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Military and Veteran Pain Research: A Focus on Measurement Science

and Practice Rosemary C. Polomano, PhD, RN, FAAN

Associate Dean for PracticeProfessor of Pain Practice

Department of Biobehavioral Health SciencesUniversity of Pennsylvania School of Nursing

Professor of Anesthesiology and Critical Care (Secondary) University of Pennsylvania Perelman School of Medicine

Philadelphia, PA

It was 2005 at the 11th International Association for the Study of Pain World Congress, Sydney, Australia.

COL Chester “Trip”

Buckenmaier III, MD

Professor in Anesthesiology

at the Uniformed Services

University of the

Health Sciences

Rollin M. Gallagher, MD, MPH

National Director of Pain

Management, Veterans

Administration and Clinical

Professor Psychiatry/Anesthesiology,

University of Pennsylvania

Daniel B. Carr, MD

Director, Tufts Program on

Pain Research, Education

and Policy

Professor, Public Health and

Community Medicine

Regional Anesthesia in the Battlefield

• In 2003, COL Chester “Trip”

Buckenmaier, MD, inserted

the first regional anesthesia

(RA) catheter for pain control

in a Combat Support Hospital

(CSH) or Field Hospital in

Balad, Iraq

Army Spc. Brian Wilhelm

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Combat Injuries are Devastating

• Most service members with major limb trauma sustained in combat had blast injuries– Improvised explosive devices (IEDs) were most

common

• We submitted a grant to the Department of Defense (DoD)

• In 2007, we received a large DoD grant to investigate multiple pain and behavioral health outcomes with major limb (extremity)trauma

://www.youtube.com/watch?v=crdPbhttpMcqAK4

Regional Anesthesia Military Battlefield Pain Outcomes Study (RAMBPOS) Team

PRINCIPAL INVESTIGATOR (PI)

Rollin M. Gallagher, MD, MPH, Department of Psychiatry and Philadelphia VA Medical Center

CO-INVESTIGATORS, UNIVERSITY OF PENNSYLVANIA

Rosemary C. Polomano, PhD, RN, FAAN, School of Nursing and Department of Anesthesiology

John T. Farrar, MD, PhD, and Wen Guo, PhD, Center for Epidemiology and Biostatistics (CCEB)

David Oslin, MD, Department of Psychiatry and Philadelphia VA Medical Center

SITE PI, DEFENSE AND VETERANS CENTER FOR INTEGRATIVE PAIN MANAGEMENT (DVCIPM)

COL Chester “Trip” Buckenmaier III, MD, Defense and Veterans Center for Integrative Pain

Management (DVCIPM, National Military Medical Center (WRNMMC) in Bethesda, MD

SITE PI, SAN ANTONIO MILITARY MEDICAL CENTER (SAMMC)

LTC Brandon J. Goff, DO, Recruitment at SAMMC in Fort Sam Houston, TX

STATISTICIAN

Lynne Taylor, PhD, Center for Epidemiology and Biostatistics (CCEB)

RESEARCH COORDINATORS

Yolanda S. Williams, MPH, Philadelphia VA Medical Center and University of Pennsylvania

Megan Vaughan, BSN, RN, Henry Jackson Foundation, DVCIPM

RESEARCH STAFF, PVAMC AND UNIVERSITY OF PENNSYLVANIA

Tiffany Huseman, BA

Olivia Antosiewicz, BA

Dana Brown, BS

Shawn Fernandes, BS

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What did we learn?: A Snapshot

• From 381 combat-injured service members studied for 2 years after acute care for their injury, we learned: – Greatest improvement in pain outcomes

occurred in the first 6 months after discharge from the hospital and then remained stable

– Incidence of behavioral health problems (anxiety, depression and Posttraumatic Stress Disorder PTSD) was concerning• 46% of the sample (158 out of 347) had PTDS symptoms

• 14% (48) had severe PTSD

Connection of Practice to Science

Science PracticePractice Science

Military Research is a Compromise: Moving to the Point of Injury• Unable to conduct a study in a Combat Support

Hospital so in 2008, COL Buckenmaier went to Landstuhl Regional Medical Center (LRMC),

Germany

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POWER Survey

Pain Outcomes for Warriors Experiences Research

Pain and Emotional Outcomes During Transport

5.3

6.8

3.5 3.64.1

0

1

2

3

4

5

6

7

8

9

10

Average

pain

Worst pain Anxiety Distress Worry

Better

Worse

Pain Intensity Levels at LRMC

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Themes that Emerged from the Air Evacuation Experience

Content Analysis of Injured

Service Members Experiences

1. Fears

2. Communi-cation

3. Concerns4. Confidence

and Trust

5. Futuristic Visons

Janet A Deatrick,

PhD, RN, FAAN

Desiree A Fleck,

PhD, RN, CRNP

Examples of Expressions of Concerns

• Concerns for others: unit and family

• “I was worried about my, two friends who died and how their wives and kids would do without them. They are both having babies in June.”

• “My guys getting hit by another IED”

• “How my crew was doing two died and one is in the ICU”

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Situating and Forecasting

• Information support

• Practical instruction• “Why did I have to go to Balad from Baghulad where I was

injured? I did not receive medical care in Balad - it seemed like a wasted step.”

• “I wasn’t getting any answers. I know I was going to Germany but after that what?”

• “How long at each place”

• Medical Treatment plans• “When would they fix my arm? Information about my injury”

2009 Camp Bastion Study

• COL Buckenmaier deployed to Camp Bastion, Afghanistan to start an Acute Pain Service (APS) – British military base located in Helmand Province,

southern Afghanistan; a dangerous region– Largest overseas British military installation since World

War II

• Our chance to get real time patient outcomes in a Combat Support Hospital (CSH)

Average Pain Intensity and Percent Pain Relief Scores (N=71)

7

4

2.531.3

74.983.1

0

10

20

30

40

50

60

70

80

90

100

0

1

2

3

4

5

6

7

8

9

10

Recalled Prehospital

(0-3hrs)

Post Primary Analgesic

Intervention

(4-6hrs)

Prior to Evacuation

(7-24hrs)

Pain Intensity % Pain Relief

% P

ain

Re

lief

Nu

me

ric

Ra

tin

g S

ca

le

Standard deviation bars shown

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19.1%

39.1%

1.5%

5.7%

2.9%

50.0%

31.9%

25.0%

20.3%

32.4%

30.9%

28.9%

73.5%

73.9%

64.8%

0% 20% 40% 60% 80% 100%

Patients managed by APS are

able to be transported sooner

APS pain management

protocols differ markedly fromwhat I usually do

Overall, APS has a significant

impact on patient outcome

Patients managed by the APS

obtain greater levels of painrelief

Patients managed by the APS

report decreased levels ofpain

Strongly Agree and Agree No opinion Strongly Disagree and Disagree

73.5%

30.9%

2.8%

37.7%

19.1%

25.0%

17.4%

24.6%

7.4%

44.1%

79.7%

37.7%

0% 20% 40% 60% 80% 100%

APS needs to improve their

services by providingeducation

Surgical team should determine

what analgesics techniqueshould be used

Regional anesthesia

interventions are too difficult touse in CSH

Complexity of care is increased

with APS involvement

Strongly Disagree and Disagree No Opinion Strongly Agree and Agree

2009: Ketamine Study

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A New Pain Scale for the Military and Veterans Health Administration

• In 2009, the Army Surgeon General chartered the Army Pain Management Task Force to recommend a comprehensive pain management strategy– COL Buckenmair, COL Galloway and Dr.

Gallagher were all leaders in this effort

• Our studies informed this comprehensive report and military policy

• The Task Force's final report contained 109 recommendations – a new pain scale would be designed, tested and implemented

Is pain really what the

experiencing person says it is?

British Military Colleagues

Tested on 350 Services

Members at the Walter

Reed National Military

Medical Center

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Percent Agreementfor Appropriate Placement of Word Descriptors

Intraclass Correlation Coeficient (a

measure of agreement)was > 0.85

A special thanks to Dr. Abby Cohen

The correlation coefficientbetween the two scores was robust and significant, r = 0.93 (P < 0.001), and supported concurrent validity.

This method obtains both concurrent validity and alternate forms reliability.

Concurrent Validity

The Value of the DVPRS: Translation to Practice

• DVPRS provides visual cues and word descriptors to anchor pain ratings with perceptual experiences and limitations imposed by pain

• DVPRS has supplemental questions on general activity, mood, level of stress and sleep to help quantify the impact of pain and screen patients for potential issues

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DVPRS Second Validation Study

Supplemental Questions

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Patients with neuropathic pain had poorer outcomes.

Dissemination

What is new?Validated Patient-Reported Outcomes (PROs)

PROMIS®: Patient Reported Outcomes Measurement

Information System (PROMIS), funded by the National Institutes of

Health (NIH) ($100 million), is a system of highly reliable, valid,

flexible, precise, and responsive assessment tools that measure

patient–reported health status.

http://www.nihpromis.org/

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Patient Reported

Outcomes

Measurement

Information Systems

Physical Health

Social Health

Mental Health

Global Health

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Military Health History

Have You Ever Served in the Military?

http://www.haveyoueverserved.com/pocket-card--posters.html