Cindy A. McGeary

A Comprehensive Review of Telehealth for Pain Management: Where We Are and The Way Ahead

Pain is generally undertreated in the United States, owing to a number of barriers including geographic distance from specialty treatment providers; functional disability that limits mobility; treatment‐related stigma; economic limitations; and educational barriers. Pain undertreatment exacerbates pain chronicity and emotional disruption that can significantly erode a pain patient’s quality of life, and there is widespread agreement that pain care must evolve to address this significant problem. The growing field of telehealth (defined for the purposes of this paper as technology that allows for distance interaction between providers and/or patients) offers a novel opportunity to expand pain assessment, consultation, and treatment services beyond the walls of the specialty pain clinic, but there is limited availability of resources describing how to best use this technology to improve access to care. A recent literature review (September 2011) using universally endorsed MeSH search criteria revealed only 32 MEDLINE references focusing on telehealth for pain. This is surprising in light of the very large number of references covering telehealth (14,164 references) and pain (104,564 references), respectively. Of the studies available, there are very few randomized trials of telehealth pain care and only one general overview of e‐health and chronic pain, which dedicates just a few paragraphs to telehealth. This manuscript represents one of the first comprehensive reviews of the current state of telehealth and pain management research and practice. The goals are to provide a rationale for the potential benefit of telehealth‐based pain management services; describe the various applications of telehealth technology for pain management; orient the reader to cost models for telehealth; present examples of services in place; and offer recommendations for future research based on the current state of knowledge.

Utilization of evidence-based psychotherapies in Veterans Affairs posttraumatic stress disorder outpatient clinics

In response to the growing numbers of veterans with posttraumatic stress disorder (PTSD), the Department of Veterans Affairs (VA) has sought to make evidence-based psychotherapies for PTSD available at every VA facility. We conducted a national survey of providers within VA PTSD clinical teams (PCTs) to describe utilization of prolonged exposure (PE) and cognitive processing therapy (CPT) and to identify individual and organizational factors associated with treatment uptake and adherence. Participants (N = 128) completed an electronic survey assessing reported utilization of PE and CPT treatments, adherence to treatment manuals, and characteristics of the provider and workplace environment. Participants reported conducting a weekly mean of 4.5 hours of PE, 3.9 hours of CPT (individual format), 1.3 hours of CPT (group format), and 13.4 hours of supportive care. Perceived effectiveness of PE and CPT were significantly associated with utilization of and adherence to those treatments. Reported number of hours conducting supportive care was positively associated with feeling the clinic was not sufficiently staffed (p = .05). Adherence to the PE treatment manual was positively associated with receiving emotional support from coworkers (p < .01). Provider attitudes and organizational factors such as staffing and work relationships may have an important impact on treatment selection and the quality of PTSD care provided in VA PCTs.

Burnout in Veterans Health Administration Mental Health Providers in Posttraumatic Stress Clinics

The purpose of this study was to conduct the first assessment of burnout among Veterans Health Administration (VHA) mental health clinicians providing evidence-based posttraumatic stress disorder (PTSD) care. This study consisted of 138 participants and the sample was mostly female (67%), Caucasian (non-Hispanic; 81%), and married (70%) with a mean age of 44.3 years (SD = 11.2). Recruitment was directed through VHA PTSD Clinical Teams (PCT) throughout the United States based on a nationwide mailing list of PCT Clinic Directors. Participants completed an electronic survey that assessed demographics, organizational work factors, absenteeism, and burnout (assessed through the Maslach Burnout Inventory-General Survey, MBI-GS). Twelve percent of the sample reported low Professional Efficacy, 50% reported high levels of Exhaustion, and 47% reported high levels of Cynicism as determined by the MBI-GS cut-off scores. Only workplace characteristics were significantly associated with provider scores on all 3 scales. Exhaustion and Cynicism were most impacted by perceptions of organizational politics/bureaucracy, increased clinical workload, and control over how work is done. Organizational factors were also significantly associated with provider absenteeism and intent to leave his or her job. Findings suggest that providers in VHA specialty PTSD-care settings may benefit from programs or supports aimed at preventing and/or ameliorating burnout.

A cohort study examining headaches among veterans of Iraq and Afghanistan wars: Associations with traumatic brain injury, PTSD, and depression

To describe the prevalence and persistence of headache and associated conditions in an inception cohort of U.S. veterans of Iraq and Afghanistan wars.

Assessment of Research Quality of Telehealth Trials in Pain Management: A Meta-Analysis

Although telehealth‐based pain management research has grown over the last decade, it is difficult to determine the state of the research because of methodological differences and variability in quality among existing studies. In a previous systematic review, we outlined these differences and preliminarily explored the promise of telehealth for pain intervention. We completed a PRISMA compliant meta‐analysis of telehealth pain management research to more precisely describe the state of the research and to uncover gaps in the existing literature that highlight directions for future research. We identified 10 relevant studies completed between 2000 and 2011 including 3 noninferiority and 7 superiority studies. Meta‐analysis revealed an overall benefit of telehealth interventions over control conditions and equivalence with in‐person intervention. However, some of the reviewed studies found no benefit for telehealth over control conditions. Some methodological concerns among the examined research included poor research quality, small sample sizes, and the examination of telehealth pain interventions without proven efficacy for in‐person treatment. Recommendations for future studies are reviewed.

Military Chronic Musculoskeletal Pain and Psychiatric Comorbidity: Is Better Pain Management the Answer?

Chronic musculoskeletal pain, such as low back pain, often appears in the presence of psychiatric comorbidities (e.g., depression, posttraumatic stress disorder (PTSD)), especially among U.S. military service members serving in the post-9/11 combat era. Although there has been much speculation about how to best address pain/trauma psychiatric symptom comorbidities, there are little available data to guide practice. The present study sought to examine how pre-treatment depression and PTSD influence outcomes in a functional restoration pain management program using secondary analysis of data from the Department of Defense-funded Functional and Orthopedic Rehabilitation Treatment (FORT) trial. Twenty-eight FORT completers were analyzed using a general linear model exploring how well depression and PTSD symptoms predict post-treatment pain (Visual Analog Scale (VAS) pain rating), disability (Oswestry Disability Index; Million Visual Analog Scale), and functional capacity (Floor-to-Waist and Waist-to-Eye Level progressive isoinertial lifting evaluation scores) in a sample of active duty military members with chronic musculoskeletal pain and comorbid depression or PTSD symptoms. Analysis revealed that pre-treatment depression and PTSD symptoms did not significantly predict rehabilitation outcomes from program completers. Implications of these findings for future research on trauma-related pain comorbidities are discussed.

Design of a clinical effectiveness trial of in-home cognitive processing therapy for combat-related PTSD

Approximately 14% of military personnel and veterans who have deployed to the combat theater are at risk for combat-related posttraumatic stress disorder (PTSD). The treatment of combat-related PTSD in active duty service members and veterans is challenging. Combat trauma may involve multiple high levels of exposure to different types of traumatic events (e.g., human carnage after explosive blasts, life threat/injuries to self/others, etc.). Many service members and veterans are unable or unwilling to receive treatment in government facilities due to avoidance, scheduling difficulties, transportation or parking problems, concerns about career advancement, or stigma associated with seeking treatment. Innovative treatment-delivery approaches are needed to help overcome these barriers. The present study is a randomized clinical trial to evaluate three versions of Cognitive Processing Therapy (CPT; [54]) for the treatment of combat-related PTSD in active duty military service members and veterans: (1) standard In-Office CPT, (2) In-Home Telebehavioral Health CPT from the providers office to the participants home, and (3) In-Home CPT in which the provider delivers treatment in the participants home. Use of an equipoise-stratified randomization design allows participants to decline one of the treatment arms. This research design partly overcomes the problems active duty military and veterans face when receiving PTSD treatment by allowing them to opt out of one inappropriate or unacceptable treatment modality and still permitting randomization to the two remaining treatment modalities. This manuscript provides an overview of the research design and methods for the study.

Conjoint Therapy for the Treatment of Chronic Pain: A Descriptive Pilot Study of Couples’ Needs

Objective: Chronic pain is a significant healthcare challenge for the United States. Most treatment and research has focused upon the chronic pain patient; however, partners of chronic pain patients report care-giver burden, poor relationship quality, and physical and psychological health problems. The authors propose a novel therapy for pain management that incorporates partners into pain treatment to improve relationship quality and pain management. The overall objective of this paper is to outline Conjoint Therapy for Pain Management, a behavioral treatment for chronic pain, and report descriptive pilot data from a Needs Assessment focused upon chronic pain patients and their partners to help refine the Conjoint Therapy for Pain Management treatment manual.

New Trends of Musculoskeletal Disorders in the Military

Musculoskeletal pain disorders are of significant concern in the US Armed Forces. This is particularly true considering the physical requirements of many military personnel and the high-risk environments in which they work. Despite continuous advances in military medicine, the rates of disability cases within the US military have been increasing at an alarming rate and nearly doubled between 1985 and 1994 (Berkowitz, Feuerstein, Lopez, & Peck, 1999; Huang, Berkowitz, Feuerstein, & Peck, 1998; Jones, Amoroso, & Canham, 1999). Pain disorders account for the largest proportion of total disability compensation, with approximately

Managing Chronic Pain in Primary Care

400 million a month (Feuerstein, Berkowitz, Pastel, & Huang, 1999). These types of disability claims are continuing to increase because of military deployments and related injuries in support of Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF). Recent data on wound patterns for the US Marines and Sailors serving in Iraq indicated that upper and lower extremity musculoskeletal injuries accounted for almost 70 % of all injuries and that, therefore, orthopedic surgery was the most commonly needed medical specialty (Zouris, Walker, Dye, & Galerneau, 2006). Another study found that 53 % of patients medically evacuated from OIF and evaluated at two military pain management centers had low back pain (Cohen, Griffith, Larkin, Villena, & Larkin, 2005). It was also found that 47 % of OIF/OEF veterans reported chronic pain after deployment, with over 80 % being diagnosed with a musculoskeletal or connective tissue disorder. Without changes in the current approach to treatment, the trends of increasing disability rates and associated costs will very likely continue in the military.