TREATMENT PREFERENCES AMONG CANADIAN MILITARY VETERANS LIVING WITH CHRONIC LOW BACK PAIN: PROTOCOL FOR A MIXED METHODS CROSS-SECTIONAL SURVEY

Appendix 1. Copy of the English version of the survey instrument.

Treatment Preferences of Canadian Military Veterans living with Chronic Low Back Pain

[Insert date]

Dear [First Name],

The Chronic Pain Centre of Excellence (CPCoE) for Canadian Veterans is working with Dr. Peter Emary, a postdoctoral research fellow under the supervision of Dr. Jason Busse, Director of Research for the CPCoE. In collaboration with the CPCoE, a study is being conducted on Canadian Veterans’ use and preferences toward health care providers and treatment approaches for the management of chronic low back pain.

This study will be used to make recommendations to health care providers and to help researchers design studies on providing better low back pain services to military personnel.

Following this cover page is a 33-question survey which should take between 15 to 20 minutes to complete. These questions are based on previous research of Veterans living with chronic low back pain, as well as feedback from Canadian Veterans and chronic pain experts. Prior to the actual survey, there are two questions to assess your eligibility for completing the survey.

If you have any questions or concerns at any point regarding the survey, please contact Peter Emary through e-mail at emaryp@mcmaster.ca.

Thank you very much for your time and assistance.

Sincerely,

Peter Emary, DC, PhD

Postdoctoral Fellow, Michael G. DeGroote National Pain Centre

McMaster University

Screening Questions

We would like to first ask you two questions to determine your eligibility for completing the survey.

I. Have you previously served in the Canadian Armed Forces?

     Yes

     No

II. Do you currently live with chronic low back pain?

Chronic low back pain is defined as low back pain on most days or every day over the past 6 months.

     Yes

     No

Demographic Questions

1. What is your gender?

     □ Female

     □ Male

     □ Other: _____________________________

     □Prefer not to answer

2. What is your age?

     □18 to 24

     □25 to 34

     □35 to 44

     □45 to 54

     □55 to 64

     □65+

3. What branch(s) of the military did you serve in (check all that apply)?

     □Royal Canadian Navy

     □Canadian Army

     □Royal Canadian Air Force

     □Canadian Special Operations Forces Command

     □Other: _____________________________

4. What was your final rank in the military?

     □Officer

     □ Warrant Officers Petty Officer and Senior Non-Commissioned Officer

     □Junior Non-Commissioned Member

     □Other: _____________________________

5. What component(s) of the military were you a part of?

     □Regular Force

     □Primary Reserve

     □Primary Reserve – Cadet Organizations Administration and Training Service

     □Primary Reserve – Canadian Rangers

     □Other: _____________________________

6. Which of the following best describes the primary focus of your occupational specialty (*) in the military?

     □ Operational or Combat-related

     □ Operational support (i.e., Non-operational or non-combat related positions that assisted operational or combat-related forces to deliver their mission)

     □ Institutional support (i.e., Non-operational or non-combat related positions that were not involved in assisting operational or combat-related forces directly; e.g., base/wing positions, support for educational institutions)

     □ Other: _____________________________

     * What was your specific trade? (e.g., infanteer, IT technician, medical assistant, combat engineer, etc.)

     ___________________________________

7. How many years did you serve in the military?

     □ Less than 5 years

     □ 5 to 10 years

     □ 11 to 15 years

     □ 16 to 20 years

     □ 21 to 25 years

     □ 26 to 30 years

     □ More than 30 years

8. How many years has it been since you released from the military?

     □ Less than 5 years

     □ 5 to 10 years

     □ 11 to 15 years

     □ 16 to 20 years

     □ More than 20 years

9. What was your province or territory of residence at the time of release from the military?

     □ Ontario

     □ Manitoba

     □ Quebec

     □ Nova Scotia

     □ New Brunswick

     □ Prince Edward Island

     □ Newfoundland and Labrador

     □ Saskatchewan

     □ Alberta

     □ British Columbia

     □ Yukon

     □ Northwest Territories

     □ Nunavut

     □ Other: _____________________________

10. What is your current province or territory of residence?

     □ Ontario

     □ Manitoba

     □ Quebec

     □ Nova Scotia

     □ New Brunswick

     □ Prince Edward Island

     □ Newfoundland and Labrador

     □ Saskatchewan

     □ Alberta

     □ British Columbia

     □ Yukon

     □ Northwest Territories

     □ Nunavut

     □ Other: _____________________________

11. What best describes your current region of residence?

     □ Urban (in the city)

     □ Rural (in the country)

     □ Suburban (mixed-use or residential area, existing either as part of a city area or as a separate residential community within commuting distance of a city)

     □ Other: _____________________________

12. What best describes your current gross income level?

     □ Below $25,000

     □ $25,000 to $49,000

     □ $50,000 to $59,000

     □ $60,000 to $79,000

     □ $80,000 to $99,000

     □ $100,000 to $150,000

     □ More than $150,000

     □ Prefer not to answer

13. Which of the following best describes your race or ethnicity?

     □ Asian – East (e.g., Chinese, Japanese, Korean)

     □ Asian – South (e.g., Indian, Pakistani, Sri Lankan, Indo-Caribbean/West Indian)

     □ Asian – Southeast (e.g., Malaysian, Filipino, Vietnamese, Cambodian)

     □ Asian – West (e.g., Afghan, Israeli, Saudi Arabian, Iranian, Turkish)

     □ Australasian – (e.g., Australia, New Zealand, New Guinea, Melanesia)

     □ Black – Africa (e.g., Ghanaian, Kenyan, Somali)

     □ Black – North America

     □ Black – Caribbean Region (e.g., Barbadian, Jamaican)

     □ Hispanic

     □ Indigenous (e.g., Inuit, First Nations, Non-Status Indian, Metis, Indigenous person from outside Canada)

     □ Latin American (e.g., Argentinean, Chilean, Salvadoran)

     □ White/European (e.g., English, Italian, Portuguese, Russian)

     □ Prefer not to answer

     □ Do not know

     □ Other: _____________________________

14. What is your highest formal education level?

     □ High School

     □ College Degree

     □ University Degree

     □ Other: _____________________________

15. What best describes your current relationship status?

     □ Single/Never Married

     □ Married

     □ Common law

     □ Separated

     □ Divorced

     □ Widowed

     □ Chronic Low Back Pain Section

The following questions seek to understand when your chronic low back pain originated, how much it impacts your day-to-day life, what treatments you have received and are currently using for your chronic low back pain, which health care providers you prefer to see for treatment of your chronic low back pain, what treatments were available to you while serving in the military, and if you feel other treatments may have been helpful.

There are no right or wrong answers. Please answer based on your own experiences and opinions.

A. Impact of chronic low back pain

16. How many years have you lived with chronic low back pain?

     □ 6 months to 1 year

     □ 1+ to 5 years

     □ 5+ to 10 years

     □ 10+ to 20 years

     □ 20+ years

17. Over the past week, on average, how would you rate your chronic low back pain?

No pain Worst pain possible

0 1 2 3 4 5 6 7 8 9 10

18. Over the past week, how much has your chronic low back pain interfered with your daily activities (housework, washing, dressing, walking, climbing stairs, getting in/out of bed/chair)?

No interference Unable to carry out activity

0 1 2 3 4 5 6 7 8 9 10

19. Over the past week, how much has your chronic low back pain interfered with your ability to take part in recreational, social, and family activities?

No interference Unable to carry out activity

0 1 2 3 4 5 6 7 8 9 10

20. Over the past week, how anxious (tense, uptight, irritable, difficulty in concentrating/relaxing) have you been feeling?

Not at all anxious Extremely anxious

0 1 2 3 4 5 6 7 8 9 10

21. Over the past week, how depressed (down-in-the-dumps, sad, in low spirits, pessimistic, unhappy) have you been feeling?

Not at all depressed Extremely depressed

0 1 2 3 4 5 6 7 8 9 10

22. Over the past week, how have you felt your work (both inside and outside the home) has affected (or would affect) your chronic low back pain?

Have made it no worse Have made it much worse

0 1 2 3 4 5 6 7 8 9 10

23. Over the past week, how much have you been able to control (reduce/help) your chronic low back pain on your own?

Completely control it No control whatsoever

0 1 2 3 4 5 6 7 8 9 10

B. Treatments and health care providers used (or currently using) for chronic low back pain

24. Which of the following treatments have you received, at any time, for your chronic low back pain? (choose all that apply):

Over-the-counter medications:

► Examples: Tylenol, Advil □ tried in the past □ currently using

Opioid medications:

► Examples: Codeine, morphine, hydromorphone, tramadol □ tried in the past □ currently using

Adjuvant medications:

► Examples: Anti-depressants (e.g., duloxetine, amitriptyline), anti-

seizure drugs (e.g., lamotrigine, gabapentin, carbamazepine) □ tried in the past □ currently using

Non-steroidal anti-inflammatory drugs (NSAIDs):

► Examples: Naproxen, celecoxib □ tried in the past □ currently using

Topical agents:

► Examples: Capsaicin, lidocaine □ tried in the past □ currently using

Muscle relaxants:

► Examples: Baclofen, tizanidine □ tried in the past □ currently using

Cannabis:

► Examples: Inhaled, oral □ tried in the past □ currently using

Injections or other interventional procedures:

► Examples: Nerve blocks, epidural or corticosteroid injections, muscle/trigger point injections (e.g., lidocaine, botox), ultrasound infusion/administration of medications (e.g., lidocaine, ketamine), nerve denervation (e.g., radiofrequency ablation) □ tried in the past □ currently using

Low back surgery:

► Examples: Spinal laminectomy, discectomy, foraminotomy,

nucleoplasty, spinal fusion, artificial disc replacement □ tried in the past □ currently using

Physiotherapy:

► Examples: Exercise therapy, stretching/mobilization, traction, TENS

(Transcutaneous electrical nerve stimulation), low-level laser therapy, therapeutic ultrasound □ tried in the past □ currently using

Chiropractic care:

► Examples: Spinal manipulation/ “adjustment”, flexion-distraction therapy (i.e., spinal decompression/manual traction), soft-tissue massage/stretching, advice on exercise/ergonomics □ tried in the past □ currently using

Psychotherapy:

► Examples: Pain neuroscience education program/chronic pain management course, family or group therapy, cognitive-behavioural therapy (individual or group), acceptance and commitment therapy, mind-body therapy (e.g., mindfulness/meditation), biofeedback □ tried in the past □ currently using

Complementary and alternative medicine (choose all that apply):

     Naturopathic treatment/homeopathic remedies: □ tried in the past □ currently using

     Acupuncture: □ tried in the past □ currently using

     Registered massage therapy: □ tried in the past □ currently using

     Osteopathy: □ tried in the past □ currently using

     Other: _____________________________ □ tried in the past □ currently using

Other treatment(s) not covered above: _____________________________ □ tried in the past □ currently using

     □ Not applicable (I have never received treatment for my chronic low back pain)

25. Which health care providers have you seen for your chronic low back pain, at any time? (check all that apply):

□ Family doctor

On a scale of 0-10, how satisfied were you with the care provided? ___ (0 = not at all satisfied, 10 = completely satisfied)

□ Physiatrist (a physician specializing in physical medicine and rehabilitation)

On a scale of 0-10, how satisfied were you with the care provided? ___ (0 = not at all satisfied, 10 = completely satisfied)

□ Orthopedic surgeon

On a scale of 0-10, how satisfied were you with the care provided? ___ (0 = not at all satisfied, 10 = completely satisfied)

□ Neurosurgeon

On a scale of 0-10, how satisfied were you with the care provided? ___ (0 = not at all satisfied, 10 = completely satisfied)

□ Nurse

On a scale of 0-10, how satisfied were you with the care provided? ___ (0 = not at all satisfied, 10 = completely satisfied)

□ Physiotherapist

On a scale of 0-10, how satisfied were you with the care provided? ___ (0 = not at all satisfied, 10 = completely satisfied)

□ Chiropractor

On a scale of 0-10, how satisfied were you with the care provided? ___ (0 = not at all satisfied, 10 = completely satisfied)

□ Occupational therapist

On a scale of 0-10, how satisfied were you with the care provided? ___ (0 = not at all satisfied, 10 = completely satisfied)

□ Registered massage therapist

On a scale of 0-10, how satisfied were you with the care provided? ___ (0 = not at all satisfied, 10 = completely satisfied)

□ Acupuncturist/Traditional Chinese Medicine practitioner

On a scale of 0-10, how satisfied were you with the care provided? ___ (0 = not at all satisfied, 10 = completely satisfied)

□ Mental health professional (e.g., psychologist)

On a scale of 0-10, how satisfied were you with the care provided? ___ (0 = not at all satisfied, 10 = completely satisfied)

□ Others (please list): _____________________________

On a scale of 0-10, how satisfied were you with the care provided? ___ (0 = not at all satisfied, 10 = completely satisfied)

□ Not applicable (I have never seen a health care provider for my chronic low back pain)

C. Attitudes toward specific health care providers for chronic low back pain

26. Which health care providers do you most prefer to see for treatment of your chronic low back pain? (1 = most preferred, 12 = least preferred):

(1) Family doctor □ (1-12)

(2) Physiatrist (a physician specializing in physical medicine and rehabilitation) □ (1-12)

(3) Orthopedic surgeon □ (1-12)

(4) Neurosurgeon □ (1-12)

(5) Nurse □ (1-12)

(6) Physiotherapist □ (1-12)

(7) Chiropractor □ (1-12)

(8) Occupational therapist □ (1-12)

(9) Registered massage therapist □ (1-12)

(10) Acupuncturist/Traditional Chinese Medicine practitioner □ (1-12)

(11) Mental health professional (e.g., psychologist) □ (1-12)

(12) Others (please list): _____________________________ □ (1-12)

□ Not applicable

► For your top 3 choices above (i.e., those you rated as being #1, 2 and 3), can you explain why you most prefer to see these health care providers for treatment of your chronic low back pain?

► For your bottom 3 choices above (i.e., those you rated as being #10, 11 and 12), can you explain why you least prefer to see these health care providers for treatment of your chronic low back pain?

D. Accessibility of low back pain services in the military

27. When during your military career did you begin experiencing low back pain?

     □ Before military service

     □ During military service

     □ After military service

28. During your military service, which health care providers did you see on base for low back pain treatment? (check all that apply):

     □ Not applicable (I did not experience low back pain while in the military)

     □ Family doctor

     □ Physiatrist (a physician specializing in physical medicine and rehabilitation)

     □ Orthopedic surgeon

     □ Neurosurgeon

     □ Nurse

     □ Physiotherapist

     □ Chiropractor

     □ Occupational therapist

     □ Registered massage therapist

     □ Acupuncturist/Traditional Chinese Medicine practitioner

     □ Mental health professional (e.g., psychologist)

     □ Others (please list): _____________________________

29. During your military service, which health care providers did you see off-base for low back pain treatment? (check all that apply):

     □ Not applicable (I did not experience low back pain while in the military)

     □ Family doctor

     □ Physiatrist (a physician specializing in physical medicine and rehabilitation)

     □ Orthopedic surgeon

     □ Neurosurgeon

     □ Nurse

     □ Physiotherapist

     □ Chiropractor

     □ Occupational therapist

     □ Registered massage therapist

     □ Acupuncturist/Traditional Chinese Medicine practitioner

     □ Mental health professional (e.g., psychologist)

     □ Others (please list): _____________________________

30. Which health care providers do you believe should be available on base for low back pain treatment? (check all that apply):

     □ Family doctor

     □ Physiatrist (a physician specializing in physical medicine and rehabilitation)

     □ Orthopedic surgeon

     □ Neurosurgeon

     □ Nurse

     □ Physiotherapist

     □ Chiropractor

     □ Occupational therapist

     □ Registered massage therapist

     □ Acupuncturist/Traditional Chinese Medicine practitioner

     □ Mental health professional (e.g., psychologist)

     □ Others (please list): _____________________________

31. Do you feel that your low back pain, when it first started, was treated effectively?

     □ Yes □ No □ Unsure

32. Do you feel that more treatment options or better access to care when your low back pain first started may have prevented it from becoming chronic?

     □ Yes □ No □ Unsure

E. Final comments

33. Are there any other comments you would like to share regarding your experiences with managing your chronic low back pain?

_____________________________

End of Survey

Thank you for your time!

If you have any further questions, please contact Dr. Peter Emary at: emaryp@mcmaster.ca