Answering the call to address chronic pain in military service members and veterans: Progress in improving pain care and restoring health

Examining Preliminary Efficacy of a Qigong Intervention in Veterans with Chronic Low Back Pain: A Randomized Controlled Pilot Study

PURPOSE

The purpose of this pilot study was to examine the preliminary efficacy of an 8-week qigong intervention in managing biopsychosocial outcomes in veterans with chronic low back pain (CLBP).

DESIGN

The study design was a longitudinal randomized controlled trial (RCT).

METHODS

Multimodal assessments (e.g., biomarkers and psychological and social measures) over multiple time points to assess the preliminary efficacy of an 8-week qigong intervention versus wait-list control group in veterans with CLBP.

RESULTS

Participants in the qigong intervention group showed greater improvement in pain intensity (p = .047), pain interference (p = .040), pain-related disability (p = .027), and sleep disturbance (p = .002). Other psychosocial outcomes were nonsignificant. A statistically significant relationship between biological outcomes (pro-inflammatory cytokines) and psychosocial outcomes was identified (e.g., tumor necrosis factor [TNF] and physical function [p < .001], pain-related disability and IL 8 [p = .049], and posttraumatic stress disorder symptoms and IL 8 [p = .043]).

CONCLUSIONS

The results indicated that all pain-related outcomes (pain intensity, low back pain-related disability, and pain interference) and sleep disturbance decreased significantly in the qigong group compared to the control group.

CLINICAL IMPLICATIONS

The combination of gentle, slow-paced movements, along with the focused mindfulness of qigong, may improve physiological and psychosocial health. Charged with this information, healthcare providers (e.g., nurses, physical therapists) should consider non-pharmacological interventions such as qigong for veterans with CLBP.

Ultrasound-Guided Lidocaine Injection as a Novel Predictor of Response to Botulinum for Patients With Myofascial Pain Syndrome: A Case Report

Botulinum injection is a well-known non-surgical intervention utilized in the management of myofascial pain syndrome (MPS). However, sparse evidence exists regarding the utility of ultrasound guidance of injectate or lidocaine as a predictive marker of patient response to botulinum toxin A (BTX-A). A 39-year-old male active duty service member demonstrated typical signs and symptoms of MPS. He reported a 10-year history of neck and back spasms that were triggered by exertion but also could occur spontaneously. Based on the characteristic regional motor-sensory defects, treatment options were discussed. With shared decision-making, the patient opted to try ultrasound-guided injection of lidocaine followed by xenomin brand BotoxA. Immediately following lidocaine injection, the patient reported complete relief of symptoms. Both injections were uncomplicated, and the patient reported great reduction in symptoms during the subsequent visit 2 months later. Relief of pain following ultrasound-guided injection of lidocaine may serve as an indicator of successful patient response to BTX-A in patients with MPS.

Stakeholder Engagement to Identify Implementation Strategies to Overcome Barriers to Delivering Chronic Pain Treatments: A NIDILRR and VA TBI Model Systems Collaborative Project

OBJECTIVE

The purpose of this article is to illustrate the process of stakeholder-engaged intervention mapping approach to identify implementation strategies to overcome data-driven prioritized barriers to receiving chronic pain services for persons with traumatic brain injury (TBI).

SETTING

Community.

PARTICIPANTS

Healthcare providers (n = 63) with 2 or more years' experience treating persons with TBI, interviewed between October 2020 and November 2021 provided data for identification of barriers. TBI, chronic pain, and qualitative research subject matter experts (SMEs) participated in the mapping approach.

DESIGN

Participatory-based research design, using descriptive and intervention mapping approaches.

RESULTS

Four barriers to accessing chronic pain treatment by persons with TBI which emerged from provider interviews were prioritized for intervention mapping: cognitive deficits of patients (67%); patient comorbidities (63%); mental health and/or substance abuse issues (59%); and patient participation (62%). SMEs used prioritized barriers to develop 4 primary objectives and implementation strategies designed to: (1) engage consumers to validate and identify strategies; (2) tailor pain treatment and delivery to overcome barriers; (3) develop and disseminate guidelines and best practices when delivering care to persons with TBI to support spread; and (4) increase awareness, skills, and readiness of workforce to deliver pain treatment to persons with TBI. SMEs used an evidence-based approach to develop a mapping matrix of the prioritized barriers, implementation objectives, and aligned implementation strategies to impact change.

CONCLUSION

Implementation science is needed to facilitate knowledge translation into practice for this complex population to overcome barriers to care. Implementation strategies to address barriers to accessing chronic pain care for individuals with TBI were chosen through a participatory approach to engaging SMEs to support these rehabilitation implementation efforts. Future work includes gathering input from individuals with TBI and chronic pain and to move the intervention (implementation) mapping matrix forward to inform future implementation research, policy, and practice.

Provider Perceived Facilitators and Barriers to Identifying, Perceiving, and Seeking Healthcare for Chronic Pain After TBI: A Qualitative NIDILRR and VA TBI Model Systems Collaborative Project

OBJECTIVE

Identify determinants to chronic pain healthcare for persons with traumatic brain injury (TBI) informed by an Access to Care Framework. Findings related to the Access Framework's core domains of identifying a need, perceptions of the need, and seeking healthcare are reported.

SETTING

Community.

PARTICIPANTS

Healthcare providers (n = 63) with 2 or more years of experience treating persons with TBI interviewed between October 2020 and November 2021.

DESIGN

Descriptive, qualitative study.

MAIN MEASURES

Semi-structured interviews with open-ended questions of chronic pain management for persons with TBI. Informed by the Access Framework, responses were coded by and categorized within the domains of identifying healthcare needs, perceptions of needs, and factors related to healthcare seeking from the supply and demand perspective.

RESULTS

For the overall sample, 14 facilitators and 6 barriers were endorsed by more than 20% of the provider cohort. Top facilitators included on-site availability of needed resources and treatments (94%), adequate time and provider capability to ensure patient comprehension of diagnosis and treatment plans (83%), and establishing patient motivation and buy-in with the treatment plan (75%). Barriers most endorsed included policies impacting access (46%), wait times for services (41%), and patient uncertainty regarding telehealth commonly due to cognitive and physical challenges (37%). Unique determinants are reported across civilian versus Department of Veterans Affairs (VA) healthcare systems and different provider types.

CONCLUSION

This is the first evidence-based study to inform policy and planning to improve access to high-quality chronic pain treatments for persons with TBI. Results will inform future interventions at the systems, patient, and policy levels of healthcare that can be tailored to healthcare settings (VA, Civilian) and types of providers (rehabilitation therapists, psychologists, and medical). Evidence-informed interventions may help minimize healthcare disparities experienced by persons with TBI and facilitate access to high-quality, evidence-informed chronic pain care.

Lifestyle factors and psychological factors are associated with central pain processing in service members with persistent low-back pain: A cross-sectional exploratory study

Persistent low-back pain (LBP) is highly prevalent in the military. Altered central pain processing is one of the mechanisms found to underlie persistent LBP. Our aim was to explore which factors are associated with altered pain processing in Dutch service members with persistent LBP. This knowledge may guide clinicians in what factors to address in the treatment of dysfunctional pain processing in service members with persistent LBP. Twenty-one service members with persistent LBP (mean age 34.0 years, 18 males) were included in this cross-sectional exploratory study. Participants completed questionnaires regarding lifestyle and psychological factors. Altered central pain processing was measured by temporal summation of pain to examine the function of the pain facilitatory system and by conditioned pain modulation to examine the pain inhibitory function. Univariable and multivariable linear regression analyses were performed. A higher local temporal summation of pain was associated with a longer sitting time, a higher level of physical activity and a higher level of pain catastrophizing. A higher local conditioned pain modulation was associated with a higher level of pain catastrophizing, anxiety and depression symptoms, and with a lower sleep quality. A higher remote conditioned pain modulation effect was associated with a higher level of physical activity, a higher body mass index and a shorter sitting time. This study succeeded in identifying lifestyle and psychological factors associated with altered pain processing in service members with persistent LBP. Prospective studies are needed to examine causality in these relationships.

Barriers to accessing pain management services among veterans with bipolar disorder

OBJECTIVE

To identify barriers veterans with bipolar disorder face to accessing chronic pain management services within a Veterans Affairs (VA) health care system.

DATA SOURCES AND STUDY SETTING

Veterans (n = 15) with chronic pain and bipolar disorder and providers (n = 15) working within a mid-Atlantic VA health care system. Data were collected from August 2017-June 2018.

STUDY DESIGN

Veteran interviews focused on their chronic pain experiences and treatment, including barriers that arose when trying to access pain management services. Provider interviews focused on whether they address chronic pain with veteran patients and, if so, what considerations arise when addressing pain in veterans with bipolar disorder and other serious mental illnesses.

DATA COLLECTION

Veterans were at least 18 years old, had a confirmed bipolar disorder and chronic pain diagnosis, and engaged in outpatient care within the VA health care system. Clinicians provided direct care services to veterans within the same VA. Interviews lasted approximately 60 min and were transcribed and analyzed using a rapid analysis protocol.

PRINCIPAL FINDINGS

Four major themes emerged from veteran and provider interviews: siloed care (unintegrated and uncoordinated mental and physical health care), mental health primacy (prioritization of mental health symptoms at expense of physical health symptoms), lagging expectations (unfamiliarity with comprehensive evidence-based pain management options), and provider-patient communication concerns (inefficient communication about pain concerns and treatment options).

CONCLUSIONS

Veterans with co-occurring pain and bipolar disorder face unique barriers that compromise equitable access to evidence-based pain treatment. Our findings suggest that educating providers about bipolar disorder and other serious mental illnesses and the benefit of effective non-pharmacological pain interventions for this group may improve care coordination and care quality and reduce access disparities.

Mechanisms of acupuncture-electroacupuncture on inflammatory pain

Acupuncture, as a traditional treatment, has been extensively used in China for thousands of years. According to the World Health Organization (WHO), acupuncture is recommended for the treatment of 77 diseases. And 16 of these diseases are related to inflammatory pain. As a combination of traditional acupuncture and modern electrotherapy, electroacupuncture (EA) has satisfactory analgesic effects on various acute and chronic pain. Because of its good analgesic effects and no side effects, acupuncture has been widely accepted all over the world. Despite the increase in the number of studies, the mechanisms via which acupuncture exerts its analgesic effects have not been conclusively established. A literature review of related research is of great significance to elaborate on its mechanisms and to inform on further research directions. We elucidated on its mechanisms of action on inflammatory pain from two levels: peripheral and central. It includes the mechanisms of acupuncture in the periphery (immune cells and neurons, purinergic pathway, nociceptive ion channel, cannabinoid receptor and endogenous opioid peptide system) and central nervous system (TPRV1, glutamate and its receptors, glial cells, GABAergic interneurons and signaling molecules). In this review, we collected relevant recent studies to systematically explain the mechanisms of acupuncture in treating inflammatory pain, with a view to providing direction for future applications of acupuncture in inflammatory pain and promoting clinical development.

The Effects of Early Physiotherapy Treatment on Musculoskeletal Injury Outcomes in Military Personnel: A Narrative Review

The risks and incidence rates of musculoskeletal injuries among military personnel are high, and the importance of physiotherapy in treating these injuries is well established. However, what is less clear is whether the timing of commencement of physiotherapy treatment affects musculoskeletal injury outcomes in military personnel. This lack of clarity is exacerbated by the known underreporting of injuries among military personnel, and the resulting self-management of musculoskeletal injuries using analgesics, non-steroidal anti-inflammatories and other means. This narrative review was designed to identify and synthesize current evidence regarding the effects of timing of physiotherapy treatment on musculoskeletal injury outcomes, focusing on potential benefits of early versus typical or delayed commencement of physiotherapy treatment. Overall, current evidence suggests early physiotherapy treatment of musculoskeletal injuries offers distinct advantages over typical or delayed commencement of physiotherapy treatment in military settings. Specifically, it appears early treatment expedites recovery in early phases following injury onset and benefits longer term mental health and well-being. It may also reduce the need for more invasive and costly health care interventions and enable earlier return to training and operational service. Importantly, a cultural shift within military contexts to ensure early reporting of musculoskeletal injuries is required if the benefits of early commencement of physiotherapy treatment are to be achieved.

Examining the effects of chronic pain on work performance in the military

BACKGROUND

Effectively managing pain is a unique challenge for the U.S. military. Chronic pain has a tremendous detrimental impact on mission readiness throughout the Armed Forces. Examining the effects of chronic pain on readiness is critical to understanding and addressing these challenges.

PURPOSE

The purpose of this study was to examine the associations of chronic pain and sleep disruption in the context of work performance among active duty military service members.

METHODOLOGICAL ORIENTATION

The study design was a cross-sectional observational study that examined associations between patients with chronic pain and sleep disruption, in the context of work performance.

RESULTS

One hundred forty-five participants completed the study. Age, depression, sleep, and pain severity were consistently strong predictors of work performance.

CONCLUSIONS

Patients performed better with age, whereas those with depression, sleep disruption, and increased pain severity performed poorly.

IMPLICATIONS FOR PRACTICE

Research focused on the differences in work performance among age groups may provide a better understanding of coping strategies. Focused depression research can lead to a greater understanding of how mental health affects pain, sleep, and work. The findings of this study open the door to explore multiple approaches that could lead to treatments and preventions for military members living with chronic pain.

The Lived Experience of Military Women With Chronic Pain: A Phenomenological Study

Introduction

Chronic pain, a persistent or recurrent pain lasting more than 3 months, is a widespread problem among military women due to combat-related injuries and post-deployment stressors. Risk factors associated with chronic pain include gender, mental health, post-traumatic stress disorder, and prior physical or military sexual trauma. The most common prevalence of chronic pain is musculoskeletal (e.g., low back and neck), migraine, osteoarthritis, and fibromyalgia. Following deployment, 25% of military women are at risk for chronic pain. Military women are prescribed opioids for pain at a higher rate than men and are at risk for prescription opioid addiction. The unique medical needs of military women, including chronic pain, are poorly understood by health care providers and need to be addressed to achieve full integration into the military. The purpose of this study was to explore a typical day for military women living with chronic pain by examining the participants’ daily life experiences.

Material and Methods

Using van Manen’s approach, 13 active duty, retired, and veteran women were interviewed to explore these lived experiences. The study was approved by the Institutional Review Board at the University of San Diego.

Results

Eight themes emerged from an analysis of the participants’ experiences: (1) chronic pain is a frustrating, persistent, daily, and an hourly struggle; (2) resilience in living with chronic pain is the new normal; (3) mission first and the impact of invisible pain; (4) self-care management and internal locus of control with nonpharmacological therapies; (5) pain accepted and managed to improve quality of life; (6) coronavirus disease 2019 (COVID-19) diminished social interactions; (7) pain of sexual trauma is not reported; and (8) disparities in health care due to self-perception of provider bias as pain is not understood.

Conclusions

The study generated new knowledge in Force Health Protection, ensuring (1) a fit and operational readiness force; (2) pre- to post-deployment care for women warriors; and (3) access to health care. The study findings supported previous research and could help direct future research into nursing, medicine, and allied health treatments for military and veterans’ gender-specific health care, education, and training. Furthermore, the military women in this study provided insight into the need for future research to explore unconscious gender bias, health disparities, and a raised awareness of military women living with chronic pain. Findings from this study merit further exploration using other qualitative research methodologies including mixed methods.

Influence of Primary Care Provider Type on Chronic Pain Management Among Veterans

Background

Chronic pain disproportionately impacts veterans and is often treated in primary care, where physician shortages in the Veterans Health Administration (VHA) healthcare system are well documented. Nurse practitioners (NPs) may represent a solution to the care shortage; however, concerns of NP opioid overprescribing have led to NP practice and prescribing restrictions in individual VHA facilities and at the state level. Little is known regarding the prescribing patterns of NPs and physician assistants (PAs) for veterans with chronic pain in the VHA.

Purpose

The purpose of this study was to compare opioid and non-opioid prescribing patterns of physicians, NPs, and PAs for chronic pain patients at VHA centers.

Methods

We used data from the U.S. Department of Veterans Affairs Survey of Healthcare Experience of Patients and Corporate Data Warehouse from October 2015 to September 2016. Patient medical records for the year were analyzed by provider type (physician, NP, or PA) for differences in providers' rates of prescribing opioid and non-opioid medications, as well as characteristics of the opioid prescriptions (e.g., high daily morphine milligram equivalent [90 MME/day] dose, long-term opioid therapy [90 days]).

Results

Medical records of a total of 39,936 patients were included. In FY 2016, 55% of patients received one opioid prescription, whereas 83.8% received one non-opioid prescription. Compared to patients of NPs and PAs, patients of physicians had higher odds of receiving opioid (vs. NPs: OR = 1.13, p < 0.01; vs. PAs: OR = 1.16, p < 0.01) and non-opioid prescriptions (vs. NPs: OR=1.08, p = 0.02; vs. PAs: OR=1.20, p < 0.01) after adjusting for patient characteristics. There were no differences in high MME/day dose (p = 0.59) or long-term opioid therapy (p = 0.99).

Conclusion

In a national sample of veterans with chronic pain, NPs and PAs did not have higher odds of opioid prescribing. Concerns of NP or PA opioid overprescribing may be addressed by considering evidence that patients of these providers are not at higher odds of receiving an opioid prescription.

Population-Focused Approaches for Proactive Chronic Pain Management in Older Adults

Chronic pain, and the ethical management thereof, is the single most imperative health issue of this decade. Although a growing majority of individuals with chronic pain are middle-aged, the largest proportion of sufferers are older adults. Shifting tides in practice and research have led to population-focused approaches to pain management; however, the practice of many healthcare providers remains reactive and individualistic, limiting the discovery and implementation of long-term solutions for pain management in older adults. Yet, nurses and other health professionals have an opportune position to provide expert pain care by proactively providing evidence-based care for patients systematically. The purpose of this article is to stimulate discussion on three paradigms important to population-focused pain management: (1) prevention; (2) restoration and rehabilitation; and (3) palliation, which are in line with current national policy initiatives for improving patients' care experience, improving overall health and quality of life, and reducing associated health care costs.

Prevalence of chronic musculoskeletal pain among active and retired military personnel: a systematic review protocol

OBJECTIVE

The objective of this review is to assess the prevalence of musculoskeletal chronic pain among active and retired members of military forces and to characterize potential factors that could influence the frequency of musculoskeletal chronic pain.

INTRODUCTION

Inherent to military occupations is a diverse source of occupational hazards that affect the well-being of individuals at any stage of their military career (active and retired). Chronic pain may result from the continuous exposure to physically demanding tasks and other risks. Moreover, chronic pain has been associated with other comorbidities, including mental health conditions.

INCLUSION CRITERIA

Scientific papers in French or English reporting on chronic pain derived from a musculoskeletal cause in active and retired military personnel will be considered. There will be no restriction on participants' country, age, or length of service.

METHODS

The published literature will be identified by exploring biomedical, pharmacological, and physiology bibliographic databases. The unpublished literature will be located through the search of thesis and gray literature repositories. This review will follow the condition-context-population approach and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. The extracted data will include any detail about the anatomic location, diagnosis, types of studies, and risk factors. The review will follow JBI methods of critical appraisal, data extraction, and data synthesis for reviews containing prevalence data. If enough evidence is found, meta-regression analysis will performed, otherwise a narrative review will be completed.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42020153704.

Overuse-Related Injuries of the Musculoskeletal System: Systematic Review and Quantitative Synthesis of Injuries, Locations, Risk Factors and Assessment Techniques

Overuse-related musculoskeletal injuries mostly affect athletes, especially if involved in preseason conditioning, and military populations; they may also occur, however, when pathological or biological conditions render the musculoskeletal system inadequate to cope with a mechanical load, even if moderate. Within the MOVIDA (Motor function and Vitamin D: toolkit for risk Assessment and prediction) Project, funded by the Italian Ministry of Defence, a systematic review of the literature was conducted to support the development of a transportable toolkit (instrumentation, protocols and reference/risk thresholds) to help characterize the risk of overuse-related musculoskeletal injury. The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) approach was used to analyze Review papers indexed in PubMed and published in the period 2010 to 2020. The search focused on stress (overuse) fracture or injuries, and muscle fatigue in the lower limbs in association with functional (biomechanical) or biological biomarkers. A total of 225 Review papers were retrieved: 115 were found eligible for full text analysis and led to another 141 research papers derived from a second-level search. A total of 183 papers were finally chosen for analysis: 74 were classified as introductory to the topics, 109 were analyzed in depth. Qualitative and, wherever possible, quantitative syntheses were carried out with respect to the literature review process and quality, injury epidemiology (type and location of injuries, and investigated populations), risk factors, assessment techniques and assessment protocols.

Evaluating Suicide Risk Using the Reasons for Dying-Reasons for Living (RFD-RFL) Index in a Military Psychiatric Inpatient Setting

The present study aimed to explore reasons for dying (RFD) and reasons for living (RFL) among suicidal inpatients, conceptualize the RFD-RFL index, and examine whether suicide risk indicators were associated with the RFD-RFL index scores. Participants were military personnel (N = 167) psychiatrically hospitalized following a suicide-related crisis who provided baseline data as part of a randomized controlled trial. Family was the most commonly reported RFL (39.7%) and was the top ranked RFL for 65.9% of participants. The most frequently endorsed RFD categories included general descriptors of self (26.9%), general statements about escape (19.7%), and others/relationships (19.1%). Greater RFD-RFL index scores were associated with a greater wish to die relative to wish to live, greater hopelessness, and with a history of lifetime multiple suicide attempts. Endorsing more RFD relative to RFL may indicate heightened suicide risk. Results of this study identify the characteristics of RFD and RFL among a high-risk, military sample, and provide preliminary support for the clinical utility of evaluating the quantities of RFD and RFL. Clinicians are encouraged to explore RFD and RFL when working with suicidal patients. Future research may explore military-specific RFD and evaluate the validity of the proposed RFD-RFL index.

Relationships between chronic pain and mood symptoms among veterans with bipolar disorder

BACKGROUND

Chronic pain is highly prevalent among individuals with mood disorders. While much is known about the relationship between pain and unipolar depression, little is known about pain experiences among people with bipolar disorder. This pilot study addresses this gap by examining pain and its relationship to mood and functioning in a sample of US military veterans with bipolar disorder.

METHODS

Qualitative interviews were conducted with 15 veterans with bipolar disorder and chronic pain who were recruited from outpatient services within a Veterans Affairs medical center.

RESULTS

Veterans reported a bidirectional relationship between pain and bipolar depression. When discussing manic episodes, individuals' experiences varied between notable reductions in pain (usually in euphoric states), increases in pain (usually in angry/irritable states), and feeling disconnected from pain. Many reported that increased activity when manic contributed to worse pain after an episode. Veterans clearly articulated how these connections negatively affected their functioning and quality of life.

LIMITATIONS

This was a small, retrospective study that included a non-random sample of veteran participants from one VA medical center. All veterans were engaged in outpatient mental health care, so the majority reported that their mood has been well-stabilized through medications and/or psychotherapy.

CONCLUSIONS

Chronic pain experiences appear to be related to depressive and manic mood states and significantly affects functioning and quality of life in Veterans with bipolar disorder. This study highlights the need to assess chronic pain among veterans with bipolar disorder, as changes in mood could have significant implications for functioning and pain management.

Sleep quality and its impacts on quality of life among military personnel in remote frontier areas and extreme cold environments

BACKGROUND

Poor sleep quality negatively affects the readiness of military operations and is also associated with the development of mental health disorders and decreased quality of life. The purpose of this study was to investigate the sleep quality of military personnel from remote boundaries of China and its relationship with coping strategies, anxiety, and health-related quality of life (HRQoL).

METHODS

A cross-sectional survey was performed among military officers and soldiers from a frontier defence department and an extreme cold environment. The participants were surveyed using the Pittsburgh Sleep Quality Index (PSQI), Trait Coping Style Questionnaire (TCSQ), Self-rating Anxiety Scale (SAS), and Short Form Health Survey (SF-36).

RESULTS

A total of 489 military officers and soldiers were included. The participants had a mean age of 22.29 years. The median overall PSQI score was 7.0 (IQR, 4.0 ~ 9.0), with 40.9% (200/489) of the subjects reporting poor sleep quality. The difficulties with sleep were mainly related to daytime dysfunction due to disrupted sleep, sleep latency, and subjective sleep quality. The median score of the SF-36 physical component was 83.5 (IQR, 73.0 ~ 90.5), and the median score of the mental component was 74.1 (IQR, 60.4 ~ 85.1). Significant correlations were found between the PSQI and SF-36 (r = - 0.435, P <  0.01). Anxiety symptoms, marital status, educational background, and global PSQI score were demonstrated as predictors of a low SF-36 physical component by multiple regression analysis (F = 17.06, P <  0.001, R2 = 0.117).

CONCLUSIONS

Sleep difficulty is a prevalent and underestimated problem in the military that negatively influences HRQoL, especially in physical and social functioning. Evaluation of and education on pain were recommended because of body pain and its negative impacts on sleep quality, coping strategies, anxious emotions and HRQoL.

Complexity of the Relationships of Pain, Posttraumatic Stress, and Depression in Combat-Injured Populations: An Integrative Review to Inform Evidence-Based Practice

BACKGROUND

Understanding the complex interrelationships between combat injuries, physical health, and mental health symptoms is critical to addressing the healthcare needs of wounded military personnel and veterans. The relationship between injury characteristics, pain, posttraumatic stress disorder (PTSD), and depression among combat-injured military personnel is unique to modern conflicts and understudied in the nursing literature.

AIM

This integrative review synthesizes clinical presentations and relationships of combat injury, PTSD, depression, and pain in Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) United States military service members and veterans.

METHODS

A literature search was conducted using relative key terms across databases to identify peer-reviewed publications between 2001 and 2016 that examined health outcomes of combat-injured persons in OEF and OIF. The quality of evidence was evaluated and results synthesized to examine the association of combat injury as a risk factor for PTSD, the relationship of PTSD and depression pre- and postinjury, and pain management throughout care.

RESULTS

Twenty-two articles were included in this review. Greater injury and pain severity poses risks for developing PTSD following combat injury, while early symptom management lessens risks for PTSD. Depression appears to be both a contributing risk factor to postinjury PTSD, as well as a comorbidity.

LINKING EVIDENCE TO ACTION

Findings demonstrate a compelling need for improvements in standardized assessment of pain and mental health symptoms across transitions in care. This integrative review informs nurse researchers and providers of the clinical characteristics of pain, PTSD, and depression following combat injury and offers implications for future research promoting optimal surveillance of symptoms.

TelePain: Primary Care Chronic Pain Management through Weekly Didactic and Case-based Telementoring

Chronic pain is a significant problem among military personnel and a priority of the military health system. The U.S. Army Surgeon General's Pain Management Task Force recommends using telehealth capabilities to enhance pain management. This article describes the development and evaluation of a telehealth intervention (TelePain) designed to improve access to pain specialist consultation in the military health system. The study uses a wait-list cluster controlled clinical trial to test: 1) effectiveness of the intervention, and 2) interviews to assess barriers and facilitators of the intervention implementation. The intervention involves a didactic presentation based on the Joint Pain Education Curriculum followed by patient case presentations and multi-disciplinary discussion via videoconference by clinicians working in the military health system. A panel of pain specialists representing pain medicine, internal medicine, anesthesiology, rehabilitation medicine, psychiatry, addiction medicine, health psychology, pharmacology, nursing, and complementary and integrative pain management provide pain management recommendations for each patient case. We use the Pain Assessment Screening Tool and Outcomes Registry (PASTOR) to measure patient outcomes, including pain, sleep, fatigue, anxiety, and depression. This article reports some of the challenges and lessons learned during early implementation of the TelePain intervention. Weekly telephone meetings among the multisite research team were instrumental in problem solving, identifying problem areas, and developing solutions. Solutions for recruitment challenges included additional outreach and networking to military health providers, both building on existing relationships and new relationships.