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
Background on Military Chronic Pain Functional Restoration Intervention – The FORT Program Chronic Pain Comorbidity STRONGSTAR
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)
Factors Contributing to Rise in Pain
Survivable extremity trauma
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
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)
Proportional Distribution of Wounds by Body Region for Combat Casualties 70 58
Head/Neck Thorax Abdomen Extremity
30 20 10
21 13.9 8
Belmont, Goodman, Zacchelli, et al. (2010)
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
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
Functional Restoration – Outcomes
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
CHCS / AHLTA
medication tracking healthcare utilization tracking
Profile Work status
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)
Gender Male Female
Race Asian African-American Caucasian, Non-Hispanic Hispanic Other
3 17 63 13 3
6 19 67 8 0
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
Rank Enlisted Officer
Pain Site Spine Extremity
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 20 10
0 -10 -20 -30
FR TAU -22 -29
SF36 PCS MVAS (HRQoL)
(Fear Avoidance) (Insomnia)
Change in Physical Variables (Pre-Post) FR Participants vs. TAU (% improved) 70
62 60 50 40
22 20 10 0 Lift FW
Lift WE 16
One-Year Psychosocial Outcomes (% Change from Post-Treatment, n=67) 100
80 60 40 20
0 -20 -40
SF36 PCS MVAS Oswestry FABQ (HRQoL)
(Fear Avoidance) (Insomnia)
One-Year Physical Outcomes (% Change from Post-Treatment, n=67) 0 -5 -10
-25 -30 -35 -40 -45
-50 Lift F-W
-47 Lift W-E 18
One-Year Socioeconomic Outcomes (n=67) †
Surgery for Pain
ER Visits for Pain
FORT (% Yes) n=34
TAU (% Yes) n=33
Fisher’s p-value (1-sided)
Pain Treatment Visits
† 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).
One-Year Socioeconomic Outcomes
d=0.29 5.1 1.8
0 MD/ER visits in last year
Both results were statistically significant
Different healthcare providers seen
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
The Chronic Pain and PTSD Comorbidity Study An Examination of Treatment Pathways for Comorbid Chronic Musculoskeletal Pain and PTSD
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
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
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
Chronic Pain PTSD Comorbid
50 40 30 20 10 0 Prevalence (%) Lew et al., 2009
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
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)
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
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
MEASURES: Healthcare Utilization, Medication Use, Medical Board Status, Return to Work, Work Retention,Treatment Satisfaction
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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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.
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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.
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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.
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