Mind-body Treatments for Chronic Back Pain StudyThank you for your interest in this study. Before we schedule a call for you to learn more about the study, it would be helpful to see if you are likely to qualify to be in the study. In order to do this, we would like to ask you some eligibility questions, which will include questions about your back pain, mental health history, medical history, and more. It should take about 15 minutes to go through these questions. We are also required to give you the number of the University of Colorado - Anschutz Medical Campus IRB which is the Ethics Board that oversees our research: it is (303) 724-1055 in case you have any questions or concerns for them. The purpose of this study is to determine the effect of mind-body treatment for chronic back pain. This entire study will be conducted virtually through tele-health. You have been invited to participate in this study because you have chronic back pain.This questionnaire is meant to determine your eligibility for this study. Once deemed eligible for the study, participants will be randomized (like a coin-flip) to one of three conditions. You will be randomized to either one of two different psychological treatments for chronic pain or to a control group without any treatment. Both of the psychological treatments in this study have been tested in previous randomized clinical trials and have shown to be safe and to improve pain-related outcomes in participants. In this present study, we want to further test the efficacy of these two psychological treatments for chronic pain and gather information on how they affect participants' experiences with pain. Treatment sessions will be conducted through tele-health. These sessions will be video recorded, but recordings will NOT be shared with anyone outside the study team. There will be 9 telehealth treatment sessions over about 1 or 1.5 months.The control group will be asked to answer the survey questions throughout the study but will not be participate in any study treatment. Payment will be between $165 for completing the study. The control group and experimental group will be compensated at the same rate. The questions below will help us assess your eligibility for the study and will take about 15 minutes to complete. All the information you provide will be kept confidential and only accessible to members of the research team. If you may be eligible based on your responses to the questions below, we will call you to provide further details about the study and see whether you'd like to participate.
First Name
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Last Name
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E-mail address
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Telephone Number
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please enter your number in this format: (555) 555-5555
Are you comfortable with email and/or text message communication?
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Yes
No
Current Age:
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What was your sex assigned at birth?
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Female
Male
Intersex
None of these describe me
Prefer not to answer
Unknown
What is your current gender identity?
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Man
Woman
Non-binary
Transgender
None of these describe me
Prefer not to answer
Unknown
If selected "none of these describe me", please indicate which are closer descriptions to your gender identity:
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Trans Man / Transgender Man / FTM
Trans Woman / Transgender Woman / MTF
Genderqueer
Genderfluid
Gender Variant
Questioning or unsure of your gender identity
None of these describe me, and I want to specify
None of these describe me, I want to specify:
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Which sexual orientation do you identify with most?
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Gay
Lesbian
Straight; that is, not gay or lesbian, etc.
Bisexual
None of these describe me
Prefer not to answer
Unknown
If selected "None of these describe me", please indicate which are closer descriptions to your gender identity:
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Queer
Polysexual, omnisexual, sapiosexual, or pansexual
Asexual
Two-spirit
Have not figured out / in the process of figuring out your sexuality
Mostly straight, but sometimes attracted to people of own sex
Do not think of yourself as having sexuality
Do not use labels to identify yourself
Do not know the answer
No, I mean something else _______
No, I mean something else:
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Which race do you identify with most?
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White
Black or African American or African
American Indian or Alaska Native
Asian
Native Hawaiian or Other Pacific Islander
More than one race
Other
Unknown
Prefer not to answer
Are you of Hispanic, Latino, or Spanish origin?
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Not Hispanic or Latino
Hispanic or Latino
Unknown
Not Reported
If "Yes, of Hispanic, Latino, or Spanish origin" selected, then please specify:
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Colombian
Cuban
Dominican
Ecuadorian
Honduran
Mexican or Mexican American
Puerto Rican
Salvadoran
Spanish
None of these fully describe me ____________
None of these fully describe me:
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What is your education level:
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No formal education
Primary level education (1st - 12th grade)
Secondary level education / GED / Equivalent
Some College
Associate degree
Trade / Vocational Training
Bachelor's Degree or Higher
Refused
Unknown
Prefer not to answer
Yearly household income level
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Less than $14,999
$15,000 to $24,999
$25,000 to $49,000
$50,000 to $74,999
$75,000 to $99,999
Over $100,000
Prefer not to answer
What is your occupation? If employed, please specify your occupation as best as possible If retired or unemployed, you may simply state your employment status
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Which of the following best describes your current living situation:
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Live alone in my own home (house, apartment, condo, trailer, etc.); may have a pet
Live in a household with other people
Live in a residential facility where meals and household help are routinely provided by paid staff (or could be if requested)
Live in a facility such as a nursing home which provides meals and 24-hour nursing care
Temporarily staying with a relative or friend
Temporarily staying in a shelter or homeless
Other, please specify _______
Prefer not to answer
Other, please specify:
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How many people were living or staying in this house, apartment, or mobile home on (date you are filling out this survey)?
What is your current marital status?
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Married
Divorced
Widowed
Separated
Never married
A member of an unmarried couple
Unknown
Prefer not to answer
Primary Language Spoken
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Do you currently have health insurance (either Medicare or medicaid or private insurance)?
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Yes
No
Unknown
Prefer not to answer
Zip Code of Primary Address
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How long has back pain been an ongoing problem for you (in years)?
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In years. e.g., 9 months would be 0.75
How often has back pain been an ongoing problem for you over the past 6 months?
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Less than half the days
Half the days
More than half the days
In the past week, how intense has your back pain been?
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0 - no pain
1
2
3
4
5
6
7
8
9
10 - pain as bad as you can imagine
Do you have leg pain that is worse than your back pain?
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Yes
No
Do you receive or have you applied for worker's compensation benefits related to your pain?
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Yes
No
Are you currently involved in any lawsuits related to your pain, or are you currently applying for any disability payments related to your pain?
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Yes
No
Do you plan to be involved in any lawsuits or apply for any disability payments related to your pain in the next 6 months?
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Yes
No
Have you received a legal settlement or other disability payments related to your pain over the past two years?
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Yes
No
The option "
Which if any of the following have you ever been diagnosed with?
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please select all that apply
Have you tried to hurt or kill yourself in the past five years? (This includes non-suicidal self-harm, such as cutting yourself on purpose. If you have intentionally hurt yourself in the past five years, please answer yes).
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Yes
No
Have you been admitted to an inpatient psychiatric unit (a locked mental health facility) within the past five years?
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Yes
No
Do you believe that you currently abuse or overuse alcohol, illegal drugs, or prescription drugs?
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Yes
No
Have you had problems with abusing alcohol, illegal drugs, or prescription drugs in the past two years?
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Yes
No
Do you have major surgery or other major medical events planned in the coming six months?
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Yes
No
Do you currently have a stable and safe place to live, and will you have a safe living space for the next six months?
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Yes
No
Will you be able to attend telehealth appointments online twice per week for the next two months?
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Yes
No
Do you have reliable access to an electronic device with access to the internet, specifically a computer, laptop, or tablet (NOT just a phone)?
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Yes
No
Do you have reliable fast internet and access to a quiet room for telehealth sessions?
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Yes
No
Are you expecting any major changes in your employment over in the next six months?
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Yes
No
Do you have a known vertebral/spinal fracture or tumor?
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Yes
No
Have you had back surgery within the last 2 years?
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Yes
No
Do you have difficulty controlling your bowel function (i.e., trouble holding in your poop).
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Yes
No
Do you have a current or recent diagnosed with cancer of the breast, thyroid, lung, kidney, prostate or blood?
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Yes
No
Do you have a current or recent diagnosis of severe cardiovascular disease?
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Yes
No
In the past year, have you had an unexplained, unintended weight loss of 20 lbs. or more?
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Yes
No
Has a doctor ever told you that you have a neurological condition?
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Yes
No
If yes, what is it?
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Have you been diagnosed with rheumatoid arthritis, polymyalgia rheumatica, scleroderma, Lupus, polymytosis, or another specific inflammatory disorder?
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Yes
No
Military or Veteran Status (i.e. have you ever served on active duty in the U.S. Armed Forces, Reserved, or National Guard?)
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Yes
No
How did you hear about this study?
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Flyer
Facebook advertisement
Doctor's Office - Physician Referral
ResearchMatch
ClinicalTrial.gov
TV
Social Media/ Internet
Other
Where was the flyer posted?
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UCHealth A.F. Williams Family Medicine - Central Park
UCHealth Family Medicine - Boulder
UCHealth Family Medicine - Westminster
UCHealth Primary Care - Lone Tree
UCHealth Internal Medicine - Anschutz Medical Campus
CU Medicine Internal Medicine - Cherry Creek (CU DIMG)
UCHealth Internal Medicine - Lowry
UCHealth Women's Integrated Services in Health (WISH) - Anschutz
UCHealth Women's Integrated Services in Health (WISH) - Lone Tree
UCHealth Spine Center
CU Sports Medicine Center
Denver Health
CU Anschutz Depression Center
Unity Healthcare
Marillac Health
Axis Health
Kaiser
UPMC
Other
Which doctors office did you hear about this study from?
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UCHealth A.F. Williams Family Medicine - Central Park
UCHealth Family Medicine - Boulder
UCHealth Family Medicine - Westminster
UCHealth Primary Care - Lone Tree
UCHealth Internal Medicine - Anschutz Medical Campus
CU Medicine Internal Medicine - Cherry Creek (CU DIMG)
UCHealth Internal Medicine - Lowry
UCHealth Women's Integrated Services in Health (WISH) - Anschutz
UCHealth Women's Integrated Services in Health (WISH) - Lone Tree
UCHealth Spine Center
CU Sports Medicine Center
Denver Health
CU Anschutz Depression Center
Unity Healthcare
Marillac Health
Axis Health
Kaiser
UPMC
Other
Please specify how you heard about this study
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If you have any other comments you think may be relevant to our research team, please note them here: