Interdisciplinary Chronic Pain and PTSD Management in a Military Population Robert J. Gatchel, Ph.D., ABPP Nancy P & John G. Penson Endowed Professor of Clinical Health Psychology Director, Center of Excellence for the Study of Health and Chronic Illnesses The University of Texas at Arlington

Overview    

Background on Military Chronic Pain Functional Restoration Intervention – The FORT Program Chronic Pain Comorbidity STRONGSTAR

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Background on Military Chronic Pain Epidemiology and Military-Specific Considerations

Chronic Pain and OIF/OEF 

47% OIF/OEF veterans reported chronic pain after deployment  

 

Over 80% of these vets were diagnosed with a musculoskeletal or connective tissue disorder 28% report Moderate to Severe pain

The rates of disability cases within the U.S. military have been increasing Pain = primary physical problem afflicting soldiers 

Roots of service-related chronic pain often begin in basic training (with up to 25% of male recruits and 50% of female recruits likely to experience at least one pain-related injury during Basic Combat Training)

Zambraski, 2006

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Factors Contributing to Rise in Pain 

Wounding Patterns 

Survivable extremity trauma



IED’s



Body Armor   

Increased survival rates Relative increase in extremity trauma Low back pain



Time in vehicles



Improvements in Medical Care  

MEDEVAC/CCATT (Critical Care Air Transport Teams) Combat medicine and in-theater hospitals

Mason, Eadie, & Holder, 2008; Hicks et al., 2010; Champion et al., 2010; Belmont et al., 2010; Nevin & Means, 2009

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Chronic Pain and OIF/OEF 

Approximately ½ of all OIF/OEF injuries are due to IEDs 

Account for 75% of all combat casualties



Casualties have dropped from 33% in prior conflicts to 4.6% in OIF/OEF



Increase representation of extremity trauma is due to decreased frequency of abdominal-thoracic injury (not a decrease in extremity trauma prevalence)

Belmont, Schoenfeld, & Goodman (2010); Belmont, Goodman, Zacchilli, et al. (2010)

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Proportional Distribution of Wounds by Body Region for Combat Casualties 70 58

60

61.1

60.2

49.4

50 40

Head/Neck Thorax Abdomen Extremity

36.2

30 20 10

21.4

21 13.9 8

9.9

16 8.4

13.4 9.4

7.5

6.9

0 WWII

Korea

Belmont, Goodman, Zacchelli, et al. (2010)

Vietnam

Current 7

Epidemiology – Military (Co$t)  



Pain disorders are a tremendous economic cost to the U. S. Armed Forces The medical discharge of one active duty U.S. military member in their 20's has been estimated to cost the government approximately $250,000 in lifetime disability payments, excluding health care costs Pain disorders account for the largest proportion of total disability compensation (~$400 million/mo)

Amoroso & Canham, 1999; Feuerstein et al., 1999

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A Functional Restoration Treatment for Military Musculoskeletal Pain The Functional Occupational Rehabilitation Treatment (FORT) Program

The FORT Program 

A functional restoration pain treatment approach characterized by:    

Biopsychosocial perspective on chronic pain Treatment tailored to the individual Primary outcome = function, not pain relief Interdisciplinary team to address complex pain   

    

Bio… Psycho… Social…

PT, RN, MD Psychologist, Counselor Group, Case Manager

Quantification of function Physician-directed Goal-oriented Outcomes monitored Opioid medications de-emphasized Mayer, McGeary, & Gatchel, 2003

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Functional Restoration – Outcomes 

Functional capacity    

 

Disability Psychosocial   

 

Depression Anxiety Fear avoidance/kinesiophobia

Health-related quality of life Socioeconomic 



Dynamic lifting Range of motion Grip strength Aerobic capacity

Healthcare utilization Work return/retention

 Pain intensity

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Military-Specific Outcomes 

Treatment cost 

CHCS / AHLTA  



Disability  



medication tracking healthcare utilization tracking

Profile Work status

Functional capacity 

Fitness test (exploratory) 12

Timelines and Randomization Groups Initial Assessment (83 Participants)

Randomization FORT Program (3 weeks) 37 participants • • • • •

Treatment as Usual (3 weeks) 46 participants

3 weeks, 4 days per week Group and Individual Therapy Physical and Occupational Therapy Biofeedback Nurse Case Management

• Continuation of prescribed medication • Continuation of medical prescription for treatment • Followed up after 3 weeks

6 Month Follow-Up 12 Month Follow-Up Gatchel, McGeary, Peterson, et al. (2009)

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Demographics VARIABLE

FORT (%)

TAU (%)

p-value

Gender Male Female

70 30

64 36

NS

Race Asian African-American Caucasian, Non-Hispanic Hispanic Other

3 17 63 13 3

6 19 67 8 0

NS

FORT = 36.9 (7.5) TAU = 34.4 (6.9) p = NS

Branch of Service U.S. Army U.S. Air Force U.S. Navy

23 77 0

25 72 3

NS

Rank Enlisted Officer

83 17

80 14

NS

Pain Site Spine Extremity

90 10

92 8

NS

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Age (yrs) Mean (sd)

Pain Duration (mos) Mean (sd) FORT = 67.8 (69.0) TAU = 63.4 (61.5) p = NS

Change in Psychosocial Variables (Pre-Post) FR Participants vs. TAU (% change) 40

30

30 20 10

5

2

0 -10 -20 -30

-11 -18

-20 -28

-40 -50

FR TAU -22 -29

-37 -47

-52

-60 BDI

(Depression)

-43

SF36 PCS MVAS (HRQoL)

OSW

(Self-Report Disability)

FABQ

-52 ISI

(Fear Avoidance) (Insomnia)

VAS

(Pain)

15

Change in Physical Variables (Pre-Post) FR Participants vs. TAU (% improved) 70

66

62 60 50 40

FR TAU

29

30

22 20 10 0 Lift FW

Lift WE 16

One-Year Psychosocial Outcomes (% Change from Post-Treatment, n=67) 100

87

80 60 40 20

13

5

FORT TAU

18

9

0 -20 -40

-22

-31 BDI

(Depression)

-12

-14 -29

-23

SF36 PCS MVAS Oswestry FABQ (HRQoL)

(Self-Report Disability)

-15

-15 -24

ISI

(Fear Avoidance) (Insomnia)

VAS (Pain)

17

One-Year Physical Outcomes (% Change from Post-Treatment, n=67) 0 -5 -10

-8

-11

-15 -20

FORT TAU

-25 -30 -35 -40 -45

-43

-50 Lift F-W

-47 Lift W-E 18

One-Year Socioeconomic Outcomes (n=67) †

RR

phi ‡

.125

.912

.213

52%

.088

.443

.196

50%

82%

.006

4.500

-.335

Surgery for Pain

0%

12%

.053

1.138

.256

Medical Board

0%

27%

.001

1.375

.400

Psych Treatment

35%

39%

.462

1.192

.042

ER Visits for Pain

0%

24%

.002

1.32

.374

Variable

FORT (% Yes) n=34

TAU (% Yes) n=33

Fisher’s p-value (1-sided)

Pain Treatment Visits

91%

100%

NSAID Use

71%

Opioid Use

† Fisher’s Exact test was used because there are some variables for which frequency is less than 5 in one group (a condition under which X-square fails to be robust). ‡ Phi values were included as a rough measure of effect size (comparable to r-square values), though max values can fall short of 1.00 or -1.00, so these are hard to interpret (Morgan et al., 2007).

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One-Year Socioeconomic Outcomes

25

FORT

23.1

TAU

20 15

d=1.423

10 5

d=0.29 5.1 1.8

2.8

0 MD/ER visits in last year

Both results were statistically significant

Different healthcare providers seen

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Conclusions 

The FR program worked:  



Immediate physical and psychosocial improvement Gains were maintained for at least one year post-tx

The FR program was cost effective: 

FR participants were less likely to:    

use opioid meds post-tx get surgery for pain concerns seek pain care in the ER receive a medical discharge recommendation 

they also significantly improved fitness test scores

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The Chronic Pain and PTSD Comorbidity Study An Examination of Treatment Pathways for Comorbid Chronic Musculoskeletal Pain and PTSD

Background 





As both pain and PTSD evolve into chronic conditions, the financial costs associated with treatment exceed hundreds of billions of dollars annually Recent research suggests that individuals suffering from comorbid chronic pain and traumatic stress may respond poorly to treatment targeting only one diagnosis The co-occurrence of chronic pain and PTSD is becoming more widely recognized

Bosse, 2002

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PTSD: Epidemiology and Impact 

PTSD incidence is on the rise (for much the same reason that chronic pain is on the rise):  

Traumatized individuals are staying alive (Lew, 2005) It is a psychologically traumatizing war and the rise in PTSD incidence is associated with greater potential for medical problems

Hoge et al., 2004; Hoge et al., 2007; Dohrenwend et al., 2004

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Comorbidity Epidemiology 

A recent review of OIF/OEF deployers found high rates of chronic pain and PTSD with a 59% comorbidity rate. 90 80 70

82 68 59

60

Chronic Pain PTSD Comorbid

50 40 30 20 10 0 Prevalence (%) Lew et al., 2009

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But this is a concern… 

The LEAP Study   



Over a 50% comorbidity between pain and PTSD PTSD was most predictive of functional capacity among pain patients Participants with comorbid pain and PTSD were significantly less likely to respond to any form of pain treatment than those without PTSD

So… How do you treat this?

Starr et al., 2004

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Explanatory Models of Pain-PTSD Comorbidity       

HPA function alterations after trauma Neurological changes in pain processing with PTSD diagnosis Complicating role of major depressive disorder Common anxiety/avoidance symptoms Shared vulnerability Mutual maintenance Coping

Liedl & Knaevelsrud, 2008; Sharp & Harvey, 2001; Resick (personal comm, 2008)

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The STRONGSTAR Study 

The STRONGSTAR Multidisciplinary PTSD Research Consortium: A multiinstitutional consortium of military, civilian, and VA institutions and investigators. STRONG STAR (South Texas Research Organizational Network Guiding Studies on Trauma and Resilience) implements several studies, to investigate the diagnosis, causes, treatment, and rehabilitation of PTSD and other trauma-related disorders.  Overall PI:  

Alan L. Peterson, Ph.D., ABPP The University of Texas Health Sciences Center at San Antonio 



In collaboration with: USA, USAF, Penn, Pitt, UT, Harvard, UMSL, Ryerson Univ

Pain and PTSD Study PI’s: 

Robert J. Gatchel, Ph.D., ABPP 



The University of Texas at Arlington

Don McGeary, Ph.D., ABPP 

Wilford Hall Medical Center, Lackland AFB 28

Study Design Recruit and Screen n = 250 Pre-Assess Randomize n = 180 Treatment as Usual n = 45

Pain Treatment Only n = 45

PTSD Treatment Only n = 45

Combined Pain/PTSD Treatment n = 45

Post-Treatment Assessments Post-tx, 6 mo, 1 yr 29

Our Project – 2 Primary Study Aims 

Study Aims: 

AIM 1: To evaluate the efficacy of specific psychosocial treatments for pain and PTSD for those with comorbid pain and PTSD  



HYPOTHESIS 1a: Specific treatment for pain will not impact pain or PTSD symptoms HYPOTHESIS 1b: Specific PTSD treatment will impact PTSD symptoms, but pain will persist

AIM 2: To evaluate the efficacy of a combined pain and PTSD treatment program to address comorbidity 

HYPOTHESIS 2: Treating for both pain and PTSD simultaneously will show greater treatment impact (for both pain and PTSD) than treating either alone or receiving treatment as usual 30

Our Project - Outcomes 

We have three domains of interest: 

Psychological and Physical Symptoms 



Socioeconomic 



MEASURES: Healthcare Utilization, Medication Use, Medical Board Status, Return to Work, Work Retention,Treatment Satisfaction

Functional Capacity 



MEASURES: Depression, Anxiety, Sleep, PTSD Symptoms, Pain Symptoms

MEASURES: Functional Capacity Evaluation, Self-Report Disability

Outcomes assessed at pre- and post-treatment as well as 6and 12-month follow-up

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References 

Amoroso P.J. & Canham, M.L. (1999). Disabilities related to the musculoskeletal system: Physical Evaluation Board data. In B.H. Jones, P.J. Amoroso & M.L. Canham, Atlas of Injuries in the U.S. Armed Forces. Mil Med,164, 4-1 to 4-73.



Belmont, P.J., Goodman, G., Zacchilli, M., et al., (2010). Incidence and epidemiology of combat injuries sustained during “the Surge” portion of Operation Iraqi Freedom by a U.S. Army Brigade Combat Team. J Trauma-Inj Infection & Care, 68, 204-210.



Belmont, P.J., Schoenfeld, A.J., & Goodman, G. (2010). Epidemiology of combat wounds in Operation Iraqi Freedom and Operation Enduring Freedom: orthopaedic burden of disease. J Surg Ortho Adv, 19, 2-7.



Bosse, M.J., MacKenzie, E.J., Kellam, J.F., et al. (2002). An analysis of two-year outcomes of reconstruction or amputations of leg-threatening injuries in level 1 trauma centers. N Engl J Med, 347, 1924-1931.



Champion, H.R., Holcomb, J.B., Lawnick, M.M., et al. (2010). Improved characterization of combat injury. J Trauma-Inj Infection & Care, 68, 1139-50.



Dohrenwend, B.P., Neria, Y., Turner, J.B., et al. (2004). Positive tertiary appraisals and posttraumatic stress disorder in U.S. male veterans of the war in Vietnam: The roles of positive affirmation, positive reformulation, and defensive denial. J Consult Clin Psychol, 72(3), 417-433.



Feuerstein, M., Berkowitz, S.M., Pastel, R., & Huang, G.D. (1999). Secondary prevention program for occupational low back pain-related disability. New Brunswick, NJ.



Gatchel, R. J., McGeary, D. D., Peterson, A. L., Moore, M, LeRoy, K., Isler, W. C., Hryshko-Mullen, A. S., & Edell, T. (2009). Preliminary Findings of a Randomized Controlled Trial of an Interdisciplinary Military Pain Program. Military Medicine, 174, 270-277.



Hicks, R.R., Fertig, S.J., Desrocher, R.E., et al. (2010). Neurological effects of blast injury. J Trauma-Inj Infection & Care, 68, 1257-63.



Hoge, C.W., Castro, C.A., Messer, S.C., McGurk, D., Cotting, D.I., & Koffman, R.L. (2004). Combat Duty in Iraq and Afghanistan, Mental Health Problems, and Barriers to Care. New England Journal of Medicine, 351(1), 13-22.



Hoge, C.W.. Terhakopian, A., Castro, C.A., Messer, S.C., & Engel, C.C. (2007). Association of posttraumatic stress disorder with somatic symptoms, health care visits, and absenteeism among Iraq war veterans. American Journal of Psychiatry, 164(1), 150-3.



Lew, H.L., Otis, J.D., Tun, C., et al. (2009). Prevalence of chronic pain, posttraumatic stress disorder, and persistent postconcussive symptoms in OIF/OEF veterans: polytrauma clinical triad. J Rehabil Res Dev, 46, 697-702.



Liedl, A. & Knaevelsrud, C. (2008). PTSD and chronic pain: development, maintenance, and comorbidity – a review. Schmerz, 22, 644-51.



Lorduy, K., Dougall, A., Haggard, R., Sanders, C. & Gatchel, R.J. (2013). The Prevalence of Comorbid Symptoms of Central Sensitization Syndrome Among Three Groups of Temporomandibular disorder patients. Pain Practice, ahead of publication.



Mayer, T.G., McGeary, D., & Gatchel, R.J. (2003). Chronic pain management through Functional Restoration for spinal disorders. In Frymoyer, J. & Wiesel, S. (Eds.), Adult and Pediatric Spine, 3rd Edition. Lippincott, Williams & Wilkins: Philadelphia, pp. 323-333.



McGeary, D.D., McGeary, C.A., Peterson, A.L., Seech, T., Vriend, C. & Gatchel, R.J. (2012). Healthcare Utilization after Interdisciplinary Chronic Pain Treatment. Part I: Description of Utilization of Costly Healthcare Interventions. Journal of Applied Biobehavioral Research, 17: 215-228.



McGeary, D., Moore, M. Vriend, C.A., Peterson, A.L., Gatchel, R.J. (2011) The Evaluation and Treatment of Comorbid Pain and PTSD in a Military Setting: An Overview. Journal of Clinical Psychology in Military Settings, 18: 155-163.



Morgan, G.A., Leech, N.L., Gloeckner, G.W., & Barrett, K. (Eds., 2007). SPSS for Introductory Statistics: Use and Interpretation, 3rd Edition. Psychology Press: New York, NY.

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References 

Nevin, R.L & Means, G.E. (2009). Pain and discomfort in deployed helicopter aviators wearing body armor. Aviation Space & Environmental Medicine, 80, 807-10.



Sharp, T. J. & Harvey, A. G. (2001). Chronic pain and posttraumatic stress disorder: Mutual maintenance? Clinical Psychology Review, 21, 857 – 877.



Starr, A.J., Smith, W.R., Frawley, W.H., et al. (2004). Symptoms of posttraumatic stress disorder after orthopaedic trauma. J Bone Joint Surg Am.



Zambraski, A. (2006). U.S. Army Medical Department. San Antonio, TX, Army Medicine, Office of the Surgeon General, Army Medical Department. Available at http://www.armymedicine.army.mil/news/mercury/06-08/usariem.cfm. Accessed January 3, 2006.

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