Ronald J. Gironda

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.

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.

Pain and psychiatric comorbidities among two groups of Iraq- and Afghanistan-era Veterans

This study aimed to (1) identify the prevalence and severity of pain and psychiatric comorbidities among personnel who had been deployed during Operation Iraqi Freedom (OIF), Operation Enduring Freedom (OEF), and Operation New Dawn (OND) and (2) assess whether the Department of Veterans Affairs (VA) Polytrauma System of Care and an OIF/OEF/OND registry reflect real differences among patients. Participants (N = 359) were recruited from two VA hospitals. They completed a clinical interview, structured diagnostic interview, and self-report measures. Results indicated pain was the most common complaint, with 87 percent experiencing pain during the prior week and 56 percent reporting moderate or severe pain. Eighty percent of participants met criteria for at least one of seven assessed comorbid problems (moderate or severe pain, postconcussional disorder, posttraumatic stress disorder [PTSD], anxiety disorder, mood disorder, substance use disorder, psychosis), and 59 percent met criteria for two or more problems. PTSD and postconcussional disorder rarely occurred in the absence of pain or other comorbidities (0.3% and 0%, respectively). The Polytrauma group had more comorbid psychiatric conditions (χ(2) = 48.67, p < 0.05) and reported greater severity of symptoms (p < 0.05) than the Registry group. This study confirmed the high prevalence of pain and concurrent mental health problems among personnel returning from military deployment.

Cluster Analysis of the Pain Outcomes Questionnaire

OBJECTIVE The purpose of this study was to derive and describe subtypes of Pain Outcomes Questionnaire (POQ) profiles produced by a large, heterogeneous multisite sample of chronic pain patients (N = 672). METHODS The POQ core scales were subjected to Wards hierarchical agglomerative cluster analyses in order to establish the optimal number of clusters in validation (N = 336) and cross-validation (N = 336) subsamples. Based on the consistency of the solutions derived from the two subsamples, a third Wards procedure was performed on the entire sample and, finally, a K-means iterative partitioning procedure was used to assign cases to the cluster groups. The resulting cluster solution was validated using a broad range of demographic, pain, and treatment outcomes data. RESULTS The cluster analytic procedure revealed the presence of eight unique subgroups of POQ profiles. The adequacy of the final solution was demonstrated using a multivariate analysis of variance and a discriminant function analysis. Group differences on the demographic and pain variables were generally consistent with expectations based on mean profiles, and therefore, provided evidence of the validity of the cluster solution. Brief descriptions of each cluster group were generated based on the correlate data. The clinical utility of the solution was in part demonstrated by differential treatment response rates among the groups. DISCUSSION The results of this study are generally consistent with those of previous cluster analytic investigations of pain patients and suggest that psychosocial/behavioral classification systems may serve a useful heuristic function in the assessment and treatment of chronic pain that is not provided by current diagnostic taxonomies.

Mental health utilization among veterans at risk for suicide: Data from a post-deployment clinic.

The current study aim was to examine mental health characteristics in a sample of returning OEF/OIF/OND veterans initially enrolling in Department of Veterans Affairs (VA) health care (N = 1,307), with a particular focus on a subgroup considered at risk for suicide (N = 445). Methods included examination of mental health screening measures and clinical interview data from a VA postdeployment clinic. Half of the sample met criteria for a mental health disorder, whereas 10% reported current suicidal or death ideation (e.g., thoughts of being better off dead or hurting oneself in some way) and 6% reported a history of suicide attempt. Sixty-eight percent of the at-risk subgroup accepted a referral for mental health treatment and a promising majority (78%) of those individuals attended their initial specialty mental health visit. At-risk veterans who accepted mental health referral were more likely to report current suicidal/death ideation; they were also more likely to have a diagnosis of a depressive disorder, anxiety disorder, or posttraumatic stress disorder. Factors associated with mental health appointment attendance included older age, being enrolled in college, and more years of military service. Results highlight the importance of early screening and referral to appropriate mental health follow-up. Implications for clinical practice and increasing engagement in VA mental health services among veterans at risk for suicide are discussed. (PsycINFO Database Record (c) 2018 APA, all rights reserved).