Rural

Grand Rounds May 1, 2026: Adapting and Implementing a Nurse Care Management Model to Care for Rural Patients With Chronic Pain: Results and Lessons Learned From the Feasibility Phase (Sebastian Tong, MD, MPH; Kushang Patel, PhD, MPH)

Posted on by Sophia Ramirez

Speakers

Sebastian Tong, MD, MPH
Associate Professor, Department of Family Medicine
University of Washington

Kushang Patel, PhD, MPH
Research Professor, Department of Anesthesiology and Pain Medicine
University of Washington

Keywords

Rural; Chronic Pain; Nurse Care Management; Feasibility

Key Points

  • Chronic pain affects roughly 20% of U.S. adults. In rural areas, that figure is closer to 30% – a disparity due, in part, to the concentration of older individuals and those with more physically demanding jobs. Rural residents often have less access to pain specialists and non-pharmacologic pain management approaches.
  • Nurse care management (NCM) has been shown to be effective in treating other diseases that disproportionately affect rural residents. In the feasibility phase, the research team sought to test and adapt a virtual NCM model – including care meetings with nurses, cognitive behavioral therapy (CBT), Tele-Enhance® fitness, and a pain tracker – for chronic pain in rural primary care.
  • The research team identified several adaptions to implement before scaling up to a 450-person randomized controlled trial. These include establishing a clinic learning collaborative; providing more take-home CBT and exercise options; implementing flexibility around who can serve as care manager; and providing asynchronous administrative support for care managers.

Discussion Themes

The research team focused on 2 systems during the feasibility phase given the research team’s limited bandwidth. In retrospect, Dr. Tong noted, continued engagement with the other health systems over the course of the feasibility phase may have helped maintain interest in the trial.

Different sites faced similar challenges; the learning collaborative will serve to harmonize implementation and provide a centralized space for troubleshooting.

While including non-RNs in care delivery makes the model more practical for rural clinics, the researchers acknowledged this creates a challenge for long-term sustainability, as insurance often only reimburses care managed by registered nurses.

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 December 5, 2025: Transcutaneous Electrical Nerve Stimulation Reduces Movement-Pain in People With Fibromyalgia: Results From FM-TIPS, a Cluster Randomized Pragmatic Trial (Leslie J. Crofford, MD; Dana Dailey, PT, PhD; Kathleen Sluka, PT, PhD, FAPTA)

Posted on by Sophia Ramirez

Speakers

Leslie J. Crofford, MD
Wilson Family Chair in Medicine
Professor of Medicine and Pathology, Microbiology & Immunology
Vanderbilt University Medical Center

Dana Dailey, PT, PhD
Assistant Research Scientist
Physical Therapy and Rehabilitation Science
University of Iowa

Kathleen Sluka, PT, PhD, FAPTA
Professor
University of Iowa

Keywords

Fibromyalgia; Pain; Physical Therapy; Rural Population

Key Points

  • Fibromyalgia (FM) is widespread pain across four quadrants of the body, exacerbated by movement. The neuropsychiatric symptoms include fatigue, cognitive effects, and syndromes like depression, headache, and abdominal pain. Clinical trial data demonstrate modest effect sizes for all drug classes.
  • Transcutaneous electrical nerve stimulation (TENS) works by activating central inhibition and reducing central excitability. It has been shown to reduce movement pain safely and effectively. The FM-TIPS pragmatic trial sought to test the feasibility and effectiveness of adding TENS to standard physical therapy care.
  • The study team found that applying TENS at an optimal dose is clinically effective for reduction of movement-evoked pain in a real-world setting. They concluded that TENS is a safe, inexpensive, and readily available treatment for FM. They shared several tips regarding selection, design, implementation, and maintaining a network and engagement.

Discussion Themes

While TENS was highly effective at modulating pain and fatigue, it resulted in only small, non-clinically relevant changes in physical function. It can be added to an existing FM treatment plan to help manage the pain flares often caused by exercise.

There was a 99% enrollment rate among rural participants who passed screening, which the team attributed to strong, trusted relationships between patients and their local providers in smaller communities.

Dr. Sluka noted her surprise that the PT-only group did not show significant improvement, underscoring the specific efficacy of TENS in this pragmatic setting.

Team cohesion, maintaining relationships with clinical sites, and remaining open to help and new ideas (i.e., bringing in specialists mid-study) were all essential to the study’s success.

Grand Rounds October 10, 2025: Integrating the BeatPain Study With PRaCTICe, a New Network Research Hub of the CARE for Health Initiative (Julie M. Fritz, PhD, PT, FAPTA; Sebastian Tong, MD, MPH)

Posted on by Sophia Ramirez

Speakers

Julie M. Fritz, PhD, PT, FAPTA
Distinguished Professor
Department of Physical Therapy & Athletic Training University of Utah

Sebastian Tong, MD, MPH
Associate Professor
University of Washington

Keywords

Engagement; Community-Engaged Research; Rural; Pain; Partnership

Key Points

  • In an assessment of 10 high-income nations, the United States ranked 10th in healthcare system performance despite maintaining a significant lead in terms of healthcare spending.
  • The capacity of clinical research to improve healthcare is limited by a lack of representation. Patients who are older; live in rural locations; are uninsured; have co-morbid conditions; belong to minority groups; and are more likely to receive non-standard treatment are all inadequately represented in trials.
  • The NIH CARE for Health Initiative seeks to address these interrelated challenges. It will develop infrastructure for a clinical research network focused on primary care (PC); establish a foundation for sustained engagement with underrepresented communities; implement innovative study designs; integrate research into routine PC without increasing the burden on providers; and facilitate the adoption of evidence-based research findings.
  • CARE for Health is based in 6 national research hubs. One is the Primary Care Rural and Frontier Clinical Trials Innovation Center (PRaCTICe), a research network partnering with 300 PC practices serving 7 underrepresented population across Oregon, Washington, Wyoming, Alaska, Montana, and Idaho.
  • PRaCTICe utilizes a continuum of community engagement, from outreach to shared leadership. Engagement strategies have included community needs assessment reviews, regional listening sessions, and a new study development process that involves co-designing studies with PRaCTICe partners.
  • In 2024, BeatPain – a pragmatic, decentralized, NIH Collaboratory Trial – was selected as 1 of 2 trials PRaCTICe would partner with during Year 1. By the presentation date, PRaCTICe had referred 165 patients to the BeatPain team, 95% of which were rural residents.
  • Rural populations simultaneously have higher incidence of chronic pain and are less likely to receive evidence-based, nonpharmacologic treatment for it. BeatPain seeks to serve this population by delivering physical therapy (PT) to federally qualified health center patients with lower back pain.
  • Over the course of their collaboration with PRaCTICe, BeatPain investigators have made strides in terms of localizing the study to partnering communities, building trust with referring providers and patients, and coordinating the end of the trial. Decentralized trial methods hold promise for engaging rural residents and clinics in clinical research.

Discussion Themes

Relationships between research staff and a variety of clinic staff were critical to effective engagement. In one example provided by Dr. Tong, staff helped identify which exercises were most effective when it came to getting providers interested in the referral process. Clinics were not passive recipients, but co-developers.

To deliver PT in a rural setting, the BeatPain team delivered a virtual intervention combining traditional PT, health coaching, motivational interviewing, and pain coping strategies. In some care processes, the hands-on component of PT is essential; less so for chronic pain. Strategic use of technology could expand access to nonpharmacologic care.

Research teams will need to be responsive to shifts in the capacity of rural hospitals and clinics due to funding cuts. This may look like designing interventions that don’t increase the burden on staff; supplying resources; and sharing strategies that clinics can use to be financially sustainable.

IT support proved central to the success of this partnered research. When clinic resources are constrained, the ability to help solve problems related to the electronic health record is essential.