weeks, the group that received SRT showed less improvement the group that received CIH therapies. However, by the end of the six-week mark, as well as at three- and six-month follow-ups, there wasn’t a significant difference in average improvement.
  • The study team’s ability to make assessments with regard to the duration of treatment is limited; participants were given the option to continue therapy for up to six weeks, so some were engaged in active therapy during the follow-up period.
  • These findings lend support to expanding access to CIH approaches. Clinicians can feel confident recommending patients start with CIH therapies if that is the patients’ preference.

Discussion Themes

Patients in the CIH arm and SRT arm received therapy for a total of 6.5 and 3 hours per week, respectively. At first blush, this indicates that a treatment hours effect could have contributed to the benefits seen in the first three weeks of the CIH arm; in practice, due to lower-than-intended participation, the actual treatment hours were only slightly higher in the CIH arm than the SRT arm.

Whether it’s caused by pain, combat experience, or adverse childhood experiences, many members of the study population experience a great deal of allostatic stress and kinesiophobia: “When I move, I hurt.” One of the study team’s theories as to why participants initially responded more positively to the CIH arm is that there was less movement involved.

Future directions may include examining the biological or neurological mechanisms underlying the interventions’ impact.

Dr. Flynn shared a resource that she noted would be helpful in defining SMART Designs and outlining some of the advantages and disadvantages:  https://jamanetwork.com/journals/jama/article-abstract/2800681

Grand Rounds September 6, 2024: Conventional, Complementary, and Integrative Pain Therapies in a Military Population With Chronic Musculoskeletal Pain: Results of a Pragmatic Clinical Trial Using SMART Design (Ardith Z. Doorenbos, PhD, RN; Diane M. Flynn, MD, MPH)

Speakers:

Ardith Z. Doorenbos, PhD, RN
Professor
Department of Biobehavioral Nursing Science
College of Nursing
University of Illinois, Chicago

Diane M. Flynn, MD, MPH
Primary Care Pain Management Advisor
Interdisciplinary Pain Management Center
Madigan Army Medical Center
Tacoma, WA

Title: Conventional, Complementary, and Integrative Pain Therapies in a Military Population With Chronic Musculoskeletal Pain: Results of a Pragmatic Clinical Trial Using SMART Design

Date: Friday, September 6, 2024, 1:00-2:00 p.m. ET

Please click the link below to join the webinar:

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August 23, 2021: BeatPain Utah Takes Pragmatic Research to New Frontiers

Posted on by Damon Seils

BeatPain Utah, an NIH Collaboratory Trial, is studying real-world implementation of a telehealth physical therapy strategy for patients with chronic back pain. Dr. Julie Fritz, the principal investigator of BeatPain Utah, discussed the study in a Zoom-based interview after the NIH Collaboratory’s annual steering committee meeting.

“[BeatPain Utah] is focused on overcoming access barriers and providing nonpharmacologic options for individuals in our state and in under-resourced communities who have chronic back pain,” said Fritz, who is a distinguished professor of physical therapy and athletic training and the associate dean for research at the University of Utah College of Health.

The project is part of the NIH HEAL Initiative, which aims to reduce reliance on prescription opioid medications.

View the full video.

Fritz highlighted the project’s partnerships with federally qualified health centers throughout the state of Utah. “Some are in urban areas serving under-resourced communities,” she said, “and others, given the geography of Utah, are in very rural and remote communities where access to specialists and allied health professionals is particularly limited.” The communities also include a significant number of patients who are Hispanic or Latino and communicate primarily in Spanish.

When asked why a pragmatic clinical trial was the best approach for BeatPain Utah, Fritz noted the urgency of the need for alternative pain management strategies, especially in low-resource populations.

“Accelerating the real-world applicability of our research is particularly critical in this area of clinical research,” Fritz said. “So for us, in addressing the needs of populations that need resources—and they need them now—a pragmatic trial that focuses on real-world solutions was a particularly attractive option,” she said.

On being part of the NIH Collaboratory, Fritz said, “So many of the things that we encounter, someone’s already dealt with or is currently working on. It’s just invaluable to have those colleagues and professionals who are trying similar aims to what we’re doing. Being part of this Collaboratory has been of tremendous value for our project.”

View the full video.

BeatPain Utah is supported by the NIH through the NIH HEAL Initiative under a grant from the National Institute of Nursing Research and receives logistical and technical support from the PRISM Resource Coordinating Center.

Screen shot of interview with Dr. Julie Fritz

April 27, 2020: NIH Announces Supplemental Funding Opportunity for Research on Stigma in Pain Management, Opioid Use, and Opioid Use Disorder

Posted on by Damon Seils

The NIH Office of Behavioral and Social Sciences Research, with other NIH Institutes, Centers, and Offices, has issued a notice of special interest calling for research on stigma in the context of chronic pain management and opioid use or opioid use disorder. The NIH will support administrative supplements to current awards and cooperative agreements under the Helping to End Addiction Long Term (HEAL) Initiative. A total of up to $3.5 million is available for the supplemental awards. Applications will be accepted through May 29, 2020.

This funding opportunity will give high priority to projects that analyze strategies to reduce stigma, discrimination, and prejudice related to chronic pain management and/or opioid use disorder; and to projects that use existing psychometrically validated tools to measure stigma (or that support the development of new measurement tools, if there is compelling rationale). Specific areas of interest include:

  • The impact of internalized and anticipated stigma on prevention, management, treatment, and recovery.
  • Prejudice by care providers that undermine treatment and health-related quality of life.
  • Strategies to address stigma among healthcare providers, workplace colleagues, emergency responders, family and friends, and others.
  • Strategies to address internalized stigma.
  • The adaption and application of existing theories of health-related stigma to chronic pain and/or opioid use disorder in reducing stigma.
  • Analyses of combinations of approaches that are known to reduce discrimination and prejudice.
  • Approaches to build resilience to discrimination and prejudice.
  • First-stage development of multicomponent approaches that could be expanded and implemented for large-scale multicomponent research projects.

Application and submission information is available in the full notice of special interest.

November 20, 2018: Upcoming NIH Funding Opportunity Announcements for Pragmatic Trials Address the Opioid Crisis

Posted on by Karen Staman

The NIH has announced an intent to publish new funding opportunity announcements (FOAs) for 5 or more embedded pragmatic clinical trials that address pain management and the opioid crisis. These projects will become part of the NIH Health Care Systems Research Collaboratory as phased UG3/UH3 cooperative research. Both FOAs will be published in early December with applications due as early as February 2019.

The two notices are:

The announcements are part of the NIH Heal (Helping to End Addiction Long-term) Initiative, which was created in April 2018 in an effort to speed scientific solutions for addressing the national opioid public health crisis.

April 9, 2018: PPACT Study Design Paper Published

Posted on by Karen Staman

Congratulations to Dr. Lynn DeBar and the investigators of the Collaborative Care for Chronic Pain in Primary Care pragmatic trial for recently publishing their study design paper. One of the NIH Collaboratory Trials, the trial is designed to test whether a primary care–based behavioral intervention the Pain Program for Active Coping and Training (PPACT)—will provide a “more effective, safer, and more satisfactory alternative to opioid-based chronic pain treatment” than usual care for patients on chronic opioid treatment (Debar et al 2018). Learn more about this innovative trial in the article in Contemporary Clinical Trials. You can also download a trial snapshot.

Full Citation: DeBar L, Benes L, Bonifay A, et al. Interdisciplinary team-based care for patients with chronic pain on long-term opioid treatment in primary care (PPACT) – Protocol for a pragmatic cluster randomized trial. Contemporary Clinical Trials. 2018;67:91-99. doi:10.1016/j.cct.2018.02.015