By Kevin T. Galloway, BSN, MHA; Chester C. Buckenmaier III, MD; and Rollin M. Gallagher, MD, MPH
In the military healthcare system, the need for aggressive management of acute pain associated with combat injuries and trauma is obvious. An equally important and possibly greater issue facing military medicine is how to treat military service members who develop significant pain caused by mechanical injuries related to wearing body armor, repeatedly jumping from vehicles, and riding for many hours in vibrating vehicles or helicopters. This population requires ongoing surveillance to identify the prevalence and nature of their pain syndromes and to assess for and manage chronic pain, which generally is of musculoskeletal origin.
The Defense and Veterans Pain Management Initiative (DVPMI), established in 2003 as the Army Regional Anesthesia & Pain Management Initiative, seeks to improve pain management in military and civilian medicine. Through research and clinical care, DVPMI dedicates experts and resources to address pain across the military’s continuum of care from level 1 (combat medic/buddy aid at the point of injury) to level 2 (forward surgical team or aid station) to level 3 (combat support hospital) and on to level 4 (major hospital outside the theater of war), with transition to services of the Veterans Health Administration (VHA) and ultimately the civilian community.
In 2009, the Army Surgeon General chartered a Pain Management Task Force to assess current pain management delivery in the military and provide recommendations for a comprehensive pain-management strategy that takes a holistic, interdisciplinary, multimodal approach. With additional representation from the Air Force, Navy, and national Veterans Administration (VA), the Task Force was directed to include all appropriate science technologies and approaches to pain management that would broaden the goals to optimizing quality of life and function for military service members and veterans with acute and chronic pain. The Task Force report, completed in May 2010, concluded that while the military meets accepted standards of care for pain management, the orientation, practice, and resourcing of pain management varies. Task Force members compiled more than 100 recommendations to advance a comprehensive pain-management strategy for military medicine.
Needed: Integrated care
Although managing pain is one of the most fundamental and basic responsibilities of healthcare professionals, clinicians and researchers continue to wrestle with evidence based and best practices to achieve effective pain management and reduce physical and psychological morbidity associated with suffering. The understanding of and approach to pain management by healthcare personnel are influenced significantly by their education and training, respective pain curricula, mentors, cultural beliefs, and personal experiences with pain. Thus, considerable variability exists in pain-management practices. To a degree, this has contributed to needless suffering, delayed access to pain experts, ineffective or inappropriate pain treatments, and financial burdens to the healthcare system.
Many patients and providers believe pain management falls within one of two categories:
- intervention-centered (for instance, nerve blocks, joint injections, or acupuncture)
- medication-centered (for example, pills and capsules).
However, neither of these unimodal approaches adequately meets the needs of many patients, who have complicated pain etiologies and histories. Instead, an effective strategy typically requires a comprehensive, integrated approach that incorporates the perspectives of various disciplines and professions, along with multimodal approaches to pain and individualized plans of care. The tools to implement this strategy fall outside of what insurance providers normally reimburse or what’s available in the average pain-management practice. Besides a physician, effective pain care may require nurses, physical therapists, behavioral health specialists, pharmacists, and other providers. Standard use of
medications and procedural interventions often requires the complementary use of acupuncture, massage therapy, mind-body techniques, and other integrative modalities.
While the military healthcare system’s pain-management challenges resemble those of civilian healthcare systems, military and VA facilities face unique challenges because of their distinctive mission, structure, and patient population. Caring for service members and their families involves responsibilities that extend beyond the usual relationship between a healthcare system and its patients. During times of war, the importance of optimizing care is heightened. The likelihood that military patients will have their health care coordinated by a single primary-care manager is relatively low because of the transience of military personnel (patients) and military healthcare providers.
Less-than-optimal continuity of care is extremely problematic when attempting to develop and implement long-term treatment plans for pain management and other chronic medical conditions. As a result, patients may face duplicate appointments, laboratory tests, and diagnostic and treatment procedures. Veteran populations commonly need care from multiple specialists and services, both within the VA system and the community. Access to consistent providers and services is paramount to continuity of care and reducing delays in care, confusion regarding point-of-care providers, and frustration encountered in navigating complex healthcare systems.
Fortunately, due to advances in combat technologies, such as improved body armor and combat casualty care, most military service members survive wounds that usually proved fatal in previous military conflicts. Survivors of complex polytrauma, however, must contend with significant life-altering challenges and pain, along with comorbid conditions, such as postconcussive syndrome, mild traumatic brain injury (TBI), and posttraumatic stress disorder (PTSD). These conditions require integrated approaches to clinical care that cross the traditional organization of healthcare specialties and patient care.
Army Pain Task Force interviews with healthcare professionals across all specialties found variability in how pain is assessed and the perceived value placed on patients’ pain scores in directing pain care. While military physicians, nurses, and medics all reported they vigilantly assess pain during each patient encounter, usually using the numeric rating scale (0–10) and the visual analog scale, significant variations occurred in how patients were instructed to report their pain levels. Also, the healthcare professionals perceived pain-assessment scales as vague and highly subjective, with few functional anchors to help patients quantify and qualify their pain.
In response to these findings, the Task Force developed a revised pain scale, called the DoD/VA Pain Rating Scale, which uses a combination of validated pain-assessment scales and functional anchors incorporated to standardize reporting of pain levels. After a comprehensive validation research study is completed, this pain scale is expected to become the standard for all Department of Defense (DoD) and VA healthcare settings. Use of a common patient-reported pain instrument is expected to promote consistency in pain-assessment practices and offer a common understanding of pain in terms of severity, function, and impact on key biopsychosocial areas. With this improved pain reporting scale, the actionable value of pain assessments should increase exponentially. (See Pain rating scale by clicking the PDF icon above.)
Another product from the DVPMI is The Military Advanced Regional Anesthesia and Analgesia Handbook. (See “Resources for additional information.”) The first textbook written specifically for management of battlefield pain in military service members, it was developed based on a recommendation by the Joint Theater Trauma System Clinical Practice Guideline that all healthcare providers be trained and focused on pain management far forward on the battlefield and in military hospitals. The book contains 32 chapters, many of which address regional anesthesia techniques and the associated care of patients receiving this therapy. This text is an outstanding resource for all nurses who collaborate with anesthesiologists to develop regional anesthesia programs.
Transitions to other healthcare systems
Another finding from the Pain Task Force highlighted the importance of coordinating care among the multiple healthcare systems used by the military. Military service members and their families often receive care across a continuum of facilities in the DoD (Army, Navy, and Air Force), VA, and civilian hospitals. The “warm hand-off” between the transferring and accepting teams is a critical component in preventing duplicate laboratory tests and unnecessary medical procedures, as well as ensuring continuity of ongoing effective treatments.
This process depends on a recently developed network of military case managers, most of them registered nurses. Case managers are part of a clinical and administrative team that coordinates communications and care among patients, families, the clinical care team, and military commands. The role of case managers is extremely important as patients move between healthcare systems that may have different formularies, equipment, and treatment protocols for treating pain.
Considerations for acute pain management
The primary objective of acute pain management is to treat pain early and aggressively. For military service members, this means starting pain management far forward on the battlefield. Those who receive prompt, aggressive treatment from an acute pain service experience a greater degree of pain relief, decreased pain intensity, and improved outcomes.
Survey data found that among those treated by an established acute pain service at a combat support hospital in Afghanistan, approximately 30% experienced pain relief in the first 1 to 3 hours, increasing to more than 80% in 7 to 10 hours. Coalition forces deployed to Iraq who received far forward treatment with early and aggressive pain management at an
interventional pain service at a Baghdad hospital had a 95% rate of return to duty; more than 90% were treated for less than 48 hours with multimodal therapy. The most common diagnosis was radiculopathy (63%), which was treated with epidural steroid injections, physical therapy, and pharmacotherapy (primarily nonsteroidal anti-inflammatory drugs), or a combination.
The Pain Outcomes for Warriors Experiences Research initiative demonstrated that more effective painmanagement strategies are needed to prepare injured military service members for long evacuation flights. A survey completed by 110 wounded military service members evacuated from Iraq and Afghanistan to a regional medical center in Germany found that only 65% reported 50% or less pain relief during transport. Pain relief scores improved at the regional medical center, with only 33% indicating 50% or less pain relief.
For military nurses deployed to combat support hospitals, pain management begins at the point of injury. Nurses working in military hospital settings assist in developing effective analgesic regimens. (See Mission of nursing in acute pain management by clicking the PDF icon above.) Raising the pain assessment to the level of the “fifth vital sign” and using standardized assessment and documentation tools greatly improve pain-management care.
Acute pain management relies on a systematic approach to treatment. (See Acute pain management: Key considerations by clicking the PDF icon above.) For nurses, an integral component of patient care is performing regular physical pain assessments and reassessments. These detailed, concise evaluations provide important data for all healthcare team members and serve as the basis for treatment plans. Elements secondary to the pain process, such as psychosocial factors, the patient’s coping mechanisms, family dynamics, and variable levels of patient and family understanding, require nurses to establish trust and a working relationship with patients and families.
Considerations for chronic pain management
For military service members, the rapid transition from being a soldier in a combat zone to returning home to the previous role as spouse, parent, or both is difficult at best. Sustaining serious polytrauma, emotional distress, and psychological exhaustion during military service significantly complicates this transition. At the outset of the current military conflicts, neither DoD nor VA was accustomed to treating survivors of serious blast injuries with significant polytrauma and other associated comorbidities. VHA directive 2009-053 calls for early and continuous treatment of military service members within the DoD, with transition of care to the VA and an integrated stepped pain-management program. Transition to the VA is promoted by a local or regional team to ensure timely initial health assessments, and by coordinators who advocate for care.
Challenges of complex polytrauma
The more complex polytrauma patients with their broader spectrum of physical injuries and comorbidities— including the triad of chronic pain, PTSD, and persistent postconcussive symptoms (the “3 Ps”)—challenge not only current perspectives of the pain continuum and its association with tissue damage and healing. They also challenge pain-management models.
For example, wounded warriors with painful injuries and postconcussive cognitive impairments may require a much more structured environment for successful use of a complex multimodal pain treatment approach. PTSD activates neuropathic pain and worsens cognitive and behavioral controls. Patients with PTSD have higher rates of psychiatric and social problems and less improvement in pain compared to those without PTSD. An effective treatment plan addresses physical and emotional signs and symptoms while providing on-going assessments for and treatment of TBI, PTSD, chronic pain, and substance abuse.
A new disorder, postdeployment multisymptom disorder, has been identified to address the prevalence and greatly increased symptom burden of patients whose pain is clustered with PTSD, mild TBI, PTSD with mild TBI, or substance abuse in patients with polytrauma. To effectively treat these patients requires not just managing individual symptoms but using multifaceted care approaches that focus on function, reintegration into family and social systems, and quality of life.
Currently, DoD and VA are evaluating a new transdisciplinary, stepped, and integrated mental healthcare model centered on maximizing quality of life for patients with postdeployment multisymptom disorder. Core treatments in this model address aspects of daily living and psychosocial functioning; specialty programs are designed to deal with specific diagnoses. Future directions include refining the model, enhancing efficiency of therapy, increasing the consumer focus (such as expanding hours for access to care), and conducting research to determine how interactions among comorbid states affect pain and identify the most effective treatments for these conditions.
Nurse’s role in chronic pain management Nurses are instrumental in achieving the goals of chronic pain therapy by helping patients navigate all aspects of treatment. Specific nursing actions include medication management, counseling (including adherence to therapy), promoting lifestyle changes (such as smoking cessation, physical therapy, and nutrition counseling), and assisting with complementary and alternative therapies. Of course, nurses are uniquely positioned to conduct pain assessments and monitor responses to analgesic therapies.
Nurses must apply the principles of multimodal analgesia and understand the rationale for both pharmacologic and nonpharmacologic approaches to pain control. Targeted pain treatments, especially multiple analgesics, require knowledge of drug mechanisms of action, dosing parameters for optimal pain relief, synergistic effects that may potentiate adverse drug effects, and guidelines for safe patient monitoring.
In both military and civilian settings, nursing is contributing to improved pain management through clinical practice and research. Nurses are integral to the success of research programs on pain at military and VHA facilities and have made substantial contributions to advancing pain science in such roles as research coordinators and associate or principal investigators. Nurses also serve as primary patient advocates in both military and civilian healthcare systems.
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Buckenmaier CC 3rd, Rupprecht C, McKnight G, et al. Pain following battlefield injury and evacuation: a survey of 110 casualties from the wars in Iraq and Afghanistan. Pain Med. 2009;10(8):1487-1496.
Clark ME, Bair MJ, Buckenmaier CC 3rd, et al. Pain and combat injuries in soldiers returning from Operations Enduring Freedom and Iraqi Freedom: implications for research and practice. J Rehabil Res Dev. 2007;44(2):179-194.
Clark ME, Walker RL, Gironda RJ, et al. Comparison of pain and emotional symptoms in soldiers with polytrauma: unique aspects of blast exposure. Pain Med. 2009; 10(3):447-455.
Lamb D. The documentation of pain management during aeromedical evacuation missions. Nurs Clin North Am. 2010;45(2):249-260.
Lew HL, Otis JD, Tun C, et al. Prevalence of chronic pain, posttraumatic stress disorder, and persistent postconcussive symptoms in OIF/OEF veterans: polytrauma clinical triad. J Rehabil Res Dev. 2009;46(6):697-702.
Office of the Army Surgeon General. Pain Management Task Force. Providing a Standardized DoD and VHA Vision and Approach to Pain Management to Optimize the Care for Warriors and Their Families. Final Report; May 2010. www.armymedicine.army.mil/reports Pain_Management_Task_Force.pdf. Accessed July 21, 2011.
Kevin T. Galloway, is Chief of Staff of the Army Pain Management Task Force of the Office of the Army Surgeon General in Alexandria, Virginia. Chester C. Buckenmaier III is director of the Defense and Veterans Center for Integrative Pain Management and an associate professor at the Uniformed Services University of the Health Sciences in Rockville, Maryland. Rollin M. Gallagher is Deputy National Program Director for Pain Management in the Veterans Affairs Health System at the Philadelphia Veteran Affairs Medical Center in Philadelphia, Pennsylvania; he is also a clinical professor of psychiatry, anesthesiology, and critical care and Director of Pain Policy Research and Primary Care at Penn Pain Medicine at the University of Pennsylvania School of Medicine in Philadelphia.