Robyn L. Walker, Ph.D., is a Clinical Research Psychologist in the Chronic Pain Rehabilitation Program at the James A. Haley VA Hospital, Tampa, Florida. Her interview brings attention to the health care needs of currently returning U.S. Military Forces. This is the first of 2 PainEDU interviews with Dr. Walker; the second interview will be posted next week.

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Questions

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Evelyn Corsini:

Are there issues unique to veterans wounded in Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF) that we should understand?

Robyn L. Walker, Ph.D.: The onset of hostilities associated with the War on Terror, and associated combat and non-combat related injuries with resultant pain, has moved pain into the forefront of VA concerns given its very high prevalence among returning OIF/OEF personnel. An initial examination of medical complaints among OIF/OEF returnees registering for care at a southern VA Medical Center revealed that 46.5% reported some degree of pain, while over 59% of those reporting pain had scores exceeding the VA threshold of = 4. Indeed, the pain scores of 57% of those reporting pain intensities exceeding the VA pain trigger value fell into the range associated with severe interference in daily functioning (= 7) (Gironda, Clark, Massengale, & Walker, 2006). Consistent with this finding, almost 82% of the individuals reporting chronic unremitting pain also had diagnoses of musculoskeletal and connective tissue disorders.

The majority of injuries in military personnel during active duty deployment are related to non-combat motor vehicle accidents and exacerbation of previous injuries (Cohen et al., 2005). However, for military personnel that are injured in active combat and receive trauma related injuries, these tend to be very complex and life threatening injuries. At this point in time, we know little about the long-term consequences of pain in these survivors. To the extent that what was once acute pain progresses to significant chronic pain, we can expect that many polytrauma patients will experience considerable pain-related impairment in the future. To combat this, and in response to the evidence that early treatment of acute or chronic pain results in improved outcomes, there will need to be development of effective pain problem identification and treatment strategies focused on minimizing the long-term consequences of pain on daily life. This will require the strengthening of relationships between government and civil medical organizations providing care to OIF/OEF returnees.

Consistent with the large number of OIF/OEF personnel registering for care at James A. Healey VA Hospital (JAHVH), we have expanded our research and clinical interests to incorporate post-deployment pain. It is likely that due to the complex nature of these pain problems, there will need to be increased integration of pain interventions throughout the entire spectrum of care. In response to this need, a pain team psychologist attends weekly polytrauma team staffings and twice weekly medical rounds. Although it was originally anticipated that interventional pain treatments would be of primary value in treating pain in this population, experience with our polytrauma team has shown that cognitive-behavioral interventions appear to be more beneficial in assisting these injured military personnel better manage their pain and maximizing their participation in rehabilitation. Areas of future research and clinical consideration include methods to improve the assessment of pain in the cognitively impaired, evaluation of relationships between early aggressive pain treatment and long-term outcomes, identification of predictors of pain outcomes in this population, and associations between injury type or severity and later life pain-related disabilities.

EC: What services for veterans experiencing chronic pain are available at James A. Haley Veterans Hospital?

RW: Multidisciplinary chronic pain services at the James A. Haley Veterans Hospital (JAHVH) began in 1988 with the establishment of a four-bed unit housed on a general rehabilitation unit and dedicated to chronic pain treatment. Initiation of services was in response to two identified problems: 1) a high rate of opioid analgesic prescriptions for veterans with chronic pain, and 2) a large number of veterans seeking chronic pain treatment through ambulatory care. In the ensuing years demand for chronic pain services grew significantly and led to lengthy waiting lists. Recognizing the ever-growing demand for quality pain treatment services, in 1994 the administration of JAHVH supported yet another expansion to twelve beds housed on our own physical unit.

The CARF accredited Chronic Pain Rehabilitation Program (CPRP) is comprised of a nineteen-day, interdisciplinary inpatient chronic pain treatment program along with associated outpatient screening and treatment clinics. Program treatments represent a wellness approach to chronic pain treatment and management. Participants are encouraged to assume responsibility for their pain and its management through psychological and physical rehabilitation approaches. Behavioral treatment, cognitive-behavioral therapy, physical therapy, medication adjustment, occupational therapy, vocational readjustment training, pool therapy, exercise, relaxation training, and education are used to assist participants in learning to better manage and cope with their pain. Nerve blocks, biofeedback, marital therapy, and other interventions may be used when indicated. All primary program treatments must be suitable for home use. Adjunctive pain services (e.g., consultation, staff training, and research) are provided by selected team members as part of our comprehensive chronic pain treatment effort.

The core philosophy of the CPRP recognizes the complex interactions between cultural, pathophysiological, emotional, social, perceptual, and situational components of chronic pain and chronic pain syndromes. In the treatment of chronic pain, we believe that pain exists when and as the individual describes it. Goals of the program are to reduce participant's perceptions of pain, increase their level of independent functioning, promote increased activity levels, enhance wellness behaviors, reduce the emotional distress associated with chronic pain, and eliminate reliance on opioid analgesics and/or muscle relaxants for pain relief.

In addition to the inpatient CPRP, there are multiple outpatient multidisciplinary pain management programs and clinics at the JAHVH. These outpatient programs are generally more appropriate for individuals with medical and/or emotional instability, life circumstances (i.e. working full time, young children at home), and/or personal preferences that would either rule out or impede full participation in an inpatient rehabilitation program. The outpatient multidisciplinary pain management programs at the JAHVH integrate psychology, physical therapy, occupational therapy, rehabilitation medicine, neurology, and anesthesia in a seamless program to maximize the benefit for the veterans. Recent expansion of our outpatient pain management programs has focused on providing services to OIF/OEF returnees with pain (particularly those related to polytrauma and blast-related injuries) to assist with integration back to civilian life and providing specialized headache pain management services to address the specific needs of veterans with chronic headache pain.