Reaching Rural Veterans: Applying Mind-Body Skills for Pain Using a Whole Health Telehealth Intervention: The RAMP Pilot Study

Abstract

Purpose:

The current study piloted a telehealth, multicomponent intervention for rural Veterans, to increase access to non-pharmacological approaches to managing chronic pain.

Methods:

This single arm pilot study examined the feasibility of trialing the Reaching Rural Veterans: Applying Mind-Body Skills for Pain Using a Whole Health Telehealth Intervention (RAMP). RAMP consisted of an individual session followed by 11 facilitated group sessions (90-minutes each), that included expert-led educational and experiential physical exercise and mind-body skill-building videos. Feasibility was assessed using pre-specified milestones for recruitment and enrollment (N = 40), satisfaction (75%), fidelity (90%), intervention engagement (75%), and data collection (surveys of pain and health outcomes at 14 weeks, 80%).

Findings:

The following milestones were met: 1) 40 rural VA patients with moderate to severe chronic pain were enrolled, 2) 90% of participants were satisfied with the intervention, and 3) facilitators delivered 100% of session activities 100% of the time. The following milestones were nearly met: 4) intervention engagement: 68% of Veterans engaged in at least 7 of 12 sessions, and 5) data collection: 75% survey completion at 14 weeks. Participants reported that the intervention supported their pain self-management capabilities, provided useful self-management opportunities and resources, and enhanced their motivation to self-manage their pain. Participant and other key stakeholders identified important areas for improvement.

Conclusions:

Pilot results demonstrated that RAMP is feasible and acceptable to rural Veterans with chronic pain and helped identify optimization strategies to enhance future program engagement.

Introduction

Pain is a complex condition influenced by interrelated biophysical, psychological, and social (BPS) factors,^1,2 including social determinants of health.^3–5 U.S. military Veterans are more likely than non-Veterans to be affected by chronic pain and factors that contribute to pain, and chronic pain and its contributors are more prevalent among rural-dwelling compared to urban-dwelling individuals.^6,7 While there have been a growing number of multi-modal non-pharmacological pain self-management programs that address pain from a BPS perspective,^8,9 including programs within the Veterans Affairs Healthcare System (VA),¹⁰ these approaches remain underutilized,¹⁰ particularly among rural-dwelling patients and patients from marginalized groups.^11–13 Moreover, programs have been developed for and conducted with predominantly White, highly educated populations, with relatively high levels of self-reported health.^8,9 This has led to an absence of programming that can meet the needs of racially diverse, rural-dwelling Veterans, who are more likely to experience negative social determinants of health and poorer health outcomes.^14,15

There are a range of evidence-based non-pharmacologic self-management modalities for improving pain outcomes,^16–21 including mind-body approaches (e.g., mindfulness practices, meditation, relaxation, guided imagery), physical activity (e.g., general and rehabilitative exercise, yoga, tai chi), lifestyle changes (e.g., for sleep, daily activities, social support), psychological strategies (e.g., behavioral or cognitive), and pain education (e.g., pain neuroscience, and pain management tips).^22,23 Rural Veterans, however, may face unique barriers to accessing these modalities, such as traveling to the main VA medical centers where non-pharmacological pain management services are offered,^24,25 need for a provider referral,^26,27 as well as lack of awareness and knowledge about non-pharmacological pain management options for pain.^28–30 Given these obstacles, there is a pressing need for evidence-based multi-modal programs that promote pain self-management in a manner that can meet rural Veterans’ needs.

To address these barriers, we designed and piloted the Reaching Rural Veterans: Applying Mind-Body Skills for Pain Using a Whole Health Telehealth (RAMP) intervention. Given the unique needs of the rural Veteran population, it was critical to rigorously assess the feasibility of this intervention, guided by the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework, with the broader goal of optimizing reach, effectiveness, adoption, implementation, and maintenance of the RAMP intervention in the VA.^31,32 The RAMP intervention was uniquely designed to deliver multiple pain self-management strategies (pain education, mindfulness, pain specific exercises, and cognitive behavioral strategies) in one intervention, to overcome existing barriers to care, and improve rural Veterans’ pain and important biopsychosocial outcomes. We conducted a pilot study of RAMP with 40 rural VA patients with chronic pain, to assess study feasibility (recruitment and retention), intervention feasibility (fidelity of intervention delivery and participant engagement rates), acceptability, and effectiveness at addressing pre-defined capabilities, opportunities and motivations.

Methods

Study Design

The study was a single arm pilot feasibility study (NIH 1UG3NR020929; Clinical Trials Registration: NCT06568250) in anticipation of a Type II randomized hybrid effectiveness-implementation trial. The study was approved by the Minneapolis VA Institutional Review Board prior to data collection (ID: 1753168). Informed consent was obtained verbally. The study was conducted and reported following the Consolidated Standards of Reporting Trials (CONSORT) extension guideline for pilot feasibility trials.³³ The RE-AIM framework was applied to inform optimization of the future full-scale study, with a focus on reach and implementation.^31,32 A six member independent Data Safety and Monitoring Board provided oversight for the study and reviewed and approved the study protocol.

Advisory Panels

Prior to conducting the pilot trial, we assembled a Veteran Engagement Panel and a Community Advisory Panel to provide input on the study. The RAMP Veteran Engagement Panel (VEP) was comprised of 12 rural-dwelling Veterans with chronic pain (6 women; 6 from racially and ethnically minoritized groups) who were receiving care in the VA. The RAMP Community Advisory Panel (CAP) was comprised of 7 leaders of Veteran Serving Organizations. Panel members advised us on recruitment materials, the study website, and intervention delivery. The feedback we received from meeting with our panels was used to refine and clarity recruitment materials, the study website, and intervention materials, prior to starting pilot recruitment. We later met again with our panels to share pilot results.

Setting and Participants

Eligible participants were 18 years of age or older, and rural-dwelling³⁴ patients from VA Healthcare System in Veterans Integrated Service Network (VISN) 7 (the Southeast region of the US), who met the following inclusion criteria: (1) two qualifying pain diagnoses in their electronic health record (EHR) within the same diagnostic category, at least 90 days apart, during the previous 2 years;³⁵ (2) pain duration ≥ 3 months, (3) Brief Pain Inventory Interference subscale³⁶ score ≥ 4/10; (4) access to a device with internet, (5) willingness to engage in intervention-specific procedures (e.g., meet remotely online for sessions), and (6) had an email address listed in the EHR. We excluded patients who (1) had severe, poorly controlled psychiatric or substance use disorder (identified by chart review); (2) were active members of our advisory panels, (3) were concurrently enrolled in a research study for pain, (4) were recently enrolled in a similar study³⁷ (5) were currently enrolled in a similar facilitated, multi-week, multi-modal pain self-management program.

Recruitment and Screening

Recruitment was conducted from July to September 2024. Potentially eligible participants who were identified using Veterans Health Administration (VHA) administrative data from the Corporate Data Warehouse (CDW) were mailed a postcard about the study, and then emailed introductory materials inviting them to complete a brief screener via the study website. Selective sampling was used to ensure representation of women and minoritized Veterans. Patients who met initial eligibility criteria were asked to complete a baseline survey, after which study staff conducted a chart review. Study staff then called eligible participants to verify availability, commitment, and necessary technology before enrolling them in the study.

Study Intervention.

The RAMP intervention was developed using the Capabilities, Opportunities, Motivational-Behavioral (COM-B) model, coupled with the dynamic biopsychosocial model of pain. The COM-B is a synthesis of 19 behavioral theoretical frameworks that posits effective self-management interventions must target individuals’ capabilities, opportunities, and motivations. The dynamic biopsychosocial model acknowledges the complex and reciprocal interactions between the evolving biopsychological or “whole” person and their external, social environment.^38–40

Two trained health coaches delivered the intervention to study participants, which aligns with the VA’s Office of Patient Centered Care and Cultural Transformation (OPCC&CT), Whole Health model of care. A key component of the model is the use of health coaches to engage in individual and group-based support to complement other healthcare services. With training in motivational communication and behavioral change techniques, coaches are well suited to support patients’ pain self-management behaviors (which was the primary goal of the intervention). Further, the use of non-clinician support is important from a future implementation perspective, given the relative lack of VA clinicians available to deliver nonpharmacological pain treatments, especially in rural-serving facilities.

The RAMP intervention was comprised of 12 sessions. The design was guided by the COM-B model coupled with the dynamic biopsychosocial model of pain.^38–40 See Table 1 for the Template for Intervention Description and Replication (TIDieR) checklist which describes the intervention in further detail. The first session was one-on-one with a health coach and focused on discussion of individual goals for pain management and overall health. This was followed by 11 group sessions facilitated by the health coach who ensured all planned activities were addressed Sessions included pre-recorded expert led education and physical exercise and mind-body skill-training videos and facilitated discussions. Education and skill training focuses on pain education, mindfulness, pain specific exercises (e.g. stretching, mobility, strength), and cognitive behavioral strategies (e.g. relaxed breathing, guided imagery). Health coaches were trained to use evidence-based behavioral change techniques⁴⁰ (e.g., goal setting, action planning, problem solving, and graded tasks) and communication (e.g., motivational interviewing) to facilitate engagement. Participants were encouraged to practice on their own between sessions consistent with their weekly goals, using a workbook and study website, which included the same downloadable videos presented in the group sessions.

Table 1.

RAMP Intervention Description (based on Template for Intervention Description and Replication (TIDieR)

		RAMP Intervention
WHY	Goal, Rationales	Goal: to enhance rural VA patients’ access to a multimodal non-pharmacological pain self-management intervention, by addressing an individual’s capabilities, opportunities, and needs for engaging in optimal pain self-management behaviors. Rationale: A health coach facilitated program with expert led videos can improve rural Veterans access to pain self-management support and content that would not otherwise be available to them.
WHAT	Participant Materials	A 200-page print and digital workbook Website with over 30 pre-recorded expert-led videos including: educational and experiential physical exercise and mind-body skill-building videos.
	Facilitator & Staff Materials	Facilitator manual for the RAMP intervention. Manual of operations detailing checklists and guidance for how to implement all intervention and study activities.
	Procedures	1 individual session followed by 11 group sessions. Group sessions included: Viewing of pre-recorded expert led education* and skill-building** videos. Group discussions. Home practice encouraged between sessions.
WHO	Information About Facilitators, Staff, Pain Self-Management Experts	Facilitation of Sessions Two Facilitators with competencies in whole health approaches. Facilitation support staff with experience working with Veteran research participants. Expert Videos Experts with degrees and/or certifications in physical therapy, chiropractic, mindfulness, exercise instruction; experience applying behavioral change techniques to engage people with pain in physical exercises and mind-body approaches (cognitive behavioral strategies, mindfulness meditations). Study Help Line (to address questions as needed) Staff with experience working with Veteran research participants.
HOW	Format, Modes of Delivery	Telehealth (using WebEx) Facilitator-led group sessions
WHERE	Location, type	Participant chose private location of preference
WHEN, HOW MUCH	Frequency, Duration	12 sessions total 1 orientation session with coach (60 minutes). 11 weekly sessions (90 minutes). Encouraged to practice daily, on own between sessions.
	Individualization	Participants chose which physical exercises (including difficulty level) and which mind-body approaches to practice, as well as timing and frequency. Participants could pursue usual care in VA system as they normally would according to their needs and preferences.
MOD-IFICATIONS	Changes to intervention (what, why, when, how)	Based on the pilot study results and recommendations from stakeholders: Remove the individual orientation session with coach and reduce number of group sessions from 11 to 9 to eliminate redundancies, decrease burden. Provide more examples that reflect rural Veterans experiences and provide more opportunities to discuss and explore in group. Emphasize the different options for engagement earlier, more frequently (e.g., self-paced make up activities for missed sessions, individual check-in calls). Offer additional engagement “touchpoints” throughout the program (e.g., reminder texts).
HOW WELL	Fidelity assessments (how, by whom, fidelity strategies)	Designated personnel attended and observed 10% of sessions. Standardized assessment of intervention activities, facilitator competencies by designated investigator.

^*Education videos: Program Orientation; Pain & the Whole Person; Pain & the Mind Body Connection; Pain & Kindness; Pain & Wellbeing; Moving with Pain; Pain & Pacing; Pain, Thoughts & Feelings; Pain and Sleep; Pain and Perspective; Pain and Social Wellbeing; Moving Forward.

^**Skill-building videos: Mind-Body Tools including cognitive behavioral strategies (e.g. relaxed breathing; progressive muscle relaxation; guided imagery; pacing, shifting thoughts & attitudes, planning for setbacks) mindfulness meditations (breath, kindness, pain awareness, body awareness); physical exercises (posture, mobility, strength).

Data Collection.

Data collection for the feasibility study included study flow data (e.g., recruitment rates), participant surveys, documentation of intervention activities, and electronic health record review. Participant surveys with patient-reported outcomes were assessed at baseline and 14 weeks. Follow-up outcome assessments were conducted mostly by online surveys; if necessary, surveys were completed by postal mail.

Feasibility outcomes.

Study feasibility assessment included recruitment rates (including percentage of female and minoritized patients recruited) and retention rates. Intervention feasibility was based on fidelity of intervention delivery and rates of participant engagement. Intervention acceptability was based on satisfaction with the intervention; we also examined satisfaction with specific intervention components. Feasibility was assessed using pre-specified milestones for recruitment and enrollment (N = 40), intervention engagement (75%), satisfaction (75%), fidelity (90%) and data collection (surveys of pain and health outcomes at baseline and 14-weeks, 80%). Intervention effectiveness was based on assessments of capabilities, opportunities, and motivations targeted by RAMP.

Fidelity of intervention delivery.

Two experts in developing and delivering mind-body interventions for pain independently observed 10% of sessions via videoconference using a structured checklist.

Participant engagement.

Study staff assessed weekly group attendance. Each week of the intervention, study staff called participants who did not attend and asked three questions: 1) whether they completed any of the previous week’s session activities on their own (i.e., if they accessed program materials from the previous session(s) on the website, 2) whether they watched any/all of the videos, and 3) whether they reviewed the workbook materials for the previous session). At the end of the intervention, participants were asked the number of times per week they completed the different intervention components. Participation in ≥ 7 out of 12 sessions either by attending the group session (i.e., synchronous participation) or reporting that they completed any of the session activities on their own (i.e., asynchronous participation) was the pre-specified threshold for intervention engagement.

Participant acceptability.

Acceptability was assessed by overall satisfaction with the RAMP intervention on a 7-point Likert scale from “very satisfied to “very dissatisfied”, percentage who would recommend to another Veteran with pain, and satisfaction with intervention components.

Perceptions of Effectiveness.

Three subscales were developed to assess perceived effectiveness at improving capabilities (7 items; e.g., learned ways to prevent my pain from flaring up; learned ways to manage my stress), opportunities (4 items; e.g., program was set up in a way that made it easy for me to participate; program was helpful for connecting me with other people who have pain), and motivations (5 items, e.g., the program provided me a sense of accomplishment in taking care of my pain myself; the program gave me hope or optimism that my pain can get better), using a 0–10 scale (0 = Completely disagree to 10 = Completely agree).

Participant surveys and medical record data.

Survey data included sample characteristics including demographics, pain diagnoses, primary and secondary outcomes, and potential mediators. Specifically, surveys included measures of pain intensity and interference;³⁶ pain impact;⁴¹ physical function;⁴² sleep disturbance;⁴² fatigue;⁴² anxiety;⁴³ depression;⁴³ post-traumatic stress disorder;⁴⁴ participation in social roles and activities;⁴² satisfaction;⁴⁵ improvement;⁴⁶ use of healthcare, medications, or other non-pharmacological approaches for pain; use of tobacco, alcohol, prescription medications, and other substances,⁴⁷ pain catastrophizing,⁴⁸ self-efficacy,⁴⁹ perceived stress,⁵⁰ and body awareness measures.⁵¹Race and ethnicity were assessed on the baseline survey using predefined response options. Mental and behavioral health diagnoses were collected from the EHR.

Sample size.

The study was designed to assess feasibility for a full-scale trial and was not powered to detect important differences in clinical outcomes. The sample size of 40 was based on the previous experience of the investigative team conducting pilot studies to test trial procedures and identify potential important barriers to successful recruitment, intervention delivery, and participant retention.

Statistical Analysis.

Analyses for this feasibility pilot were for descriptive purposes only to inform feasibility. Means, standard deviations, and percentages were calculated.

Results

Study Feasibility.

A total of 197 rural-dwelling Veterans from the VA Southeast network (Alabama, Georgia, and South Carolina) were screened, and 166 completed the baseline survey; 40 were enrolled and assigned to the experimental intervention. Of the 126 not enrolled, 89 did not complete study procedures within the time window, 10 declined to be enrolled during screening, 24 were ineligible based on inclusion/exclusion criteria, and 3 were unable to be contacted. Reasons for declines included lack of interest, not enough time to participate, or a decline to complete required HIPAA forms (Figure 1). Of the 40 enrolled participants, half (52.5%) identified as women, over half as a member of a racial or ethnic minoritized group, and 82.5% had high impact chronic pain (see Table 2 for sample characteristics). Time between enrollment and starting in the RAMP program ranged from 12– 40 days (mean = 23.2 days and median = 21.5 days). Three-quarters (75%) of participants completed the final outcome assessment at 14 weeks. All of the 30 participants who completed the 14-week outcome assessment had participated in at least one RAMP session and 27 participated in at least 7 sessions.

Figure 1.

CONSORT

Table 2.

Socio-demographic and health-related characteristics of sample (N = 40).

Demographics	N (%) or M(SD)
Sex
Men	19 (47.5%)
Women	21 (52.5%)
Age in years	57.2 (12.3)
Hispanic/Latino Ethnicity	2 (5.0%)
Race
Black or African American	14 (35.0%)
American Indian/Alaska Native	1 (2.5%)
White American	16 (40.0%)
Multiracial American	5 (12.5%)
Other race/unknown	4 (10.0%)
Annual household income
Less than $25,000	5 (12.5%)
$25,000 - $49,999	10 (25.0%)
$50,000 - $74,999	7 (17.5%)
$75,000 - $99,999	9 (22.5%)
$100,000 or more	9 (22.5%)
Marital status
Married/Domestic Partner	28 (70.0%)
Divorced/Separated/Widowed	8 (20.0%)
Never Married	3 (7.5%)
Unknown	1 (2.5%)
Employment status
Full-time employment	8 (20.0%)
Part time employment	2 (5.0%)
Not employed	28 (70.0%)
Unknown	2 (5.0%)
Education
High School or less	8 (20.0%)
Some College	12 (30.0%)
Bachelors	15 (37.5%)
Masters +	5 (12.5%)
Health characteristics
Pain Duration (in months)	121 (116)
Substance Use (TAPS-5) N (%) yes	21 (55.3%)
Pain Functioning (BPI – Pain Interference)	7.0 (1.7)
Pain Intensity (BPI – Pain Intensity)	6.8 (1.7)
Graded Chronic Pain Scale Revised
Chronic Pain Absent	--
Mild Chronic Pain	--
Bothersome Chronic Pain	7 (17.5%)
High Impact Chronic Pain	33 (82.5%)
Physical function (PROMIS)	10.7 (3.2)
Fatigue (PROMIS)	15.0 (3.3)
Sleep disturbance (PROMIS)	22.4 (5.5)
Sleep duration (PSQI)	5.0 (0.9)
Participation in social roles and activities (PROMIS)	8.6 (2.7)
Self-efficacy for managing chronic conditions-managing emotions (PROMIS)	12.0 (4.3)
Self-efficacy for managing chronic conditions-managing social interactions (PROMIS)	13.5 (4.3)
Self-efficacy for managing chronic conditions-managing symptoms (PROMIS)	11.3 (3.3)
Self-efficacy for managing chronic conditions-managing daily activities (PROMIS)	11.4 (3.0)
Anxiety (GAD-2)	3.5 (2.0)
Depression (PHQ-2)	3.1 (1.9)
Primary Care PTSD Screen (PC-PTSD-5)	2.9 (2.0)
Perceived stress (PSS-10)	23.1 (3.8)
Pain catastrophizing (PCS)	14.3 (6.1)

Intervention Feasibility.

The fidelity review of 10% of sessions found that coaches delivered all planned session activities at each session. Overall, 83% of Veterans participated in at least one session and over two-thirds (68%) participated in at least 7 of 12 sessions, either synchronously (accounting for 86% of sessions) or asynchronously (accounting for 14% of sessions). The participants who did not start the RAMP intervention (i.e., did not participate in any sessions), were unable to be contacted despite multiple attempts. Among Veterans who started the program, over one-third reported using the RAMP physical exercise videos at least four times per week (39.4%: Table 3). Mini-practices and mind-body videos were utilized at least 4 times per week by 36.4% and 27.3% of participants respectively. Educational videos were most typically viewed 1–3 times per week (60.6% of participants). The workbook was more frequently referenced than the website; 36.4% utilized the workbook at least 4 times per week, compared to 6.1% for the website (Table 3).

Table 3.

Completion of intervention activities in a typical week among Veterans who started the RAMP intervention (n = 33).

	N (%)
Mini-practices
None	1 (3.0%)
1–3 times per week	16 (48.5%)
≥ 4 times per week	12 (36.4%)
Unknown	4 (12.1%)
Physical exercise videos
None	2 (6.1%)
1–3 times per week	14 (42.4%)
≥ 4 times per week	13 (39.4%)
Unknown	4 (12.1%)
Educational videos
None	3 (9.1%)
1–3 times per week	20 (60.6%)
≥ 4 times per week	6 (18.2%)
Unknown	4 (12.1%)
Mind-body activity videos
None	1 (3.0%)
1–3 times per week	19 (57.6%)
≥ 4 times per week	9 (27.3%)
Unknown	4 (12.1%)
The workbook
None	2 (6.1%)
1–3 times per week	15 (45.5%)
≥ 4 times per week	12 (36.4%)
Unknown	4 (12.1%)
The website
None	7 (21.2%)
1–3 times per week	20 (60.6%)
≥ 4 times per week	2 (6.1%)
Unknown	4 (12.1%)

Intervention acceptability.

The majority of Veterans who started the program, 79% (26/33), reported being very or somewhat satisfied with the intervention overall, and 82% (27/33) said they would recommend it to another Veteran with chronic pain. The percentage of Veterans who were completely or very satisfied with the intervention components (e.g., videos, workbooks) ranged from 75.8% to 84.8% (Table 4). No adverse events were reported.

Table 4.

Intervention Acceptability Among Veterans who Started the RAMP Intervention (n = 33).

	Satisfied N (%)	Neutral N (%)	Dissatisfied N (%)	Unknown N (%)
Mini-practices	25 (75.8%)	3 (9.1%)	1 (3.0%)	4 (12.1%)
Physical exercise videos	26 (78.8%)	2 (6.1%)	1 (3.0%)	4 (12.1%)
Educational videos	26 (78.8%)	0 (0.0%)	3 (9.1%)	4 (12.1%)
Mind-body activity videos	26 (78.8%)	1 (3.0%)	2 (6.1%)	4 (12.1%)
The workbook	25 (75.8%)	3 (9.1%)	1 (3.0%)	4 (12.1%)
The group discussions	27 (81.8%)	1 (3.0%)	1 (3.0%)	4 (12.1%)
The health coach/facilitator	28 (84.8%)	1 (3.0%)	0 (0.0%)	4 (12.1%)
The video conferencing technology	27 (81.8%)	2 (6.1%)	0 (0.0%)	4 (12.1%)
The website	26 (78.8%)	2 (6.1%)	0 (0.0%)	5 (15.2%)

Perceptions of effectiveness.

Participants viewed the intervention as supporting their pain self-management capabilities (means 6.6 – 8.1 on 0–10 scale, where 0 = Completely disagree to 10 = Completely agree); providing useful self-management opportunities and resources (means 8.4 – 9.4); and enhancing their motivation to self-manage their pain (means 7.6 – 8.2), see Table 5.

Table 5.

Perceptions of effectiveness.

	M (SD)
Capabilities
I learned ways to prevent my pain from flaring up	7.3 (2.1)
I learned ways to manage my pain when it is bothering me	8.1 (1.9)
I learned ways to help me do my daily activities comfortably (e.g., driving, sitting at a desk, lifting)	7.7 (2.3)
I learned ways to get more physically active	7.3 (2.9)
I learned ways to manage my sleep	6.6 (2.3)
I learned ways to manage my stress	7.3 (1.9)
I learned ways to deal with worrying thoughts and feelings about my pain	7.2 (2.5)
Opportunities
The program was set up in a way that made it easy for me to participate	9.0 (1.7)
The program took a reasonable amount of time	8.4 (2.2)
The program staff provided helpful reminders	9.4 (1.0)
The program was helpful for connecting me with other people who have pain	8.8 (2.1)
Motivations
The program provided me a sense of accomplishment in taking care of my pain myself	8.2 (2.0)
The program provided me a plan for how to take care of my pain myself	8.2 (1.8)
The program helped me get into a habit of taking care of my pain without having to think about it too much	7.6 (2.4)
The program gave me confidence that looking after my pain is something I can do myself	8.2 (1.9)
The program gave me hope or optimism that my pain can get better	7.8 (2.7)

Discussion

These findings support the feasibility of the RAMP study and feasibility, acceptability, and effectiveness (at addressing pre-defined capabilities, opportunities and motivations) of the RAMP intervention. Guided by the RE-AIM framework³¹, our feasibility findings indicate that we were able to reach a diverse rural population of Veterans with predominantly high-impact chronic pain. The sample included 60% of participants from minoritized racial groups and over one-third of the sample reported an annual household income < $50,000 per year. Further, Veterans who completed the program were highly satisfied and reported that the program supported their pain self-management capabilities, provided useful self-management opportunities and resources, and enhanced their motivation to self-manage their pain. Further, the delivery format – telehealth delivery of expert-led videos – has the potential to improve access to multimodal pain self-management interventions for rural Veterans who often face barriers to accessing such care.^11–13 This is particularly important given the growing evidence base to support non-pharmacological approaches for managing chronic pain, especially when bundled together to address pain from a biopsychosocial perspective.^1,2,16 While the VA has become a leader in advancing non-pharmacological pain management through its Whole Health Initiative,⁵² there remain many barriers, especially for rural patients. This includes lack of awareness/knowledge about non-pharmacological pain management approaches; shortage of availability and accessibility of Whole Health pain care services; and absence of the necessary ongoing support to successfully engage in ongoing non-pharmacological pain self-management.^{24,28–30,53} The RAMP intervention addresses these barriers.

While this pilot supports the overall acceptability and feasibility of the RAMP intervention, we also identified optimization strategies to enhance engagement. Attrition rates were slightly higher than anticipated and most occurred at the onset of the study (i.e., between enrollment and beginning the RAMP intervention). To reduce attrition, numerous strategies have been implemented in the larger trial to enhance the likelihood of future sustainment within the VA healthcare system. To increase engagement and retention in the larger trial, we will decrease the time between randomization and program start, which is expected to increase participant attendance at the first RAMP intervention session. This may require increased research team staffing to allow for additional screening to better determine whether participants are fully ready, willing, and able to commit to study participation. In addition, placing more emphasis on the importance of timing for participants (e.g., making sure that this is the right time to commit to the intervention or thinking about participating in a later session offering to potentially avoid conflict with other life priorities) might help to ensure that potential participants are ready to commit to the intervention. Engagement in group sessions and a reduction in attrition will also be enhanced by emphasizing various options for engagement earlier and more frequently, including the ability to review content in a self-paced manner outside of group sessions, as well as the availability of individual check-in calls. Finally, participants will be offered additional engagement “touchpoints” throughout the program (e.g., through text message reminders). To address engagement and future sustainment of the RAMP intervention in the VA healthcare system, the intervention format has been adjusted to better fit with current VA programing (e.g. shortening the overall program length from 12 weeks to 9 weeks and making all sessions group based).

The broad format of RAMP—a telehealth intervention that does not require a specific type of licensed professional for delivery--could fit optimally in the VA’s overall approach to multidisciplinary pain care, thereby maximizing the likelihood of implementation in the VA.^54–56 In the VA, pain care can be delivered via the major medical centers, at community-based outpatient clinics, or by a centralized resource of experts at the VISN level. Other approaches to rural VA pain care are also leveraging innovative delivery models to increase rural Veterans access to pain care. This includes the TelePain program which uses a hub-and-spoke model to deliver pain care from clinical resource hubs²⁵ and the telecollaborative care model, where a centralized nurse care manager coordinates pain care for rural Veterans.⁵⁷ Future implementation work, guided by the RE-AIM framework, will be needed to identify how to best situate the RAMP intervention in the VA healthcare system (e.g., central or local placement) to optimize reach, effectiveness, adoption, implementation, and maintenance.^31,32

This study had some limitations. This pilot was a non-randomized one-arm design without a comparator as the main feasibility questions focused on recruitment, retention, and optimization for the RAMP program. The research team was not concerned about potential issues with enrollment or retention in a usual care comparison arm as we recently completed a large randomized trial for chronic pain in the VA with successful recruitment and enrollment along with high retention in a usual care arm ³⁷. The high retention in that large trial was facilitated by providing the active pain self-management programs to usual care participants following the study⁵⁸ which is also planned for the full-scale RAMP trial. Further, we were unable to collect acceptability data from study non-completers, who could have potentially had a more negative view of the intervention. In addition, the telehealth format of this intervention means that it requires access to reliable internet, either in the home, or via use of VA resources. Finally, this work was piloted in a specific healthcare system, the VHA, and only a subset of potentially eligible Veterans chose to participate, and as such, generalizability of findings would need to be tested across other healthcare settings.

Conclusion

The current findings largely support the feasibility and acceptability of the RAMP intervention. This intervention was designed for rural Veterans with chronic pain, a group that faces unique barriers to receiving multidisciplinary pain care. A hybrid randomized control trial of the RAMP intervention is needed as a next step, to both assess effectiveness and prepare for future implementation of the RAMP intervention within the VA healthcare system.