The Development and Preliminary Evaluation of MOTIVATE: Moving to Improve Chronic Back Pain and Depression in Older Adults




Yang, Ailing Eileen

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BACKGROUND: Chronic low back pain (cLBP) is the 2nd most common reason for physician visits; annual related costs exceed USD 100 billion and are expected to rise with the aging population. cLBP and depression often coexist, and current non-pharmacologic interventions have not focused on older adults with these challenging comorbidities. A feasible, effective non-pharmacologic intervention targeting cLBP and comorbid depressive symptoms in older adults is needed. MOTIVATE (Moving to Improve Chronic Back Pain and Depression in Older Adults) is a novel 8-session, 12-week, telephonic behavioral intervention targeting older adults with cLBP and comorbid depressive symptoms. A health coach utilizes motivational interviewing and value-concordant goal setting to capture individual motivations to increase physical activity. The ultimate goal is to improve back pain-related pain interference, disability, and depressive symptoms. OBJECTIVE: To develop a unique telephone-delivered behavioral intervention that is feasible, increases physical activity, and ultimately improves pain, function, and depressive symptoms among older Veterans. METHODS: In Phase 1, Dr. Makris' research team developed a telephone-delivered multicomponent behavioral intervention that targets older Veterans (>65 years old) with cLBP and comorbid depressive symptoms. Input from stakeholder groups [experts in pain, geriatrics, geriatric psychology, primary care, behavioral interventions, among others (n=8), patients (n=5), and key clinical leaders (n=6)] was used to inform and refine content for this unique population. In Phase 2, we conducted a single-arm rollout of MOTIVATE in older Veterans with cLBP and depressive symptoms to further refine future intervention content, procedures, and delivery based on stakeholder feedback. For qualitative interviews, the Promoting Action on Research Implementation in Health Services (PARIHS) framework was used to develop the discussion guide and facilitate individual interviews with the following key stakeholder groups: Veteran participants (n=4) over the age of 65 with comorbid cLBP and depressive symptoms who received MOTIVATE, primary care providers (PCP) (n=4), clinic director (n=1), and health coach (n=1). RESULTS: Informed by interviews with 14 experts and 5 Veterans, we developed and iteratively refined the MOTIVATE manual and study procedures for Phase 1. In the single-arm MOTIVATE rollout (Phase 2), we enrolled 7 Veterans, with a mean age of 69 years who were predominately white (71%), male (86%), married (57%), and had some education beyond high school (71%). The eligibility mean pain intensity score was 7.3/10; baseline cLBP Pain, Enjoyment of Life, and General (PEG-3) Activity Scale was 7.14/10, back pain-specific Roland Morris Disability Questionnaire (RMDQ) Scale was 16.5/24; and depression PHQ-9 score was 16.7/27, with higher scores indicating greater impairment. Two case studies are provided for additional context and to more fully articulate important MOTIVATE intervention concepts. Upon completion of the intervention, semi-structured interviews with Veterans and other stakeholders provided valuable feedback on how to modify MOTIVATE moving forward. Briefly, Veterans who completed MOTIVATE engaged well with the health coach, were motivated to walk with a pedometer, and felt that being more active reduced pain and depressive symptoms. Of the four PCPs interviewed, all attributed the success of the intervention to the skills and engagement of the health coach; we also learned about the variability in how PCPs would like results relating to patient-identified values and goals to be communicated with them. The health coach noted that Veterans were able to identify value-concordant goals and easily link these to physical activities. All stakeholders stated that the individual health coach plays a critical role in activating and motivating older Veterans with complex medical and psychiatric conditions. CONCLUSION: MOTIVATE content and procedures were developed in Phase 1. The Phase 2 rollout showed that we were able to effectively recruit older Veterans with cLBP and depressive symptoms and deliver MOTIVATE via telephone. Feedback from key stakeholders regarding the iterative refinement of recruitment, study procedures, and content will aid the future evaluation and implementation of MOTIVATE in a pilot randomized controlled trial.

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