Michael E. Clark

Prevalence of chronic pain, posttraumatic stress disorder, and persistent postconcussive symptoms in OIF/OEF veterans: polytrauma clinical triad.

This study examines the prevalence and coprevalence with which returning Operation Iraqi Freedom (OIF)/Operation Enduring Freedom (OEF) veterans were reporting symptoms consistent with chronic pain, posttraumatic stress disorder (PTSD), and persistent postconcussive symptoms (PPCS). The medical records of 340 OIF/OEF veterans seen at a Department of Veterans Affairs Polytrauma Network Site were comprehensively reviewed. Analyses indicated a high prevalence of all three conditions in this population, with chronic pain, PTSD, and PPCS present in 81.5%, 68.2%, and 66.8%, respectively. Only 12 of the veterans (3.5%) had no chronic pain, PTSD, or PPCS. The frequency at which these three conditions were present in isolation (10.3%, 2.9%, and 5.3%, respectively) was significantly lower than the frequency at which they were present in combination with one another, with 42.1% of the sample being diagnosed with all three conditions simultaneously. The most common chronic pain locations were the back (58%) and head (55%). These results underscore the complexity of the presenting complaints in OIF/OEF veterans and support the importance of a multidisciplinary team approach to assessment and treatment.

Pain and combat injuries in soldiers returning from Operations Enduring Freedom and Iraqi Freedom: implications for research and practice.

Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) have resulted in a growing number of seriously injured soldiers who are evacuated to the United States for comprehensive medical care. Trauma-related pain is an almost universal problem among these war-injured soldiers, and several military and Department of Veterans Affairs initiatives have been implemented to enhance pain care across the continuum of medical services. This article describes several innovative approaches for improving the pain care provided to OEF and OIF military personnel during acute stabilization, transport, medical-surgical treatment, and rehabilitation and presents summary data characterizing the soldiers, pain management services provided, and associated outcomes. We also identify some of the pain assessment, classification, and treatment challenges emerging from work with this population and provide recommendations for future research and practice priorities.

Traumatic brain injury, polytrauma, and pain: challenges and treatment strategies for the polytrauma rehabilitation.

PROBLEM Chronic pain conditions are common sequelae of traumatic brain injury (TBI). Unfortunately, the incidence of TBI among personnel deployed for Operations Enduring Freedom and Iraqi Freedom (OEF/OIF) is significant, and there is growing evidence that ongoing pain, particularly headaches, will be a primary concern for these individuals. OBJECTIVE This article synthesizes empirical data from civilian and veteran populations and clinical experience with OEF/OIF personnel with polytrauma to provide recommendations for the assessment and treatment of chronic pain among those with TBI. CONCLUSIONS The available data signal the need for the incorporation of early and aggressive pain management strategies into existing treatment models. Challenges to providing effective pain management for OEF/OIF veterans are numerous and include comorbid cognitive, medical, and emotional impairments that complicate readjustment to civilian life. It is likely that the problem of polytrauma pain and associated comorbid conditions such as posttraumatic stress disorder and postconcussive syndrome will require the development of integrated approaches to clinical care which bridge traditional subspecialty divisions. A proposed model of treatment is presented.

Systematic Review of the Literature on Pain in Patients with Polytrauma Including Traumatic Brain Injury

OBJECTIVE To review the literature addressing the assessment and management of pain in patients with polytraumatic injuries including traumatic brain injury (TBI) and blast-related headache, and to identify patient, clinician and systems factors associated with pain-related outcomes. DESIGN Systematic review. METHODS We conducted searches in MEDLINE of literature published from 1950 through July 2008. Due to a limited number of studies using controls or comparators, we included observational and rigorous qualitative studies. We systematically rated the quality of systematic reviews, cohort, and case-control design studies. RESULTS One systematic review, 93 observational studies, and one qualitative research study met inclusion criteria. The literature search yielded no published studies that assessed measures of pain intensity or pain-related functional interference among patients with cognitive deficits due to TBI, that compared patients with blast-related headache with patients with other types of headache, or that assessed treatments for blast-related headache pain. Studies on the association between TBI severity and pain reported mixed findings. There was limited evidence that the following factors are associated with pain among TBI patients: severity, location, and multiplicity of injuries; insomnia; fatigue; depression; and post-traumatic stress disorder. CONCLUSIONS Very little evidence is currently available to guide pain assessment and treatment approaches in patients with polytrauma. Further research employing systematic observational as well as controlled intervention designs is clearly indicated.

Development and validation of the Pain Outcomes Questionnaire-VA

The development of effective pain treatment strategies requires the availability of precise and practical measures of treatment outcomes, the importance of which has been noted in the Veterans Health Administrations (VHAs) National Pain Initiative. This paper presents the results of a 5-year collaborative effort to develop and validate a comprehensive and efficient self-report measure of pain treatment outcomes. Two samples of veterans (957 total subjects) undergoing inpatient or outpatient pain treatment at six VHA facilities completed Pain Outcomes Questionnaire-VA (POQ-VA) items and several additional measures. We used a comprehensive, multistage analytic procedure to evaluate the psychometric properties of the instrument. Results provided strong support for the reliability, validity, and clinical use of the POQ-VA when used to evaluate the effectiveness of treatment for veterans experiencing chronic noncancer pain.

Comparison of pain and emotional symptoms in soldiers with polytrauma: Unique aspects of blast exposure.

OBJECTIVES To compare the physical and emotional presentation and pain treatment outcomes of service members who sustained polytrauma secondary to blast with those of soldiers injured by other means. DESIGN Retrospective medical record review. SETTING AND PATIENTS One of four Veterans Affairs multidisciplinary inpatient Polytrauma Rehabilitation Centers. One hundred twenty-eight Operation Enduring Freedom and Operation Iraqi Freedom military personnel with serious polytrauma injuries and concomitant pain categorized into three groups based on type of injuries: blast injuries, combat injuries other than blast, and noncombat, nonblast injuries. INTERVENTIONS Intensive, interdisciplinary inpatient rehabilitation and pain treatment. OUTCOME MEASURES Pain intensity ratings; Functional Independence Measure scores; Rancho Los Amigos levels; and opioid analgesic doses. RESULTS Service members injured via blast demonstrated a broader spectrum of physical injuries, higher levels of admission and discharge opioid analgesic use, reduced improvement in pain intensity following treatment, and much higher rates of posttraumatic stress disorder and other psychiatric diagnoses than those injured via other means. CONCLUSIONS Blast injury may be associated with differential physical, emotional, and pain-related symptoms that pose increased challenges for successful treatment.

Preliminary evaluation of reliability and criterion validity of Actiwatch- Score

The restoration of normal physical activity is a primary objective of most chronic pain rehabilitative interventions, yet few clinically practical objective measures of activation exist. Actigraphy is one technology that promises to fill this void in the field of pain outcomes assessment. This study evaluates the measurement properties of one of several commercially available actigraphs: the Actiwatch-Score (AW-S). We conducted separate trials to examine concordance between units when worn concurrently at the same and different body sites and to compare the AW-S to a validated optical three-dimensional motion-tracking system. The data indicate that the AW-S has excellent interunit reliability and good criterion validity, but its intersite reliability varies with activity type. These results suggest that this device, and those like it, warrants further investigation and is likely to yield valuable data regarding the optimal application of this technology.

Detection of back random responding: effectiveness of MMPI-2 and Personality Assessment Inventory validity indices.

Two experiments examined the detection and effects of back random responding (BRR) on the Minnesota Multiphasic Personality Inventory--2 (MMPI-2) and the Personality Assessment Inventory (PAI). Experiment 1 revealed that MMPI-2 Clinical and Content scales were relatively resistant to the effects of BRR. Fb--F > or = 20T was the most effective index for identifying invalid protocols. Experiment 2 revealed greater susceptibility of the PAI interpretive scales to the effects of BRR and less successful detection of BRR. The most effective PAI validity index was the combined indicator, ICN > or = 73T or INF > or = 75T. Clinical and empirical implications of these findings are discussed, and tentative modifications to the MMPI-2 interpretative guidelines are provided.

MMPI-2 Negative Treatment Indicators Content and Content Component Scales: Clinical Correlates and Outcome Prediction for Men with Chronic Pain.

The current study evaluated the utility of the Negative Treatment Indicators (TRT) Minnesota Multiphasic Personality Inventory-2 (J. N. Butcher, W. G. Dahlstrom, J. R. Graham, A. Tellegen, & B. Kaemmer, 1989) Content and Content Component (TRT1 and TRT2 scales using a clinical sample of men with chronic pain. Results indicate that TRT correlates for this patient sample were similar to those for normative sample men. External test correlates indicate that TRT, TRTI, and TRT2 scores reflected, at least in part, emotional distress. Furthermore, TRT and TRTI were significant predictors of treatment-related change and posttreatment functioning for some measures. However, caution is warranted when interpreting the scales, as high TRT and TRTI scores may predict either negative or positive treatment response, depending on the treatment context and the outcome measures employed.

Access to the US Department of Veterans Affairs health system: self-reported barriers to care among returnees of Operations Enduring Freedom and Iraqi Freedom

BackgroundThe U.S. Department of Veterans Affairs (VA) implemented the Polytrauma System of Care to meet the health care needs of military and veterans with multiple injuries returning from combat operations in Afghanistan and Iraq. Studies are needed to systematically assess barriers to use of comprehensive and exclusive VA healthcare services from the perspective of veterans with polytrauma and with other complex health outcomes following their service in Afghanistan and Iraq. These perspectives can inform policy with regard to the optimal delivery of care to returning veterans.MethodsWe studied combat veterans (n = 359) from two polytrauma rehabilitation centers using structured clinical interviews and qualitative open-ended questions, augmented with data collected from electronic health records. Our outcomes included several measures of exclusive utilization of VA care with our primary exposure as reported access barriers to care.ResultsNearly two thirds of the veterans reported one or more barriers to their exclusive use of VA healthcare services. These barriers predicted differences in exclusive use of VA healthcare services. Experiencing any barriers doubled the returnees’ odds of not using VA exclusively, the geographic distance to VA barrier resulted in a 7 fold increase in the returnees odds of not using VA, and reporting a wait time barrier doubled the returnee’s odds of not using VA. There were no striking differences in access barriers for veterans with polytrauma compared to other returning veterans, suggesting the barriers may be uniform barriers that predict differences in using the VA exclusively for health care.ConclusionsThis study provides an initial description of utilization of VA polytrauma rehabilitation and other medical care for veteran returnees from all military services who were involved in combat operations in Afghanistan or Iraq. Our findings indicate that these veterans reported important stigmatization and barriers to receiving services exclusively from the VA, including mutable health delivery system factors.