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 and OIF/OEF Combat Injuries: Implications for Research and Practice. Journal of Rehabilitation Research & Development. Closs, S. J., Barr, B., Briggs, M., Cash, K., & Seers, K. (2004). A comparison of five pain assessment scales for nursing home residents with varying degrees of cognitive impairment. J.Pain Symptom.Manage., 27, 196-205. 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 of Operations Enduring Freedom and Iraqi Freedom. Pain Medicine, In press. Kehlet, H., Jensen, T. S., & Woolf, C. J. (2006). Persistent postsurgical pain: risk factors and prevention. Lancet, 367, 1618-1625. Kotwal, R. S., O'Connor, K. C., Johnson, T. R., Mosely, D. S., Meyer, D. E., & Holcomb, J. B. (2004). A novel pain management strategy for combat casualty care. Ann.Emerg.Med., 44, 121-127. Patel, T. H., Wenner, K. A., Price, S. A., Weber, M. A., Leveridge, A., & McAtee, S. J. (2004). A U.S. Army Forward Surgical Team's experience in Operation Iraqi Freedom. J.Trauma, 57, 201-207. Peoples,G.E., Jezior, JR., & Shriver, CD. (2004). Caring for the Wounded in Iraq — A Photo Essay. The New England Journal of Medicine, 351, 2476-2480. Shipton, E. A., Tait, B., Shipton, E. A., & Tait, B. (2005). Flagging the pain: preventing the burden of chronic pain by identifying and treating risk factors in acute pain. European Journal of Anaesthesiology, 22, 405-412. VHA National Pain Management Strategy Coordinating Committee (2006). Consensus Statement from the for Assessing Pain in the Patient with Impaired Communication. www.chronicpain.org [On-line]. Available: www.vachronicpain.org. www.icasualties.org (2006). Iraq Coalition Casualty Count. www.icasualties.org/oif [On-line]. Available: http://icasualties.org/oif/.
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