Walking without Pain: Piloting a digital program for people 50 years and over experiencing chronic low back pain

Brief name: Walking without Pain What materials: Participants in the intervention group will receive: • The Pain Course (eCentreClinic) – an online psychological program designed for people managing different pain conditions. The aims of the course are to provide information about chronic pain and to share skills for managing the impact of chronic pain on daily life and emotional wellbeing. • An Individual Walking Program (IWP) – a digitally delivered, tailored and progressive walking program targeting daily walk time. • Physical Activity Coaching – 2-5 telehealth sessions with an Exercise Physiologist to support participants during the IWP. Sessions delivered by the Exercise Physiologist will be guided by a script. Participants in the intervention group will be provided: • An Actigraph (GT9X) - a wrist-worn physical activity monitoring device to support them during the Individual Walking Program (IWP). What procedures: Pain Course: • Participants will be onboarded (pre-arranged appointment) remotely to the Pain Course by the Clinical Psychologist, who is a member of the research team. • The Pain Course will be delivered by the eCentre Clinic and will run for 8 weeks with lessons in weeks 1, 2, 4, 5, & 7. Total time involvement is expected to amount to 4hrs/week with optional weekly support (pre-arranged) via telephone or private messaging platform with the Clinical Psychologist. Content summary: The Pain Course is a validated Internet-delivered pain management program that is based on the principles of cognitive-behavioral therapy and transdiagnostic psychological intervention. It consists of 5 modules, delivered as a slide show, and 5 downloadable homework assignments to assist participants in learning and applying the skills described in the lessons. Detailed case stories and examples are included throughout all materials. Additional resources on related topics (eg, managing sleep, problem solving) are also available. Materials are released systematically over 8 weeks. Brief module contents: a. Week 1 - Psychoeducation about chronic pain and symptoms of anxiety and depression. Introduction of a CBT model incorporating pain, physical symptoms, thoughts, and behaviours. b. Week 2 and 3 - Education about the importance of managing thoughts to help manage pain. Thought monitoring and cognitive challenging. c. Week 4 - Physical symptoms of anxiety and depression and their relationship to managing the impact of chronic pain. Controlled breathing and activity scheduling. d. Week 5 and 6 - Behavioural symptoms of anxiety, depression and chronic pain. Activity pacing and a guide for gradual increase in activity. e. Week 7 and 8 - Information about lapses in chronic pain, depression and anxiety. Relapse prevention planning and goal-setting. Mode of training: materials are presented as slide shows consisting of static text and images. These are also available as PDF downloads. Duration of onboarding: approximately 10 minutes. Adherence: the eCentreClinic website records % completion for each module. Individual Walking Program (IWP): Participants will: • Wear a waist-worn activity monitoring device (McRoberts Monitor) for 7 days at baseline to determine baseline physical activity levels. • Be onboarded remotely (pre-arranged appointment) to the IWP and wrist-worn physical activity monitoring device in week 3. • Receive REDCap delivered email or text message reminders to charge the device daily. • Receive tailored daily step goals sent weekly via REDCap and delivered as an email or text message. Participants will be asked to wear an activity monitor for 7 days at baseline. The device will record their daily steps. An average will be taken from the days recorded to determine their baseline activity levels. Participants will receive 2-5 telehealth physical activity coaching sessions with a member of the research team. These sessions are scheduled to take place at week 3, 6, 8, 10 and 12 of the 14-week intervention period to coincide with the Walking Program (12-weeks) and Pain Course (8-weeks). During these coaching sessions, participants will be supported with their physical activity behaviour – daily walking. This will include reviewing individual effort/adherence (number of daily walks/week, daily steps), individual tailoring, addressing barriers etc. Participants will be loaned a wrist worn physical activity monitoring device throughout the intervention in order to monitor their own daily step count. When the intervention is complete, these devices will be returned and the data extracted (daily walk time, steps). Physical Activity Coaching: • Participants will be offered 5 physical activity coaching sessions (pre-arranged appointments). • 2 of the 5 sessions are essential (week 3 and 6). The first (week 3) coincides with the onboarding to the IWP and the Actigraph GT9X and is expected to take 45 minutes. The second (week 6), is estimated to take 30 minutes and aligns with Pain Course lessons about activity scheduling, activity pacing, and graded exposure. • The remaining three sessions (week 8, 10, 12) are for review/feedback and are optional. We expect they will take participants 10 minutes each. Session 1 week 3 (45 minutes): the purpose of this contact is to onboard the participant to the IWP and activity monitoring device (wrist worn). Encourage goal setting and action planning, introduce habit formation including prompts/cues. Session 2 week 6 (30 minutes): the purpose of this contact is to review goal progress, support problem solving, discuss Pain Course lesson 3,4 (activity scheduling, activity pacing, graded exposure) in relation to their daily walking goal. Session 3,4,5 week 8,10,12 (10 minutes): participants can opt in/out (via survey) of a review phone call (scheduled) every 2 weeks for the remainder of the IWP. The purpose of these contacts is to check in, support the participant via tailoring, problem solving, etc. Session attendance will be monitored in the study database. Who: Individual Walking Program (IWP) and Physical Activity Coaching: Delivered by an Exercise Physiologist. Exercise Physiologists are university qualified allied health professionals, trained in clinical exercise interventions and behaviour change. Pain Course: Developed by the eCentre Clinic, (a specialist research unit at Macquarie University), is an internet delivered pain management program, supported by a Clinical Psychologist. How: Individual Walking Program (IWP): internet delivered, tailored daily step goals sent weekly via REDCap and delivered as an email or text message. Physical Activity Coaching: delivered via telehealth (telephone or videoconference (zoom) with or without video based on participant preference). Pain Course: internet delivered, contact via phone or private messaging platform from Clinical Psychologist. Where: NeuRA and the eCentre Clinic are both located in Sydney, Australia. Participants from the intervention group and waitlist control group will attend NeuRA once to complete a baseline assessment. The intervention itself is completed remotely. Intervention participants do not need to attend NeuRA or the eCentre Clinic during the intervention or follow-up period. Based on the inclusion criteria, participants will reside within the Sydney Metropolitan area. When and how much: The intervention period will be 14 weeks long with a 6-month follow-up period calculated from the the baseline. Participants will not be required to perform any study related tasks between the 15-week timepoint and 6-month timepoint. Individual Walking Program (IWP): starts in week 3 and is 12-weeks in duration. Participants receive a daily step goal calculated from their baseline activity levels, and is gradually increased by 10% each week, with the overall aim of 7,000 – 10,000 steps per day by the end of the 12-weeks. Physical Activity Coaching: 2-5 sessions, with 2 of these sessions required (week 3 and 6). The required sessions coincide with the IWP, with session 1 and 2 estimated to take 45 minutes and 30 minutes respectively. The remaining 3 sessions (week 8, 10, 12) are optional and are estimated at 10 minutes each. Pain Course: 8 weeks, 5 lessons, 4hrs/week, weekly optional contact (10-20 minutes) Tailoring: Individual Walking Program (IWP): At baseline, participants will receive a waist-worn physical activity monitoring device (McRoberts Monitor) via post and be asked to wear this for 7 days, returning it via reply paid envelope. The data from the device will be analysed and used to tailor the IWP. Participants will receive a daily step target based on their baseline activity levels. This step target will gradually increase by 10% (or slightly more) of their baseline daily steps each week, to ensure that at the end of the 12 weeks, their daily steps meet the target of between 7,000-10,000 steps per day. To achieve the step target, participants will be encouraged to engage in an extra exercise walk each day. This means that participants will be asked to go for an exercise walk of approximately 4 minutes (based on step count and average walking speed in week 1), gradually building up to a walk of a maximum of 48 minutes over the 12 weeks. Physical Activity Coaching: The sessions will encourage positive behaviour change through 1) conversation guided by motivational interviewing (MI), and 2) behaviour change techniques (BCTs) such as goals and planning, feedback and monitoring, shaping knowledge, habit formation (associations, repetition and substitution). The Exercise Physiologist delivering these sessions will refer to a script to guide the conversation, however as it is guided by MI, coaching is flexible and therefore not linear. Pain Course: The Pain Course comes with a recommended timeline (5 lessons across week 1, 2, 4, 5, 7). Participants are encouraged to read all of the materials particularly focusing on the materials that are most relevant to them. A clinical psychologist from the eCentre Clinic will contact participants throughout the Pain Course in an optional guided arrangement. The clinical psychologist will contact participants at the start of the Pain Course to orient them to the course and find out about participant contact preferences. Some participants may choose weekly contact, while others may choose to contact the clinical psychologist as needed, or to be contacted less frequently e.g., at the mid-point, and the end, of the Pain Course.