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SDR 07-047 – HSR&D Study

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SDR 07-047
Pain, Psychiatric Disorders, and Disability Among Veterans with and without Polytrauma
Michael E Clark PhD MA
James A. Haley Veterans' Hospital, Tampa, FL
Tampa, FL
Funding Period: July 2007 - December 2010

BACKGROUND/RATIONALE:
Pain and psychiatric disturbance are common among Veterans returning from OIF and OEF. The limited research available in this area suggests that these problems are particularly common and disabling among VHA patients with polytraumatic combat injuries. However, no information is available concerning the prevalence of specific pain problems or psychiatric diagnoses among these individuals, the course of these problems over time, current rehabilitation treatment approaches, or their impact on functioning and community reintegration.

OBJECTIVE(S):
Specific objectives are: a) Describe the prevalence, types, and course of pain and emotional disorders among patients with and without polytraumatic injuries; b) Determine whether patients with polytrauma have unique pain-related or emotional problems compared to OEF and OIF returnees registered for VHA care but without polytrauma; c) Identify risk factors for the development of chronic pain and emotional disorders in these cohorts; d) Determine whether and to what degree pain and emotional disorder comorbidities interact to heighten pain or emotional symptom severity; and e) Describe the functional outcomes, associated disabilities, and community reintegration challenges associated with pain and emotional disorders among OEF/OIF service members with and without polytrauma. Sub-studies will be used to develop tentative PRC pain assessment recommendations for the cognitively impaired, validate a new measure of deployment stress exposure, assess VHA pain and emotional treatment satisfaction, determine 12-month incidence of new-onset pain and emotional disorders, and evaluate the frequency and type of non-VHA medical service utilization among OEF/OIF medical care registrants.

METHODS:
This study utilizes an observational cohort design to compare samples of 141 polytrauma and 218 non-polytrauma OEF/OIF Veterans or active duty military personnel from two sites (Minneapolis and Tampa Vas) over three time points (baseline and 6 and 12 months post-enrollment). All participants have completed the baseline assessment. The follow up data collection is continuing. Participants undergo pain and emotional status evaluations at baseline and during follow up using a series of clinical evaluations, structured interviews, and self-report instruments. Independent variables include presence or absence of polytrauma injuries, combat exposure, and combat-related injuries, blast exposure, deployment length, time since return from deployment, presence/absence of pre-deployment pain or emotional conditions, and military status prior to deployment (e.g., active duty vs. active or inactive reserve). Dependent measures include deployment history and stressors; pain and emotional symptoms, diagnoses, related impairments, and treatment satisfaction; perceived barriers to VHA healthcare; and reported utilization of non-VHA medical resources.

FINDINGS/RESULTS:
Project Results: Preliminary analysis of baseline data has confirmed the high prevalence of pain and emotional comorbidities among both of our samples. Problem prevalence and symptom severity was highest for individuals treated in the polytrauma care system, but remained significant for individuals not identified with polytrauma. Substantial life interference was reported, and the majority of our sample met criteria for more than one pain and emotional disorder diagnosis.

IMPACT:
We believe information to be obtained from this proposed study will prove critical for planning future VHA healthcare strategies and developing effective and efficient treatments targeting pain and emotional adjustment difficulties among individuals with polytrauma and returning Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) personnel. More specifically, this study will be the first to provide systematic data regarding pain and emotional problem prevalence, course, associated impairments, risk factors, and barriers to care and community reintegration among returning OEF and OIF service members with and without polytrauma (QUERI Steps 1 and 3).

PUBLICATIONS:

Journal Articles

  1. Buckenmaier III CC, Gallagher RM, Cahana A, Clark ME, Davis SA, Brandon-Edwards H, Griffith S, Houston JS, Jankovich E, Kurihara C, Mackey S, Rupprecht C, Spevak C. War on Pain: New Strategies in Pain Management for Military Personnel and Veterans. Federal practitioner : for the health care professionals of the VA, DoD, and PHS. 2011 Jan 1; 28(Suppl 2):1-16.
  2. Walker RL, Clark ME, Sanders SH. The Postdeployment multi-symptom disorder: An emerging syndrome in need of a new treatment paradigm. Psychological Services. 2010 Aug 1; 7(3):136-147.
  3. Walker RL, Clark ME, Nampiaparampil DE, McIlvried L, Gold MS, Okonkwo R, Kerns RD. The hazards of war: blast injury headache. The journal of pain : official journal of the American Pain Society. 2010 Apr 1; 11(4):297-302.
  4. Dobscha SK, Clark ME, Morasco BJ, Freeman M, Campbell R, Helfand M. Systematic review of the literature on pain in patients with polytrauma including traumatic brain injury. Pain medicine (Malden, Mass.). 2009 Oct 1; 10(7):1200-17.
  5. Gironda RJ, Clark ME, Ruff RL, Chait S, Craine M, Walker R, Scholten J. Traumatic brain injury, polytrauma, and pain: challenges and treatment strategies for the polytrauma rehabilitation. Rehabilitation Psychology. 2009 Aug 1; 54(3):247-58.
  6. Clark ME. Cost-effectiveness of multidisciplinary pain treatment: are we there yet? Pain medicine (Malden, Mass.). 2009 Jul 1; 10(5):778-9.
  7. Clark ME, Scholten JD, Walker RL, Gironda RJ. Assessment and treatment of pain associated with combat-related polytrauma. Pain medicine (Malden, Mass.). 2009 Apr 1; 10(3):456-69.
  8. Clark ME, Walker RL, Gironda RJ, Scholten JD. Comparison of pain and emotional symptoms in soldiers with polytrauma: unique aspects of blast exposure. Pain medicine (Malden, Mass.). 2009 Apr 1; 10(3):447-55.
  9. Lew HL, Otis JD, Tun C, Kerns RD, Clark ME, Cifu DX. Prevalence of chronic pain, posttraumatic stress disorder, and persistent postconcussive symptoms in OIF/OEF veterans: polytrauma clinical triad. Journal of rehabilitation research and development. 2009 Jan 1; 46(6):697-702.
  10. Kalra R, Clark ME, Scholten JD, Murphy JL, Clements KL. Managing pain among returning service members. Federal practitioner : for the health care professionals of the VA, DoD, and PHS. 2008 Jan 1; 25:36-45.
Conference Presentations

  1. Awosika CO, Sanders SH, Clark ME, Banou E. The Effects of Opioid Use on Veterans with Primary Chronic Headaches Participating in Inpatient Chronic Pain Rehabilitation. Poster session presented at: American Headache Society Annual Meeting; 2011 Jun 4; Washington, DC.
  2. Clark ME. Pain and emotional comorbidities among OEF/OIF service members: Implications for care. Paper presented at: Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury / National Institutes of Health / VA Trauma Spectrum Annual Conference; 2010 Dec 7; Bethesda, MD.
  3. Clark ME. Integrated care for pain and war-related comorbidities. Paper presented at: Case Western Reserve University / Cleveland VAMC Grand Rounds; 2010 Nov 18; Cleveland, OH.
  4. Clark ME. Post-deployment Multi-symptom Disorder. Paper presented at: VA VISN 12 Special Topics in Pain Management Conference; 2010 Nov 10; Milwaukee, WI.
  5. Clark ME. Polytrauma Pain: Characteristics, Complexities, and Care. Paper presented at: VA Walter Reed Army Medical Center War On Pain New Strategies in Pain Management for Military Personnel and Veterans Clinical Assembly; 2010 Sep 30; Washington, DC.
  6. Clark ME. Integrated Mental Health Stepped Care for Returning OEF/OIF Service Members. Paper presented at: VA VISN 8 Executive Leadership Council Meeting; 2010 Jun 8; Tampa, FL.
  7. Clark ME. Integrated Mental Health and Pain Care for Returning OEF/OIF Service Members. Paper presented at: VA Psychology Leadership Conference; 2010 May 12; San Antonio, TX.
  8. Adams E, Clark ME, Norton C, Walker R, Gironda R. Pain and Comorbid Psychiatric Diagnoses Among OEF/OIF Returnees: Evidence for a Post-deployment Multi-symptom Disorder. Poster session presented at: American Pain Society Annual Meeting; 2010 May 6; Baltimore, MD.
  9. Bosco MA, Clark ME, Walker R, Takagishi C. Post-deployment Multi-symptom Disorder: An Integrated Behavioral Health Approach to Treatment. Poster session presented at: American Pain Society Annual Meeting; 2010 May 6; Baltimore, MD.
  10. Clark ME. Pain and War-Related Comorbidities: Is Integrated Care a Solution? Paper presented at: American Pain Society Annual Meeting; 2010 May 6; Baltimore, MD.
  11. Clark ME, Ruff R, Gallagher R. Pain, PTSD, and Mild TBI Among Returning Service Members: The Need for Integrated Care. Paper presented at: American Pain Society Annual Meeting; 2010 May 6; Baltimore, MD.
  12. Clark ME, Norton C. Post-Deployment Multi-symptom Disorder (PMD): Treating OEF/OIF Veterans’ Symptoms. Poster session presented at: VA HSR&D Field-Based Mental Health and Substance Use Disorders Meeting; 2010 Apr 27; Little Rock, AR.
  13. Clark ME. Post-deployment Multi-symptom Disorder (PMD): The Need for Integrated Care. Paper presented at: VA Brooke Army Medical Center Grand Rounds; 2010 Jan 12; San Antonio, TX.
  14. Bosco M, Clark ME, Walker RL. An Integrated Behavioral Health Program for Post-Deployment Multi-Symptom Disorder (PMD). Poster session presented at: VA / DoD Evolving Paradigms II OEF / OIF National Conference; 2009 Sep 1; Las Vegas, NV.
  15. Clark ME. Epidemiology of Pain, PTSD, and Persistent Post-concussive Syndrome among OEF/OIF Veterans. Paper presented at: VA Pain Research National Summit; 2009 Sep 1; New Haven, CT.
  16. Clark ME. Overview of Pain and Polytrauma. Paper presented at: VA / DoD Evolving Paradigms II OEF / OIF National Conference; 2009 Sep 1; Las Vegas, NV.
  17. Clark ME, Haskell S, Randolph BJ, Reichers RG, Tolchin R. Pain Rehabilitation and Life Skills. Presented at: VA / DoD Evolving Paradigms II OEF / OIF National Conference; 2009 Sep 1; Las Vegas, NV.
  18. Andrews EE, Walker RL, Clark ME. The Occurrence of Headache Pain among Polytrauma Patients with and without Traumatic Brain Injury. Paper presented at: American Pain Society Annual Meeting; 2009 Jul 1; San Diego, CA.
  19. Shealy SE, Saxon LC, Clark ME. Coordinating Care for Substance-abusing Veterans with Chronic Pain. Poster session presented at: American Psychological Association Annual Convention; 2009 Jul 1; Toronto, Canada.
  20. Clark ME. Beyond the Battlefield: Pain, Distress, and Disability in Returning Service Members. Paper presented at: Advanced Pain Management Conference; 2009 May 1; Milwaukee, WI.
  21. Clark ME. Pain, PTSD, and Mild TBI: The Case for Integrative Care. Paper presented at: VA National Pain Management Conference; 2009 Apr 1; Reno, NV.
  22. Clark ME. Pain, PTSD, and Mild TBI: The Case for Integrative Care. Paper presented at: VA National Pain Management Conference; 2009 Feb 1; Fort Lauderdale, FL.
  23. Clark ME. Polytrauma Multi-symptom Disorder: An Integrated Approach to Care. Paper presented at: VA Palo Alto Polytrauma Rehabilitation Center Conference; 2009 Jan 1; Palo Alto, CA.
  24. Clark ME. Pain and Emotional Problems in OEF/OIF Service Members. Paper presented at: Pain State Of The Art Research Meeting; 2007 Sep 1; Palm Springs, CA.
  25. Clark ME. Polytrauma Pain Overview. Paper presented at: VA Polytrauma Support Clinical Teams Conference; 2007 Aug 1; Chicago, IL.


DRA: Military and Environmental Exposures, Mental, Cognitive and Behavioral Disorders, Acute and Combat-Related Injury
DRE: Epidemiology, Diagnosis, Prevention
Keywords: Deployment, Pain
MeSH Terms: none

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