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Pain Issues Among OEF and OIF Returnees

VIEWS: 20 PAGES: 61

									Pain Issues Among OEF and
OIF Returnees

                        Michael E. Clark, Ph.D.
           Chair, National Polytrauma Pain Subcommittee
   Clinical Director, Chronic Pain Rehabilitation Program (CPRP)
                  James A. Haley Veterans Hospital
          Associate Professor, University of South Florida
                           Tampa, Florida
Collaborators
 Lt. Col. Chester C. Buckenmaier III, M.D.,
    Department of Anesthesiology, Walter Reed Army
    Medical Center, Washington, D.C.
   Robyn L. Walker, Ph.D., Polytrauma/CPRP Pain
    Psychologist, Tampa VA, FL.
   Jennifer L. Murphy, Ph.D., OEF/OIF Pain
    Psychologist, CPRP, Tampa VA, FL.
   Ronald J. Gironda, Ph.D., CPRP Outpatient
    Psychological Services Director, Tampa, FL.
   Mathew J. Bair, M.D., Roudebush VA Center of
    Excellence, Indianapolis, IN
                         CLARK- 2006                 2
Deployment Rates
 Over 1 million military personnel have
  been deployed since the start of war.
 At any given time, approximately 150,000
  are in Iraq, 18,000 are in Afghanistan, and
  35,000 are in Kuwait and other supporting
  areas.
 Approximately 50% of all Active Duty and
  25% of all Reserves and National Guard
  have been deployed.

                    CLARK- 2006                 3
Casualties and Wounded (as of 9/8/06)
 3001 US deaths (3373 total)
 20,846 US combat wounded
 Of those wounded, approximately 30%
  (6250) were medically evacuated by air.
 Approximately 6400 additional US soldiers
  have been evacuated for non-combat
  injuries, and another 17,600 for disease.
 Despite injury severity, 90% of the injured
  survive.

                    CLARK- 2006             4
Combat Trauma Care




                          Lynsey Addario/Corbis, NY Times

            CLARK- 2006                                     5
                             Wounded are quickly
                              transported to a field
                              hospital
                             Emergency trauma care is
                              provided for stabilization
                             Severely wounded then
                              moved rapidly to a military
                              hospital (e.g., Landstuhl,
                              Germany), at times arriving
                              in 24 hours or less
                             From there, most serious
                              cases are air-evacuated to
                              US MTFs, and may arrive
                              within 36-48 hours post-
                              injury
From Peoples et al., 2004
Combat Injuries
(From Clark, Bair, Buckenmaier, Gironda, and Walker, in press)

                                                     Male                        Female
     Characteristic                                 (n=269)                      (n=18)
Mean Age in Years (sd)                              28.1 (.5)                    27.5 (1.7)
Injury Mechanism
  Blast or Fragment                              164 (61.0%)                     6 (33.3%)
  Bullet                                          38 (14.1%)                      1 (5.6%)
  MVA                                              11 (4.1%)                     3 (16.7%)
  Other                                            12 (4.4%)                     2 (11.1%)
  Unknown                                         44 (16.4%)                     6 (33.3%)
Injury Distribution
  Orthopedic                                     189 (70.3%)                    15 (83.3%)
  Polytrauma                                      72 (26.8%)                     2 (11.1%)
  Other single site                                8 (2.9%)                       1 (5.6%)
       Based on 287 Walter Reed Army Medical Center evacuees treated with Regional Analgesia
                                              CLARK- 2006                                      7
Number of Orthopedic Injuries and Sites
(From Clark, Bair, Buckenmaier, Gironda, and Walker, in press)


                                                Male                   Female
      Characteristic                           (n=269)                 (n=18)
  Orthopedic Injuries
          0                                 7 (2.6%)                   1 (5.6%)
          1                                124 (46.1%)                 7 (38.9%)
          2                                86 (31.9%)                  4 (22.2%)
          3                                33 (12.3%)                  4 (22.2%)
          >3                                19 (7.1%)                  2 (11.1%)
  Number of Injury Sites
          1                                 82 (30.5%)                 7 (38.9%)
          2                                 71 (26.4%)                 5 (27.8%)
          3                                 57 (21.2%)                 3 (16.7%)
          >3                                59 (21.9%)                 3 (16.7%)
           Based on 287 Walter Reed Army Medical Center evacuees treated with Regional Analgesia
                                                CLARK- 2006                                        8
Casualty Air Evacuation




                            From Peoples et al., 2004




              CLARK- 2006                               9
Lynsey Addario/Corbis
NY Times
OIF/OEF Casualty Evacuation

 Evacuation flights are crowded, dim, noisy,
  and long
 High patient to staff ratios typical, and
  physicians usually not on board
 Monitoring equipment is limited and at
  times during the flight the crew may be
  unable to communicate with the ground



                     CLARK- 2006              11
Trauma Pain Issues: Challenges and
Responses
  Focus on the battlefield and during transport is survival,
   not pain.
  Use of morphine for pain control is problematic due to rapid
   evacuation and limited monitoring.
     In response, military anesthesiologists pioneered the
      use of regional anesthesia (in 2003) and continuous
      peripheral nerve blocks (in 2005) during stabilization
      and evacuation.
  PCA was not available for use during air evacuations.
     In 2005 a modified PCA prototype was designed and
      currently is in use during air evacuations.
  Advanced pain control technology now routinely used
   during transport.



                             CLARK- 2006                        12
MTF Care and Rehabilitation




  From Peoples et al., 2004

                              CLARK- 2006   13
 MTF Care and Rehabilitation
 After air evacuation to US, most wounded are
  admitted to MTFs (Walter Reed or Bethesda) for
  continuing care.
 MTFs provide acute care which often involves a
  series of surgical procedures.
 Some also undergo rehabilitation (e.g., amputee
  rehab program at WRAMC).
 Pain treatment at MTFs includes a combination of
  analgesics and advanced technologies such as
  regional anesthesia, continuous peripheral nerve
  blocks, and PCAs.
                       CLARK- 2006                   14
 Field and MTF Surgeries (1)*
                                    Operations in    Operations at
           Procedure                Field (n=931)** WRAMC (n=634)**
           Orthopedic                   n=290           n=265
Amputation                               114             40
Amputation revision                       ---            55
External Fixation                        104             11
Internal Fixation                         39             85
Joint Exploration                         13             15
Joint fixation/manipulation               ---             8
Joint
reconstruction/replacement                ---                    9
Bone grafting                              1                     2
Hardware removal                          ---                   11
Ligament repair                           ---                   10
Nerve repair/neurolysis                    3                     8
Tendon repair/transfer                     6                    11
Other                                     10                    ---
* Sample = 287 evacuees treated at WRAMC (Clark et al., in press).
**Average of 5.5 surgeries per casualty CLARK- 2006                   15
 Field and MTF Surgeries (2)
                                 Operations in     Operations at
           Procedure             Field (n=931)    WRAMC (n=634)
          Soft Tissue                n=249            n=330
Exploration/Debridement
VAC                                   219              287
Foreign body removal                   14                1
Burn wound care                         9               ---
Skin grafting or flap coverage          7               30
Scar release                           ---               5
Wound closure                          ---               7
           Vascular                  n=82              n=1
Major repair                           32                1
Fasciotomy                             34               ---
Other                                  16               ---



                                    CLARK- 2006                    16
 Field and MTF Surgeries (3)
                            Operations in      Operations at
           Procedure        Field (n=931)     WRAMC (n=634)
            Thoracic            n=24               n=1
Tube thoracostomy                 14                ---
Pericardiotomy                     3                ---
Other                              7                 1
   Abdominal exploration        n=23                ---
Solid organ injury repair          4
Hollow viscera
repair/diversion                 4
Other                            17
        Head and neck            32                 37
             Other               32                 37
           Unknown               19                 ---


                                CLARK- 2006                    17
Polytrauma Rehabilitation




                       Tampa Polytrauma Rehabilitation Center photos


              CLARK- 2006                                              18
VA Polytrauma Care
 Polytrauma is defined by the VHA as
  “…two or more injuries to physical
  regions or organ systems, one of which
  may be life threatening, resulting in
  physical, cognitive, psychological, or
  psychosocial impairments and functional
  disability”.
 PRCs were developed to respond to the
  complexity of polytrauma rehabilitation.

                   CLARK- 2006               19
VA PRCs
 Four Level 1 inpatient centers established
  (Minneapolis; Palo Alto; Richmond;
  Tampa) to provide intensive rehabilitation.
  Selection was based on the availability of
  inpatient TBI programs at these VAs.
 PRC network includes 21 Level 2
  outpatient programs for continuing care
  organized under the Level 1 PRCs (VISN 7
  Level 2 program is at Augusta VA under
  the Tampa Level 1 PRC).
                    CLARK- 2006                20
   Polytraumatic Injuries at Tampa
   PRC (n=50)
 Method of Injury:
      IEDs: 70%
      Airborne shrapnel: 26%
      Mortar rounds: 22%
      Gunshot wounds: 6%
 Type of Injury (Average #: 3.3):
      TBI: 80%
         Closed: 22%
                                 Eye: 44%
         Penetrating: 58%
                                 Burns: 12%
      Ortho: 50%                Compartment syndrome: 12%
      Soft Tissue: 48%          Limb amputation: 12%
      Hearing: 48%              SCI: 10%
                              CLARK- 2006               21
    Cognitive Issues
 Cognitive limitations are quite common among the
    TPRC soldiers.
   Average admission Rancho Los Amigos Scale
    Score was 5.2 (SD = 1.9)
   Average initial Glasgow Coma Scale Score was 9.2
    (SD = 3.9)
   71% had Rancho scores below 7 at admission
    indicating moderate to severe TBI
   76% received Glasgow scores below 13 at
    admission indicating moderate to severe TBI

                         CLARK- 2006                 22
 Polytrauma Pain
 Of the 50 records reviewed, 96% experienced >
  1 pain problem during rehabilitation
 Valid pain intensity ratings were obtained from
  68% of those patients at admission
     Mean pain score: 5.6 (SD: 2.2)
 Average duration of pain at admission was 83.7
  days (SD: 152.7; Range: 24 - 1054)
 70% of patients with pain, experienced it in
  more than one site
     Mean # pain sites: 2.3 (SD: 1.4)

                           CLARK- 2006              23
  Polytrauma Pain Locations

Primary Pain Location        Secondary Pain Location
     Head = 32%                       Head = 22%
     Leg(s) = 23%                     Low back = 16%
     Shoulder(s) = 13%                Face = 14%
     Arm(s) = 11%                     Hand(s) = 14%
     Hand(s) = 6%                     Leg(s) = 12%
     Neck = 4%                        Neck = 10%
                                       Abdomen = 10%

                          CLARK- 2006                    24
Pain Related Impairments

 Recreational or physical activity: 42%
 Emotional functioning: 34%
 Social activity: 18%
 Family relationships: 18%
 Sleep: 14%
 Sexual functioning: 2%


                  CLARK- 2006          25
PRC Pain-Related Problems at
Admission (in order of frequency)
 Inadequate pain control
 Excessive sedation (preventing
  rehabilitation involvement)
 Avoidance of rehabilitation therapies that
  cause pain
 Sleep difficulties
 Family problems
 Irritability, emotional lability

                    CLARK- 2006                26
PRC Pain Management
Approach
 Early and continued treatment
    To minimize likelihood of chronic pain
     problems
Multidisciplinary in nature
 Behavioral                Medical
      Pain Psychologist           R/O and manage causes
      Therapists                  Medications
      Nursing                        Opioid reductions

      Family/Friends                 Transfer of Rx between

                                       MTF and VA
                           CLARK- 2006                    27
PRC Pain Management Components

 Medication management: 100%
 Physical therapy: 40%
     TENS unit: 6%
 Occupational therapy: 38%
 Cognitive behavioral therapy: 13%
  (including pain education)
 Nerve blocks: 8%
 Medication pump implantation: 4%


                      CLARK- 2006     28
Polytrauma Pain Outcomes
 10% reduction in prescription of opioid pain
    medications (58% to 48%)
   Increased use of NSAIDS at discharge
   Average pain intensity declined from 5.6 (2.2) to 3.7
    (3.3) which was significant [F(1,27) = 6.681, p = .015]
   Nevertheless, pain continues to be a problem at
    discharge
   Ultimate course of pain in polytrauma is unknown.
    There is some indirect evidence that chronic pain
    and chronic pain syndromes may be more likely to
    develop than in other acute injuries.
                            CLARK- 2006                  29
Polytrauma Pain: Possible Course




                             From Clark et al., in press


               CLARK- 2006                                 30
Polytrauma Pain: Implications for
VA Care
 Pain needs to be consistently assessed and
  treated across the continuum of polytrauma care
 Alternate methods of pain evaluation and Tx need
  to be developed and utilized with cognitively
  impaired patients
 Polytrauma patients may be at greater risk for the
  development of chronic pain and CPS
 Aggressive multidisciplinary pain management
  incorporating medical and behavioral pain
  specialists is needed at all levels of care


                       CLARK- 2006                 31
OIF/OEF Post-Deployment Pain




                      Spc. Joshua McPhie, 1st Calvary Public Affairs

              CLARK- 2006                                              32
Persian Gulf War Aftermath
 1 in 4 US Service Members who
  participated in Operation Desert Storm are
  now classified as “disabled”, with
  additional claims pending.
 Monetary costs > 1 billion dollars annually
 Most frequent complaints are fatigue,
  musculoskeletal pain, sleep disturbance,
  cognitive dysfunction, and moodiness.
 High rates of headaches, joint pain, back
  pain, muscle pain, and abdominal pain.

                    CLARK- 2006             33
Prevalence of OIF/OEF Pain
 Our initial record review of 619 registrants for VA
  care at Tampa revealed that 42.7% reported pain
  as a problem, with over 50% of them reporting
  pain scores ≥ 4 (Clark, 2004).
 A follow up review of an additional 970 cases
  yielded a pain prevalence of 46.5% (Gironda et al.,
  2006). This compares to an estimated pain
  prevalence of 34.8% for GW personnel.
 Among a random sample of 100 of those with
  pain, 57% reported pain scores that fell into the
  moderately severe to severe range (pain ≥ 7).

                        CLARK- 2006                 34
Tampa OIF/OEF Pain Programs
 Phase 1 (Pain Outreach) funded and
  implemented in November 2005
     Pain psychologist directly contacts
      OIF/OEF registrants by telephone
     Conducts brief pain screening to identify
      whether pain is an issue, and arranges in
      depth assessment if indicated
 Phase 2 (Pain Treatment) funded in 2006
   When fully implemented will provide a
    range of outpatient pain services to these
    individuals
                       CLARK- 2006                35
OIF/OEF Outreach Data
 A review of 525 OIF/OEF returnees’ CPRS
 records reveal:
     50.5% have an existing chronic pain condition
      which is clearly reflected in their records.
     19.2% do not have enough information in their
      records to determine if they have chronic pain.
     30.3% do not appear to have a pain problem.
 114 of those with chronic pain have been
 seen in the OIF/OEF Pain Clinic for detailed
 interviews and assessments.
                          CLARK- 2006                   36
OIF/OEF Pain Characteristics




              CLARK- 2006      37
Service Branch

 Service Branch at Deployment
   Army  54%
   Navy – 16%
   Marines – 14%
   Air Force – 9%
   National Guard – 7%



                 CLARK- 2006     38
Deployment and Duty Info
 Pre-deployment Status           Current Duty Status
      Active Duty: 77%                    Completed Svc: 47%
      Active Reserve: 23%                 IRR: 29%
   Average Deployment                     Active Reserve: 19%
      9.3 months                          TDRL: 5%
   Range
      1 – 22 months
   OIF only: 82%
   OEF only: 10%
   Both: 8%


                          CLARK- 2006                         39
Age and Gender
 Age
     Average = 33.2
     Range = 22 – 54
     In 20’s = 43%
     In 30’s = 30%
     In 40’s = 27%
 Gender
     Males = 88.5% Females = 11.5%


                        CLARK- 2006   40
Race and Marital Status
 Race
    Caucasian = 46%
    African American = 25%
    Hispanic/Latino = 21%
    Other = 8%
 Marital Status
    Married = 56%
    Divorced or Separated = 18.7%
    Never Married = 20%
    Other = 5.3%




                       CLARK- 2006   41
Employment, Education, and SC

 Employment Status
    Full-time: 63% / Part-time: 3%
    Unemployed and looking for work: 15%
    Unemployed and disabled: 4%
    Student only: 13%
    Unemployed and not looking for work: 2%
 Education
    Average years: 13.5
 Service Connection
    SC: 50%
    Claim Pending: 30%



                          CLARK- 2006          42
OIF/OEF Pain Problems
 Average Pain Rating = 5.3
 Primary Pain Locations
   Low back         41.0%
   Knee             20.0%
   Shoulder           11%
   Head                6%
   Neck                4%
   Ankle / Foot        4%
   Hand / Wrist        2%
   Other              12%
                   CLARK- 2006   43
Headaches

 58% endorsed presence of
  headaches when asked
 42% reported interference – average
  of 4 headaches per week
 Those who denied interference
  averaged 2 headaches per week


                 CLARK- 2006            44
Pain Onset and Duration
 Pain/Injury Onset
    Deployment:                   38%
       24% non-combat; 14% combat

    Pre-deployment:               27%
    Post-deployment:               6%
    Pre-service:                   3%
    No specific onset:            26%
 Pain Duration
    Average: 57.6 months
    Less than 36 months:          56.0%
    36-72 months:                 34.7%
    More than 72 months:          21.3%
                       CLARK- 2006         45
Injury

 Injury Type                 Method of Injury
    Soft tissue: 57%           Blast: 9%
    Fracture: 7%               Fall: 9%
    Penetrating wound:         Vehicular: 7%
     7%                         GSW 5%
    Other: 3%                  Other: 44%
    No injury: 26%             No injury: 26%




                      CLARK- 2006                 46
Pain Interference
 Physical / Recreational:      82%
 Sleep:                        66%
 Emotional:                    62%
 Occupational:                 61%
 Familial:                     29%
 Social:                       28%
 Sexual:                       20%

                  CLARK- 2006         47
POQ Scores

  Scale        Mean Score Outpt %ile
 ADLs:            4.8       40th
 Mobility        12.7       12th
 Vitality        14.2       10th
 Negative Affect 17.6       28th
 Fear            11.0       40th

                CLARK- 2006        48
Pain Medications
 Current
   Anti-inflammatory:            65%
   Opioid:                       17%
   Muscle Relaxant:              12%
   Anticonvulsant:                9%
   Antidepressant:                7%
   Other:                        21%
 Past
   Opioids:                      30%
   Muscle Relaxants:             15%

                    CLARK- 2006         49
OIF/OEF Emotional Issues




            CLARK- 2006    50
OIF/OEF Emotional Issues
 58% reported an active mental health
  problem at the time of evaluation
 Etiology:
     Problem began prior to deployment- 19%
     Problem began during deployment- 5%
     Problem began after returned-      76%
 Average pain ratings (0-10):
     5.3 for those reporting emotional problems
     4.9 for those denying emotional problems
                      CLARK- 2006              51
PTSD
 Arousal:              43%
 Avoidance:            39%
 Detached:             37%
 Nightmares:           24%
 Symptom onset average: 17 months
 32% met the initial PTSD screening criteria
 47% responded positively to at least 1
  PTSD screening item

                    CLARK- 2006             52
Substance Abuse
 12% reported a problem with alcohol
 Another 7% presented with signs of
  suspected alcohol abuse
 Army researchers have reported that 21%
  of soldiers were misusing alcohol 1 year
  after returning vs. 13% prior to
  deployment.



                   CLARK- 2006           53
Fatigue

 81% endorsed symptoms of fatigue
 Average person experienced fatigue
  4.7 out of 7 days/week
 48% of those with fatigue reported it
  was present either 6 or 7 days/week
 Various attributions – long hours at
  work, poor sleep, pain interference
                 CLARK- 2006              54
Other Emotional Issues

 Depression- 36%
 Post-deployment adjustment
  problems- 23%
 Anxiety- 20%
 Marital/Family problems- 19%
 Anger difficulties- 15%

                CLARK- 2006      55
OIF/OEF Pain Challenges




            CLARK- 2006   56
Barriers to VA Care
 Less likely to report pain-related
  problems spontaneously (especially
  headaches)
 High proportion employed full time
  (scheduling difficulties)
 Belief that they are undeserving of
  care when compared to their
  severely injured comrades.
 Some are very angry with the
  military.       CLARK- 2006           57
Barriers to Adjustment
 Significant survivor guilt
 Conflict between their actions in
  combat and their internal sense of
  humanity
 Concern about re-deployment
 Feel “changed” and isolated
     Difficulty relating to former friends
     Frequent marital or relationship conflict
 Reluctance to take medications
                       CLARK- 2006                58
Conclusions
 Pain and emotional distress are as or more
  common among OIF/OEF personnel than among
  GW personnel.
 Average level and duration of stress is greater for
  OIF/OEF returnees when compared to GW.
  Implies more downrange adjustment difficulties.
 Prevalence of pain, headaches (IEDs?), and
  fatigue appears higher than in GW.
 Opportunities exist for proactive action to reduce
  the longer term consequences of OIF/OEF
  deployment.
                        CLARK- 2006                 59
    Selected References
   Bryant, R. A., Marosszeky, J. E., Crooks, J., Baguley, I. J., Gurka, J. A., Bryant, R. A. et al.
    (2001). Posttraumatic stress disorder and psychosocial functioning after severe traumatic
    brain injury. Journal of Nervous & Mental Disease, 189, 109-113.
   Buckenmaier, C. C., III, Lee, E. H., Shields, C. H., Sampson, J. B., & Chiles, J. H. (2003).
    Regional anesthesia in austere environments. Reg Anesth.Pain Med., 28, 321-327.
   Buckenmaier, C. C., McKnight, G. M., Winkley, J. V., Bleckner, L. L., Shannon, C., Klein, S.
    M. et al. (2005). Continuous peripheral nerve block for battlefield anesthesia and evacuation.
    Reg Anesth Pain Med, 30, 202-205.
   Clark, M. E. (2004). Post-deployment pain: a need for rapid detection and intervention. Pain
    Med, 5, 333-334.
   Clark, M.E., Bair, M.J., Buckenmaier III, C.C., Gironda, R.J., & Walker, R.L. (in press). Pain
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   Closs, S. J., Barr, B., Briggs, M., Cash, K., & Seers, K. (2004). A comparison of five pain
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   Edwards, W. T. (2001). Posttrauma Pain. In J.D.Loeser (Ed.), Bonica's Management of Pain
    (3rd ed., pp. 788-793). Philadelphia: Lippincott Williams & Wilkins.


                                               CLARK- 2006                                             60
   Gawande, A. (2004). Casualties of war--military care for the wounded from Iraq and
    Afghanistan. N.Engl.J.Med., 351, 2471-2475.
   Gironda, R. J., Clark, M. E., Massengale, J., & Walker, R. L. (2006). Pain among Veterans
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   Kehlet, H., Jensen, T. S., & Woolf, C. J. (2006). Persistent postsurgical pain: risk factors and
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   Peoples,G.E., Jezior, JR., & Shriver, CD. (2004). Caring for the Wounded in Iraq — A Photo
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