Whole Health

Abdelfatah MM, Beacham MC, Freedman M, Tillmann HL. Can Battlefield Acupuncture Improve Colonoscopy Experience? Med Acupunct. 2018 Oct 1;30(5):279-281. doi: 10.1089/acu.2018.1289. Epub 2018 Oct 15.

BACKGROUND

Currently, patients undergoing colonoscopy receive sedation, but pain management with acupuncture could be a safer alternative.

CASES

This article describes 3 cases for which Battlefield Acupuncture was applied during colonoscopy to avoid using opioids for sedation. One case was a patient with a life-threating morphine allergy, and 2 other cases avoided sedation completely.

RESULTS

Pain was reduced in all 3 cases to allow completion of colonoscopies without sedation. In Case 2, the patient also gained relief of preexisting mild joint pain.

CONCLUSIONS

More data are needed, so potentially more patients can indeed avoid morphine/benzodiazepam-based sedation by use of acupuncture to make colonoscopies safer and more pleasant.

Allende S, Mathersul DC, Schulz-Heik JR, Avery TJ, Mahoney L, Bayley PJ. Yoga is effective for treating chronic pain in veterans with Gulf War Illness at long-term follow-up. BMC Complement Med Ther. 2023 Sep 13;23(1):319.

BACKGROUND

Clinical Practice Guidelines for Gulf War Illness (GWI) recommend integrative health approaches such as yoga for relief from symptoms, yet little is known about the long-term efficacy of yoga in reducing symptoms of GWI. Here, we evaluated the long-term efficacy of yoga and cognitive-behavioral therapy (CBT) chronic pain treatment in a randomized controlled trial (RCT) of 75 Veterans (57 men, 42-71 ± 7.1 years of age) with Gulf War Illness (GWI).

METHODS

Participants received either 10 weeks of yoga or 10 weeks of CBT for chronic pain. The primary outcome measures were pain severity, and pain interference (Brief Pain Inventory-Short Form). The secondary outcome measures were fatigue, as indicated by a measure of functional exercise capacity (6-Minute Walk Test), depression, autonomic symptom severity, and quality of life. Piecewise linear mixed models were used to examine study hypotheses.

RESULTS

Compared to the CBT group, yoga was associated with greater reductions in pain severity during the 6-month follow-up period (group × time interaction: b = 0.036, se = 0.014, p = .011). Although we did not find between-group differences in the other primary or secondary outcome measures during follow-up (p's > 0.05), exploratory analyses revealed within-group improvements in pain interference, total pain (an experimental outcome variable which combines pain severity and interference), and fatigue in the yoga group (p's < 0.05) but not in the CBT group.

CONCLUSIONS

This is the first study to report long-term follow-up results of yoga as a treatment for GWI. Our results suggest that yoga may offer long-term efficacy in reducing pain, which is a core symptom of GWI.

Allsop VL, Schmid AA, Miller KK, Slaven JE, Daggy JK, Froman A, Kline M, Sargent C, French DD, Ang D, Van Puymbroeck M, Schalk NL, Bair MJ. The Pain Outcomes Comparing Yoga vs. Structured Exercise (POYSE) Trial in Veterans With Fibromyalgia: Study Design and Methods. Front Pain Res (Lausanne). 2022 Jul 7;3:934689.

BACKGROUND

Fibromyalgia is a common pain condition that often leads to significant disability. Unfortunately, the effectiveness of most medications for fibromyalgia is limited, and there is a need for alternative, non-pharmacological therapies. Yoga and aerobic exercise are both evidence-based non-pharmacological treatments for fibromyalgia. However, no prior studies have directly compared the effectiveness of yoga vs. exercise.

OBJECTIVE

This article describes the study design and recruitment outcomes of the Pain Outcomes comparing Yoga vs. Structured Exercise (POYSE) Trial, a two-arm randomized comparative effectiveness trial.

METHODS

Veterans with fibromyalgia, defined by the 2010 American College of Rheumatology diagnostic criteria, who also experienced at least moderate pain severity were enrolled. The participants were randomized to a 12-week yoga-based or a structured exercise program (SEP) and will undergo comprehensive outcome assessments at baseline, 1, 3, 6, and 9 months by interviewers blinded to treatment assignment. The primary outcome will be the overall severity of fibromyalgia as measured by the total Fibromyalgia Impact Questionnaire-Revised. Secondary outcomes included depression, anxiety, health-related quality of life, pain beliefs, fatigue, sleep, and self-efficacy.

RESULTS

A total of 2,671 recruitment letters were sent to potential participants with fibromyalgia. Of the potential participants, 623 (23.3%) were able to be contacted by telephone and had their eligibility assessed. Three hundred seventy-one of those interviewed were found to be eligible (59.6%) and 256 (69.0%) agreed to participate and were randomized to the YOGA (n = 129) or the SEP (n = 127) arm of the trial.

CONCLUSIONS

Clinicians are faced with numerous challenges in treating patients with fibromyalgia. The interventions being tested in the POYSE trial have the potential to provide primary care and other care settings with new treatment options for clinicians while simultaneously providing a much needed relief for patients suffering from fibromyalgia.

Ashrafioun L, Allen KD, Pigeon WR. Utilization of complementary and integrative health services and opioid therapy by patients receiving Veterans Health Administration pain care. Complement Ther Med. 2018 Aug;39:8-13. doi: 10.1016/j.ctim.2018.05.008. Epub 2018 May 18. PubMed PMID: 30012396

The aims of the current study were to characterize veterans who used a complementary and integrative health (CIH) service in the Veterans Health Administration (VHA) and to assess the extent to which using a CIH-related service was associated with receiving an opioid analgesic prescription following the initiation of specialty pain service, a time at which higher intensity care is needed for patients experiencing greater psychiatric and medical complexity.

This study utilized a retrospective cohort design of veterans using specialty pain services. The index visit was defined as the first specialty pain visit in Fiscal Years 2012-2015. Demographics, opioid analgesic prescriptions, psychiatric disorder diagnoses, medical comorbidity, pain severity scores, and pain conditions were extracted from VHA administrative data.

The cohort was comprised of veterans who had at least one visit with a specialty pain service as identified by a billing code.

The main outcome measures were use of a CIH-related service in the 365 days prior to the index visit and opioid analgesic prescription within 365 days after the index visit. Adjusted logistic regression analyses accounted for key covariate and potential confounding variables.

Use of CIH-related services was relatively low across the cohort (1.9%). Veterans who used a CIH-related service in the 365 days prior to the index visit were more likely to be female, be younger, have less medical comorbidity, have less severe pain, and were less likely to have received an opioid prescription in the 365 days prior to the index visit. After accounting for key covariates and potential confounders, veterans who used a CIH-related service were less likely to receive an opioid analgesic prescription in the 365 days following the index visit.

CIH-related services were not commonly used among Veterans initiating specialty pain services. Engaging in CIH-related services prior to specialty pain services is associated with decreased opioid analgesic and non-opioid analgesic prescriptions.

Baldawi M, McKelvey G, Patel VR, Krish B, Kumar AJ, Patel P. Battlefield Acupuncture Use for Perioperative Anesthesia in Veterans Affairs Surgical Patients: A Single-Center Randomized Controlled Trial. J Integr Complement Med. 2022 Aug;28(8):683-688.

INTRODUCTION

The risks from opioid use are well known in and mandate nonpharmacological modalities for the management of postoperative pain. The aim of this study was to investigate the effectiveness of battlefield acupuncture (BFA) as an adjunct therapy for postoperative pain in U.S. veteran patients undergoing major surgery under general anesthesia.

METHODS

Patients undergoing major surgery performed under general anesthesia from June 2017 to June 2018 were enrolled in the study. Patients were randomly assigned to receive either BFA or sham acupuncture. Outcomes such as pain intensity measured by visual analog scale score, opioid consumption, and the incidence of analgesia-related adverse effects were compared between the study groups.

RESULTS

A total of 72 subjects were included in this study (36 subjects in each study group). The median 24-h opioid postoperative consumption measured in morphine milligram equivalent (MME) was lower in the BFA group compared to the sham acupuncture group (18.3 [±12.2] MME vs. 38.6 [±15.9] MME, p < 0.001). Pain intensity reported by patients at 6, 12, 18, and 24 h postoperatively was lower in the BFA group compared to the sham acupuncture group. The incidence of postsurgical nausea and vomiting was lower in patients receiving BFA compared to patients receiving sham acupuncture. There were no intergroup differences in terms of postoperative anxiety or hospital length of stay.

CONCLUSION

The results from this study reveal the potential clinical benefits of using BFA for reducing pain intensity and opioid requirements in surgical patients.

Bastian LA, Heapy A, Becker WC, Sandbrink F, Atkins D, Kerns RD. Understanding Pain and Pain Treatment for Veterans: Responding to the Federal Pain Research Strategy. Pain Med. 2018 Sep 1;19(suppl_1):S1-S4. doi: 10.1093/pm/pny143. No abstract available

The Veterans Health Administration (VHA) is the largest integrated health system in the United States, providing care for some 9 million veterans annually at more than 1,700 sites across all 50 states, Puerto Rico, and other territories. With a research appropriation of $722 million in 2018 and over 20 years of electronic health record data, the VHA serves as critical laboratory for studying and improving care for common health conditions. One of the most important of these is chronic pain, both for its effect on function and disability and for its contributions to an epidemic of opioid use in the United States. Chronic pain is reported by more than one-third of veterans in our care [1]. This and other factors have made the VHA a fertile ground for pain research: a national opioid safety initiative has reduced overall opioid use; the VHA is ahead of other systems in offering nonopioid alternatives for pain; with a global budget, it can support new models for pain care without worrying about reimbursement patterns; and the VHA is part of an interagency federal strategy for pain research.

Bayley PJ, Schulz-Heik RJ, Cho R, Mathersul D, Collery L, Shankar K, Ashford JW, Jennings JS, Tang J, Wong MS, Avery TJ, Stanton MV, Meyer H, Friedman M, Kim S, Jo B, Younger J, Mathews B, Majmundar M, Mahoney L. Yoga is effective in treating symptoms of Gulf War illness: A randomized clinical trial. J Psychiatr Res. 2020 Nov 11:S0022-3956(20)31083-9. doi: 10.1016/j.jpsychires.2020.11.024.

Many Veterans of the 1990-1991 Gulf War report symptoms of Gulf War Illness, a condition involving numerous chronic symptoms including pain, fatigue, and mood/cognition symptoms. Little is known about this condition's etiology and treatment. This study reports outcomes from a randomized controlled single-blind trial comparing yoga to cognitive behavioral therapy for chronic pain and other symptoms of Gulf War Illness. Participants were Veterans with symptoms of GWI: chronic pain, fatigue and cognition-mood symptoms. Seventy-five Veterans were randomized to treatment via selection of envelopes from a bag (39 yoga, 36 cognitive behavioral therapy), which consisted of ten weekly group sessions. The primary outcomes of pain severity and interference (Brief Pain Inventory- Short Form) improved in the yoga condition (Cohen's d = .35, p = 0.002 and d = 0.69, p < 0.001, respectively) but not in the CBT condition (d = 0.10, p = 0.59 and d = 0.25 p = 0.23). However, the differences between groups were not statistically significant (d = 0.25, p = 0.25; d = 0.43, p = 0.076), though the difference in an a-priori-defined experimental outcome variable which combines these two variables into a total pain variable (d = 0.47, p = 0.047) was significant. Fatigue, as indicated by a measure of functional exercise capacity (6-min walk test) was reduced significantly more in the yoga group than in the CBT group (between-group d = .27, p = 0.044). Other secondary outcomes of depression, wellbeing, and self-reported autonomic nervous system symptoms did not differ between groups. No adverse events due to treatment were reported. Yoga may be an effective treatment for core Gulf War Illness symptoms of pain and fatigue, making it one of few treatments with empirical support for GWI. Results support further evaluation of yoga for treating veterans with Gulf War Illness.

Belitskaya-Levy I, Clark JD, Shih MC, Bair MJ. Treatment Preferences for Chronic Low Back Pain: Views of Veterans and Their Providers. J Pain Res. 2021 Jan 27;14:161-171.

PURPOSE

This study was conducted to characterize chronic low back pain (cLBP) and to identify treatment histories and preferences for cLBP management among Veterans and primary care providers within the Veterans Affairs (VA) healthcare system.

PARTICIPANTS AND METHODS

Veterans with cLBP from five geographically diverse VA medical centers were identified using International Classification of Diseases (ICD) 9 and 10 codes from VA administrative data as were primary care providers at these same sites. From these data, Veterans (200/per site) and providers (160/per site) were selected and mailed surveys. Open-ended interview data were collected from a subset of Veterans and providers.

RESULTS

In total, 235 Veterans and 67 providers returned completed surveys. More than 80% of the Veteran respondents had daily back pain for more than 1 year. Most Veterans had tried several treatments for their pain with medications and physical therapy being the most commonly used. Veterans and providers had similar attitudes towards many cLBP treatments with the exception of psychological therapies that were more favored by providers. Open-ended interview data showed that Veterans and providers emphasized the need for multi-component approaches to treatment.

CONCLUSIONS

Among Veterans, cLBP is typically of sustained duration, is relatively severe, and also interferes significantly with normal functioning. Veterans are experienced with respect to treatments and had similar attitudes towards many cLBP treatments as their providers, especially tailored approaches.

Berry ME, Chapple IT, Ginsberg JP, Gleichauf KJ, Meyer JA, Nagpal ML. Non-pharmacological Intervention for Chronic Pain in Veterans: A Pilot Study of Heart Rate Variability Biofeedback. Glob Adv Health Med. 2014

Chronic pain is an emotionally and physically debilitating form of pain that activates the body's stress response and over time can result in lowered heart rate variability (HRV) power, which is associated with reduced resiliency and lower self-regulatory capacity. This pilot project was intended to determine the effectiveness of HRV coherence biofeedback (HRVCB) as a pain and stress management intervention for veterans with chronic pain and to estimate the effect sizes. It was hypothesized that HRVCB will increase parasympathetic activity resulting in higher HRV coherence measured as power and decrease self-reported pain symptoms in chronic pain patients.

Fourteen veterans receiving treatment for chronic pain were enrolled in the pre-post intervention study. They were randomly assigned, with 8 subjects enrolled in the treatment group and 6 in the control group. The treatment group received biofeedback intervention plus standard care, and the other group received standard care only. The treatment group received four HRVCB training sessions as the intervention.

Pre-post measurements of HRV amplitude, HRV power spectrum variables, cardiac coherence, and self-ratings of perceived pain, stress, negative emotions, and physical activity limitation were made for both treatment and control groups.

The mean pain severity for all subjects at baseline, using the self-scored Brief Pain Inventory (BPI), was 26.71 (SD=4.46; range=21-35) indicating a moderate to severe perceived pain level across the study subjects. There was no significant difference between the treatment and control groups at baseline on any of the measures. Post-HRVCB, the treatment group was significantly higher on coherence (P=.01) and lower (P=.02) on pain ratings than the control group. The treatment group showed marked and statistically significant (1-tailed) increases over the baseline in coherence ratio (191%, P=.04) and marked, significant (1-tailed) reduction in pain ratings (36%, P<.001), stress perception (16%, P=.02), negative emotions (49%, P<.001), and physical activity limitation (42%, P<.001). Significant between-group effects on all measures were found when pre-training values were used as covariates.

HRVCB intervention was effective in increasing HRV coherence measured as power in the upper range of the LF band and reduced perceived pain, stress, negative emotions, and physical activity limitation in veterans suffering from chronic pain. HRVCB shows promise as an effective non-pharmacological intervention to support standard treatments for chronic pain.

Betthauser LM, Forster JE, Bortz A, Penzenik M, Hernández TD, Bahraini N, Brenner LA. Strength and awareness in action: Feasibility of a yoga-based intervention for post-acute mild TBI headaches among veterans. Contemp Clin Trials Commun. 2021 Apr 2;22:100762.

BACKGROUND

Mild traumatic brain injury (mTBI) is a signature injury sustained by Veterans during recent conflicts. For some, mTBI/concussion is associated with disabling symptoms, including post-concussive headaches (PCH). However, there are limited evidence-based treatments for persistent PCH.

OBJECTIVE

Investigators assessed the feasibility of design elements of a yoga-based interventional trial for PCH among Veterans, as well as the acceptability of the intervention.

METHODS

This randomized controlled acceptability and feasibility trial was implemented using a waitlist-control design. Design elements of interest included: an exercise run-in class; recruitment and retention strategies; and, ecological momentary assessment (EMA) modalities to track headaches and yoga practice. Veteran satisfaction regarding the intervention was also evaluated. A descriptive analysis was conducted on candidate outcomes including PCH, post-concussive symptoms, pain, and daily functioning.

RESULTS

Twenty-seven participants (out of 70 consented and eligible after Study Visit 1) completed each evaluation timepoint and regularly attended yoga sessions, with 89% of these Veterans reporting moderate to high levels of satisfaction with the intervention at study completion. Qualitatively, participants endorsed improvements in headaches, chronic pain, and mood. Feasibility results were mixed. Initial feasibility criterion regarding yoga attendance was not met; however, modifications, such as expansion to an additional clinic site and reduction of in-person yoga sessions with increased encouragement to use study-created online yoga videos improved feasibility of the study design. Participants most frequently used mobile and web-based EMA modalities to track yoga practice.

CONCLUSION

Although challenges with feasibility of the study design elements were noted, results suggested acceptability of the yoga-based intervention for Veterans with persistent PCH. Additional exploration regarding the frequency and modality of yoga delivery (e.g., in-person, telehealth) is warranted.

Black AC, Zeliadt SB, Kerns RD, Skanderson M, Wang R, Gelman H, Douglas JH, Becker WC. Association Between Exposure to Complementary and Integrative Therapies and Opioid Analgesic Daily Dose Among Patients on Long-term Opioid Therapy. Clin J Pain. 2022 Jun 1.

OBJECTIVES

To describe the association between exposure to selected complementary and integrative health (CIH) modalities and the trajectory of prescribed opioid analgesic dose within a national cohort of patients receiving long-term opioid therapy (LTOT) in the Veterans Health Administration (VHA).

MATERIALS AND METHODS

Using national data from VHA electronic health records between October 1, 2017 and September 30, 2019, CIH use was analyzed among 57,437 patients receiving LTOT within 18 VHA facilities serving as evaluation sites of VHA's Whole Health System of Care. Using linear mixed effects modeling controlling for covariates, opioid dose was modeled as a function of time, CIH exposure, and their interaction.

RESULTS

Overall, 11.91% of patients on LTOT used any of the focus CIH therapies; 43.25% of those had 4 or more encounters. Patients used acupuncture, chiropractic care, and meditation modalities primarily. CIH use was associated with being female, Black, having a mental health diagnosis, obesity, pain intensity, and baseline morphine-equivalent daily dose. Mean baseline morphine-equivalent daily dose was 40.81 milligrams and dose decreased on average over time. Controlling for covariates, patients with any CIH exposure experienced 38% faster dose tapering, corresponding to a mean difference in 12-month reduction over patients not engaging in CIH of 2.88 milligrams or 7.06% of the mean starting dose.

DISCUSSION

Results support the role of CIH modalities in opioid tapering. The study design precludes inference about the causal effects of CIH on tapering. Analyses did not consider the trend in opioid dose before cohort entry nor the use of other nonopioid treatments for pain. Future research should address these questions and consider tapering-associated adverse events.

Bolton RE, Fix GM, VanDeusen Lukas C, Elwy AR, Bokhour BG. Biopsychosocial benefits of movement-based complementary and integrative health therapies for patients with chronic conditions. Chronic Illn. 2018 Jan 1:1742395318782377. doi: 10.1177/1742395318782377. [Epub ahead of print]

OBJECTIVES

Complementary and integrative health practices are growing in popularity, including use of movement-based therapies such as yoga, tai-chi, and qigong. Movement-based therapies are beneficial for a range of health conditions and are used more frequently by individuals with chronic illness. Yet little is known about how patients with chronic conditions characterize the health benefits of movement-based therapies.

METHODS

We conducted focus groups with 31 patients enrolled in yoga and qigong programs for chronic conditions at two VA medical centers. Transcripts were analyzed using conventional content analysis with codes developed inductively from the data. Participants' descriptions of health benefits were then mapped to Engel's biopsychosocial model. Results Participants described improvements in all biopsychosocial realms, including improved physical and mental health, reduced opiate and psychotropic use, enhanced emotional well-being, and better social relationships. Changes were attributed to physical improvements, development of coping skills, and increased self-awareness.

DISCUSSION

Patients with chronic illnesses in our sample reported multiple benefits from participation in movement-based therapies, including in physical, mental, and social health realms. Providers treating patients with complex comorbidities may consider referrals to movement-based therapy programs to address multiple concerns simultaneously, particularly among patients seeking alternatives to medication or adjunctive to an opiate reduction strategy.

Boyd H. The Integrative Therapy Nurse: A Valuable Player in Symptom Management. Am J Nurs. 2018 Nov;118(11):64-69. doi: 10.1097/01.NAJ.0000547679.76699.49.

With the support of colleagues and hospital management, the author, an RN with board certification in therapeutic massage and bodywork, developed and implemented the role of the integrative therapy nurse on the spinal cord injury and disorders unit at the Minneapolis Veterans Affairs Medical Center. The goal of this initiative was to provide patients with additional nonpharmacologic options for addressing their symptoms through the creation of an integrative therapy nurse role within the existing interdisciplinary team of physicians, NPs, psychologists, registered dieticians, physical therapists, occupational therapists, speech pathologists, and staff nurses. This article outlines the process of creating this role, discusses implications for practice, and reports the outcomes of three years of its implementation. The outcomes of decreased pain and increased relaxation among the veterans who participated in this initiative warrant its further expansion to additional clinical settings.

Chapman C, Bakkum BW. Chiropractic management of a US Army veteran with low back pain and piriformis syndrome complicated by an anatomical anomaly of the piriformis muscle: a case study. J Chiropr Med. 2012 Mar;11(1):24-9. doi: 10.1016/j.jcm.2011.06.011.

OBJECTIVE

The purpose of this article is to present the case of a patient with an anatomical anomaly of the piriformis muscle who had a piriformis syndrome and was managed with chiropractic care.

CASE REPORT

A 32-year-old male patient presented to a chiropractic clinic with a chief complaint of low back pain that radiated into his right buttock, right posterior thigh, and right posterior calf. The complaint began 5 years prior as a result of injuries during Airborne School in the US Army resulting in a 60% disability rating from the Veterans Administration. Magnetic resonance imaging demonstrated a mildly decreased intradiscal T2 signal with shallow central subligamentous disk displacement and low-grade facet arthropathy at L5/S1, a hypolordotic lumbar curvature, and accessory superior bundles of the right piriformis muscle without morphologic magnetic resonance imaging evidence of piriformis syndrome.

INTERVENTION AND OUTCOME

Chiropractic treatment included lumbar and sacral spinal manipulation with soft tissue massage to associated musculature and home exercise recommendations. Variations from routine care included proprioceptive neuromuscular facilitation stretches, electric muscle stimulation, acupressure point stimulation, Sacro Occipital Technique pelvic blocking, CranioSacral therapy, and an ergonomic evaluation.

CONCLUSION

A patient with a piriformis anomaly with symptoms of low back pain and piriformis syndrome responded positively to conservative chiropractic care, although the underlying cause of the piriformis syndrome remained.

Chester JE, Rowneki M, Van Doren W, Helmer DA. Progression of intervention-focused research for Gulf War illness. Mil Med Res. 2019 Oct 18;6(1):31.

The Persian Gulf War of 1990 to 1991 involved the deployment of nearly 700,000 American troops to the Middle East. Deployment-related exposures to toxic substances such as pesticides, nerve agents, pyridostigmine bromide (PB), smoke from burning oil wells, and petrochemicals may have contributed to medical illness in as many as 250,000 of those American troops. The cluster of chronic symptoms, now referred to as Gulf War Illness (GWI), has been studied by many researchers over the past two decades. Although over $500 million has been spent on GWI research, to date, no cures or condition-specific treatments have been discovered, and the exact pathophysiology remains elusive. Using the 2007 National Institute of Health (NIH) Roadmap for Medical Research model as a reference framework, we reviewed studies of interventions involving GWI patients to assess the progress of treatment-related GWI research. All GWI clinical trial studies reviewed involved investigations of existing interventions that have shown efficacy in other diseases with analogous symptoms. After reviewing the published and ongoing registered clinical trials for cognitive-behavioral therapy, exercise therapy, acupuncture, coenzyme Q10, mifepristone, and carnosine in GWI patients, we identified only four treatments (cognitive-behavioral therapy, exercise therapy, CoQ10, and mifepristone) that have progressed beyond a phase II trial. We conclude that progress in the scientific study of therapies for GWI has not followed the NIH Roadmap for Medical Research model. Establishment of a standard case definition, prioritized GWI research funding for the characterization of the pathophysiology of the condition, and rapid replication and adaptation of early phase, single site clinical trials could substantially advance research progress and treatment discovery for this condition.

Clark JD, Bair MJ, Belitskaya-Lévy I, Fitzsimmons C, Zehm LM, Dougherty PE, Giannitrapani KF, Groessl EJ, Higgins DM, Murphy JL, Riddle DL, Huang GD, Shih MC. Sequential and comparative evaluation of pain treatment effectiveness response (SCEPTER), a pragmatic trial for conservative chronic low back pain treatment. Contemp Clin Trials. 2022 Dec 7;125:107041. doi: 10.1016/j.cct.2022.107041.

BACKGROUND

Chronic low back pain (cLBP) is a common and highly disabling problem world-wide. Although many treatment options exist, it is unclear how to best sequence the multitude of care options to provide the greatest benefit to patients.

METHODS

The Sequential and Comparative Evaluation of Pain Treatment Effectiveness Response (SCEPTER) trial uses a pragmatic, randomized, stepped design. Enrollment targets 2529 participants from 20 Veterans Affairs (VA) medical centers. Participants with chronic low back pain will first be randomized to one of three options: 1) an internet-based self-management program (Pain EASE); 2) a tailored physical therapy program (Enhanced PT); or 3) continued care with active monitoring (CCAM), a form of usual care. Participants not achieving a 30% or 2-point reduction on the study's primary outcome (Brief Pain Inventory Pain Interference (BPI-PI) subscale), 3 months after beginning treatment may undergo re-randomization in a second step to cognitive behavioral therapy for chronic pain, spinal manipulation therapy, or yoga. Secondary outcomes include pain intensity, back pain-related disability, depression, and others. Participants will be assessed every three months until 12 months after initiating their final trial therapy. Companion economic and implementation analyses are also planned.

RESULTS

The SCEPTER trial is currently recruiting and enrolling participants.

CONCLUSIONS

Trial results will inform treatment decisions for the stepped management of chronic low back pain - a common and disabling condition. Additional analyses will help tailor treatment selection to individual patient characteristics, promote efficient resource use, and identify implementation barriers of interventions.

Collinge W, Kahn J, Soltysik R. Promoting reintegration of National Guard veterans and their partners using a self-directed program of integrative therapies: a pilot study. Mil Med. 2012 Dec;177(12):1477-85.

This article reports pilot data from phase I of a project to develop and evaluate a self-directed program of integrative therapies for National Guard personnel and significant relationship partners to support reintegration and resilience after return from Iraq or Afghanistan. Data are reported on 43 dyads. Intervention was an integrated multimedia package of guided meditative, contemplative, and relaxation exercises (CD) and instruction in simple massage techniques (DVD) to promote stress reduction and interpersonal connectedness. A repeated measures design with standardized instruments was used to establish stability of baseline levels of relevant mental health domains (day 1, day 30), followed by the intervention and assessments 4 and 8 weeks later. Significant improvements in standardized measures for post-traumatic stress disorder, depression, and self-compassion were seen in both veterans and partners; and in stress for partners. Weekly online reporting tracked utilization of guided exercises and massage. Veterans reported significant reductions in ratings of physical pain, physical tension, irritability, anxiety/worry, and depression after massage, and longitudinal analysis suggested declining baseline levels of tension and irritability. Qualitative data from focus groups and implications for continued development and a phase II trial are discussed.

Conboy L, Gerke T, Hsu KY, St John M, Goldstein M, Schnyer R. The Effectiveness of Individualized Acupuncture Protocols in the Treatment of Gulf War Illness: A Pragmatic Randomized Clinical Trial. PLoS One. 2016 Mar 31;11(3):e0149161. doi: 10.1371/journal.pone.0149161. eCollection 2016.

BACKGROUND

Gulf War Illness is a Complex Medical Illness characterized by multiple symptoms, including fatigue, sleep and mood disturbances, cognitive dysfunction, and musculoskeletal pain affecting veterans of the first Gulf War. No standard of care treatment exists.

METHODS

This pragmatic Randomized Clinical Trial tested the effects of individualized acupuncture treatments offered in extant acupuncture practices in the community; practitioners had at least 5 years of experience plus additional training provided by the study. Veterans with diagnosed symptoms of Gulf War Illness were randomized to either six months of biweekly acupuncture treatments (group 1, n = 52) or 2 months of waitlist followed by weekly acupuncture treatments (group 2, n = 52). Measurements were taken at baseline, 2, 4 and 6 months. The primary outcome is the SF-36 physical component scale score (SF-36P) and the secondary outcome is the McGill Pain scale.

RESULTS

Of the 104 subjects who underwent randomization, 85 completed the protocol (82%). A clinically and statistically significant average improvement of 9.4 points (p = 0.03) in the SF-36P was observed for group 1 at month 6 compared to group 2, adjusting for baseline pain. The secondary outcome of McGill pain index produced similar results; at 6 months, group 1 was estimated to experience a reduction of approximately 3.6 points (p = 0.04) compared to group 2.

CONCLUSIONS

Individualized acupuncture treatment of sufficient dose appears to offer significant relief of physical disability and pain for veterans with Gulf War Illness. This work was supported by the Office of the Assistant Secretary of Defense for Health Affairs through the Gulf War Illness Research Program under Award No. W81XWH-09-2-0064. Opinions, interpretations, conclusions and recommendations are those of the author and are not necessarily endorsed by the Department of Defense.

Corcoran KL, Dunn AS, Formolo LR, Beehler GP. Chiropractic Management for US Female Veterans With Low Back Pain: A Retrospective Study of Clinical Outcomes. J Manipulative Physiol Ther. 2017 Oct;40(8):573-579. doi: 10.1016/j.jmpt.2017.07.001. PubMed PMID: 29187308.

OBJECTIVE

The purpose of this study was to determine if female US veterans had clinically significant improvement in low back pain after chiropractic management.

METHODS

This is a retrospective chart review of 70 courses of care for female veterans with a chief complaint of low back pain who received chiropractic management through the VA Western New York Healthcare System in Buffalo, New York. A paired t test was used to compare baseline and discharge outcomes for the Back Bournemouth Questionnaire. The minimum clinically important difference was set as a 30% improvement in the outcome measure from baseline to discharge.

RESULTS

The average patient was 44.8 years old, overweight (body mass index 29.1 kg/m2), and white (86%). The mean number of chiropractic treatments was 7.9. Statistical significance was found for the Back Bournemouth Questionnaire outcomes. The mean raw score improvement was 12.4 points (P < .001), representing a 27.3% change from baseline with 47% of courses of care meeting or exceeding the minimum clinically important difference.

CONCLUSION

For our sample of female veterans with low back pain, clinical outcomes from baseline to discharge improved under chiropractic care. Although further research is warranted, chiropractic care may be of value in contributing to the pain management needs of this unique patient population

Corcoran KL, Dunn AS, Green BN, Formolo LR, Beehler GP. Changes in female veterans' neck pain following chiropractic care at a hospital for veterans. Complement Ther Clin Pract. 2018 Feb;30:91-95. doi: 10.1016/j.ctcp.2017.12.013. Epub 2017 Dec 13. PubMed PMID: 29389486.

OBJECTIVE

To determine if U.S. female veterans had demonstrable improvements in neck pain after chiropractic management at a Veterans Affairs (VA) hospital.

METHODS

This was a retrospective cross-sectional study of medical records from female veterans attending a VA chiropractic clinic for neck pain from 2009 to 2015. Paired t-tests were used to compare baseline and discharge numeric rating scale (NRS) and Neck Bournemouth Questionnaire (NBQ) scores with a minimum clinically important difference (MCID) set at a 30% change from baseline.

RESULTS

Thirty-four veterans met the inclusion criteria and received a mean of 8.8 chiropractic treatments. For NRS, the mean score improvement was 2.7 (95%CI, 1.9-3.5, p < .001). For the NBQ, the mean score improvement was 13.7 (95%CI, 9.9-17.5, p < .001). For the MCID, the average percent improvement was 45% for the NRS and 38% for the NBQ.

CONCLUSION

Female veterans with neck pain experienced a statistically and clinically significant reduction in NRS and NBQ scores.

Cosio D, Lin E. Role of Active Versus Passive Complementary and Integrative Health Approaches in Pain Management. Glob Adv Health Med. 2018;7:2164956118768492. Published 2018 Apr 10. doi:10.1177/2164956118768492

BACKGROUND

A general conclusion about the treatment of chronic, noncancer pain is that the results from traditional, passive modalities are disheartening. Perhaps this may be due to the propensity of patients to seek out passive versus active treatments. In pain management, active treatments should be the primary focus, with passive interventions as an adjunct.

OBJECTIVE

The current study tested the hypotheses that Veterans would report a greater significant increase in active versus transitional and active versus passive complementary and integrative health (CIH) utilization after completing a formal pain education program.

METHODS

The current study is a secondary analysis of existing data from an original study. The current study used a quasi-experimental, 1-group, pre-/posttest design. One hundred three Veterans completed a 12-week, "Pain Education School" program at a Midwestern VA Medical Center between November 4, 2011, and October 26, 2012. As part of the introduction and conclusion of the program, all Veterans completed a pre- and posteducation assessment which included an adaptation of the Complementary and Alternative Medicine Questionnaire©, SECTION A: Use of Alternative Health Care Providers measure.

RESULTS

Significant differences were found between the pre- and posttest measures of use of active (P = .000) (p<.001), transitional (P = .011), and passive (P = .007) CIH modalities.

CONCLUSION

The current findings suggest that an educational intervention in conjunction with the availability of treatment options has the potential to increase the use of those treatments. The current pain education program also seems to be aligned with the goal of pain self-management, which is to utilize more active interventions as a primary therapy.

Cosio D, Lin EH. Effects of a pain education program in Complementary and Alternative Medicine treatment utilization at a VA medical center. Complement Ther Med. 2015 Jun;23(3):413-22. doi: 10.1016/j.ctim.2015.04.005. Epub 2015 Apr 28.

BACKGROUND

Past studies have shown that U.S. Veterans are consumers of CAM. However, more than 75% of Veteran non-users report they would utilize these treatment options if made available. Thus, Veterans may not be fully aware of the CAM options currently available to them in the current U.S. VA health care system.

OBJECTIVES

The current study tested the hypothesis that Veterans would report an increase in CAM utilization after completing a formal pain education program in a VA medical center.

DESIGN

The study used a quasi-experimental, one-group, pre/post-test design.

SETTING

Midwestern, U.S. VA Medical Center.

PARTICIPANTS

The responses from 103 Veterans who elected to participate in the program and the assessment measures were included in the outcome analyses.

INTERVENTION

"Pain Education School" is a 12-week, educational program that is open to all Veterans and their families. It is a comprehensive program that introduces patients to 23 different disciplines at the VA Medical Center that deal with chronic, non-cancer pain.

MAIN OUTCOME MEASURES

An adaptation of the Complementary and Alternative Medicine Questionnaire(©), SECTION A: Use of Alternative Health Care Providers.

RESULTS

There was a significant difference found in overall utilization of CAM after completing the pain education program. The most utilized CAM modality was the chiropractor; the least utilized were hypnosis and aromatherapy.

CONCLUSIONS

Not all health care systems or providers may have access to an education-focused, professionally driven program as an amenity. However, lessons can be learned from this study in terms of what pain providers may be able to accomplish in their practice.

Crawford P, Penzien DB, Coeytaux R. Reduction in Pain Medication Prescriptions and Self-Reported Outcomes Associated with Acupuncture in a Military Patient Population. Med Acupunct. 2017 Aug 1;29(4):229-231. doi: 10.1089/acu.2017.1234. PubMed PMID: 28874924; PubMed Central PMCID: PMC5580367

BACKGROUND

Acupuncture is being offered to patients as part of routine medical care in selected military bases in the United States. There is little published information about the clinical outcomes associated with acupuncture in these clinical settings.

OBJECTIVE

The goal of this research was to assess clinical outcomes observed among adult patients who received acupuncture treatments at a United States Air Force medical center. Materials and

METHODS

This retrospective chart review was performed at the Nellis Family Medicine Residency in the Mike O'Callaghan Military Medical Center at Nellis Air Force Base in Las Vegas, NV. The charts were from 172 consecutive patients who had at least 4 acupuncture treatments within 1 year. The main outcome measures were prescriptions for opioid medications, muscle relaxants, benzodiazepines, and nonsteroidal anti-inflammatory drugs (NSAIDS) in the 60 days prior to the first acupuncture session and in the corresponding 60 days 1 year later; and Measure Yourself Medical Outcome Profile (MYMOP2) values for symptoms, ability to perform activities, and quality of life.

RESULTS

Opioid prescriptions decreased by 45%, muscle relaxants by 34%, NSAIDs by 42%, and benzodiazepines by 14%. MYMOP2 values decreased 3.50-3.11 (P < 0.002) for question 1, 4.18-3.46 (P < 0.00001) for question 3, and 2.73-2.43 (P < 0.006) for question 4.

CONCLUSIONS

In this military patient population, the number of opioid prescriptions decreased and patients reported improved symptom control, ability to function, and sense of well-being after receiving courses of acupuncture by their primary care physicians.

Dahlhamer J, Lucas J, Zelaya C, Nahin R, Mackey S, DeBar L, Kerns R, Von Korff M, Porter L, Helmick C. Prevalence of Chronic Pain and High-Impact Chronic Pain Among Adults - United States, 2016. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6146950/

Chronic pain, one of the most common reasons adults seek medical care (1), has been linked to restrictions in mobility and daily activities (2,3), dependence on opioids (4), anxiety and depression (2), and poor perceived health or reduced quality of life (2,3). Population-based estimates of chronic pain among U.S. adults range from 11% to 40% (5), with considerable population subgroup variation. As a result, the 2016 National Pain Strategy called for more precise prevalence estimates of chronic pain and high-impact chronic pain (i.e., chronic pain that frequently limits life or work activities) to reliably establish the prevalence of chronic pain and aid in the development and implementation of population-wide pain interventions (5). National estimates of high-impact chronic pain can help differentiate persons with limitations in major life domains, including work, social, recreational, and self-care activities from those who maintain normal life activities despite chronic pain, providing a better understanding of the population in need of pain services. To estimate the prevalence of chronic pain and high-impact chronic pain in the United States, CDC analyzed 2016 National Health Interview Survey (NHIS) data. An estimated 20.4% (50.0 million) of U.S. adults had chronic pain and 8.0% of U.S. adults (19.6 million) had high-impact chronic pain, with higher prevalences of both chronic pain and high-impact chronic pain reported among women, older adults, previously but not currently employed adults, adults living in poverty, adults with public health insurance, and rural residents. These findings could be used to target pain management interventions.

Davis BA, Dunn AS, Golley DJ, Chicoine DR. Chiropractic Clinical Outcomes Among Older Adult Male Veterans With Chronic Lower Back Pain: A Retrospective Review of Quality-Assurance Data. J Chiropr Med. 2022 Jun;21(2):77-82. doi: 10.1016/j.jcm.2022.02.004.

OBJECTIVE

The purpose of this study was to determine whether a sample of older adult male U.S. veterans demonstrated clinically and statistically significant improvement in chronic lower back pain on validated outcome measures after a short course of chiropractic care.

METHODS

We performed a retrospective review of a quality-assurance data set of outcome metrics for male veterans, aged 65 to 89 years, who had chronic low back pain, defined as pain in the lower back region present for at least 3 months before evaluation. We included those who received chiropractic management from January 1, 2010, to December 31, 2018. Paired t tests were used to compare outcomes after 4 treatments on both a numeric rating scale (NRS) and the Back Bournemouth Questionnaire (BBQ). The minimum clinically important difference (MCID) was set at 30% change from baseline.

RESULTS

There were 217 individuals who met the inclusion criteria. The mean NRS score change from baseline was 2.2 points, representing a 34.1% reduction (t = 13.5, P < .001). The mean score change for BBQ was 14.7 points, representing a 35.9% reduction (t = 16.7, P < .001). The percentage of participants reaching the MCID for the NRS was 57% (n = 124) and for the BBQ was 59% (n = 126), with 41% (n = 90) of the sample reaching the MCID for both the NRS and BBQ.

CONCLUSION

This retrospective review revealed clinically and statistically significant improvement in NRS and BBQ scores for this sample of older male U.S. veterans treated with chiropractic management for chronic low back pain.

Denneson LM, Corson K, Dobscha SK. Complementary and alternative medicine use among veterans with chronic noncancer pain. J Rehabil Res Dev. 2011;48(9):1119-28.

We describe prior use and willingness to try complementary and alternative medicine (CAM) among 401 veterans experiencing chronic noncancer pain and explore differences between CAM users and nonusers. Participants in a randomized controlled trial of a collaborative intervention for chronic pain from five Department of Veterans Affairs (VA) primary care clinics self-reported prior use and willingness to try chiropractic care, massage therapy, herbal medicines, and acupuncture. Prior CAM users were compared with nonusers on demographic characteristics, pain-related clinical characteristics, disease burden, and treatment satisfaction. A majority of veterans ( n = 327, 82%) reported prior use of at least one CAM modality, and nearly all (n = 399, 99%) were willing to try CAM treatment for pain. Chiropractic care was the least preferred option, whereas massage therapy was the most preferred (75% and 96%, respectively). CAM users were less likely to have service-connection disabilities (54% vs 68%; chi square = 4.64, p = 0.03) and reported having spent a larger percentage of their lives in pain (26% vs 20%; Z = 1.40, p = 0.04) than nonusers. We detected few differences between veterans who had tried CAM and those who had not, suggesting that CAM may have broad appeal among veterans with chronic pain. Implications for VA policy and practice and for clinicians treating veterans with chronic pain are discussed.

Donaldson MT, Polusny MA, MacLehose RF, Goldsmith ES, Hagel Campbell EM, Miron LR, Thuras PD, Krebs EE.  Patterns of conventional and complementary non-pharmacological health practice use by US military veterans: a cross-sectional latent class analysis. BMC Complement Altern Med. 2018 Sep 5;18(1):246. doi: 10.1186/s12906-018-2313-7.

BACKGROUND

Non-pharmacological therapies and practices are commonly used for both health maintenance and management of chronic disease. Patterns and reasons for use of health practices may identify clinically meaningful subgroups of users. The objectives of this study were to identify classes of self-reported use of conventional and complementary non-pharmacological health practices using latent class analysis and estimate associations of participant characteristics with class membership.

METHODS

A mailed survey (October 2015 to September 2016) of Minnesota National Guard Veterans from a longitudinal cohort (n = 1850) assessed current pain, self-reported overall health, mental health, substance use, personality traits, and health practice use. We developed the Health Practices Inventory, a self-report instrument assessing use of 19 common conventional and complementary non-pharmacological health-related practices. Latent class analysis was used to identify subgroups of health practice users, based on responses to the HPI. Participants were assigned to their maximum-likelihood class, which was used as the outcome in multinomial logistic regression to examine associations of participant characteristics with latent class membership.

RESULTS

Half of the sample used non-pharmacological health practices. Six classes of users were identified. "Low use" (50%) had low rates of health practice use. "Exercise" (23%) had high exercise use. "Psychotherapy" (6%) had high use of psychotherapy and support groups. "Manual therapies" (12%) had high use of chiropractic, physical therapy, and massage. "Mindfulness" (5%) had high use of mindfulness and relaxation practice. "Multimodal" (4%) had high use of most practices. Use of manual therapies (chiropractic, acupuncture, physical therapy, massage) was associated with chronic pain and female sex. Characteristics that predict use patterns varied by class. Use of self-directed practices (e.g., aerobic exercise, yoga) was associated with the personality trait of absorption (openness to experience). Use of psychotherapy was associated with higher rates of psychological distress.

CONCLUSIONS

These observed patterns of use of non-pharmacological health practices show that functionally similar practices are being used together and suggest a meaningful classification of health practices based on self-directed/active and practitioner-delivered. Notably, there is considerable overlap in users of complementary and conventional practices.

Dougherty PE, Karuza J, Dunn AS, Savino D, Katz P.  Spinal Manipulative Therapy for Chronic Lower Back Pain in Older Veterans: A Prospective, Randomized, Placebo-Controlled Trial.  Geriatr Orthop Surg Rehabil. 2014 Dec

INTRODUCTION

Chronic lower back pain (CLBP) is problematic in older veterans. Spinal manipulative therapy (SMT) is commonly utilized for CLBP in older adults, yet there are few randomized placebo-controlled trials evaluating SMT.

METHODS

The purpose of the study was to compare the effectiveness of SMT to a sham intervention on pain (Visual Analogue Scale, SF-36 pain subscale), disability (Oswestry Disability Index), and physical function (SF-36 subscale, Timed Up and Go) by performing a randomized placebo-controlled trial at 2 Veteran Affairs Clinics.

RESULTS

Older veterans (≥ 65 years of age) who were naive to chiropractic were recruited. A total of 136 were included in the study with 69 being randomly assigned to SMT and 67 to sham intervention. Patients were treated 2 times per week for 4 weeks assessing outcomes at baseline, 5, and 12 weeks postbaseline. Both groups demonstrated significant decrease in pain and disability at 5 and 12 weeks. At 12 weeks, there was no significant difference in pain and a statistically significant decline in disability scores in the SMT group when compared to the sham intervention group. There were no significant differences in adverse events between the groups.

CONCLUSIONS

The SMT did not result in greater improvement in pain when compared to our sham intervention; however, SMT did demonstrate a slightly greater improvement in disability at 12 weeks. The fact that patients in both groups showed improvements suggests the presence of a nonspecific therapeutic effect.

Dougherty PE, Karuza J, Savino D, Katz P. Evaluation of a modified clinical prediction rule for use with spinal manipulative therapy in patients with chronic low back pain: a randomized clinical trial. Chiropr Man Therap. 2014 Nov 18;22(1):41. doi: 10.1186/s12998-014-0041-8. eCollection 2014.

BACKGROUND

Spinal Manipulative Therapy (SMT) and Active Exercise Therapy (AET) have both demonstrated efficacy in the treatment of Chronic Lower Back Pain (CLBP). A Clinical Prediction Rule (CPR) for responsiveness to SMT has been validated in a heterogeneous lower back pain population; however there is a need to evaluate this CPR specifically for patients with CLBP, which is a significant source of disability.

METHODS

We conducted a randomized controlled trial (RCT) in Veteran Affairs and civilian outpatient clinics evaluating a modification of the original CPR (mCPR) in CLBP, eliminating acute low back pain and altering the specific types of SMT to improve generalizability. We enrolled and followed 181 patients with CLBP from 2007 to 2010. Patients were randomized by status on the mCPR to undergo either SMT or AET twice a week for four weeks. Providers and statisticians were blinded as to mCPR status. We collected outcome measures at 5, 12 and 24-weeks post baseline. We tested our study hypotheses by a general linear model repeated measures procedure following a univariate analysis of covariance approach. Outcome measures included, Visual Analogue Scale, Bodily pain subscale of SF-36 and the Oswestry Disability Index, Patient Satisfaction and Patient Expectation.

RESULTS

Of the 89 AET patients, 69 (78%) completed the study and of the 92 SMT patients, 76 (83%) completed the study. As hypothesized, we found main effects of time where the SMT and AET groups showed significant improvements in pain and disability from baseline. There were no differences in treatment outcomes between groups in response to the treatment, given the lack of significant treatment x time interactions. The mCPR x treatment x time interactions were not significant. The differences in outcomes between treatment groups were the same for positive and negative on the mCPR groups, thus our second hypothesis was not supported.

CONCLUSIONS

We found no evidence that a modification of the original CPR can be used to discriminate CLBP patients that would benefit more from SMT. Further studies are needed to further clarify the patient characteristics that moderate treatment responsiveness to specific interventions for CLBP.

Driscoll MA, Higgins D, Shamaskin-Garroway A, Burger A, Buta E, Goulet JL, Heapy A, Kerns RD, Brandt CA, Haskell SG.  Examining Gender as a Correlate of Self-Reported Pain Treatment Use Among Recent Service Veterans with Deployment-Related Musculoskeletal Disorders. Pain Med. 2017 Sep 1;18(9):1767-1777. doi: 10.1093/pm/pnx023.

OBJECTIVE

Women veterans with chronic pain utilize health care with greater frequency than their male counterparts. However, little is known about gender differences in the use of specialty pain care in this population. This investigation examined gender differences in self-reported use of opioids, interventional pain treatments, rehabilitation therapies, and complementary and integrative health (CIH) services for chronic pain treatment both within and outside of the Veterans Health Administration in a sample of veterans who served in support of recent conflicts.

METHODS

Participants included 325 veterans (54% women) who completed a baseline survey as part of the Women Veterans Cohort Study and reported deployment-related musculoskeletal conditions and chronic pain. Measures included self-reported use of pain treatment modalities, pain severity, self-rated health, access to specialty care, disability status, and presence of a mental health condition.

RESULTS

Men were more likely to report a persistent deployment-related musculoskeletal condition but were no more likely than women to report chronic pain. Overall, 21% of the sample reported using opioids, 27% used interventional strategies, 59% used rehabilitation therapies, and 57% used CIH services. No significant gender differences in use of any pain treatment modality were observed.

CONCLUSIONS

Use of pain specialty services was common among men and women, particularly rehabilitative and CIH services. There were no gender differences in the self-reported use of different modalities. These results are inconsistent with documented gender differences in pain care. They encourage further examination of gender differences in preferences and other individual difference variables as predictors of specialty pain care utilization.

Dunn AS, Baylis S, Ryan D. Chiropractic management of mechanical low back pain secondary to multiple-level lumbar spondylolysis with spondylolisthesis in a United States Marine Corps veteran: a case report. J Chiropr Med. 2009 Sep;8(3):125-30. doi: 10.1016/j.jcm.2009.04.003.

OBJECTIVE

This case report describes the evaluation and conservative management of mechanical low back pain secondary to multiple-level lumbar spondylolysis with spondylolisthesis in a United States Marine Corps veteran within a Veterans Affairs Medical Center chiropractic clinic.

CLINICAL FEATURES

The 43-year-old patient had a 20-year history of mechanical back pain secondary to an injury sustained during active military duty. He had intermittent radiation of numbness and tingling involving the right lower extremity distal to the knee. Radiographs of the lumbosacral region demonstrated a grade I spondylolisthesis of L3 in relation to L4 and a grade II spondylolisthesis of L4 in relation to L5 secondary to bilateral pars interarticularis defects. There was marked narrowing of the L4-5 disk space with associated subchondral sclerosis.

INTERVENTION AND OUTCOME

A course of conservative management consisting of 10 treatments including lumbar flexion/distraction and activity modification was provided over an 8-week period. Despite the long-standing nature of the complaint and underlying multiple-level lumbar spondylolysis with spondylolisthesis, there was a 25% reduction in low back pain severity on the numeric rating scale and a 22% reduction in perceived disability related to low back pain on the Revised Oswestry Disability Questionnaire.

CONCLUSIONS

Conservative management is considered to be the standard of care for spondylolysis and should be explored in its various forms for symptomatic low back pain patients who present without neurologic deficits and with spondylolisthesis below grade III. The response to treatment for the veteran patient in this case suggests that lumbar flexion/distraction may serve as a safe and effective component of conservative management of mechanical low back pain for some patients with spondylolysis and spondylolisthesis.

Dunn AS, Green BN, Formolo LR, Chicoine DR. Chiropractic management for veterans with neck pain: a retrospective study of clinical outcomes. J Manipulative Physiol Ther. 2011 Oct;34(8):533-8. doi: 10.1016/j.jmpt.2011.08.009. Epub 2011 Sep 9.

OBJECTIVE

The purpose of this study was to report demographic characteristics, chiropractic treatment methods and frequency, and clinical outcomes for chiropractic management of neck pain in a sample of veteran patients.

METHODS

This is a retrospective case series of 54 veterans with a chief complaint of neck pain who received chiropractic care through a Veterans Health Administration medical center. Descriptive statistics and paired t tests were used with the numeric rating scale and Neck Bournemouth Questionnaire serving as the outcome measures. A minimum clinically important difference was set as 30% improvement from baseline for both outcomes.

RESULTS

The mean number of chiropractic treatments was 8.7. For the numeric rating scale, the mean raw score improvement was 2.6 points, representing 43% change from baseline. For the Neck Bournemouth Questionnaire, the mean raw score improvement was 13.9 points, representing 33% change from baseline. For both measures, 36 (67%) patients met or exceeded the minimum clinically important difference.

CONCLUSION

Mean chiropractic clinical outcomes were both statistically significant and clinically meaningful for this sample of veterans presenting with neck pain.

Edmond SN, Becker WC, Driscoll MA, Decker SE, Higgins DM, Mattocks KM, Kerns RD, Haskell SG.  Use of Non-Pharmacological Pain Treatment Modalities Among Veterans with Chronic Pain: Results from a Cross-Sectional Survey. J Gen Intern Med. 2018 May;33(Suppl 1):54-60. doi: 10.1007/s11606-018-4322-0.

BACKGROUND

Despite strong evidence for the effectiveness of non-pharmacological pain treatment modalities (NPMs), little is known about the prevalence or correlates of NPM use.

OBJECTIVE

This study examined rates and correlates of NPM use in a sample of veterans who served during recent conflicts.

DESIGN

We examined rates and demographic and clinical correlates of self-reported NPM use (operationalized as psychological/behavioral therapies, exercise/movement therapies, and manual therapies). We calculated descriptive statistics and examined bivariate associations and multivariable associations using logistic regression.

PARTICIPANTS

Participants were 460 veterans endorsing pain lasting ≥ 3 months who completed the baseline survey of the Women Veterans Cohort Study (response rate 7.7%.

MAIN MEASURES

Outcome was self-reported use of NPMs in the past 12 months.

KEY RESULTS

Veterans were 33.76 years old (SD = 10.72), 56.3% female, and 80.2% White. Regarding NPM use, 22.6% reported using psychological/behavioral, 50.9% used exercise/movement and 51.7% used manual therapies. Veterans with a college degree (vs. no degree; OR = 2.51, 95% CI = 1.46, 4.30, p = 0.001) or those with worse mental health symptoms (OR = 2.88, 95% CI = 2.11, 3.93, p < 0.001) were more likely to use psychological/behavioral therapies. Veterans who were female (OR = 0.63, 95% CI = 0.43, 0.93, p = 0.02) or who used non-opioid pain medications (OR = 1.82, 95% CI = 1.146, 2.84, p = 0.009) were more likely to use exercise/movement therapies. Veterans who were non-White (OR = 0.57, 95% CI = 0.5, 0.94, p = 0.03), with greater educational attainment (OR = 2.11, 95% CI = 1.42, 3.15, p < 0.001), or who used non-opioid pain medication (OR = 1.71, 95% CI = 1.09, 2.68, p = 0.02) were more likely to use manual therapies.

CONCLUSIONS

Results identified demographic and clinical characteristics among different NPMs, which may indicate differences in veteran treatment preferences or provider referral patterns. Further study of provider referral patterns and veteran treatment preferences is needed to inform interventions to increase NPM utilization. Research is also need to identify demographic and clinical correlates of clinical outcomes related to NPM use.

Eskander JP, Beakley BD, Zhang S, Paetzold J, Sharma B, Kaye AD, Sharma S.  A Multimodal Approach to Pain Management for Patients with Chronic Back Pain: Outcome Measures at 1 Year. Curr Pain Headache Rep. 2019 Jul 8;23(8):54.

PURPOSE OF REVIEW

The purpose of this study is to evaluate the effectiveness of a multimodal approach to treating chronic low back pain.

RECENT FINDINGS

Chronic non-cancer-related back pain is often a frustrating and poorly managed problem for patients. It poses a significant public health issue worsened by the widespread use of narcotics. In 2016, the CDC released guidelines with noticeably more strict recommendations on prescription of narcotics for pain. Veterans at an interventional pain clinic presenting with chronic back pain refractory to medical and to surgical care were enrolled in an 8-week interdisciplinary pain management program. Pain scores were significantly reduced 1 year after completion of the program. Patients in this study benefitted from lower and sustained pain scores, a reduction in emergency room, and urgent care clinic visits, as well as generally high satisfaction with the interdisciplinary program.

Evans EA, Herman PM, Washington DL, Lorenz KA, Yuan A, Upchurch DM, Marshall N, Hamilton AB, Taylor SL.  Gender Differences in Use of Complementary and Integrative Health by U.S. Military Veterans with Chronic Musculoskeletal Pain. Womens Health Issues. 2018

AIMS

The Veterans Health Administration promotes evidence-based complementary and integrative health (CIH) therapies as nonpharmacologic approaches for chronic pain. We aimed to examine CIH use by gender among veterans with chronic musculoskeletal pain, and variations in gender differences by race/ethnicity and age.

METHODS

We conducted a secondary analysis of electronic health records provided by all women (n = 79,537) and men (n = 389,269) veterans age 18 to 54 years with chronic musculoskeletal pain who received Veterans Health Administration-provided care between 2010 and 2013. Using gender-stratified multivariate binary logistic regression, we examined predictors of CIH use, tested a race/ethnicity-by-age interaction term, and conducted pairwise comparisons of predicted probabilities.

RESULTS

Among veterans with chronic musculoskeletal pain, more women than men use CIH (36% vs. 26%), with rates ranging from 25% to 42% among women and 15% to 29% among men, depending on race/ethnicity and age. Among women, patients under age 44 who were Hispanic, White, or patients of other race/ethnicities are similarly likely to use CIH; in contrast, Black women, regardless of age, are least likely to use CIH. Among men, White and Black patients, and especially Black men under age 44, are less likely to use CIH than men of Hispanic or other racial/ethnic identities.

CONCLUSIONS

Women veteran patients with chronic musculoskeletal pain are more likely than men to use CIH therapies, with variations in CIH use rates by race/ethnicity and age. Tailoring CIH therapy engagement efforts to be sensitive to gender, race/ethnicity, and age could reduce differential CIH use and thereby help to diminish existing health disparities among veterans.

Fan AY, Miller DW, Bolash B, Bauer M, McDonald J, Faggert S, He H, Li YM, Matecki A, Camardella L, Koppelman MH, Stone JAM, Meade L, Pang J. Acupuncture's Role in Solving the Opioid Epidemic: Evidence, Cost-Effectiveness, and Care Availability for Acupuncture as a Primary, Non-Pharmacologic Method for Pain Relief and Management-White Paper 2017. J Integr Med. 2017 Nov;15(6):411-425. doi: 10.1016/S2095-4964(17)60378-9. PubMed PMID: 29103410.

The United States (U.S.) is facing a national opioid epidemic, and medical systems are in need of non-pharmacologic strategies that can be employed to decrease the public's opioid dependence. Acupuncture has emerged as a powerful, evidence-based, safe, cost-effective, and available treatment modality suitable to meeting this need. Acupuncture has been shown to be effective for the management of numerous types of pain conditions, and mechanisms of action for acupuncture have been described and are understandable from biomedical, physiologic perspectives. Further, acupuncture's cost-effectiveness can dramatically decrease health care expenditures, both from the standpoint of treating acute pain and through avoiding addiction to opioids that requires costly care, destroys quality of life, and can lead to fatal overdose. Numerous federal regulatory agencies have advised or mandated that healthcare systems and providers offer non-pharmacologic treatment options for pain. Acupuncture stands out as the most evidence-based, immediately available choice to fulfill these calls. Acupuncture can safely, easily, and cost-effectively be incorporated into hospital settings as diverse as the emergency department, labor and delivery suites, and neonatal intensive care units to treat a variety of commonly seen pain conditions. Acupuncture is already being successfully and meaningfully utilized by the Veterans Administration and various branches of the U.S. Military, in some studies demonstrably decreasing the volume of opioids prescribed when included in care.

Federman DG, Poulin LM, Ruser CB, Kravetz JD. Implementation of shared medical appointments to offer battlefield acupuncture efficiently to veterans with pain. Acupunct Med. 2018 Apr;36(2):124-126. doi: 10.1136/acupmed-2016-011315. Epub 2017 Jun 19. PubMed PMID: 28630048.

BACKGROUND

The use of prescription opioids in the treatment of pain has increased notably over recent decades. With this increase, dramatic unintended consequences have arisen. Rates of death from prescribed opioids increased fourfold between 2000 and 2014. Integrative care has been suggested as a potentially safer alternative to opioids in the treatment of chronic non-cancer pain and acupuncture has been shown to be an effective treatment for chronic pain. Battlefield acupuncture (BFA), an easily learnt subset of auricular acupuncture, has been proposed to treat a variety of painful disorders in active military members and veterans. Patients undergo insertion of five auricular semi-permanent (ASP) needles to the following traditional ear acupuncture points bilaterally: Cingulate Gyrus, Thalamus, Omega 2, Point Zero and Shenmen. While other investigators have evaluated models for integrating medical acupuncture into practice,5 to our knowledge, there has been no evaluation of how to incorporate BFA efficiently into a busy primary care (PC) practice. Since shared medical appointments (SMA) have been shown to be helpful in chronic disease management and may decrease healthcare utilisation, we developed an SMA approach to deliver BFA in the setting of a US Department of Veterans Affairs (VA) PC practice.

Federman DG, Radhakrishnan K, Gabriel L, Poulin LM, Kravetz JD. Group Battlefield Acupuncture in Primary Care for Veterans with Pain. South Med J. 2018 Oct;111(10):619-624. doi: 10.14423/SMJ.0000000000000877. PubMed PMID: 30285269.

OBJECTIVE

To obtain preliminary data on the short- and intermediate-term effects of battlefield acupuncture (BFA) on self-reported pain intensity in a relatively large cohort of veterans to assess whether a more comprehensive clinical trial evaluation is warranted.

METHODS

The treatment, in an outpatient group setting, consisted of up to five auricular semipermanent needles inserted into each ear at prespecified points. Efficacy of treatment was measured by self-reported pain, using the Defense and Veterans Pain Rating Scale, just before treatment and at posttreatment days 0, 1, 7, and 30.

RESULTS

A total of 112 patients attended the group clinics. The mean pretreatment pain score was 6.8, with an immediate postprocedure decrease of 2.4 points. The proportion of patients reporting decreased pain was 88.4%, 80.7%, 52.4%, and 51% at posttreatment days 0, 1, 7, and 30, respectively.

CONCLUSIONS

The short- and intermediate-term beneficial effect of BFA on chronic pain is clinically meaningful. The large proportion of patients reporting decreased pain even 30 days after treatment suggests that the long-term effect of BFA merits further investigation.

Federman DG, Zeliadt SB, Thomas ER, Carbone GF Jr, Taylor SL. Battlefield Acupuncture in the Veterans Health Administration: Effectiveness in Individual and Group Settings for Pain and Pain Comorbidities. Med Acupunct. 2018 Oct 1;30(5):273-278. doi: 10.1089/acu.2018.1296. Epub 2018 Oct 15. PubMed PMID: 30377463; PubMed Central PMCID: PMC6205767.

OBJECTIVE

The Department of Veterans Affairs trained primary-care providers to deliver Battlefield Acupuncture (BFA), a subset of auricular acupuncture, to patients. However, little is known about BFA effectiveness in group or individual sessions or repeated administrations versus singular use. The aim of this study was to examine the use and effectiveness of BFA for back pain and four pain-comorbid conditions in group and individual sessions at a large Veterans Affairs (VA) medical center.

MATERIALS AND METHODS

This cross-sectional study was conducted at the West Haven VA Medical Center, in West Haven CT. Between October 2016 and December 2017, 284 veterans with pain received BFA. The BFA was administered in group clinics or in individual encounters. The Defense and Veterans Pain Rating Scale was used to assess self-reported pain immediately before and after each BFA administration. RESULTS Over the study period, an average of 57 (range: 50–66) new patients per month received BFA. Of 753 total patient encounters, an immediate decrease in self-reported pain occurred in 616 (82.0%) patients, no change occurred in 73 (9.7%) patients, and an increase occurred in 62 (8.3%) patients. Decreases in pain were common in the group and individual settings, even in patients with originally high pain scores, and the effectiveness remained with repeated uses.

CONCLUSIONS

BFA can be effective for immediate relief of pain—whether the BFA is administered in a group or individual setting—for the overwhelming majority of veterans and, as such, holds promise as a nonpharmacologic pain-management intervention.

Fletcher CE, Mitchinson AR, Trumble EL, Hinshaw DB, Dusek JA. Perceptions of other integrative health therapies by Veterans with pain who are receiving massage. J Rehabil Res Dev. 2016;53(1):117-26. doi: 10.1682/JRRD.2015.01.0015. PubMed PMID: 27004453; PubMed Central PMCID: PMC4829362.

Veterans are increasingly using complementary and integrative health (CIH) therapies to manage chronic pain and other troubling symptoms that significantly impair health and quality of life. The Department of Veterans Affairs (VA) is exploring ways to meet the demand for access to CIH, but little is known about Veterans' perceptions of the VA's efforts. To address this knowledge gap, we conducted interviews of 15 inpatients, 8 receiving palliative care, and 15 outpatients receiving CIH in the VA. Pain was the precipitating factor in all participants' experience. Participants were asked about their experience in the VA and their opinions about which therapies would most benefit other Veterans. Participants reported that massage was well-received and resulted in decreased pain, increased mobility, and decreased opioid use. Major challenges were the high ratio of patients to CIH providers, the difficulty in receiving CIH from fee-based CIH providers outside of the VA, cost issues, and the role of administrative decisions in the uneven deployment of CIH across the VA. If the VA is to meet its goal of offering personalized, proactive, patient-centered care nationwide then it must receive support from Congress while considering Veterans' goals and concerns to ensure that the expanded provision of CIH improves outcomes.

Flynn D, Eaton LH, Langford DJ, Ieronimakis N, McQuinn H, Burney RO, Holmes SL, Doorenbos AZ.  A SMART design to determine the optimal treatment of chronic pain among military personnel. Contemp Clin Trials. 2018 Oct;73:68-74. doi: 10.1016/j.cct.2018.08.008. Epub 2018 Aug 24.

Chronic pain is a leading cause of disability among active duty service members in the U.S. armed forces. Standard rehabilitative care and complementary and integrative health therapies are used for chronic pain rehabilitation. However, the optimal sequence and duration of these therapies has yet to be determined. This article describes a sequential multiple assignment randomized trial (SMART) protocol being used to identify the optimal components and sequence of standard rehabilitative care and complementary and integrative health therapies for reducing pain impact and improving other patient outcomes. Active duty service members referred to Madigan Army Medical Center for treatment of chronic pain are being recruited to the Determinants of the Optimal Dose and Sequence of Functional Restoration and Integrative Therapies study. Study participants are randomized to either standard rehabilitative care (physical and occupational therapy and psychoeducation) or complementary and integrative health therapies (chiropractic, acupuncture, yoga and psychoeducation). Those participants who do not respond to the first 3 weeks of treatment are randomized to receive an additional 3 weeks of either (1) the alternative treatment or (2) the first-stage treatment plus the alternative treatment. This study will also determine factors associated with treatment response that can support clinical decision making, such as baseline fitness, pain catastrophizing, kinesiophobia, post-traumatic stress, pain self-efficacy, and biological indicators. The information gained from this research will be applicable to all integrative chronic pain rehabilitation programs throughout the U.S. Department of Defense and the U.S. Department of Veterans Affairs, and the broader rehabilitation community.

Flynn DM, McQuinn H, Fairchok A, Eaton LH, Langford DJ, Snow T, Doorenbos AZ. Enhancing the success of functional restoration using complementary and integrative therapies: Protocol and challenges of a comparative effectiveness study in active duty service members with chronic pain. Contemp Clin Trials Commun. 2018

Chronic pain significantly impairs physical, psychological and social functioning. Among military populations, pain due to injuries sustained both on and off the battlefield is a leading cause of short and long-term disability. Improving the quality of pain care for active duty service members is a major priority of the Department of Defense. This article describes an ongoing comparative effectiveness study which aims to (1) evaluate the benefit of a multimodal complementary and integrative health (CIH) pain management program when added to standard rehabilitative care (SRC) prior to an intensive functional restoration (FR) program compared to SRC alone, and (2) identify factors that predict improvement in pain impact following treatment completion. Using a randomized controlled trial design, active duty service members with pain related to musculoskeletal injury are assigned to a 3-week course of either SRC or SRC combined with CIH therapies prior to beginning a 3-week course of FR. Outcomes are collected at baseline, at the end of stage 1 treatment, post-FR, and at 3- and 6-months post-FR. Outcome measures include provider-measured functional assessments and patient-reported assessment through the Pain Assessment Screening Tool and Outcomes Registry (PASTOR). The military health system provides a supportive environment for implementation of this research protocol. Challenges to conducting the study have included new technology systems at the study site, slower than projected enrollment, and program delivery issues. These challenges have been successfully managed and have not significantly impacted study participant enrollment and completion of study treatments.

Gellad WF, Good CB, Shulkin DJ. Addressing the Opioid Epidemic in the United States: Lessons From the Department of Veterans Affairs. JAMA Intern Med. 2017 May 1;177(5):611-612. doi: 10.1001/jamainternmed.2017.0147. PubMed PMID: 28288245.

Over the past 15 years, more than 165 000 people in the United States have died from overdoses related to prescription opioids,1 and millions more have suffered adverse consequences. The misuse and abuse of prescription opioids have contributed to a precipitous increase in heroin and fentanyl overdoses.

Patients treated in the health care system of the Department of Veterans Affairs (VA) are part of this epidemic. Chronic pain impacts half of veterans using the VA, complicated by high rates of psychiatric comorbidities such as substance use disorder and posttraumatic stress disorder.4 In 2009, the VA established a national office to coordinate and improve pain management practices, and in 2011, developed standardized metrics for opioid use across the system. Nonetheless, by 2012, nearly 25% of veterans receiving outpatient care in the VA were receiving an opioid.

Giannitrapani K, McCaa M, Haverfield M, Kerns RD, Timko C, Dobscha S, Lorenz K. Veteran Experiences Seeking Non-pharmacologic Approaches for Pain. Mil Med. 2018 Nov 1;183(11-12):e628-e634. doi: 10.1093/milmed/usy018. PubMed PMID: 29590422.

INTRODUCTION

Pain is a longstanding and growing concern among US military veterans. Although many individuals rely on medications, a growing body of literature supports the use of complementary non-pharmacologic approaches when treating pain. Our objective is to characterize veteran experiences with and barriers to accessing alternatives to medication (e.g., non-pharmacologic treatments or non-pharmacologic approaches) for pain in primary care.

MATERIALS AND METHODS

Data for this qualitative analysis were collected as part of the Effective Screening for Pain (ESP) study (2012-2017), a national randomized controlled trial of pain screening and assessment methods. This study was approved by the Veterans Affairs (VA) Central IRB and veteran participants signed written informed consent. We recruited a convenience sample of US military veterans in four primary care clinics and conducted semi-structured interviews (25-65 min) elucidating veteran experiences with assessment and management of pain in VA Healthcare Systems. We completed interviews with 36 veterans, including 7 females and 29 males, from three VA health care systems. They ranged in age from 28 to 94 yr and had pain intensity ratings ranging from 0 to 9 on the "pain now" numeric rating scale at the time of the interviews. We analyzed interview transcripts using constant comparison and produced mutually agreed upon themes.

RESULTS

Veteran experiences with and barriers to accessing complementary non-pharmacologic approaches for pain clustered into five main themes: communication with provider about complementary approaches ("one of the best things the VA has ever given me was pain education and it was through my occupational therapist"), care coordination ("I have friends that go to small clinic in [area A] and I still see them down in [facility in area B] and they're going through headaches upon headaches in trying to get their information to their primary care docs"), veteran expectations about pain experience ("I think as a society we have shifted the focus to if this doctor doesn't relieve me of my pain I will find someone who does"), veteran knowledge and beliefs about various complementary non-pharmacologic approaches ("how many people know that tai chi will help with pain?… Probably none. I saw them doing tai chi down here at the VA clinic and the only reason I knew about it was because I saw it being done"), and access ("the only physical therapy I ever did… it helped…but it was a two-and-a-half-hour drive to get there three times a week… I can't do this"). Specific access barriers included local availability, time, distance, scheduling flexibility, enrollment, and reimbursement.

CONCLUSION

The veterans in this qualitative study expressed interest in using non-pharmacologic approaches to manage pain, but voiced complex multi-level barriers. Limitations of our study include that interviews were conducted only in five clinics and with seven female veterans. These limitations are minimized in that the clinics covered are diverse ranging to include urban, suburban, and rural residents. Future implementation efforts can learn from the veterans' voice to appropriately target veteran concerns and achieve more patient-centered pain care.

Gibson CJ, Grasso J, Li Y, et al. An Integrated Pain Team Model: Impact on Pain-Related Outcomes and Opioid Misuse in Patients with Chronic Pain [published online ahead of print, 2020 Feb 25]. Pain Med. 2020;pnaa003. doi:10.1093/pm/pnaa003

OBJECTIVE

Biopsychosocial integrated pain team (IPT) care models are being implemented in Veterans Health Administration (VA) and other health care systems to address chronic pain and reduce risks related to long-term opioid therapy, with little evaluation of effectiveness to date. We examined whether IPT improves self-reported pain-related outcomes and opioid misuse.

DESIGN

Single-group quality improvement study.

SETTING

Large VA health care system.

Subjects

Veterans with chronic pain (N = 99, 84% male, mean age [SD] = 60 [13] years).

METHODS

Using paired t tests and Wilcoxon matched-pairs signed-ranks tests, we examined pain experience (Brief Pain Inventory, Pain Catastrophizing Scale), opioid misuse (Current Opioid Misuse Measure), treatment satisfaction (Pain Treatment Satisfaction Scale), and pain management strategies among patients with chronic pain before and after three or more IPT encounters.

RESULTS

After an average (SD) of 14.3 (9) weeks engaged in IPT, patients reported improvement in pain interference (mean [SD] = 46.0 [15.9] vs 40.5 [16.2], P < 0.001), pain catastrophizing (mean [SD] = 22.9 [13.0] vs 19.3 [14.1], P = 0.01), treatment satisfaction (i.e., "very satisfied" = 13.1% at baseline vs 25.3% at follow-up, P = 0.01), and reduced opioid misuse (mean [SD] = 11.0 [7.5] vs 8.2 [6.1], P = 0.01). Patients reported increased use of integrative (i.e., acupuncture, 11% at baseline vs 26% at follow-up, P < 0.01) and active pain management strategies (i.e., exercise, 8% at baseline vs 16% at follow-up, P < 0.01) and were less likely to use only pharmacological pain management strategies after IPT engagement (19% at baseline vs 5% at follow-up, P < 0.01).

CONCLUSIONS

Biopsychosocial, integrated pain care may improve patient-centered outcomes related to opioid misuse and the subjective experience and nonpharmacological self-management of chronic pain.

Glynn LH, Chen JA, Dawson TC, Gelman H, Zeliadt SB. Bringing chronic-pain care to rural veterans: A telehealth pilot program description. Psychol Serv. 2020 Jan 16. doi: 10.1037/ser0000408. Epub ahead of print. PMID: 31944817.

Opioid-related harms disproportionately affect rural communities. Recent research-based policy changes have called for reductions in opioid prescribing and substitution of safe and effective alternatives to opioids for treating chronic pain, but such alternatives are often difficult to access in rural areas. Telehealth services can help address this disparity by bringing evidence-based, biopsychosocial chronic-pain services to rural and underserved patients with chronic pain. This article describes a 2-year pilot project for delivering chronic-pain care by pain specialists from central hubs at Veterans Health Administration (VA) medical centers to spokes at VA community-based outpatient clinics (CBOCs). The VA Puget Sound Pain Telehealth pilot program offered pain education classes, cognitive-behavioral therapy groups, opioid-safety education, and acupuncture education. The program delivered 501 encounters to patients from 1 hub to 4 CBOC spoke sites from 2016 to 2018, and supported training, administration, equipment acquisition, and grant-writing. The quality-improvement project was rolled out using existing local resources. We present initial findings about the patients who utilized Pain Telehealth, share lessons learned, and discuss future directions for expansion. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Goertz CM, Long CR, Vining RD, Pohlman KA, Walter J, Coulter I. Effect of Usual Medical Care Plus Chiropractic Care vs Usual Medical Care Alone on Pain and Disability Among US Service Members With Low Back Pain: A Comparative Effectiveness Clinical Trial. JAMA Netw Open. 2018 May 18;1(1):e180105. doi: 10.1001/jamanetworkopen.2018.0105.

OBJECTIVE

To determine whether the addition of chiropractic care to usual medical care results in better pain relief and pain-related function when compared with usual medical care alone.

DESIGN, SETTING, AND PARTICIPANTS

A 3-site pragmatic comparative effectiveness clinical trial using adaptive allocation was conducted from September 28, 2012, to February 13, 2016, at 2 large military medical centers in major metropolitan areas and 1 smaller hospital at a military training site. Eligible participants were active-duty US service members aged 18 to 50 years with low back pain from a musculoskeletal source.

INTERVENTIONS

The intervention period was 6 weeks. Usual medical care included self-care, medications, physical therapy, and pain clinic referral. Chiropractic care included spinal manipulative therapy in the low back and adjacent regions and additional therapeutic procedures such as rehabilitative exercise, cryotherapy, superficial heat, and other manual therapies.

MAIN OUTCOMES AND MEASURES

Coprimary outcomes were low back pain intensity (Numerical Rating Scale; scores ranging from 0 [no low back pain] to 10 [worst possible low back pain]) and disability (Roland Morris Disability Questionnaire; scores ranging from 0-24, with higher scores indicating greater disability) at 6 weeks. Secondary outcomes included perceived improvement, satisfaction (Numerical Rating Scale; scores ranging from 0 [not at all satisfied] to 10 [extremely satisfied]), and medication use. The coprimary outcomes were modeled with linear mixed-effects regression over baseline and weeks 2, 4, 6, and 12.

RESULTS

Of the 806 screened patients who were recruited through either clinician referrals or self-referrals, 750 were enrolled (250 at each site). The mean (SD) participant age was 30.9 (8.7) years, 175 participants (23.3%) were female, and 243 participants (32.4%) were nonwhite. Statistically significant site × time × group interactions were found in all models. Adjusted mean differences in scores at week 6 were statistically significant in favor of usual medical care plus chiropractic care compared with usual medical care alone overall for low back pain intensity (mean difference, -1.1; 95% CI, -1.4 to -0.7), disability (mean difference, -2.2; 95% CI, -3.1 to -1.2), and satisfaction (mean difference, 2.5; 95% CI, 2.1 to 2.8) as well as at each site. Adjusted odd ratios at week 6 were also statistically significant in favor of usual medical care plus chiropractic care overall for perceived improvement (odds ratio = 0.18; 95% CI, 0.13-0.25) and self-reported pain medication use (odds ratio = 0.73; 95% CI, 0.54-0.97). No serious related adverse events were reported.

CONCLUSIONS AND RELEVANCE

Chiropractic care, when added to usual medical care, resulted in moderate short-term improvements in low back pain intensity and disability in active-duty military personnel. This trial provides additional support for the inclusion of chiropractic care as a component of multidisciplinary health care for low back pain, as currently recommended in existing guidelines. However, study limitations illustrate that further research is needed to understand longer-term outcomes as well as how patient heterogeneity and intervention variations affect patient responses to chiropractic care.

Goldsmith ES, MacLehose RF, Jensen AC, et al. Complementary, Integrative, and Nondrug Therapy Use for Pain Among US Military Veterans on Long-term Opioids. Med Care. 2020;58 Suppl 2 9S(Suppl 2 9 Suppl):S116-S124.

BACKGROUND

Long-term opioid therapy for chronic pain arose amid limited availability and awareness of other pain therapies. Although many complementary and integrative health (CIH) and nondrug therapies are effective for chronic pain, little is known about CIH/nondrug therapy use patterns among people prescribed opioid analgesics.

OBJECTIVE

The objective of this study was to estimate patterns and predictors of self-reported CIH/nondrug therapy use for chronic pain within a representative national sample of US military veterans prescribed long-term opioids for chronic pain.

RESEARCH DESIGN

National two-stage stratified random sample survey combined with electronic medical record data. Data were analyzed using logistic regressions and latent class analysis.

Subjects: US military veterans in Veterans Affairs (VA) primary care who received ≥6 months of opioid analgesics.

Measures: Self-reported use of each of 10 CIH/nondrug therapies to treat or cope with chronic pain in the past year: meditation/mindfulness, relaxation, psychotherapy, yoga, t'ai chi, aerobic exercise, stretching/strengthening, acupuncture, chiropractic, massage; Brief Pain Inventory-Interference (BPI-I) scale as a measure of pain-related function.

RESULTS

In total, 8891 (65%) of 13,660 invitees completed the questionnaire. Eighty percent of veterans reported past-year use of at least 1 nondrug therapy for pain. Younger age and female sex were associated with the use of most nondrug therapies. Higher pain interference was associated with lower use of exercise/movement therapies. Nondrug therapy use patterns reflected functional categories (psychological/behavioral, exercise/movement, manual).

CONCLUSIONS

Use of CIH/nondrug therapies for pain was common among patients receiving long-term opioids. Future analyses will examine nondrug therapy use in relation to pain and quality of life outcomes over time.

Goldstein JN, Ibrahim SA, Frankel ES, Mao JJ.  Race, Pain, and Beliefs Associated with Interest in Complementary and Alternative Medicineamong Inner City Veterans. Pain Med. 2015 Aug;16(8):1467-74. doi: 10.1111/pme.12756. Epub 2015 Jun 10.

OBJECTIVE

To investigate the prevalence and determinants of complementary and alternative medicine (CAM) interest level among a racially diverse cohort of inner city veterans who receive primary care at the VA Medical Center.

DESIGN

Cross-sectional survey study

SETTING

Philadelphia VA Medical Center

SUBJECTS

Primary care patients (n = 258) METHODS Interest in CAM was measured using a single item question. Patient treatment beliefs were assessed using validated instruments. We evaluated factors associated with patient interest in CAM using a multivariate logistic regression model.

RESULTS

In this sample of 258 inner city primary care VA patients, interest in CAM was high 80% (n = 206). Interest in CAM was strongly associated with African American race [adjusted odds ratio (AOR) 2.19, 95% Confidence Interval (CI) 1.05-4.60, P = 0.037], higher levels of education (AOR 4.33, 95% CI 1.80-10.40, P = 0.001), presence of moderate to severe pain (AOR 2.02, 95% CI 1.02-4.78, P = 0.043), and expectations of benefit from CAM use (AOR 1.21, 95% CI 1.06-1.36, P = 0.004).

CONCLUSIONS

CAM approaches have broad appeal within this inner city cohort of veterans, particularly among African Americans, those that experience pain and those that expect greater benefit from CAM. These findings may inform the development of patient-centered integrative pain management for veterans.

Groessl EJ, Liu L, Chang DG, Wetherell JL, Bormann JE, Atkinson JH, Baxi S, Schmalzl L. Yoga for Military Veterans with Chronic Low Back Pain: A Randomized Clinical Trial.Am J Prev Med. 2017 Nov;53(5):599-608. doi: 10.1016/j.amepre.2017.05.019. Epub 2017 Jul 20. PubMed PMID: 28735778; PubMed Central PMCID: PMC6399016.

INTRODUCTION

Chronic low back pain (cLBP) is prevalent, especially among military veterans.

Many cLBP treatment options have limited benefits and are accompanied by side effects. Major efforts to reduce opioid use and embrace nonpharmacological pain treatments have resulted. Research with community cLBP patients indicates that yoga can improve health outcomes and has few side effects. The benefits of yoga among military veterans were examined.

DESIGN

Participants were randomized to either yoga or delayed yoga treatment in 2013–2015. Outcomes were assessed at baseline, 6 weeks, 12 weeks, and 6 months. Intention-to-treat analyses occurred in 2016.

RESULTS

Participant characteristics were mean age 53 years, 26% were female, 35% were unemployed or disabled, and mean back pain duration was 15 years. Improvements in Roland Morris Disability Questionnaire scores did not differ between the two groups at 12 weeks, but yoga participants had greater reductions in Roland Morris Disability Questionnaire scores than delayed treatment participants at 6 months  2.48 (95% CI¼  4.08,  0.87). Yoga participants improved more on pain intensity at 12 weeks and at 6 months. Opioid medication use declined among all participants, but group differences were not found.

CONCLUSIONS

Yoga improved health outcomes among veterans despite evidence they had fewer resources, worse health, and more challenges attending yoga sessions than community samples studied previously. The magnitude of pain intensity decline was small, but occurred in the context of reduced opioid use. The findings support wider implementation of yoga programs for veterans.

Groessl EJ, Liu L, Schmalzl L, Chang DG, McCarthy A, Chun WI, Sinclair C, Bormann JE. Secondary Outcomes from a Randomized Controlled Trial of Yoga for Veterans with Chronic Low-Back Pain. Int J Yoga Therap. 2019 Sep 11. doi: 10.17761/2020-D-19-00036. [Epub ahead of print]

Chronic low-back pain (cLBP) is a prevalent condition, and rates are higher among military veterans. cLBP is a persistent condition, and treatment options have either modest effects or a significant risk of side-effects, which has led to recent efforts to explore mind-body intervention options and reduce opioid medication use. Prior studies of yoga for cLBP in community samples, and the main results of a recent trial with military veterans, indicate that yoga can reduce back-related disability and pain intensity. Secondary outcomes from the trial of yoga with military veterans are presented here. In the study, 150 military veterans (Veterans Administration patients) with cLBP were randomized to either yoga or a delayed-treatment group receiving usual care between 2013 and 2015. Assessments occurred at baseline, 6 weeks, 12 weeks, and 6 months. Intent-to-treat analyses were conducted. Yoga classes lasting 60 minutes each were offered twice weekly for 12 weeks. Yoga sessions consisted of physical postures, movement, focused attention, and breathing techniques. Home practice guided by a manual was strongly recommended. The primary outcome measure was Roland-Morris Disability Questionnaire scores after 12 weeks. Secondary outcomes included pain intensity, pain interference, depression, fatigue, quality of life, self-efficacy, and medication usage. Yoga participants improved more than delayed-treatment participants on pain interference, fatigue, quality of life, and self-efficacy at 12 weeks and/or 6 months. Yoga participants had greater improvements across a number of important secondary health outcomes compared to controls. Benefits emerged despite some veterans facing challenges with attending yoga sessions in person. The findings support wider implementation of yoga programs for veterans, with attention to increasing accessibility of yoga programs in this population.

Groessl EJ, Weingart KR, Johnson N, Baxi S. The benefits of yoga for women veterans with chronic low back pain.  J Altern Complement Med. 2012 Sep;18(9):832-8. doi: 10.1089/acm.2010.0657. Epub 2012 Jul 19.

OBJECTIVES

Chronic low back (CLBP) pain is prevalent among military veterans and often leads to functional limitations, psychologic symptoms, lower quality of life, and higher health care costs. An increasing proportion of U.S. veterans are women, and women veterans may have different health care needs than men veterans. The purpose of this study was to assess the impact of a yoga intervention on women and men with CLBP. SUBJECTS/SETTING/INTERVENTION VA patients with CLBP were referred by primary care providers to a clinical yoga program.

DESIGN

Research participants completed a brief battery of questionnaires before their first yoga class and again 10 weeks later in a single-group, pre-post study design.

OUTCOME MEASURES:

Questionnaires included measures of pain (Pain Severity Scale), depression (CESD-10), energy/fatigue, and health-related quality of life (SF-12). Yoga attendance and home practice of yoga were also measured. Repeated-measures analysis of variance was used to analyze group differences over time while controlling for baseline differences.

RESULTS

The 53 participants who completed both assessments had a mean age of 53 years, and were well educated, 41% nonwhite, 49% married, and had varying employment status. Women participants had significantly larger decreases in depression (p=0.046) and pain "on average" (p=0.050), and larger increases in energy (p=0.034) and SF-12 Mental Health (p=0.044) than men who participated. The groups did not differ significantly on yoga attendance or home practice of yoga.

CONCLUSIONS

These results suggest that women veterans may benefit more than men veterans from yoga interventions for chronic back pain. Conclusions are tentative because of the small sample size and quasi-experimental study design. A more rigorous study is being designed to answer these research questions more definitively.

Grover MP et al. Am J Clin Hypn. (2018) The Association Between Mindfulness and Hypnotizability: Clinical and Theoretical Implications.

Mindfulness-based interventions and hypnosis are efficacious treatments for addressing a large number of psychological and physical conditions, including chronic pain. However, there continues to be debate surrounding the relative uniqueness of the theorized mechanisms of these treatments-reflected by measures of mindfulness facets and hypnotizability-with some concern that there may be so much overlap as to make the mechanism constructs (and, therefore, the respective interventions) redundant. Given these considerations, the primary aim of the current study was to examine the degree of unique versus shared variance between two common measures of mindfulness facets and hypnotizability: the Five Facet Mindfulness Questionnaire and the Stanford Hypnotic Clinical Scale. A cross-sectional survey was conducted with a sample of (N = 154) veterans with heterogeneous chronic pain conditions. Bivariate Pearson correlations were used to examine the associations between the target scales. Results showed that the correlations between the Five Facet Mindfulness Questionnaire scales and Stanford Hypnotic Clinical Scale total score were uniformly weak, although significant negative correlations were found between mindfulness facets of observe and nonreact with hypnotizability (ps < 0.05). Thus, not only are the mindfulness and hypnotizability constructs unique, but when significantly associated, hypnotic suggestibility corresponds with a tendency to be less mindful. These findings have important implications for future research aimed toward matching patients to the treatment most likely to be of benefit, and suggest that matching patients on the basis of these theoretically derived "unique" moderators may hold potential.

Guthrie RM, Chorba R. Physical Therapy Treatment Of Chronic Neck Pain A Discussion And Case Study: Using Dry Needling And Battlefield Acupuncture. J Spec Oper Med. 2016 Spring;16(1):1-5.

PURPOSE

Chronic mechanical neck pain can have a complex clinical presentation and is often difficult to treat. This case study illustrates a successful physical therapy treatment approach using dry needling and auricular acupuncture techniques.

CASE REPORT

A 51-year-old active-duty, male US Marine was treated by a physical therapist in a direct-access military clinic for chronic neck pain poorly responsive to previous physical therapy, pharmacologic, and surgical interventions. Needling techniques were combined with standard physical therapy interventions to address the comprehensive needs of the patient. Within five treatments, the patient reported reduced pain levels from 8-9/10 to 0-2/10, improved sleep quality, and increased function with daily activities. Over several months, the patient reduced multiple medication use by greater than 85%. The effects of treatment were lasting, and the patient accomplished a successful transition to an independent maintenance program.

CONCLUSION

Needling techniques have the potential to expedite favorable physical therapy outcomes for active-duty service members suffering from chronic mechanical and degenerative neck pain. The dramatic improvements observed in this case warrant additional exploration of treatment efficacy and delineation of best practices in the delivery of these techniques.

Halpin, S. N., Wei Huang, & Perkins, M. M. (2015). Comparisons between Body Needle Acupuncture, Auricular Acupuncture, and Auricular Magnet Therapy Given to Veterans Suffering from Chronic Pain. American Acupuncturist, 71, 7–12.

No known research has investigated patients' attitudes toward different acupuncture techniques, including those that require less training to administer and potentially could be made more widely available in order to meet the growing demand for acupuncture. The aim of this study was to determine attitudes toward and expectations regarding three different types of acupuncture. The cohort included all patients (n=114) who received acupuncture treatment at the Atlanta Veterans Affairs Medical Center between May 2012 and May 2014. The patients were mailed questionnaires. Patients who agreed to be contacted by phone also participated in semi-structured telephone interviews. The respondents to the mailed surveys (n=72) varied in their demographics and attitudes toward experiences with different types of acupuncture. Of these, a subset of respondents also completed semi-structured telephone interviews (n=45). Thematic analysis of the data revealed three key themes, including (1) perceived time commitment versus return on investment; (2) anxiety, pain, and fear of needles; and (3) the importance of the patient/clinician relationship. Findings showed that the quality of the patient/clinician relationship was a critical factor that shaped the respondents' attitudes toward the different treatment options and also influenced satisfaction with treatment. Patients who were disinclined toward needles and those who wanted longer-lasting pain relief were more likely to endorse auricular magnet therapy.

Han L, Goulet JL, Skanderson M, Bathulapalli H, Luther SL, Kerns RD, Brandt CA. Evaluation of Complementary and Integrative Health Approaches Among US Veterans with Musculoskeletal Pain Using Propensity Score Methods. Pain Med. 2018 Mar 23. doi: 10.1093/pm/pny027. [Epub ahead of print] PubMed PMID: 29584926.

OBJECTIVES

To examine the treatment effectiveness of complementary and integrative health approaches (CIH) on chronic pain using Propensity Score (PS) methods.

Design, Settings, and PARTICIPANTS

A retrospective cohort of 309,277 veterans with chronic musculoskeletal pain assessed over three years after initial diagnosis.

METHODS

CIH exposure was defined as one or more clinical visits for massage, acupuncture, or chiropractic care. The treatment effect of CIH on self-rated pain intensity was examined using a longitudinal model. PS-matching and inverse probability of treatment weighting (IPTW) were used to account for potential selection and confounding biases.

RESULTS

At baseline, veterans with (7,621) and without (301,656) CIH exposure differed significantly in 21 out of 35 covariates. During the follow-up period, on average CIH recipients had 0.83 (95% confidence interval [CI] = 0.77 to 0.89) points higher pain intensity ratings (range = 0-10) than nonrecipients. This apparent unfavorable effect size was reduced to 0.37 (95% CI = 0.28 to 0.45) after PS matching, 0.36 (95% CI = 0.29 to 0.44) with IPTW on the treated (IPTW-T) weighting, and diminished to null when integrating IPTW-T with PS matching (0.004, 95% CI = -0.09 to 0.10).

CONCLUSIONS

PS-based causal methods successfully eliminated baseline difference between exposure groups in all measured covariates, yet they did not detect a significant difference in the self-rated pain intensity outcome between veterans who received CIHs and those who did not during the follow-up period.

Herman PM, Yuan AH, Cefalu MS, Chu K, Zeng Q, Marshall N, Lorenz KA, Taylor SL The use of complementary and integrative health approaches for chronic musculoskeletal pain in younger US Veterans: An economic evaluation. PLoS One. 2019 Jun 5

OBJECTIVES

To estimate the cost-effectiveness to the US Veterans Health Administration (VA) of the use of complementary and integrative health (CIH) approaches by younger Veterans with chronic musculoskeletal disorder (MSD) pain.

PERSPECTIVE

VA healthcare system.

METHODS

We used a propensity score-adjusted hierarchical linear modeling (HLM), and 2010-2013 VA administrative data to estimate differences in VA healthcare costs, pain intensity (0-10 numerical rating scale), and opioid use between CIH users and nonusers. We identified CIH use in Veterans' medical records through Current Procedural Terminology, VA workload tracking, and provider-type codes.

RESULTS

We identified 30,634 younger Veterans with chronic MSD pain as using CIH and 195,424 with no CIH use. CIH users differed from nonusers across all baseline covariates except the Charlson comorbidity index. They also differed on annual pre-CIH-start healthcare costs ($10,729 versus $5,818), pain (4.33 versus 3.76), and opioid use (66.6% versus 54.0%). The HLM results indicated lower annual healthcare costs (-$637; 95% CI: -$1,023, -$247), lower pain (-0.34; -0.40, -0.27), and slightly higher (less than a percentage point) opioid use (0.8; 0.6, 0.9) for CIH users in the year after CIH start. Sensitivity analyses indicated similar results for three most-used CIH approaches (acupuncture, chiropractic care, and massage), but higher costs for those with eight or more CIH visits.

CONCLUSIONS

On average CIH use appears associated with lower healthcare costs and pain and slightly higher opioid use in this population of younger Veterans with chronic musculoskeletal pain. Given the VA's growing interest in the use of CIH, further, more detailed analyses of its impacts are warranted.

Highland KB, et al.  Benefits of the Restorative Exercise and Strength Training for Operational Resilience and Excellence Yoga Program for Chronic Low Back Pain in Service Members: A Pilot Randomized Controlled Trial.  Arch Phys Med Rehabil. 2018 Jan;99(1):91-98. doi: 10.1016/j.apmr.2017.08.473. Epub 2017 Sep 14.

OBJECTIVE

To examine the feasibility and preliminary effectiveness of an individualized yoga program.

DESIGN

Pilot randomized controlled trial.

SETTING

Military medical center.

PARTICIPANTS

Patients (N=68) with chronic low back pain.

INTERVENTIONS

Restorative Exercise and Strength Training for Operational Resilience and Excellence (RESTORE) program (9-12 individual yoga sessions) or treatment as usual (control) for an 8-week period.

MAIN OUTCOME MEASURES

The primary outcome was past 24-hour pain (Defense & Veterans Pain Rating Scale 2.0). Secondary outcomes included disability (Roland-Morris Disability Questionnaire) and physical functioning and symptom burden (Patient-Reported Outcomes Measurement Information System-29 subscales). Assessment occurred at baseline, week 4, week 8, 3-month follow-up, and 6-month follow-up. Exploratory outcomes included the proportion of participants in each group reporting clinically meaningful changes at 3- and 6-month follow-ups.

RESULTS

Generalized linear mixed models with sequential Bonferroni-adjusted pairwise significance tests and chi-square analyses examined longitudinal outcomes. Secondary outcome significance tests were Bonferroni adjusted for multiple outcomes. The RESTORE group reported improved pain compared with the control group. Secondary outcomes did not retain significance after Bonferroni adjustments for multiple outcomes, although a higher proportion of RESTORE participants reported clinically meaningfully changes in all outcomes at 3-month follow-up and in symptom burden at 6-month follow-up.

CONCLUSIONS

RESTORE may be a viable nonpharmacological treatment for low back pain with minimal side effects, and research efforts are needed to compare the effectiveness of RESTORE delivery formats (eg, group vs individual) with that of other treatment modalities.

Holliday SB, Hull A, Lockwood C, Eickhoff C, Sullivan P, Reinhard M.  Physical health, mental health, and utilization of complementary and alternative medicine services among Gulf War veterans. Med Care. 2014 Dec;52(12 Suppl 5):S39-44. doi: 10.1097/MLR.0000000000000223.

BACKGROUND

Gulf War veterans represent a unique subset of the veteran population. It has been challenging to identify interventions that result in improvements in physical and mental health for this population. Recently, there has been recognition of a potential role for complementary and alternative medicine (CAM) interventions.

OBJECTIVES

This paper examines the characteristics of Gulf War and non-Gulf War veterans referred to a CAM clinic, and explores the utilization of services by this population.

METHOD AND SUBJECTS

Participants included 226 veterans enrolled in a CAM clinic at a Veterans Affairs medical center, 42 of whom were Gulf War veterans. Self-report measures of physical/mental health were administered, and service utilization was obtained from participants' medical records for a 6-month period.

RESULTS

Gulf War veterans enrolled in the program reported more severe physical and mental health symptoms than non-Gulf War veterans. However, examining only veterans who participated in services in the 6 months following enrollment, the 2 groups reported similar symptom severity. Both groups were similar in their attendance of individual acupuncture and iRest yoga nidra, although Gulf War veterans attended fewer sessions of group acupuncture.

CONCLUSIONS

Although Gulf War veterans who enroll in a CAM program may have more severe symptoms than non-Gulf War veterans, those who actually participate in services are similar to non-Gulf War veterans on these measures. These groups also differ in their pattern of service utilization. Future research should explore the reasons for these differences, and to identify ways to promote treatment engagement with this population.

Huang W, Halpin SN, Perkins MM.  A case series of auricular acupuncture in a veteran's population using a revised auricular mapping-diagnostic paradigm (RAMP-uP).  Complement Ther Med. 2016 Aug;27:130-6. doi: 10.1016/j.ctim.2016.06.002. Epub 2016 Jun 24.

OBJECTIVES

To evaluate clinical effects of auricular acupuncture treatments for pain based on a revised auricular mapping and diagnostic paradigm (RAMP-uP).

DESIGN

Retrospective chart review.

SETTING

A major US Veterans Affairs Medical Centre located in the Southeaster United States.

MAIN OUTCOME MEASURES

Pain and efficacy rating scores based on visual analogue scales during each clinical visit. Duration of acupuncture treatment effects based on clinic notes documentation.

RESULTS

Patients' average pain score decreased by almost 60% (p<0.0001). The treatment effects lasted 1-3 months (47%). The overall efficacy reported by most patients was helpful (83.6%).

CONCLUSION

The observed clinical effects of auricular acupuncture based on RAMP-uP are promising. Further research is needed to assess its feasibility to generalize and generate clinical effects in randomized controlled clinical trials.

Jonas WB, Bellanti DM, Paat CF, Boyd CC, Duncan A, Price A, Zhang W, French LM, Chae H. A Randomized Exploratory Study to Evaluate Two Acupuncture Methods for the Treatment of Headaches Associated with Traumatic Brain Injury. Med Acupunct. 2016 Jun 1;28(3):113-130.

BACKGROUND

Headaches are prevalent among Service members with traumatic brain injury (TBI); 80% report chronic or recurrent headache. Evidence for nonpharmacologic treatments, such as acupuncture, are needed.

OBJECTIVE

The aim of this research was to determine if two types of acupuncture (auricular acupuncture [AA] and traditional Chinese acupuncture [TCA]) were feasible and more effective than usual care (UC) alone for TBI-related headache.

Materials and METHODSDESIGN

This was a three-armed, parallel, randomized exploratory study. SETTING The research took place at three military treatment facilities in the Washington, DC, metropolitan area. Patients: The subjects were previously deployed Service members (18-69 years old) with mild-to-moderate TBI and headaches.

INTERVENTION

The interventions explored were UC alone or with the addition of AA or TCA. Outcome Measures: The primary outcome was the Headache Impact Test (HIT). Secondary outcomes were the Numerical Rating Scale (NRS), Pittsburgh Sleep Quality Index, Post-Traumatic Stress Checklist, Symptom Checklist-90-R, Medical Outcome Study Quality of Life (QoL), Beck Depression Inventory, State-Trait Anxiety Inventory, the Automated Neuropsychological Assessment Metrics, and expectancy of outcome and acupuncture efficacy.

RESULTS

Mean HIT scores decreased in the AA and TCA groups but increased slightly in the UC-only group from baseline to week 6 [AA, -10.2% (-6.4 points); TCA, -4.6% (-2.9 points); UC, +0.8% (+0.6 points)]. Both acupuncture groups had sizable decreases in NRS (Pain Best), compared to UC (TCA versus UC: P = 0.0008, d = 1.70; AA versus UC: P = 0.0127, d = 1.6). No statistically significant results were found for any other secondary outcome measures.

CONCLUSIONS

Both AA and TCA improved headache-related QoL more than UC did in Service members with TBI.

Juberg M, Jerger KK, Allen KD, Dmitrieva NO, Keever T, Perlman AI. Pilot study of massage in veterans with knee osteoarthritis. J Altern Complement Med. 2015

OBJECTIVES

To (1) assess the feasibility and acceptability of Swedish massage among Department of Veterans Affairs (VA) health care users with knee osteoarthritis (OA) and (2) collect preliminary data on efficacy of Swedish massage in this patient group.

DESIGN

Experimental pilot study.

SETTING

Duke Integrative Medicine clinic and VA Medical Center, Durham, North Carolina.

PATIENTS

Twenty-five veterans with symptomatic knee OA.

INTERVENTIONS

Eight weekly 1-hour sessions of full-body Swedish massage.

OUTCOME MEASURES

Primary: Western Ontario and McMaster University Osteoarthritis Index (WOMAC) and global pain (Visual Analog Scale [VAS]). Secondary: National Institutes of Health Patient Reported Outcomes Measurement Information System-Pain Interference Questionnaire 6b (PROMIS-PI 6b), 12-Item Short-Form Health Survey (SF-12 v1) and the EuroQol health status index (EQ-5D-5L), knee range of motion (ROM), and time to walk 50 feet.

RESULTS

Study feasibility was established by a 92% retention rate with 99% of massage visits and 100% of research visits completed. Results showed significant improvements in self-reported OA-related pain, stiffness and function (30% improvement in Global WOMAC scores; p=0.001) and knee pain over the past 7 days (36% improvement in VAS score; p<0.001). PROMIS-PI, EQ-5D-5L, and physical composite score of the SF-12 also significantly improved (p<0.01 for all), while the mental composite score of the SF-12 and knee ROM showed trends toward significant improvement. Time to walk 50 feet did not significantly improve.

CONCLUSIONS

Results of this pilot study support the feasibility and acceptability of Swedish massage among VA health care users as well as preliminary data suggesting its efficacy for reducing pain due to knee OA. If results are confirmed in a larger randomized trial, massage could be an important component of regular care for these patients.

Kearney DJ, Simpson TL, Malte CA, Felleman B, Martinez ME, Hunt SC. Mindfulness-based Stress Reduction in Addition to Usual Care Is Associated with Improvements in Pain, Fatigue, and Cognitive Failures Among Veterans with Gulf War Illness. Am J Med. 2016 Feb;129(2):204-14.

BACKGROUND

Many Gulf War I veterans report ongoing negative health consequences. The constellation of pain, fatigue, and concentration/memory disturbances is referred to as "Gulf War illness." Prior research suggests that mindfulness-based stress reduction may be beneficial for these symptoms, but mindfulness-based stress reduction has not been studied for veterans with Gulf War illness. The objective of this trial was to conduct a pilot study of mindfulness-based stress reduction for veterans with Gulf War illness.

METHODS

Veterans (N = 55) with Gulf War illness were randomly assigned to treatment as usual plus mindfulness-based stress reduction or treatment as usual only. Mindfulness-based stress reduction was delivered in 8 weekly 2.5-hour sessions plus a single 7-hour weekend session. Pain, fatigue, and cognitive failures were the primary outcomes, assessed at baseline, after mindfulness-based stress reduction, and 6 months follow-up. Secondary outcomes included symptoms of posttraumatic stress disorder and depression.

RESULTS

In intention-to-treat analyses, at 6-month follow-up, veterans randomized to mindfulness-based stress reduction plus treatment as usual reported greater reductions in pain (f = 0.33; P = .049), fatigue (f = 0.32; P = .027), and cognitive failures (f = 0.40; P < .001). Depressive symptoms showed a greater decline after mindfulness-based stress reduction (f = 0.22; P = .050) and at 6 months (f = 0.27; P = .031) relative to treatment as usual only. Veterans with posttraumatic stress disorder at baseline randomized to mindfulness-based stress reduction plus treatment as usual experienced significantly greater reductions in symptoms of posttraumatic stress disorder after mindfulness-based stress reduction (f = 0.44; P = .005) but not at 6 months follow-up (f = 0.31; P = .082).

CONCLUSIONS

Mindfulness-based stress reduction in addition to treatment as usual is associated with significant improvements in self-reported symptoms of Gulf War illness, including pain, fatigue, cognitive failures, and depression.

Kerns RD, Brandt CA. NIH-DOD-VA Pain Management Collaboratory: Pragmatic Clinical Trials of Nonpharmacological Approaches for Management of Pain and Co-occurring Conditions in Veteran and Military Health Systems: Introduction. Pain Med. 2020;21(Suppl 2):S1-S4. doi:10.1093/pm/pnaa358

Military service members and veterans are widely recognized as having a high burden of pain, and, when present, pain is commonly severe, disabling, and complex, often co-occurring with medical conditions and mental health and substance use disorders [12, 13]. The U.S. Department of Defense (DOD) and its Defense Health Agency (DHA) and the VHA are particularly well suited to conducting PCTs on nonpharmacological pain management approaches. These systems are large, integrated, learning health care organizations, with opportunities to optimize the use of integrated electronic health records and other patient, provider, and organizational data. These systems have an infrastructure that supports clinical research, including multisite clinical trials. The DHA and VHA have prioritized pain management and have promoted non-opioid pharmacological and nonpharmacological approaches, including complementary and integrative health approaches. In 2017, the U.S. Department of Health and Human Services National Institutes of Health (NIH) partnered with the DOD and VA in funding a novel Pain Management Collaboratory (PMC), which supports the conduct of 11 PCTs of nonpharmacological approaches for the management of pain and co-occurring conditions in veterans and military service members and their dependents. The NIH also funds a PMC Coordinating Center to support this initiative. A description of the PMC has been published previously in this journal [14]. In addition to the present Introduction, this special supplement to the journal includes descriptions of these 11 PCTs. These articles are complemented by an additional guest editorial from Lieutenant General (Retired) Eric Schoomaker, former U.S. Army Surgeon General and a key advocate for this initiative [15]. Additional articles by Dr. Kirsha Gordon and colleagues [16] describe important considerations relevant to the design of PCTs of nonpharmacological approaches for managing pain, and an article authored by Bastian and her colleagues [17] discusses the benefits of stakeholder engagement in the design and conduct of PCTs, drawing on examples from the PMC studies.

Kerns RD, Dobscha SK. Pain among veterans returning from deployment in Iraq and Afghanistan: update on the Veterans Health Administration Pain Research Program. Pain Med. 2009 Oct;10(7):1161-4. doi: 10.1111/j.1526-4637.2009.00722.x. PubMed PMID: 19818026.

In November 1998, the former Undersecretary for Health for the Department of Veterans Affairs (VA), Dr. Kenneth Kizer, launched the Veterans Health Administration (VHA) National Pain Management Strategy establishing pain management as a national priority. The overall objective of the national strategy is to develop a comprehensive, multicultural, integrated, system-wide approach to pain management that reduces pain and suffering and improves quality of life for veterans experiencing acute and chronic pain associated with a wide range of injuries and illnesses, including terminal illness. Among the key elements of the strategy, a need to "expand basic and applied research on management of acute and chronic pain, emphasizing conditions that are most prevalent among Veterans," was articulated.

King CH, Moore LC, Spence CD. Exploring Self-Reported Benefits of Auricular Acupuncture Among Veterans With Posttraumatic Stress Disorder. J Holist Nurs. 2016 Sep;34(3):291-9. doi: 10.1177/0898010115610050.

PURPOSE

Auricular acupuncture treatments are becoming increasingly available within military treatment facilities, resulting in an expansion of nonpharmacologic treatment options available to veterans with posttraumatic stress disorder (PTSD). This study aimed to explore the self-reported benefits of auricular acupuncture treatments for veterans living with PTSD.

DESIGN

A qualitative research methodology, thematic content analysis, was used to analyze data.

METHOD

Seventeen active duty veterans with PTSD provided written comments to describe their experiences and perceptions after receiving a standardized auricular acupuncture regimen for a 3-week period as part of a pilot feasibility study.

FINDINGS

A variety of symptoms experienced by veterans with PTSD were improved after receiving auricular acupuncture treatments. Additionally, veterans with PTSD were extremely receptive to auricular acupuncture treatments. Four themes emerged from the data: (1) improved sleep quality, (2) increased relaxation, (3) decreased pain, and (4) veterans liked/loved the auricular acupuncture treatments.

CONCLUSIONS

Veterans with PTSD reported numerous benefits following auricular acupuncture treatments. These treatments may facilitate healing and recovery for veterans with combat-related PTSD, although further investigations are warranted into the mechanisms of action for auricular acupuncture in this population.

King K, Gosian J, Doherty K, Chapman J, Chapman J, Walsh C, Pokaski Azar J, Pokaski Azar J, Danhauer SC, Moye J.. Implementing yoga therapy adapted for older veterans who are cancer survivors. Int J Yoga Therap. 2014;24:87-96.

OBJECTIVES

This goal of this paper is to describe the reach, application, and effectiveness of an 8-week yoga therapy protocol with older cancer survivors within a Veterans Health Administration setting.

METHODS

To document the reach of this intervention, recruitment efforts, attendance, and practice rates were tracked. To explore the application of the protocol to this population, physical therapy preassessment and observations by the yoga therapist were recorded to ascertain necessary pose modifications. Effectiveness was measured through pre- and post-course structured interviews, tracking self-reported symptoms of combat-related posttraumatic stress disorder, depression, anxiety, fatigue, insomnia, and pain.

RESULTS

Regarding reach, 15% of eligible veterans (n = 14) enrolled, participated in 3-16 classes (M±SD = 11.64±3.39), and practiced at home for 0-56 days (M±SD = 26.36±17.87). Participants were primarily Caucasian (n = 13), male (n = 13), ranged in age from 55 to 78 years (M±SD = 65.64±5.15), and had multiple medical problems. During application, substantial individualized modifications to the yoga therapy protocol were necessary. Effectiveness of the intervention was mixed. During post-course interviews, participants reported a variety of qualitative benefits. Notably, the majority of participants reported that breathing and relaxation techniques were the most useful to learn. Group comparisons of mean pre- and post-course scores on standardized measures showed no significant differences.

CONCLUSIONS

A minority of older veterans express an interest in yoga, but those who do have high rates of class attendance and home practice. Careful physical pre-assessment and attentive therapists are required to undertake the adaptations required by participants with multiple comorbidities. The effectiveness of yoga in this setting requires additional study.

Kligler B, Bair MJ, Banerjea R, DeBar L, Ezeji-Okoye S, Lisi A, Murphy JL, Sandbrink F, Cherkin DC. Clinical Policy Recommendations from the VHA State-of-the-Art Conference on Non-Pharmacological Approaches to Chronic Musculoskeletal Pain. J Gen Intern Med. 2018 May;33(Suppl 1):16-23. doi: 10.1007/s11606-018-4323-z. PubMed PMID: 29633133; PubMed Central PMCID: PMC5902342.

As a large national healthcare system, Veterans Health Administration (VHA) is ideally suited to build on its work to date and develop a safe, evidence-based, and comprehensive approach to the care of chronic musculoskeletal pain conditions that de-emphasizes opioid use and emphasizes non-pharmacological strategies. The VHA Office of Health Services Research and Development (HSR&D) held a state-of-the-art (SOTA) conference titled "Non-pharmacological Approaches to Chronic Musculoskeletal Pain Management" in November 2016. Goals of the conference were (1) to establish consensus on the current state of evidence regarding non-pharmacological approaches to chronic musculoskeletal pain to inform VHA policy in this area and (2) to begin to identify priorities for the future VHA research agenda. Workgroups were established and asked to reach consensus recommendations on clinical and research priorities for the following treatment strategies: psychological/behavioral therapies, exercise/movement therapies, manual therapies, and models for delivering multimodal pain care. Participants in the SOTA identified nine non-pharmacological therapies with sufficient evidence to be implemented across the VHA system as part of pain care. Participants further recommended that effective integration of these non-pharmacological approaches across the VHA and especially into VHA primary care, pain care, and mental health settings should be a priority, and that these treatments should be offered early in the course of pain treatment and delivered in a team-based, multimodal treatment setting concurrently with active self-care and self-management approaches. In addition, we recommend that VHA leadership and policy makers systematically address the barriers to implementation of these approaches by expanding opportunities for clinician and veteran education on the effectiveness of these strategies; supporting and funding further research to determine optimal dosage, duration, sequencing, combination, and frequency of treatment; emphasizing multimodal care with rigorous evaluation grounded in team-based approaches to test integrated models of delivery and stepped-care approaches; and working to address socioeconomic and cultural barriers to veterans' access to non-pharmacological approaches.

Lisi AJ, Corcoran KL, DeRycke EC, Bastian LA, Becker WC, Edmond SN, Goertz CM, Goulet JL, Haskell SG, Higgins DM, Kawecki T, Kerns RD, Mattocks K, Ramsey C, Ruser CB, Brandt CA. Opioid Use Among Veterans of Recent Wars Receiving Veterans Affairs Chiropractic Care. Pain Med. 2018 Sep 1;19(suppl_1):S54-S60. doi: PubMed PMID: 30203014.

OBJECTIVE

To examine patient sociodemographic and clinical characteristics associated with opioid use among Veterans of Operations Enduring Freedom/Iraqi Freedom/New Dawn (OEF/OIF/OND) who receive chiropractic care, and to explore the relationship between timing of a chiropractic visit and receipt of an opioid prescription.

METHODS

Cross-sectional analysis of administrative data on OEF/OIF/OND veterans who had at least one visit to a Veterans Affairs (VA) chiropractic clinic between 2004 and 2014. Opioid receipt was defined as at least one prescription within a window of 90 days before to 90 days after the index chiropractic clinic visit.

RESULTS

We identified 14,025 OEF/OIF/OND veterans with at least one chiropractic visit, and 4,396 (31.3%) of them also received one or more opioid prescriptions. Moderate/severe pain (odds ratio [OR] = 1.87, 95% confidence interval [CI] = 1.72-2.03), PTSD (OR = 1.55, 95% CI = 1.41-1.69), depression (OR = 1.40, 95% CI = 1.29-1.53), and current smoking (OR = 1.39, 95% CI = 1.26-1.52) were associated with a higher likelihood of receiving an opioid prescription. The percentage of veterans receiving opioid prescriptions was lower in each of the three 30-day time frames assessed after the index chiropractic visit than before.

CONCLUSIONS

Nearly one-third of OEF/OIF/OND veterans receiving VA chiropractic services also received an opioid prescription, yet the frequency of opioid prescriptions was lower after the index chiropractic visit than before. Further study is warranted to assess the relationship between opioid use and chiropractic care.

Lisi AJ, Salsbury SA, Hawk C, Vining RD, Wallace RB, Branson R, Long CR, Burgo-Black AL, Goertz CM. Chiropractic Integrated Care Pathway for Low Back Pain in Veterans: Results of a Delphi Consensus Process. J Manipulative Physiol Ther. 2018 Feb;41(2):137-148. doi: 10.1016/j.jmpt.2017.10.001. PubMed PMID: 29482827; PubMed Central PMCID: PMC6103526.

OBJECTIVE

The purpose of this study was to develop an integrated care pathway for doctors of chiropractic, primary care providers, and mental health professionals who manage veterans with low back pain, with or without mental health comorbidity, within Department of Veterans Affairs health care facilities.

METHODS

The research method used was a consensus process. A multidisciplinary investigative team reviewed clinical guidelines and Veterans Affairs pain and mental health initiatives to develop seed statements and care algorithms to guide chiropractic management and collaborative care of veterans with low back pain. A 5-member advisory committee approved initial recommendations. Veterans Affairs-based panelists (n = 58) evaluated the pathway via e-mail using a modified RAND/UCLA methodology. Consensus was defined as agreement by 80% of panelists.

RESULTS

The modified Delphi process was conducted in July to December 2016. Most (93%) seed statements achieved consensus during the first round, with all statements reaching consensus after 2 rounds. The final care pathway addressed the topics of informed consent, clinical evaluation including history and examination, screening for red flags, documentation, diagnostic imaging, patient-reported outcomes, adverse event reporting, chiropractic treatment frequency and duration standards, tailored approaches to chiropractic care in veteran populations, and clinical presentation of common mental health conditions. Care algorithms outlined chiropractic case management and interprofessional collaboration and referrals between doctors of chiropractic and primary care and mental health providers.

CONCLUSION

This study offers an integrative care pathway that includes chiropractic care for veterans with low back pain.

Lisi AJ. Management of Operation Iraqi Freedom and Operation Enduring Freedom veterans in a VeteransHealth Administration chiropractic clinic: a case series. J Rehabil Res Dev. 2010;47(1):1-6.

Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF) veterans commonly seek care for musculoskeletal complaints in Veterans Health Administration (VHA) facilities. Chiropractic services for musculoskeletal conditions have recently been introduced to VHA. No reports have been published on chiropractic care for OIF/OEF veterans. This study was designed to describe elements of the processes and outcomes of care for OIF/OEF veterans in a VHA chiropractic clinic. A retrospective review of consecutive cases consulted to one VHA chiropractic clinic was conducted. Thirty-one cases were identified. Consultations originated in primary care and specialty clinics that commonly manage musculoskeletal conditions. Military traumatic injury and posttraumatic stress disorder were common. Adverse effects of treatment were mild and transitory. In 19 cases (61%), a pain decrease above the threshold for minimally important change was reported. This article is the first description of health services delivered to OIF/OEF veterans in a VHA chiropractic clinic. Chiropractic management was safe in these cases, and results support the hypothesis that such management may be effective in certain OIF/OIF veterans. A better understanding of the characteristics of these particular patients and the processes of care received in VHA chiropractic clinics is needed to improve the clinical care of these veterans.

Liu K, Madrigal E, Chung JS, Parekh M, Kalahar CS, Nguyen D, Timmerman M, Harris OA. Preliminary Study of Virtual-reality-guided Meditation for Veterans with Stress and Chronic Pain. Altern Ther Health Med. 2021 Sep 24:AT6861.

CONTEXT

Studies have found evidence for meditation's positive effects on health and well-being, but the difficulty of learning and engaging in meditation practice has been identified as a major barrier. Virtual reality (VR) technology may facilitate meditation practice by immersing users in a distraction-free and calming virtual environment, although this theory has yet to be rigorously tested.

OBJECTIVE

This study intended to examine the efficacy of VR-guided meditation in a population of US veterans as a tool to facilitate meditation and relaxation practice for reduction of stress and chronic pain as well as to elicit participants' feedback regarding their perceptions of VR-guided meditation.

DESIGN

The research team designed a preliminary study to identify the scope of future investigations.

SETTING

The study was conducted at an outpatient polytrauma clinic in a Veterans Affairs (VA) Palo Alto Health Care System, located in Palo Alto, California.

PARTICIPANTS

Participants were a convenience sample of 31 veterans, with an average age of 55.2 years, who were patients at the polytrauma clinic and who had conditions with varying levels of stress and chronic pain.

INTERVENTION

All participants completed a 10-minute, VR-guided-meditation session based on the Zen form of meditation.

OUTCOME MEASURES

At baseline immediately before and postintervention immediately after the VR meditation session, self-report ratings of pain and stress, physiological measures testing heart rate (HR) and blood pressure (BP), and participants' survey responses that assessed their experiences with, attitudes toward, and concerns about VR for clinical therapy were obtained.

RESULTS

Participants showed statistically significant reductions in self-reported pain and stress, HR, and systolic and diastolic BP. Participants reported high satisfaction with VR-guided meditation, and few reported negative side-effects.

CONCLUSIONS

The study provided evidence for the usefulness of VR technology as a facilitator of meditation practice for reduction of stress and chronic pain. Future studies are needed to examine the long-term effects of repeated VR-guided-meditation sessions for patients with stress and chronic pain.

Long CR, Salsbury SA, Vining RD, Lisi AJ, Corber L, Twist E, Abrams T, Wallace RB, Goertz CM. Care Outcomes for Chiropractic Outpatient Veterans (COCOV): a single-arm, pragmatic, pilot trial of multimodal chiropractic care for U.S. veterans with chronic low back pain. Pilot Feasibility Stud. 2022 Mar 7;8(1):54. doi: 10.1186/s40814-022-01008-0. PMID: 35256010; PMCID: PMC8900358.

BACKGROUND

Over 25% of veterans seeking care at U.S. Veterans Health Administration facilities have chronic low back pain (LBP), with high rates of mental health comorbidities. The primary objective of this study was to assess the feasibility of participant recruitment, retention, and electronic data collection to prepare for the subsequent randomized trial of multimodal chiropractic care for pain management of veterans with chronic low back pain. The secondary objectives were to estimate effect sizes and variability of the primary outcome and choose secondary outcomes for the full-scale trial.

METHODS

This single-arm pilot trial enrolled 40 veterans with chronic LBP at one Veterans Health Administration facility for a 10-week course of pragmatic multimodal chiropractic care. Recruitment was by (1) provider referral, (2) invitational letter from the electronic health record pre-screening, and (3) standard direct recruitment. We administered patient-reported outcome assessments through an email link to REDCap, an electronic data capture platform, at baseline and 5 additional timepoints. Retention was tracked through adherence to the treatment plan and completion rates of outcome assessments. Descriptive statistics were calculated for baseline characteristics and outcome variables.

RESULTS

We screened 91 veterans over 6 months to enroll our goal of 40 participants. Seventy percent were recruited through provider referrals. Mean age (range) was 53 (22-79) years and 23% were female; 95% had mental health comorbidities. The mean number of chiropractic visits was 4.5 (1-7). Participants adhered to their treatment plan, with exception of 3 who attended only their first visit. All participants completed assessments at the in-person baseline visit and 80% at the week 10 final endpoint. We had no issues administering assessments via REDCap. We observed clinically important improvements on the Roland-Morris Disability Questionnaire [mean change (SD): 3.6 (6.1)] and on PROMIS® pain interference [mean change (SD): 3.6 (5.6)], which will be our primary and key secondary outcome, respectively, for the full-scale trial.

CONCLUSIONS

We demonstrated the feasibility of participant recruitment, retention, and electronic data collection for conducting a pragmatic clinical trial of chiropractic care in a Veterans Health Administration facility. Using the pilot data and lessons learned, we modified and refined a protocol for a full-scale, multisite, pragmatic, National Institutes of Health-funded randomized trial of multimodal chiropractic care for veterans with chronic LBP that began recruitment in February 2021.

Maddox D, Deschner B, Goodsun D, Lapiz-Bluhm MD. Veterans Team Recovery Integrative Immersion Process (Vet TRIIP): A Qualitative Evaluation of Participation and Impact [published online ahead of print, 2020 Mar 31]. Mil Med. 2020;usaa053. doi:10.1093/milmed/usaa053

INTRODUCTION

The Veterans Team Recovery Integrative Immersion Process (Vet TRIIP) is a short-term multi-modality complementary, integrative immersion program for veterans with chronic pain, post-traumatic stress, and related symptoms. Geared toward Veterans, active duty servicemembers, family members, and caregivers, Vet TRIIP aims to honor and empower them to create healthy, happy, and productive civilian lives. This study evaluates the program to determine its impact on the quality of life and ways to improve and develop Vet TRIIP.

MATERIALS AND METHODS

In total, 14 clients participated in the qualitative review of the Vet TRIIP program in San Antonio. The participants were interviewed related to their reason for participating, their most bothersome symptoms and the effects of Vet TRIIP on those symptoms, service provided that is most and least appreciated, suggestions for improvement, and things learned from Vet TRIIP that helped them daily. Responses were analyzed for emerging themes.

RESULTS

The main reasons for participating were physiological and psychological needs, social support, and curiosity to address their reported symptoms such as pain, stress/anxiety, and depression. Vet TRIIP reportedly improved their quality of life and decreased stress. The participants liked most the support of the Vet TRIIP staff and the interventions such as reiki and massage. Other participants did not like acupuncture. Participants suggested the addition of professional psychological services could be helpful. They reported that emotional freedom technique (EFT/tapping) and guided breathing were most useful in their daily lives. Each participant reported that Vet TRIIP was a positive experience that helped with their pain, anxiety, and stress management, providing an improvement in their quality of life. It also imparted an eye-opening experience to nontraditional non-pharmacological interventions for pain, anxiety, and stress.

CONCLUSIONS

Evaluative studies on organizations that support Veterans are useful to gauge the effectiveness and impact. Through this study, Veterans expressed perceived strengths and weaknesses of the program so further development and appropriate services will be provided. Similar studies on the impact of non-profit organizations are encouraged. Vet TRIIP significantly impacts the lives of many through stress and pain reduction, potentially preventing suicide.

Mannes ZL, Stohl M, Fink DS, Olfson M, Keyes KM, Martins SS, Gradus JL, Saxon AJ, Maynard C, Livne O, Gutkind S, Hasin DS. Non-pharmacological Treatment for Chronic Pain in US Veterans Treated Within the Veterans Health Administration: Implications for Expansion in US Healthcare Systems. J Gen Intern Med. 2022 Jan 19:1–10.

BACKGROUND

Consensus guidelines recommend multimodal chronic pain treatment with increased use of non-pharmacological treatment modalities (NPM), including as first-line therapies. However, with many barriers to NPM uptake in US healthcare systems, NPM use may vary across medical care settings. Military veterans are disproportionately affected by chronic pain. Many veterans receive treatment through the Veterans Health Administration (VHA), an integrated healthcare system in which specific policies promote NPM use.

OBJECTIVE

To examine whether veterans with chronic pain who utilize VHA healthcare were more likely to use NPM than veterans who do not utilize VHA healthcare.

DESIGN

Cross-sectional nationally representative study.

Participants: US military veterans (N = 2,836).

Main measures: In the 2019 National Health Interview Survey, veterans were assessed for VHA treatment, chronic pain (i.e., past 3-month daily or almost daily pain), symptoms of depression and anxiety, substance use, and NPM (i.e., physical therapy, chiropractic/spinal manipulation, massage, psychotherapy, educational class/workshop, peer support groups, or yoga/tai chi).

KEY RESULTS

Chronic pain (45.2% vs. 26.8%) and NPM use (49.8% vs. 39.4%) were more prevalent among VHA patients than non-VHA veterans. After adjusting for sociodemographic characteristics, psychiatric symptoms, physical health indicators, and use of cigarettes or prescription opioids, VHA patients were more likely than non-VHA veterans to use any NPM (adjusted odds ratio [aOR] = 1.52, 95% CI: 1.07-2.16) and multimodal NPM (aOR = 1.80, 95% CI: 1.12-2.87) than no NPM. Among veterans with chronic pain, VHA patients were more likely to use chiropractic care (aOR = 1.90, 95% CI = 1.12-3.22), educational class/workshop (aOR = 3.02, 95% CI = 1.35-6.73), or psychotherapy (aOR = 4.28, 95% CI = 1.69-10.87).

CONCLUSIONS

Among veterans with chronic pain, past-year VHA use was associated with greater likelihood of receiving NPM. These findings may suggest that the VHA is an important resource and possible facilitator of NPM. VHA policies may offer guidance for expanding use of NPM in other integrated US healthcare systems.

Marshall A, Joyce CT, Tseng B, Gerlovin H, Yeh GY, Sherman KJ, Saper RB, Roseen EJ. Changes in Pain Self-Efficacy, Coping Skills, and Fear-Avoidance Beliefs in a Randomized Controlled Trial of Yoga, Physical Therapy, and Education for Chronic Low Back Pain. Pain Med. 2022 Apr 8;23(4):834-843. doi: 10.1093/pm/pnab318.

OBJECTIVE

We evaluated exercise interventions for cognitive appraisal of chronic low back pain (cLBP) in an underserved population.

We conducted a secondary analysis of the Back to Health Trial, showing yoga to be noninferior to physical therapy (PT) for pain and function outcomes among adults with cLBP (n = 320) recruited from primary care clinics with predominantly low-income patients. Participants were randomized to 12 weeks of yoga, PT, or education. Cognitive appraisal was assessed with the Pain Self-Efficacy Questionnaire (PSEQ), Coping Strategies Questionnaire (CSQ), and Fear-Avoidance Beliefs Questionnaire (FABQ). Using multiple imputation and linear regression, we estimated within- and between-group changes in cognitive appraisal at 12 and 52 weeks, with baseline and the education group as references.

RESULTS

Participants (mean age = 46 years) were majority female (64%) and majority Black (57%), and 54% had an annual household income <$30,000. All three groups showed improvements in PSEQ (range 0-60) at 12 weeks (yoga, mean difference [MD] = 7.0, 95% confidence interval [CI]: 4.9, 9.0; PT, MD = 6.9, 95% CI: 4.7 to 9.1; and education, MD = 3.4, 95% CI: 0.54 to 6.3), with yoga and PT improvements being clinically meaningful. At 12 weeks, improvements in catastrophizing (CSQ, range 0-36) were largest in the yoga and PT groups (MD = -3.0, 95% CI: -4.4 to -1.6; MD = -2.7, 95% CI: -4.2 to -1.2, respectively). Changes in FABQ were small. No statistically significant between-group differences were observed on PSEQ, CSQ, or FABQ at either time point. Many of the changes observed at 12 weeks were sustained at 52 weeks.

CONCLUSION

All three interventions were associated with improvements in self-efficacy and catastrophizing among low-income, racially diverse adults with cLBP.

Mathersul DC, Dixit K, Avery TJ, Schulz-Heik RJ, Zeitzer JM, Mahoney LA, Cho RH, Bayley PJ. Heart rate and heart rate variability as outcomes and longitudinal moderators of treatment for pain across follow-up in Veterans with Gulf War illness. Life Sci. 2021 Jul 15;277:119604. doi: 10.1016/j.lfs.2021.119604. Epub 2021 May 11. PMID: 33984356.

AIMS

Accumulating evidence suggests Gulf War illness (GWI) is characterized by autonomic nervous system dysfunction (higher heart rate [HR], lower heart rate variability [HRV]). Yoga - an ancient mind-body practice combining mindfulness, breathwork, and physical postures - is proposed to improve autonomic dysfunction yet this remains untested in GWI. We aimed to determine (i) whether HR and HRV improve among Veterans with GWI receiving either yoga or cognitive behavioral therapy (CBT) for pain; and (ii) whether baseline autonomic functioning predicts treatment-related pain outcomes across follow-up.

MAIN METHODS

We present secondary analyses of 24-hour ambulatory cardiac data (mean HR, square root of the mean squared differences between successive R-R intervals [RMSSD], high frequency power [HF-HFV], and low-to-high frequency ratio [LF/HF] extracted from a 5-min window during the first hour of sleep) from our randomized controlled trial of yoga versus CBT for pain among Veterans with GWI (ClinicalTrials.govNCT02378025; N = 75).

KEY FINDINGS

Veterans who received CBT tended towards higher mean HR at end-of-treatment. Better autonomic function (lower mean HR, higher RMSSD/HF-HRV) at baseline predicted greater reductions in pain across follow-up, regardless of treatment group. Better baseline autonomic function (mid-range-to-high RMSSD/HF-HRV) also predicted greater pain reductions with yoga, while worse baseline autonomic function (higher mean HR, lower RMSSD/HF-HRV) predicted greater pain reductions with CBT.

SIGNIFICANCE

To our knowledge, this is the first study to suggest that among Veterans with GWI, HR may increase with CBT yet remain stable with yoga. Furthermore, HR and HRV moderated pain outcome across follow-up for yoga and CBT.

Mathersul DC, Mahoney LA, Bayley PJ. Tele-yoga for Chronic Pain: Current Status and Future Directions. Glob Adv Health Med. 2018 Apr 2;7:2164956118766011. doi: 10.1177/2164956118766011. eCollection 2018. PubMed PMID: 29637012; PubMed Central PMCID: PMC5888810.

Pain is a pervasive, debilitating disorder that is resistant to long-term pharmacological interventions. Although psychological therapies such as cognitive behavior therapy demonstrate moderate efficacy, many individuals continue to have ongoing difficulties following treatment. There is a current trend to establish complementary and integrative health interventions for chronic pain, for which yoga has been found to have exciting potential. Nevertheless, an important consideration within the field is accessibility to adequate care. Telehealth can be used to provide real-time interactive video conferencing leading to increased access to health care for individuals located remotely or who otherwise have difficulty accessing services, perhaps through issues of mobility or proximity of adequate services. This article assesses the current status and feasibility of implementing tele-yoga for chronic pain. Methodological limitations and recommendations for future research are discussed.

McCarthy A, Liu L, Groessl E. Mediational Analysis of Yoga's Effect on Chronic Low-Back Pain in Veterans: What Factors Really Matter? Int J Yoga Therap. 2022 Jan 1;32(2022):Article 9. doi: 10.17761/2022-D-21-00020. PMID: 35921688.

Considerable evidence supports yoga as a treatment for chronic low-back pain (CLBP), yet more research is needed on the mechanisms of yoga. Yoga may be particularly helpful for military veteran populations, where there is a high prevalence of CLBP due to intensive training requirements. Our objective was to examine possible mechanisms by which yoga reduced disability in a clinical trial of yoga for veterans with CLBP. Using data from a prior randomized controlled trial, we used mediation analysis to examine factors that may mediate or influence the effects of yoga on disability over time. The 12-week yoga intervention study measured outcomes at baseline, 6 weeks, 12 weeks, and 6 months. Fatigue and pain were the variables that met all statistical criteria for mediation of the effect of yoga on disability. The total effect of yoga on disability was significant (β = -2.28; 95% CI -3.93 to -0.64), and this consisted of a direct effect of yoga (β = -1.40; 95% CI -3.02 to 0.25) and a statistically significant indirect effect (β = -0.88, 95% CI -1.91 to -0.15) that was mediated by pain and fatigue. The indirect effect accounted for 38% of yoga's effect on back-pain disability. Fatigue and pain were not significant as individual mediators. The other mediators-self-efficacy, spinal range of motion, grip strength, core strength, and balance-did not meet published criteria for mediation. Our results suggest that in veterans with CLBP, yoga may reduce pain and fatigue and contribute to reductions in disability. Although pain may be an expected precursor of disability, the finding that fatigue mediates the relationship between a mind-body intervention like yoga and disability appears novel. Fatigue should be measured more widely in yoga research and considered when designing interventions for specific populations such as military veterans with chronic pain.

McCulloch Gallagher R, Sandbrink F.  The Socioeconomic Burden of Pain From War. Am J Public Health. 2018 Nov 29:e1-e5. doi: 10.2105/AJPH.2018.304744. [Epub ahead of print]

War's burden on the health and well-being of combatants, civilians, and societies is well documented. Although the examination of soldiers' injuries in modern combat is both detailed and comprehensive, less is known about war-related injuries to civilians and refugees, including victims of torture. The societal burden of war-related disabilities persists for decades in war's aftermath. The complex injuries of combat survivors, including multiple pain conditions and neuropsychiatric comorbidities, challenge health care systems to reorganize care to meet these survivors' special needs. We use the case study method to illustrate the change in pain management strategies for injured combat survivors in one national health system, the US Department of Veterans Affairs (VA). The care of veterans' disabling injuries suffered in Vietnam contrasts with the care resulting from the VA's congressional mandate to design and implement a pain management policy that provides effective pain management to veterans injured in the recent Middle East conflicts. The outcomes-driven, patient-centric Stepped Care Model of biopsychosocial pain management requires system-wide patient education, clinician training, social networking, and administrative monitoring. Societies are encouraged to develop their health care system's capacity to effectively respond to the victims of warfare, including combatants and refugees.

McGeary DD, Jaramillo C, Eapen B, Blount TH, Nabity PS, Moreno J, Pugh MJ, Houle TT, Potter JS, Young-McCaughan S, Peterson AL, Villarreal R, Brackins N, Sikorski Z, Johnson TR, Tapia R, Reed D, Caya CA, Bomer D, Simmonds M, McGeary CA. Mindfulness-Based Interdisciplinary Pain Management Program for Complex Polymorbid Pain in Veterans: A Randomized Controlled Trial. Arch Phys Med Rehabil. 2022 Oct;103(10):1899-1907.

OBJECTIVE

To evaluate the effects of interdisciplinary pain management on pain-related disability and opioid reduction in polymorbid pain patients with 2 or more comorbid psychiatric conditions.

DESIGN

Two-arm randomized controlled trial testing a 3-week intervention with assessments at pre-treatment, post-treatment, 6-month, and 12-month follow-up.

Setting: Department of Veterans Affairs medical facility.

Participants: 103 military veterans (N=103) with moderate (or worse) levels of pain-related disability, depression, anxiety, and/or posttraumatic stress disorder randomly assigned to usual care (n=53) and interdisciplinary pain management (n=50). All participants reported recent persistent opioid use. Trial participants had high levels of comorbid medical and mental health conditions.

Interventions: Experimental arm-a 3-week, interdisciplinary pain management program guided by a structured manual; comparison arm-usual care in a large Department of Veterans Affairs medical facility.

Main outcome measures: Oswestry Disability Index (pain disability); Timeline Followback Interview and Medication Event Monitoring System (opioid use). Analysis used generalized linear mixed model with all posttreatment observations (posttreatment, 6-month follow-up, 12-month follow-up) entered simultaneously to create a single posttreatment effect.

RESULTS

Veterans with polymorbid pain randomized to the interdisciplinary pain program reported significantly greater decreases in pain-related disability compared to veterans randomized to treatment as usual (TAU) at posttreatment, 6-month, and 12-month follow-up. Aggregated mean pain disability scores (ie, a summary effect of all posttreatment observations) for the interdisciplinary pain program were -9.1 (95% CI: -14.4, -3.7, P=.001) points lower than TAU. There was no difference between groups in the proportion of participants who resumed opioid use during trial participation (32% in both arms).

CONCLUSION

These findings offer the first evidence of short- and long-term interdisciplinary pain management efficacy in polymorbid pain patients, but more work is needed to examine how to effectively decrease opioid use in this population.

McNamara CF, Kravetz JD, Federman DG. Cessation of group battlefield acupuncture visits due to COVID-19: a pilot study. Acupunct Med. 2022 Oct;40(5):470-473. doi: 10.1177/09645284221104833. Epub 2022 Jun 28. PMID: 35765785.

BACKGROUND

Prior to the COVID-19 pandemic, battlefield acupuncture (BFA) was offered to veterans with chronic pain in multidisciplinary group visits.

OBJECTIVE

We aimed to assess the impact of cessation of BFA due to COVID-19 and to determine the utility of different aspects of the group visits for chronic pain management.

METHODS

Participants who had attended at least three BFA group visits completed questionnaires assessing the impact of treatment interruption on pain, overall function and desire to resume treatment.

RESULTS

Thirty-nine veterans were surveyed; 49% responded to the questionnaire. Ninety percent (17/19) agreed that BFA was an important part of pain management and that their pain had worsened after treatment interruption. Seventy-four percent (14/19) responded that they were taking more pain medications since BFA had ended. Ninety-five percent (18/19) responded that BFA improved daily function; 79% (15/19) agreed that BFA improved their sleep. Ninety-five percent (18/19) were interested in resuming BFA. Camaraderie was mentioned as the most helpful aspect of the group by 8/19 (42%) of participants. Participation of health psychology and nutrition were each mentioned as a most helpful aspect of the group by 5/19 (26%) of participants.

CONCLUSION

Our results suggest that participants may have believed that BFA, camaraderie, and input from nutrition and health psychology services were important contributors to their pain control. The results also suggest that veterans may have suffered worsening pain, used more pain medications, and had worsening quality of sleep and daily function during the COVID-related clinic disruption, and that they were interested in resumption of the program.

Meerwijk EL, Larson MJ, Schmidt EM, Adams RS, Bauer MR, Ritter GA, Buckenmaier C 3rd, Harris AHS. Nonpharmacological Treatment of Army Service Members with Chronic Pain Is Associated with Fewer Adverse Outcomes After Transition to the Veterans Health Administration. J Gen Intern Med. 2019 Oct 28. doi: 10.1007/s11606-019-05450-4.

BACKGROUND

Potential protective effects of nonpharmacological treatments (NPT) against long-term pain-related adverse outcomes have not been examined.

OBJECTIVE

To compare active duty U.S. Army service members with chronic pain who did/did not receive NPT in the Military Health System (MHS) and describe the association between receiving NPT and adverse outcomes after transitioning to the Veterans Health Administration (VHA).

DESIGN AND PARTICIPANTS

A longitudinal cohort study of active duty Army service members whose MHS healthcare records indicated presence of chronic pain after an index deployment to Iraq or Afghanistan in the years 2008-2014 (N = 142,539). Propensity score-weighted multivariable Cox proportional hazard models tested for differences in adverse outcomes between the NPT group and No-NPT group.

EXPOSURES

NPT received in the MHS included acupuncture/dry needling, biofeedback, chiropractic care, massage, exercise therapy, cold laser therapy, osteopathic spinal manipulation, transcutaneous electrical nerve stimulation and other electrical manipulation, ultrasonography, superficial heat treatment, traction, and lumbar supports.

MAIN MEASURES

Primary outcomes were propensity score-weighted proportional hazards for the following adverse outcomes: (a) diagnoses of alcohol and/or drug disorders; (b) poisoning with opioids, related narcotics, barbiturates, or sedatives; (c) suicide ideation; and (d) self-inflicted injuries including suicide attempts. Outcomes were determined based on ICD-9 and ICD-10 diagnoses recorded in VHA healthcare records from the start of utilization until fiscal year 2018.

KEY RESULTS

The propensity score-weighted proportional hazards for the NPT group compared to the No-NPT group were 0.92 (95% CI 0.90-0.94, P < 0.001) for alcohol and/or drug use disorders; 0.65 (95% CI 0.51-0.83, P < 0.001) for accidental poisoning with opioids, related narcotics, barbiturates, or sedatives; 0.88 (95% CI 0.84-0.91, P < 0.001) for suicide ideation; and 0.83 (95% CI 0.77-0.90, P < 0.001) for self-inflicted injuries including suicide attempts.

CONCLUSIONS

NPT provided in the MHS to service members with chronic pain may reduce risk of long-term adverse outcomes.

Mitchinson A, Fletcher CE, Kim HM, Montagnini M, Hinshaw DB.  Integrating massage therapy within the palliative care of veterans with advanced illnesses: an outcome study. Am J Hosp Palliat Care. 2014 Feb;31(1):6-12. doi: 10.1177/1049909113476568. Epub 2013 Feb 18.

AIMS

To describe the integration of massage therapy into a palliative care service and to examine the relationship between massage and symptoms in patients with advanced illnesses.

METHODS

Between April 1, 2009, and July 31, 2010, 153 patients received massage at the VA Ann Arbor Health Care System. Data on pain, anxiety, dyspnea, relaxation, and inner peace were collected pre and post massage. Diagnoses, chronic pain, and social support were also abstracted. Analysis of covariance was used to examine changes over time.

RESULTS

All short-term changes in symptoms showed improvement and all were statistically significant. Pain intensity decreased by 1.65 (0-10 scale, P < .001), anxiety decreased by 1.52 (0-10 scale, P < .001), patients' sense of relaxation increased by 2.92 (0-10 scale, P < .001), and inner peace improved by 1.80 (0-10 scale, P < .001).

CONCLUSION

Massage is a useful tool for improving symptom management and reducing suffering in palliative care patients.

Mitchinson A, Fletcher CE, Trumble E. Integrating Massage Therapy Into the Health Care of Female Veterans. Fed Pract. 2022 Feb;39(2):86-92. doi: 10.12788/fp.0223. Epub 2022 Feb 9. PMID: 35444384; PMCID: PMC9014938.

BACKGROUND

Female veterans experience higher rates of chronic pain, depression, and anxiety than do male veterans. Gynecologic examinations and procedures can be stressful, painful, and anxiety provoking. Research has shown that massage can help reduce pain and anxiety. The purpose of this study was to examine the relationship between massage and well-being in female veterans.

METHODS

A pre- and post visit study design was used. In advance of their clinic visit, female veterans were asked by clinic staff whether they would like a relaxation massage in conjunction with their visit. Effleurage massages were administered by licensed volunteer massage therapists in a private space and performed on the back, neck, hands/arms, legs/feet. Patients rated their pain intensity, pain unpleasantness, anxiety, shortness of breath, relaxation, and inner peace pre- and post massage on 0 to 10 scales. Demographics and data were abstracted from the medical records.

RESULTS

Results are based on the first massage received by 96 individuals: A majority of participants were aged ≤ 40 years (53%) and were White women (68%). Most (70%) were scheduled for an invasive procedure (eg, pelvic examination, biopsy). Seventy-nine percent had a history of chronic pain; 65% had a diagnosis of depression. Mean scores for pain intensity decreased by 1.9 points, pain unpleasantness by 2.0, and anxiety by 2.4. Relaxation increased by 4.3 points and sense of inner peace by 3.5 points. These changes were all statistically significant (P < .001).

CONCLUSIONS

Results from this pilot study suggest massage therapy may be an effective, inexpensive, and safe treatment for pain and/or anxiety in female veterans attending a gynecology appointment. Further research should assess the effects of massage therapy in female veterans with chronic pain and coexistent mental health conditions.

Mitchinson, A. MPH, NCTMB; Hyungjin Myra Kim, ScD; Jack M. Rosenberg, MD; Michael Geisser, PhD; Marvin Kirsh, MD; Dolores Cikrit, MD; Daniel B. Hinshaw, MD. Acute Postoperative Pain Management Using Massage as an Adjuvant Therapy. ARCH SURG/VOL 142 (NO. 12), DEC 2007

HYPOTHESIS

Adjuvant massage therapy improves pain management and postoperative anxiety among many patients who experience unrelieved postoperative pain. Pharmacologic interventions alone may not address all of the factors involved in the experience of pain. DESIGN Randomized controlled trial.

SETTING

Department of Veterans Affairs hospitals in Ann Arbor, Michigan, and Indianapolis, Indiana. Patients: Six hundred five veterans (mean age, 64 years) undergoing major surgery from February 1, 2003, through January 31, 2005. Interventions: Patients were assigned to the following 3 groups: (1) control (routine care), (2) individualized attention from a massage therapist (20 minutes), or (3) back massage by a massage therapist each evening for up to 5 postoperative days. Main Outcome Measure: Short- and long-term (_4 days) pain intensity, pain unpleasantness, and anxiety measured by visual analog scales.

RESULTS

Compared with the control group, patients in the massage group experienced short-term (preintervention vs postintervention) decreases in pain intensity (P=.001), pain unpleasantness (P_.001), and anxiety (P=.007). In addition, patients in the massage group experienced a faster rate of decrease in pain intensity (P=.02) and unpleasantness (P=.01) during the first 4 postoperative days compared with the control group. There were no differences in the rates of decrease in long-term anxiety, length of stay, opiate use, or complications across the 3 groups.

CONCLUSION

Massage is an effective and safe adjuvant therapy for the relief of acute postoperative

Mullur RS, Kaur Cheema SP, Alano RE, Chang LE. Tele-Integrative Medicine to Support Rehabilitative Care. Phys Med Rehabil Clin N Am. 2021 May;32(2):393-403. doi: 10.1016/j.pmr.2020.12.006.

ABSTRACT

Complementary and integrative health (CIH) modalities have therapeutic value in the multidisciplinary rehabilitation of chronic pain patients. Evidence of such has been seen with the Whole Health Model at the (Veterans Affairs) VA Healthcare system. CIH therapies, including yoga, tai chi, mindfulness meditation, hypnosis, self-massage, and acupressure, are significantly effective for managing chronic pain with little to no negative effects, and can be easily incorporated into telemedicine care with great potential benefit. The future of wellness in telemedicine is evolving with great potential, and needs further attention to addressing barriers of care.

Munk N, Daggy JK, Evans E, Kline M, Slaven JE, Laws B, Foote T, Matthias MS, Bair MJ. Therapist-Delivered Versus Care Ally-Assisted Massage for Veterans With Chronic Neck Pain: Protocol for a Randomized Controlled Trial. JMIR Res Protoc. 2022 Sep 27;11(9):e38950. doi: 10.2196/38950. PMID: 36166287; PMCID: PMC9555333.

BACKGROUND

Chronic neck pain (CNP) is prevalent, and it reduces functional status and quality of life and is associated with deleterious psychological outcomes in affected individuals. Despite the desirability of massage and its demonstrated effectiveness in CNP treatment, multiple accessibility barriers exist. Caregiver-applied massage has demonstrated feasibility in various populations but has not been examined in Veterans with CNP or compared in parallel to therapist-delivered massage.

OBJECTIVE

This manuscript described the original study design, lessons learned, and resultant design modifications for the Trial Outcomes for Massage: Care Ally-Assisted Versus Therapist-Treated (TOMCATT) study.

METHODS

TOMCATT began as a 3-arm, randomized controlled trial of 2 massage delivery approaches for Veterans with CNP with measures collected at baseline, 1 and 3 months after intervention, and 6 months (follow-up). Arm I, care ally-assisted massage, consisted of an in-person, 3.5-hour training workshop, an instructional DVD, a printed treatment manual, and three 30-minute at-home care ally-assisted massage sessions weekly for 3 months. Arm II, therapist-treated massage, consisted of two 60-minute sessions tailored to individual pain experiences and treatments per week for 3 months. The treatments followed a standardized Swedish massage approach. Arm III consisted of wait-list control.

RESULTS

Retention and engagement challenges in the first 30 months were significant in the care ally-assisted massage study arm (63% attrition between randomization and treatment initiation) and prompted modification to a 2-arm trial, that is, removing arm I.

CONCLUSIONS

The modified TOMCATT study successfully launched and exceeded recruitment goals 2.5 months before the necessary COVID-19 pause and is expected to be completed by early 2023.

Nassif H, Chapman J, Sandbrink F et al. (2016) Mindfulness meditation and chronic pain management in Iraq and Afghanistan veterans with traumatic brain injury: A pilot study. Military Behavioral Health, 4:1, 82-89, DOI: 10.1080/21635781.2015.1119772

This study examined the effectiveness of iRest meditation for chronic pain in veterans with moderate traumatic brain injury (TBI). Veterans were randomly assigned to iRest (n = 4) or treatment as usual (n = 5) for eight weeks. Patient-reported pain intensity and interference were assessed at baseline, end point, and four-week follow-up. Veterans receiving iRest reported clinically meaningful reductions in pain intensity (23% to 42%) and pain interference (34% to 41%) for most outcome measures and time points. Effect sizes were large for pain interference (g = 0.92–1.13) and medium to large for intensity (g = 0.37–0.61). We conclude that iRest is a promising self-management approach for chronic pain in veterans with moderate TBI.

Okamoto CS, Dunn AS, Green BN, Formolo LR, Chicoine D.  Correlation of Body Composition and Low Back Pain Severity in a Cross-Section of US Veterans. J Manipulative Physiol Ther. 2017 Jun;40(5):358-364. doi: 10.1016/j.jmpt.2017.03.003. Epub 2017 May 26.

OBJECTIVE

Back pain is more prevalent in the obese, but whether back pain severity is directly correlated to obesity in veterans is unknown. We sought to determine if there was a correlation between body composition and low back pain severity in a sample of veterans. The hypothesis was that veterans with higher body mass index values would report higher low back pain severity scores.

METHODS

This study was a retrospective chart review of 1768 veterans presenting to a Veterans Affairs chiropractic clinic with a chief complaint of low back pain between January 1, 2009 and December 31, 2014. Spearman's rho was used to test for correlation between body composition as measured by body mass index and low back pain severity as measured by the Back Bournemouth Questionnaire.

RESULTS

On average, the sample was predominantly male (91%), older than 50, and overweight (36.5%) or obese (48.9%). There was no correlation between body mass index and Back Bournemouth Questionnaire scores, r = .088, p < .001.

CONCLUSIONS

The majority of veterans with low back pain in this sample were either overweight or obese. There was no correlation between body composition and low back pain severity in this sample of veterans.

Okvat HA, Davis MC, Mistretta EG, Mardian AS. Mindfulness-based training for women veterans with chronic pain: A retrospective study. Psychol Serv. 2021 Nov 22. doi: 10.1037/ser0000599.

ABSTRACT

The majority of women veterans experience chronic pain and many have comorbid posttraumatic stress disorder (PTSD). To enhance resilience in these veterans in terms of both physical functioning and psychosocial well-being, a mindfulness-based, trauma-informed, eight-session group pilot program was designed to target emotion regulation and social belonging. Women who engaged in treatment were asked to complete questionnaires assessing pain, functioning, and affective and social well-being before and after the program. The present retrospective research study evaluated (a) whether women who engaged in treatment showed pre-to-post treatment improvement in psychosocial and physical functioning and (b) whether women referred to the program who engaged versus did not engage in treatment differed in demographic and clinical data (i.e., pain diagnoses, mental health diagnoses, documented trauma history) obtained from medical record review. The sample consisted of 36 women who began the program and filled out a pregroup questionnaire (intent-to-treat sample; ITT) and 105 women who were referred but did not engage in treatment. The majority had a documented history of trauma, a mood disorder, and a PTSD diagnosis. ITT analyses indicated that veterans showed moderate-to-large pre-post improvements in pain severity, pain catastrophizing, physical functioning, depression, self-compassion, and positive affect. Veterans who engaged in treatment were similar to those who did not in demographics, number of pain diagnoses, and mental health diagnoses, but were more likely to have a documented history of trauma. Despite the limitations of this study, the findings are encouraging and point to the value of a future randomized controlled trial.

Paige NM, Miake-Lye IM, Booth MS, Beroes JM, Mardian AS, Dougherty P, Branson R, Tang B, Morton SC, Shekelle PG. Association of Spinal Manipulative Therapy With Clinical Benefit and Harm for Acute Low Back Pain: Systematic Review and Meta-analysis. JAMA. 2017 Apr 11;317(14):1451-1460. doi: 10.1001/jama.2017.3086. Review. PubMed PMID: 28399251.

Importance

Acute low back pain is common and spinal manipulative therapy (SMT) is a treatment option. Randomized clinical trials (RCTs) and meta-analyses have reported different conclusions about the effectiveness of SMT.

OBJECTIVE

To systematically review studies of the effectiveness and harms of SMT for acute (≤6 weeks) low back pain.

DATA SOURCES

Search of MEDLINE, Cochrane Database of Systematic Reviews, EMBASE, and Current Nursing and Allied Health Literature from January 1, 2011, through February 6, 2017, as well as identified systematic reviews and RCTs, for RCTs of adults with low back pain treated in ambulatory settings with SMT compared with sham or alternative treatments, and that measured pain or function outcomes for up to 6 weeks. Observational studies were included to assess harms.

DATA EXTRACTION AND SYNTHESIS

Data extraction was done in duplicate. Study quality was assessed using the Cochrane Back and Neck (CBN) Risk of Bias tool. This tool has 11 items in the following domains: randomization, concealment, baseline differences, blinding (patient), blinding (care provider [care provider is a specific quality metric used by the CBN Risk of Bias tool]), blinding (outcome), co-interventions, compliance, dropouts, timing, and intention to treat. Prior research has shown the CBN Risk of Bias tool identifies studies at an increased risk of bias using a threshold of 5 or 6 as a summary score. The evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) criteria.

FINDINGS

Of 26 eligible RCTs identified, 15 RCTs (1711 patients) provided moderate-quality evidence that SMT has a statistically significant association with improvements in pain (pooled mean improvement in the 100-mm visual analog pain scale, -9.95 [95% CI, -15.6 to -4.3]). Twelve RCTs (1381 patients) produced moderate-quality evidence that SMT has a statistically significant association with improvements in function (pooled mean effect size, -0.39 [95% CI, -0.71 to -0.07]). Heterogeneity was not explained by type of clinician performing SMT, type of manipulation, study quality, or whether SMT was given alone or as part of a package of therapies. No RCT reported any serious adverse event. Minor transient adverse events such as increased pain, muscle stiffness, and headache were reported 50% to 67% of the time in large case series of patients treated with SMT.

CONCLUSIONS AND RELEVANCE

Among patients with acute low back pain, spinal manipulative therapy was associated with modest improvements in pain and function at up to 6 weeks, with transient minor musculoskeletal harms. However, heterogeneity in study results was large.

Polomano RC, Galloway KT, Kent ML, Brandon-Edwards H, Kwon KN, Morales C, Buckenmaier C' 3rd. Psychometric Testing of the Defense and Veterans Pain Rating Scale (DVPRS): A New Pain Scale for Military Population. Pain Med. 2016 Aug;17(8):1505-19. doi: 10.1093/pm/pnw105. Epub 2016 Jun 6. PubMed PMID: 27272528.

OBJECTIVE

The Defense and Veterans Pain Rating Scale (DVPRS 2.0) is a pain assessment tool that utilizes a numerical rating scale enhanced by functional word descriptors, color coding, and pictorial facial expressions matched to pain levels. Four supplemental questions measure how much pain interferes with usual activity and sleep, and affects mood and contributes to stress.

METHODS

Psychometric testing was performed on a revised DVPRS 2.0 using data from 307 active duty service members and Veterans experiencing acute or chronic pain. A new set of facial representations designating pain levels was tested.

RESULTS

Results demonstrated acceptable internal consistency reliability (Cronbach's alpha = 0.871) and test-retest reliability (r = 0.637 to r = 0.774) for the five items. Excellent interrater agreement was established for correctly ordering faces depicting pain levels and aligning them on the pain intensity scale (Kendall's coefficient of concordance, W = 0.95 and 0.959, respectively). Construct validity was supported by an exploratory principal component factor analysis and known groups validity testing. Most participants, 70.9%, felt that the DVPRS was superior to other pain rating scales.

CONCLUSION

The DVPRS 2.0 is a reliable and valid instrument that provides standard language and metrics to communicate pain and related outcomes.

Reid KF, Bannuru RR, Wang C, Mori DL, Niles BL. The Effects of Tai Chi Mind-Body Approach on the Mechanisms of Gulf War Illness: an Umbrella Review. Integr Med Res. 2019 Sep;8(3):167-172. doi: 10.1016/j.imr.2019.05.003.

Gulf War illness (GWI) is a chronic and multisymptom disorder affecting military veterans deployed to the 1991 Persian Gulf War. It is characterized by a range of acute and chronic symptoms, including but not limited to, fatigue, sleep disturbances, psychological problems, cognitive deficits, widespread pain, and respiratory and gastrointestinal difficulties. The prevalence of many of these chronic symptoms affecting Gulf War veterans occur at markedly elevated rates compared to nondeployed contemporary veterans. To date, no effective treatments for GWI have been identified. The overarching goal of this umbrella review was to critically evaluate the evidence for the potential of Tai Chi mind-body exercise to benefit and alleviate GWI symptomology. Based on the most prevalent GWI chronic symptoms and case definitions established by the Centers for Disease Control and Prevention and the Kansas Gulf War Veterans Health Initiative Program, we reviewed and summarized the evidence from 7 published systematic reviews and meta-analyses. Our findings suggest that Tai Chi may have the potential for distinct therapeutic benefits on the major prevalent symptoms of GWI. Future clinical trials are warranted to examine the feasibility, efficacy, durability and potential mechanisms of Tai Chi for improving health outcomes and relieving symptomology in GWI.

Reneau M, Nichols M. Veterans' Insights on Heart Rate Variability Biofeedback to Treat Fibromyalgia-Related Pain. Pain Manag Nurs. 2021 Jul 17:S1524-9042(21)00164-8. doi: 10.1016/j.pmn.2021.06.003.

BACKGROUND

Heart rate variability biofeedback (HRVB) is a self-management strategy that guides individuals to breathe at a designated resonance frequency of the cardiovascular system. Resonant breathing may reduce FM-related symptoms as well as improve physical functioning and quality of life. Although prior research recommends HRVB for chronic pain, we found no studies testing the feasibility for individuals with FM regarding protocol adherence or acceptability of the treatment.

AIMS

To determine the feasibility and acceptability of a heart rate variability biofeedback (HRVB) protocol in a group of Veterans with fibromyalgia (FM).

DESIGN

A multi-method feasibility and acceptability study.

Settings

A Veterans Health outpatient pain medicine clinic. Participants/subjects: We enrolled 7 women and 3 men between the ages of 33 and 68 years with a diagnosis of FM.

METHODS

We enrolled 10 veterans in a HRVB study using a recommended protocol to treat FM. Veterans were given a HRVB device, emWave2, and instructed to practice at home twice daily for 20 minutes per session. Following a 7-week intervention period, we conducted an end of study focus group. We used content analysis to develop themes to determine the feasibility of engaging in HRVB and adhering to the intervention protocol, as well as insights of veterans about the intervention.

RESULTS

Three common themes emerged: intervention implementation, protocol adherence, and self-awareness.

CONCLUSIONS

Results of this study suggest difficulties operating the emWave2 and scheduling challenges interfered with HRVB implementation. However, veterans reported self-awareness of the benefits of HRVB, positive physiological effects, and improved psychological effects. Future studies require a larger sample size to provide a deeper insight.

Roberts JA, Wolfe TM. Chiropractic management of a veteran with lower back pain associated with diffuse idiopathic skeletal hypertrophy and degenerative disk disease. J Chiropr Med. 2012 Dec;11(4):293-9. doi: 10.1016/j.jcm.2012.10.007.

OBJECTIVE

The purpose of this article is to report the response of chiropractic care of a geriatric veteran with degenerative disk disease and diffuse idiopathic skeletal hyperostosis.

CLINICAL FEATURES

A 74-year-old man presented with low back pain (LBP) and loss of feeling in his lower extremities for 3 months. The LBP was of insidious onset with a 10/10 pain rating on the numeric pain scale (NPS) and history of degenerative disk disease and diffuse idiopathic skeletal hypertrophy. Oswestry questionnaire was 44% and health status questionnaire was 52%, which were below average for his age. The patient presented with antalgia and severe difficulty with ambulation and thus used a walker.

INTERVENTION AND OUTCOME

Chiropractic care included Activator Methods protocol. Two weeks into treatment, he reported no back pain; and after 4 treatments, he was able to walk with a cane instead of a walker. The NPS decreased from a 10/10 to a 0/10, and his Revised Oswestry score decreased from 44/100 to 13.3/100. His Health Status Questionnaire score increased 25 points to 77/100, bringing him from below average for his age to above average for his age. Follow-up with the patient at approximately 1 year and 9 months showed an Oswestry score of 10/100 and a Health Status Questionnaire score of 67/100, still above average for his age.

CONCLUSION

The findings in this case study showed that Activator-assisted spinal manipulative therapy had positive subjective and objective results for LBP and ambulation in a geriatric veteran with degenerative disk disease and diffuse idiopathic skeletal hyperostosis.

Roseen EJ, Pinheiro A, Lemaster CM, Plumb D, Wang S, Elwy AR, Streeter CC, Lynch S, Groessl E, Sherman KJ, Weinberg J, Saper RB. Yoga Versus Education for Veterans with Chronic Low Back Pain: a Randomized Controlled Trial. J Gen Intern Med. 2023 Jul;38(9):2113-2122.

BACKGROUND

Yoga is effective for chronic low back pain (cLBP) in civilians but understudied among Veterans.

OBJECTIVE

Determine whether yoga is more effective than an educational book for improving disability and pain among Veterans with cLBP.

DESIGN, SETTING, AND PARTICIPANTS

Veterans diagnosed with cLBP at a VA medical center enrolled in a randomized controlled trial from March to December of 2015.

INTERVENTIONS

Twelve weekly hatha yoga classes or education using The Back Pain Helpbook.Measures: Co-primary outcomes were changes from baseline at 12 weeks in back-related disability on the modified Roland Morris Disability Questionnaire and pain on the Defense & Veterans Pain Rating Scale. Secondary outcomes were global improvement, patient satisfaction, pain medication use, and post-traumatic stress symptoms. An intention-to-treat approach was used in primary analyses.

RESULTS

One hundred twenty Veterans (mean age, 55.5 [SD = 16.9]; 11 [9%] women; mean number of chronic conditions, 5.5) were randomized to yoga (n = 62) and education (n = 58). At 12 weeks, reductions in back-related disability in yoga (mean difference [MD] = - 3.50, 95% CI: - 5.03, - 1.97) were not significantly different than education (MD = - 2.55, 95% CI: - 4.10, - 0.99; between-group difference: - 0.95 [95% CI: - 3.14, 1.23], p = 0.39). For pain, there was no significant difference between yoga (MD = - 1.01, 95% CI: - 1.67, - 0.35) and education (MD = - 0.81, 95% CI: - 1.36, - 0.27; between-group difference: - 0.20, 95% CI: - 1.06, 0.66, p = 0.65). More yoga than education participants reported being very much or extremely improved (39% vs 19%, OR = 3.71, 95% CI: 1.37, 10.02, p = 0.01) and very satisfied with treatment (60% vs 31%, OR = 4.28, 95% CI: 1.70, 10.77, p = 0.002). No differences in pain medication use or post-traumatic stress symptoms were observed at 12 weeks. No serious adverse events were reported in either group.Conclusion: Twelve weekly yoga classes were not more effective than an education intervention for improving pain or disability outcomes among mostly older male Veterans with cLBP and multiple comorbid health conditions.

Salsbury SA, Twist E, Wallace RB, Vining RD, Goertz CM, Long CR. Care Outcomes for Chiropractic Outpatient Veterans (COCOV): a qualitative study with veteran stakeholders from a pilot trial of multimodal chiropractic care. Pilot Feasibility Stud. 2022 Jan 14;8(1):6. doi: 10.1186/s40814-021-00962-5. PMID: 35031072; PMCID: PMC8759237.

BACKGROUND

Low back pain (LBP) is common among military veterans seeking treatment in Department of Veterans Affairs (VA) healthcare facilities. As chiropractic services within VA expand, well-designed pragmatic trials and implementation studies are needed to assess clinical effectiveness and program uptake. This study evaluated veteran stakeholder perceptions of the feasibility and acceptability of care delivery and research processes in a pilot trial of multimodal chiropractic care for chronic LBP.

METHODS

The qualitative study was completed within a mixed-method, single-arm, pragmatic, pilot clinical trial of chiropractic care for LBP conducted in VA chiropractic clinics. Study coordinators completed semi-structured, in person or telephone interviews with veterans near the end of the 10-week trial. Interviews were audio recorded and transcribed verbatim. Qualitative content analysis using a directed approach explored salient themes related to trial implementation and delivery of chiropractic services.

RESULTS

Of 40 participants, 24 completed interviews (60% response; 67% male gender; mean age 51.7 years). Overall, participants considered the trial protocol and procedures feasible and reported that the chiropractic care and recruitment methods were acceptable. Findings were organized into 4 domains, 10 themes, and 21 subthemes. Chiropractic service delivery domain encompassed 3 themes/8 subthemes: scheduling process (limited clinic hours, scheduling future appointments, attendance barriers); treatment frequency (treatment sufficient for LBP complaint, more/less frequent treatments); and chiropractic clinic considerations (hire more chiropractors, including female chiropractors; chiropractic clinic environment; patient-centered treatment visits). Outcome measures domain comprised 3 themes/4 subthemes: questionnaire burden (low burden vs. time-consuming or repetitive); relevance (items relevant for LBP study); and timing and individualization of measures (questionnaire timing relative to symptoms, personalized approach to outcomes measures). The online data collection domain included 2 themes/4 subthemes: user concerns (little difficulty vs. form challenges, required computer skills); and technology issues (computer/internet access, junk mail). Clinical trial planning domain included 2 themes/5 subthemes: participant recruitment (altruistic service by veterans, awareness of chiropractic availability, financial compensation); and communication methods (preferences, potential barriers).

CONCLUSIONS

This qualitative study highlighted veteran stakeholders' perceptions of VA-based chiropractic services and offered important suggestions for conducting a full-scale, veteran-focused, randomized trial of multimodal chiropractic care for chronic LBP in this clinical setting.

Saper RB, Lemaster CM, Elwy AR, Paris R, Herman PM, Plumb DN, Sherman KJ, Groessl EJ, Lynch S, Wang S, Weinberg J. Yoga versus education for Veterans with chronic low back pain: study protocol for a randomized controlled trial. Trials. 2016 Apr 29;17(1):224. doi: 10.1186/s13063-016-1321-5. PubMed PMID: 27129472; PubMed Central PMCID: PMC4850721.

BACKGROUND

Chronic low back pain is the most frequent pain condition in Veterans and causes substantial suffering, decreased functional capacity, and lower quality of life. Symptoms of post-traumatic stress, depression, and mild traumatic brain injury are highly prevalent in Veterans with back pain. Yoga for low back pain has been demonstrated to be effective for civilians in randomized controlled trials. However, it is unknown if results from previously published trials generalize to military populations.

METHODS/DESIGN

This study is a parallel randomized controlled trial comparing yoga to education for 120 Veterans with chronic low back pain. Participants are Veterans ≥18 years old with low back pain present on at least half the days in the past six months and a self-reported average pain intensity in the previous week of ≥4 on a 0-10 scale. The 24-week study has an initial 12-week intervention period, where participants are randomized equally into (1) a standardized weekly group yoga class with home practice or (2) education delivered with a self-care book. Primary outcome measures are change at 12 weeks in low back pain intensity measured by the Defense and Veterans Pain Rating Scale (0-10) and back-related function using the 23-point Roland Morris Disability Questionnaire. In the subsequent 12-week follow-up period, yoga participants are encouraged to continue home yoga practice and education participants continue following recommendations from the book. Qualitative interviews with Veterans in the yoga group and their partners explore the impact of chronic low back pain and yoga on family relationships. We also assess cost-effectiveness from three perspectives: the Veteran, the Veterans Health Administration, and society using electronic medical records, self-reported cost data, and study records.

DISCUSSION

This study will help determine if yoga can become an effective treatment for Veterans with chronic low back pain and psychological comorbidities.

Schulz-Heik RJ, Avery TJ, Jo B, Mahoney L, Bayley PJ. Posttraumatic Stress Disorder Does Not Compromise Behavioral Pain Treatment: Secondary Analysis of a Randomized Clinical Trial Among Veterans. Glob Adv Health Med. 2022 Feb 16;11:21649561221075578.

BACKGROUND

Individuals with posttraumatic stress disorder (PTSD) and chronic pain evince different presentations, coping strategies, and treatment utilization patterns than individuals with chronic pain alone. Theorists have suggested that comorbid PTSD may complicate chronic pain treatment, and that integrated pain and PTSD treatment may be preferable to pain treatment alone.

OBJECTIVE

Assess whether comorbid PTSD moderates Veterans' response to yoga and/or cognitive behavioral therapy (CBT) for pain.

METHODS

Veterans with Gulf War illness (n = 75) were assessed using the Brief Pain Inventory at baseline and posttreatment as part of a randomized clinical trial. PTSD status was abstracted from participants' medical records.

RESULTS

PTSD+ participants (n = 41) reported more pain at baseline than PTSD- participants (n = 34; d = .66, p < .01). PTSD+ participants experienced more improvement in pain from baseline to posttreatment than PTSD- participants by a small to moderate, marginally statistically significant amount (d = .39, p = .07). The relationship between PTSD and treatment outcome was not moderated by treatment type (yoga vs CBT; p = .99). Observation of treatment responses across PTSD status (+ vs -) and treatment (yoga vs CBT) revealed that PTSD+ participants responded well to yoga.

CONCLUSION

PTSD is not associated with reduced effectiveness of behavioral chronic pain treatment among Veterans with Gulf War illness. Therefore behavioral pain treatment should be made readily available to Veterans with pain and PTSD. Yoga deserves further consideration as a treatment for pain among individuals with PTSD.

Shao X, Corcoran M, O'Bryan M.  The Use of Battlefield Acupuncture Prior to Botulinum Toxin A Administration: A 2-Patient Case Series. Med Acupunct. 2018 Oct 1;30(5):282-284. doi: 10.1089/acu.2018.1302. Epub 2018 Oct 15.

BACKGROUND

Botulinum toxin type A injection is a common and safe procedure used for the treatment of overactive muscles through local injection. This toxin inhibits the release of acetylcholine in the neuromuscular junction. The benefits usually last only 3-6 months; thus, repeated injections are often required. The procedure, however, can be difficult if a patient's spasticity and pain prevents access to the muscles for injection or if a patient is anxious. Battlefield Acupuncture (BFA), a technique developed by Richard C. Niemtzow, MD, PhD, MPH, in 2001, is a form of auricular acupuncture using a very specific sequence of gold Aiguille semipermanente needles inserted into the ear. BFA can be very effective for reducing pain quickly, with few potential side-effects. Cases: BFA was performed prior to Botulinum toxin A injections on 2 patients who had either pain limitations or anxiety limitations during prior Botulinum toxin A injections. Case 1 was a 70-year-old male veteran with painful, right upper-extremity spasticity with hand contractures. Case 2 was a 69-year-old male veteran with spasticity who had anxiety related to his fear of needles.

RESULTS

Application of BFA prior to Botulinum toxin A injections enabled the 2 patients who either had pain limitations or anxiety limitations to tolerate the toxin injections much better.

CONCLUSIONS

BFA is a safe and effective treatment option for rapid pain reduction, enabling Botulinum toxin A to be administered more easily to patients who have had pain or anxiety during prior injections.

Sharp SJ, Huynh MT, Filart R.  Frequency-Specific Microcurrent as Adjunctive Therapy for Three Wounded Warriors. Med Acupunct. 2019 Jun 1;31(3):189-192. doi: 10.1089/acu.2019.1366. Epub 2019 Jun 17.

BACKGROUND

Acupuncture is frequently offered for wounded warriors as a component of an integrated approach to pain and associated symptoms, with increasing availability at military treatment facilities and Veterans Administration hospitals. While medications can be effective for many patients, acupuncture and microcurrent therapies address the growing need to offer nonopiate, nonpharmaceutical therapeutics in integrative pain management. Frequency-specific microcurrent (FSM) is a newer, adjustable, microcurrent, electrical stimulation modality with applications for pain and other associated symptoms. Using low amperage, electrical current delivered transcutaneously affects and repairs tissues at the cellular level. Additionally, concomitant treatment with acupuncture is possible, which is particularly helpful when space and time limit the frequency with which acupuncture treatments can be provided. Cases: For 3 wounded warriors, FSM was combined with acupuncture treatments, resulting in more-rapid reduction of their pain and associated symptoms; including memory problems, mental sluggishness, and post-traumatic stress disorder.

RESULTS

FSM was found to be a safe, nonpainful, noninvasive treatment that could be administered concurrently and beneficially with acupuncture.

CONCLUSIONS

While additional, more-rigorous studies are needed, this case series demonstrates the potential that FSM has within an integrated pain treatment program for wounded warriors.

Shekelle PG et al. . (2017)  The Effectiveness and Harms of Spinal Manipulative Therapy for the Treatment of Acute Neck and Lower Back Pain: A Systematic Review [Internet]

Back pain and neck pain are among the most common symptoms prompting patients to seek care. Many treatments are used for back pain. Spinal manipulative therapy (SMT) is a treatment option available in VA. In order to better understand the potential role of SMT in treating acute back or neck pain, VA requested an up-to-date synthesis of the evidence.

Smeeding SJ, Bradshaw DH, Kumpfer K, Trevithick S, Stoddard GJ. Outcome evaluation of the Veterans Affairs Salt Lake City Integrative Health Clinic for chronic pain and stress-related depression, anxiety, and post-traumatic stress disorder. J Altern Complement Med. 2010 Aug;16(8):823-35. doi: 10.1089/acm.2009.0510. PubMed PMID: 20649442.

OBJECTIVES

The purpose of this longitudinal outcome research study was to determine the effectiveness of the Integrative Health Clinic and Program (IHCP) and to perform a subgroup analysis investigating patient benefit. The IHCP is an innovative clinical service within the Veterans Affairs Health Care System designed for nonpharmacologic biopsychosocial management of chronic nonmalignant pain and stress-related depression, anxiety, and symptoms of post-traumatic stress disorder (PTSD) utilizing complementary and alternative medicine and mind-body skills.

METHODS

A post-hoc quasi-experimental design was used and combined with subgroup analysis to determine who benefited the most from the program. Data were collected at intake and up to four follow-up visits over a 2-year time period. Hierarchical linear modeling was used for the statistical analysis. The outcome measures included: Health-Related Quality of Life (SF-36), the Beck Depression Inventory (BDI), and Beck Anxiety Inventory (BAI). Subgroup comparisons included low anxiety (BAI < 19, n = 82), low depression (BDI < 19, n = 93), and absence of PTSD (n = 102) compared to veterans with high anxiety (BAI > or = 19, n = 77), high depression (BDI > 19, n = 67), and presence of PTSD (n = 63).

RESULTS

All of the comparison groups demonstrated an improvement in depression and anxiety scores, as well as in some SF-36 categories. The subgroups with the greatest improvement, seen at 6 months, were found in the high anxiety group (Cohen's d = 0.52), the high-depression group (Cohen's d = 0.46), and the PTSD group (Cohen's d = 0.41).

CONCLUSIONS

The results suggest IHCP is an effective program, improving chronic pain and stress-related depression, anxiety, and health-related quality of life. Of particular interest was a significant improvement in anxiety in the PTSD group. The IHCP model offers innovative treatment options that are low risk, low cost, and acceptable to patients and providers.

Smeeding SJ, Bradshaw DH, Kumpfer KL, Trevithick S, Stoddard GJ. Outcome evaluation of the Veterans Affairs Salt Lake City Integrative Health Clinic for Chronic Nonmalignant Pain.  Clin J Pain. 2011 Feb;27(2):146-55

OBJECTIVES

the purpose of this longitudinal outcome study was to investigate the effectiveness of the Integrative Health Clinic and Program, an innovative outpatient clinical service that provides nonpharmacologic, biopsychosocial interventions using research based mind-body skills and complementary and alternative therapies. The study assessed improvement in chronic nonmalignant pain and related depression, anxiety, and health-related quality of life.

METHODS

the study was a retrospective post-hoc quasi-experimental design with a group analysis comparing chronic nonspinal-related pain (CNSP) (eg, joint pain, headache, and fibromyalgia) (n=53) to chronic spinal-related pain (CSP) (eg, back pain and neck pain) (n=88). Data were collected at intake and up to 4 follow-up visits. Hierarchical Linear Modeling was used for statistical analysis. Outcome measures included: Quality of Life (Short Form-36), the Beck Depression Inventory, and Beck Anxiety Inventory.

RESULTS

there were statistically significant differences within and between the CNSP and CSP groups across all follow-up visits. For the CNSP group, depression, anxiety, and bodily pain significantly improved with moderate-to-large effect sizes at 6 months (Cohen's d=0.74, 0.53, and 0.66, respectively) and these benefits persisted across all follow-up visits. The CSP group showed an improvement trend in bodily pain (Cohen's d=0.26).

DISCUSSION

Significant study findings revealed that the greatest improvement after participation in Integrative Health Clinic and Program were seen in the CNSP group with benefits persisting to 24 months in mood and in some health-related quality of life subcategories.

Sodders MD, Martin AM, Coker J, Hammond FM, Hoffman JM. Acupuncture use for pain after traumatic brain injury: a NIDILRR Traumatic Brain Injury Model Systems cohort study. Brain Inj. 2023 May 12;37(6):494-502. doi: 10.1080/02699052.2023.2187088.

BACKGROUND

Pain after traumatic brain injury (TBI) is common and can become chronic. Acupuncture is an increasingly popular non-pharmacologic option in the United States and is commonly used for pain.

OBJECTIVE

We explored demographics, injury characteristics, and pain characteristics of individuals who reported using acupuncture for chronic pain after TBI.

METHODS

We analyzed a subset of data collected as part of the Pain After Traumatic Brain Injury collaborative study and identified individuals reporting a history of acupuncture as part of management for chronic pain after TBI. We characterized and compared basic demographic data, pain treatment engagements, pain severity, pain interference, functional independence, and pain locations using descriptive and inferential statistics.

RESULTS

Our sample included 1,064 individuals. Acupuncture use (n = 208) was lower proportionally among females, Blacks/African Americans, Asians, less educated, and nonmilitary service members. Insurance type varied between acupuncture and non-acupuncture users. Functional and pain outcomes were similar, but acupuncture users reported a higher number of pain sites.

DISCUSSION

Acupuncture is one treatment utilized by individuals with TBI and chronic pain. Further investigation would be helpful to understand the barriers and facilitators of acupuncture use to inform clinical trials to examine the potential benefit of acupuncture on pain outcomes after TBI.

Stoelb BL, Jensen MP, Tackett MJ.  Hypnotic analgesia for combat-related spinal cord injury pain: a case study. Am J Clin Hypn. 2009 Jan;51(3):273-80.

A U.S. Army soldier stationed in Iraq developed myriad pain problems after sustaining a high-level spinal cord injury (SCI) from a gunshot wound. These problems were negatively impacting his ability to participate fully in his physical rehabilitation and care. Ten sessions of self-hypnosis training were administered to the patient over a 5-week period to help him address these problems. Both the patient and his occupational therapist reported a substantial reduction in pain over the course of treatment, which allowed the patient to actively engage in his therapies. Six months post treatment, the patient reported continued use of the hypnosis strategies taught, which effectively reduced his experience of pain. This case study demonstrates the efficacy of hypnotic analgesia treatment for U.S. military veterans who are experiencing pain problems due to traumatic or combat-related SCIs.

Tan G, Rintala DH, Jensen MP, Fukui T, Smith D, Williams W. A randomized controlled trial of hypnosis compared with biofeedback for adults with chroniclow back pain. Eur J Pain. 2015 Feb

BACKGROUND

Chronic low back pain (CLBP) is common and results in significant costs to individuals, families and society. Although some research supports the efficacy of hypnosis for CLBP, we know little about the minimum dose needed to produce meaningful benefits, the roles of home practice and hypnotizability on outcome, or the maintenance of treatment benefits beyond 3 months.

METHODS

One hundred veterans with CLBP participated in a randomized, four-group design study. The groups were (1) an eight-session self-hypnosis training intervention without audio recordings for home practice; (2) an eight-session self-hypnosis training intervention with recordings; (3) a two-session self-hypnosis training intervention with recordings and brief weekly reminder telephone calls; and (4) an eight-session active (biofeedback) control intervention.

RESULTS

Participants in all four groups reported significant pre- to post-treatment improvements in pain intensity, pain interference and sleep quality. The hypnosis groups combined reported significantly more pain intensity reduction than the control group. There was no significant difference among the three hypnosis conditions. Over half of the participants who received hypnosis reported clinically meaningful (≥ 30%) reductions in pain intensity, and they maintained these benefits for at least 6 months after treatment. Neither hypnotizability nor amount of home practice was associated significantly with treatment outcome.

CONCLUSIONS

The findings indicate that two sessions of self-hypnosis training with audio recordings for home practice may be as effective as eight sessions of hypnosis treatment. If replicated in other patient samples, the findings have important implications for the application of hypnosis treatment for chronic pain management.

Taylor SL, Herman PM, Marshall NJ, Zeng Q, Yuan A, Chu K, Shao Y, Morioka C, Lorenz KA. Use of Complementary and Integrated Health: A Retrospective Analysis of U.S. Veterans with Chronic Musculoskeletal Pain Nationally. J Altern Complement Med. 2019 Jan;25(1):32-39.

OBJECTIVE

To partially address the opioid crisis, some complementary and integrative health (CIH) therapies are now recommended for chronic musculoskeletal pain, a common condition presented in primary care. As such, health care systems are increasingly offering CIH therapies, and the Veterans Health Administration (VHA), the nation's largest integrated health care system, has been at the forefront of this movement. However, little is known about the uptake of CIH among patients with chronic musculoskeletal pain. As such, we conducted the first study of the use of a variety of nonherbal CIH therapies among a large patient population having chronic musculoskeletal pain.

MATERIALS AND METHODS

We examined the frequency and predictors of CIH therapy use using administrative data for a large retrospective cohort of younger veterans with chronic musculoskeletal pain using the VHA between 2010 and 2013 (n = 530,216). We conducted a 2-year effort to determine use of nine types of CIH by using both natural language processing data mining methods and administrative and CPT4 codes. We defined chronic musculoskeletal pain as: (1) having 2+ visits with musculoskeletal diagnosis codes likely to represent chronic pain separated by 30-365 days or (2) 2+ visits with musculoskeletal diagnosis codes within 90 days and with 2+ numeric rating scale pain scores ≥4 at 2+ visits within 90 days.

RESULTS

More than a quarter (27%) of younger veterans with chronic musculoskeletal pain used any CIH therapy, 15% used meditation, 7% yoga, 6% acupuncture, 5% chiropractic, 4% guided imagery, 3% biofeedback, 2% t'ai chi, 2% massage, and 0.2% hypnosis. Use of any CIH therapy was more likely among women, single patients, patients with three of the six pain conditions, or patients with any of the six pain comorbid conditions.

CONCLUSIONS

Patients appear willing to use CIH approaches, given that 27% used some type. However, low rates of some specific CIH suggest the potential to augment CIH use.

Turner AP, Edwards KA, Jensen MP, Ehde DM, Day MA, Williams RM. Effects of hypnosis, mindfulness meditation, and education for chronic pain on substance use in veterans: A supplementary analysis of a randomized clinical trial. Rehabil Psychol. 2023 Aug;68(3):261-270.

PURPOSE/OBJECTIVE

To examine the impact of three behavioral interventions for chronic pain on substance use.Research method/design: Participants were 328 Veterans with chronic pain receiving care at one of two Veterans Affairs Medical Centers in the northwest United States. Participants were randomly assigned to one of three 8-week manualized in-person group treatments: (a) hypnosis (HYP), (b) mindfulness meditation (MM), or (c) active education control (ED). Substance use frequency was assessed using 10 individual items from the WHO-ASSIST, administered at baseline prior to randomization and at 3- and 6-month posttreatment.

RESULTS

Baseline substance use (i.e., any use) in the past 3 months was reported by 22% (tobacco), 27% (cannabis), and 61% (alcohol) of participants. Use of all other substances assessed was reported by < 7% of participants. Results showed that MM, as compared to ED, significantly reduced risk of daily cannabis use by 85% and 81% at the 3- and 6-month posttreatment follow-ups, respectively, after adjusting for baseline use. HYP, as compared to ED, significantly reduced risk of daily cannabis use by 82% at the 6-month posttreatment follow-up after adjusting for baseline use. There was no intervention effect on tobacco or alcohol use at either posttreatment follow-up.Conclusions/implications: HYP and MM for chronic pain may facilitate reductions in cannabis use, even when reducing such use is not a focus of treatment. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Vanneman ME, Larson MJ, Chen C, Adams RS, Williams TV, Meerwijk E, Harris AHS. Treatment of Low Back Pain With Opioids and Nonpharmacologic Treatment Modalities for Army Veterans. Med Care. 2018 Oct;56(10):855-861.

BACKGROUND

In the Veterans Health Administration (VHA) there is growing interest in the use of nonpharmacologic treatment (NPT) for low back pain (LBP) as pain intensity and interference do not decrease with opioid use.

OBJECTIVES

To describe overall and facility-level variation in the extent to which specific NPT modalities are used in VHA for LBP, either alone or as adjuncts to opioid medications, and to understand associations between veterans' clinical and demographic characteristics and type of treatment.

DESIGN

This retrospective cohort study examined use of opioids and 21 specific NPT modalities used by veterans.

Subjects: VHA-enrolled Iraq and Afghanistan veterans who utilized care in ("linked" to) 130 VHA facilities within 12 months after their separation from the Army between fiscal years 2008-2011, and who were diagnosed with LBP within 12 months after linkage (n=49,885).

Measures: Measures included per patient: days' supply of opioids, number of visits for NPT modalities, and pain scores within one year after a LBP diagnosis.

RESULTS

Thirty-four percent of veterans filled a prescription for opioids, 35% utilized at least 1 NPT modality, and 15% used both within the same year. Most patients with LBP receiving NPT, on average, had moderate pain (36%), followed by low pain (27%), severe pain (15%), and no pain (11%). Eleven percent had no pain scores recorded.

CONCLUSIONS

About 65% of VHA patients with a LBP diagnosis did not receive NPT, and about 43% of NPT users also were prescribed an opioid. Understanding utilization patterns and their relationship with patient characteristics can guide pain management decisions and future study.

Vining R, Minkalis A, Long CR, Corber L, Franklin C, Gudavalli MR, Xia T, Goertz CM. Assessment of chiropractic care on strength, balance, and endurance in active-duty U.S. military personnel with low back pain: a protocol for a randomized controlled trial.Trials. 2018 Dec 5;19(1):671. doi: 10.1186/s13063-018-3041-5. PubMed PMID: 30518400; PubMed Central PMCID: PMC6280458.

BACKGROUND

Low back pain (LBP) is a common cause of disability among U.S. military personnel. Approximately 20% of all diagnoses resulting in disability discharges are linked to back-related conditions. Because LBP can negatively influence trunk muscle strength, balance, and endurance, the military readiness of active-duty military personnel with LBP is potentially compromised. Chiropractic care may facilitate the strengthening of trunk muscles, the alteration of sensory and motor signaling, and a reduction in pain sensitivity, which may contribute to improving strength, balance, and endurance for individuals with LBP. This trial will assess the effects of chiropractic care on strength, balance, and endurance for active-duty military personnel with LBP.

METHODS/DESIGN

This randomized controlled trial will allocate 110 active-duty military service members aged 18-40 with non-surgical acute, subacute, or chronic LBP with pain severity of ≥2/10 within the past 24 h. All study procedures are conducted at a single military treatment facility within the continental United States. Participants are recruited through recruitment materials approved by the institutional review board, such as posters and flyers, as well as through provider referrals. Group assignment occurs through computer-generated random allocation to either the study intervention (chiropractic care) or the control group (waiting list) for a 4-week period. Chiropractic care consists primarily of spinal manipulation at a frequency and duration determined by a chiropractic practitioner. Strength, balance, and endurance outcomes are obtained at baseline and after 4 weeks. The primary outcome is a change between baseline and 4 weeks of peak isometric strength, which is measured by pulling on a bimanual handle in a semi-squat position. Secondary outcomes include balance time during a single-leg standing test and trunk muscle endurance with the Biering-Sorensen test. Patient-reported outcomes include pain severity, disability measured with the Roland Morris Disability Questionnaire, symptom bothersomeness, PROMIS-29, Fear Avoidance Beliefs Questionnaire, expectations of care, physical activity, and global improvement.

DISCUSSION

This trial may help inform further research on biological mechanisms related to manual therapies employed by chiropractic practitioners.

Williams RM, Day MA, Ehde DM, Turner AP, Ciol MA, Gertz KJ, Patterson D, Hakimian S, Suri P, Jensen MP. Effects of Hypnosis vs Mindfulness Meditation vs Education on Chronic Pain Intensity and Secondary Outcomes in Veterans: A Randomized Clinical Trial. Pain. 2022 Jan 25.

Effective, rigorously evaluated nonpharmacological treatments for chronic pain are needed. This study compared the effectiveness of training in hypnosis (HYP) and mindfulness meditation (MM) to an active education control (ED). Veterans (N=328) were randomly assigned to 8 manualized, group-based, in-person sessions of HYP (n = 110), MM (n = 108), or ED (n = 110). Primary (average pain intensity; API) and secondary outcomes were assessed at pretreatment, posttreatment, and 3- and 6-months posttreatment. Treatment effects were evaluated using linear regression, a generalized estimating equation approach, or a Fisher exact test, depending on the variable. There were no significant omnibus between-group differences in pre- to posttreatment change in API, however pre- to posttreatment improvements in API and several secondary variables were seen for participants in all three conditions. Participation in MM resulted in greater decreases in API and pain interference at 6-months posttreatment relative to ED. Participation in HYP resulted in greater decreases in API, pain interference, and depressive symptoms at 3- and 6-months posttreatment compared to ED. No significant differences on outcomes between HYP and MM were detected at any time point. This study suggests that all three interventions provide posttreatment benefits on a range of outcomes, but the benefits of HYP and MM continue beyond the end of treatment, while the improvements associated with ED dissipate over time. Future research is needed to determine whether the between-group differences that emerged posttreatment are reliable, whether there are benefits of combining treatments, and to explore moderating and mediating factors.

Williams RM, Ehde DM, Day M, Turner AP, Hakimian S, Gertz K, Ciol M, McCall A, Kincaid C, Pettet MW, Patterson D, Suri P, Jensen MP. The chronic pain skills study: Protocol for a randomized controlled trial comparing hypnosis, mindfulness meditation and pain education in veterans. Contemp Clin Trials. 2020 Jan 8:105935. doi: 10.1016/j.cct.2020.105935.

OBJECTIVES

To describe the protocol of a randomized controlled trial to evaluate the effectiveness and mechanisms of three behavioral interventions.

METHODS

Participants will include up to 343 Veterans with chronic pain due to a broad range of etiologies, randomly assigned to one of three 8-week manualized in-person group treatments: (1) Hypnosis (HYP), (2) Mindfulness Meditation (MM), or (3) Education Control (EDU).

PROJECTED OUTCOMES

The primary aim of the study is to compare the effectiveness of HYP and MM to EDU on average pain intensity measured pre- and post-treatment. Additional study aims will explore the effectiveness of HYP and MM compared to EDU on secondary outcomes (i.e., pain interference, sleep quality, depression and anxiety), and the maintenance of effects at 3- and 6-months post-treatment. Participants will have electroencephalogram (EEG) assessments at pre- and post-treatment to determine if the power of specific brain oscillations moderate the effectiveness of HYP and MM (Study Aim 2) and examine brain oscillations as possible mediators of treatment effects (exploratory aim). Additional planned exploratory analyses will be performed to identify possible treatment mediators (i.e., pain acceptance, catastrophizing, mindfulness) and moderators (e.g., hypnotizability, treatment expectations, pain type, cognitive function).

SETTING

The study treatments will be administered at a large Veterans Affairs Medical Center in the northwest United States. The treatments will be integrated within clinical infrastructure and delivered by licensed and credentialed health care professionals.

Zaccari B, Loftis JM, Haywood T, Hubbard K, Clark J, Kelly UA. Synchronous Telehealth Yoga and Cognitive Processing Group Therapies for Women Veterans with Posttraumatic Stress Disorder: A Multisite Randomized Controlled Trial Adapted for COVID-19. Telemed J E Health. 2022 Mar 29. doi: 10.1089/tmj.2021.0612.

BACKGROUND

Providing care over telehealth grew slowly until the COVID-19 pandemic. Since the onset of the COVID-19 pandemic, providing mental health care was readily adapted to virtual means; however, clinical trial research is nascent in adapting methods and procedures to the virtual world.

METHODS

We present protocol modifications to pivot a multisite randomized controlled trial study, conducted at Southeastern and Pacific Northwestern Veterans Affairs Health Care Systems, from being conducted in-person to virtually, following the onset of the COVID-19 pandemic. We measured outcomes of posttraumatic stress disorder (PTSD) symptoms and psychophysiological markers of stress among female Veterans with PTSD secondary to military sexual trauma. We collected qualitative data about provider and participant experiences with telehealth.

RESULTS

Across sites, 200 participants were consented (48 virtually), 132 were randomized (28 to virtual groups), and 117 completed data collection and treatment (69 completed all or some data collection or treatment virtually).

CONCLUSIONS

The pivots made for this study were in response to the COVID-19 pandemic and offer innovative procedures leveraging technology and contributing to the broader landscape of conducting research virtually.

Zeliadt SB, Coggeshall S, Thomas E, Gelman H, Taylor SL. The APPROACH trial: Assessing pain, patient-reported outcomes, and complementary and integrative health [published online ahead of print, 2020 Jun 10]. Clin Trials. 2020;1740774520928399. doi:10.1177/1740774520928399

Electronic health record data can be used in multiple ways to facilitate real-world pragmatic studies. Electronic health record data can provide detailed information about utilization of treatment options to help identify appropriate comparison groups, access historical clinical characteristics of participants, and facilitate measuring longitudinal outcomes for the treatments being studied. An additional novel use of electronic health record data is to assess and understand referral pathways and other business practices that encourage or discourage patients from using different types of care. We describe an ongoing study utilizing access to real-time electronic health record data about changing patterns of complementary and integrative health services to demonstrate how electronic health record data can provide the foundation for a pragmatic study when randomization is not feasible. Conducting explanatory trials of the value of emerging therapies within a healthcare system poses ethical and pragmatic challenges, such as withholding access to specific services that are becoming widely available to patients. We describe how prospective examination of real-time electronic health record data can be used to construct and understand business practices as potential surrogates for direct randomization through an instrumental variables analytic approach. In this context, an example of a business practice is the internal hiring of acupuncturists who also provide yoga or Tai Chi classes and can offer these classes without additional cost compared to community acupuncturists. Here, the business practice of hiring internal acupuncturists is likely to encourage much higher rates of combined complementary and integrative health use compared to community referrals. We highlight the tradeoff in efficiency of this pragmatic approach and describe use of simulations to estimate the potential sample sizes needed for a variety of instrument strengths. While real-time monitoring of business practices from electronic health records provides insights into the validity of key independence assumptions associated with the instrumental variable approaches, we note that there may be some residual confounding by indication or selection bias and describe how alternative sources of electronic health record data can be used to assess the robustness of instrumental variable assumptions to address these challenges. Finally, we also highlight that while some clinical outcomes can be obtained directly from the electronic health record, such as longitudinal opioid utilization and pain intensity levels for the study of the value of complementary and integrative health, it is often critical to supplement clinical electronic health record–based measures with patientreported outcomes. The experience of this example in evaluating complementary and integrative health demonstrates the use of electronic health record data in several novel ways that may be of use for designing future pragmatic trials.