Detecting long-term concussion in athletes

Detecting long-term concussion in athletes

Researchers develop method that could one day be used in brain trauma lawsuits

Lawyers representing both sides in concussion lawsuits against sports leagues may eventually have a new tool at their disposal: a diagnostic signature that uses artificial intelligence to detect brain trauma years after it has occurred.

While the short-term effects of head trauma can be devastating, the long-term effects can be equally hard for patients. The symptoms may linger years after the concussion happened. The problem is it is often hard to say whether their symptoms are being caused by a concussion or other factors like another neurological condition or the normal aging process. Continue reading »

sickle cell disease

New treatment for sickle cell disease approved by the FDA

First approval for this rare blood disorder in nearly 20 years.
For Immediate Release: July 7, 2017 – via

The U.S. Food and Drug Administration today approved Endari (L-glutamine oral powder) for patients age five years and older with sickle cell disease to reduce severe complications associated with the blood disorder.

“Endari is the first treatment approved for patients with sickle cell disease in almost 20 years,” said Richard Pazdur, M.D., acting director of the Office of Hematology and Oncology Products in the FDA’s Center for Drug Evaluation and Research and director of the FDA’s Oncology Center of Excellence. “Until now, only one other drug was approved for patients living with this serious, debilitating condition.” Continue reading »

clot retrieval stroke

Your Patient who had a stroke is being considered for clot retrieval. Which statement about this procedure is correct?

Clot retrieval is surgical treatment for acute stroke that involves the mechanical removal of a blood clot from a patient’s brain. It is offered as a treatment for patients who have experienced a stroke as the result of narrowing of the arteries in their brain.

Quiz Time: Your Patient who had a stroke is being considered for clot retrieval. Which statement about this procedure is correct? Continue reading »

sexual activity contraceptive teen

Sexual Activity and Contraceptive Use Among Teenagers USA 2011-2015

Objective – This report presents national estimates of sexual activity and contraceptive use among males and females aged 15–19 in the United States in 2011–2015, based on data from the National Survey of Family Growth (NSFG). For selected indicators, data are also presented from the 1988, 1995, 2002, and 2006–2010 NSFGs, and from the 1988 and 1995 National Survey of Adolescent Males, which was conducted by the Urban Institute.

Methods – NSFG data were collected through in-person interviews with nationally representative samples of men and women aged 15–44 in the household population of the United States. NSFG 2011–2015 interviews were conducted between September 2011 and September 2015 with 20,621 men and women, including 4,134 teenagers (2,047 females and 2,087 males). The response rate was 72.5% for male teenagers and 73.0% for female teenagers. Continue reading »

Maintain Weight Loss

How to maintain weight loss successfully

Suggestions based on a 20-year national study. Body weight is a key factor to protect us from chronic disease. Although obese people can lose weight through healthy diet, exercise programs, medicine, and surgery, more than 75% of them regain weight after losing it.

To learn more about maintaining weight loss, researchers founded the National Weight Control Registry (NWCR) as a long-term study project in 1994. Currently, 10,000+ people have joined in the project. Researchers gathered self-report data from those who are successfully maintain weight loss. The finding is published in The journal for Nurse Practitioners. Continue reading »

Building moral resilience to neutralize moral distress

Moral distress occurs when one recognizes one’s moral responsibility in a situation; evaluates the various courses of action; and identifies, in accordance with one’s beliefs, the morally correct decision—but is then prevented from following through.
The literature is replete with the mounting evidence of the incidence and sources of moral distress. Continue reading »

Fall prevention: Applying the evidence

This is the first in a series of three case studies illustrating success stories in preventing falls and injuries from falls. The series is brought to you by Posey. Watch for the next case study in the September issue of American Nurse Today.

Successful fall prevention programs use multimodal interventions, such as detailed fall risk assessments, frequent monitoring by staff, and appropriate use of equipment. Healthcare facilities typically implement best practices in bundles, making it often difficult to determine which interventions are the most effective.

UPMC St. Margaret Hospital in Pittsburgh, Pennsylvania joined the Pennsylvania Hospital Engagement Network (PA HEN) in April 2012 to reduce falls with injury. This set us on a path that resulted in a 75% reduction in falls with serious injuries. (See Falls with serious injury graph)

Here is how we accomplished this reduction.

Analysis: Role of data and best practices

After joining PA HEN, we formed a multidisciplinary team tasked with reviewing and investigating all fall events, extracting and analyzing data, and evaluating best practices implemented as a result of root cause analysis.

The multidisciplinary fall team implemented prevalence rounding and post fall debriefing. Despite best practice implementation, we discovered variations and inconsistencies in our practice environment. We found that making sense of the data collected through a revised post-fall debriefing and delivering the information to staff in an easily understood format was the “magic bullet” in our success story.

Strategy: Debriefing

Debriefing engages staff, patients, and families while providing educational opportunities. Our debriefing process was critical for abstracting usable data. The facilitator who is responsible for debriefing the fall event needs to have expertise in the debriefing process to ensure data integrity. He or she must be objective and promote a nonjudgmental atmosphere of inquiry. The goal is to engage all participants, including the patient and family. At the end of the debriefing, the facilitator determines root causes and shares them with team members. Identifying root causes is invaluable to the debriefing process.

Root causes are then converted into frequency charts, which are useful for analysis and clearly illustrate the variables with the greatest impact on particular outcomes. Our team focused on tangible root causes, such as safety equipment, which proved successful in reducing falls in our facility. (See Case study.)

Strategy: Enhancing equipment use

Commonly used fall prevention equipment includes bed alarms, chair alarms, low beds, floor mats, and nurse call system/alarm integration. Based on its analysis of various types of falls and process-improvement initiatives, the team put interventions in place that essentially resolved identified equipment issues.

The debriefing process identified the following equipment issues.

Outcomes: Falls reduction

In the first year of our initiative, we had a 50% reduction in falls with injuries and won the 2013 Hospital Association of Pennsylvania Achievement Award for Patient Safety.

We’ve achieved the following reductions over the past 4 years:

• 75% reduction in falls that resulted in serious injuries

• 60% reduction in falls that resulted in injuries

• 25% reduction in all falls.

Our ability to sustain these improvements keeps patients safer during hospitalization.

Kathleen Fowler, MSN, RN, CMSRN Quality Improvement Manager UPMC St. Margaret, Pittsburgh, Pennsylvania As told to Janet Boivin, BSN, RN

Tracking Down the Salt in Food with Professor Saul T. infographic

Tracking Down the Salt in Food with Professor Saul T. infographic

Tracking Down the Salt in Food with Professor Saul T. infographic

This infographic is brought to you by Million Hearts.

Acute kidney injury

Acute kidney injury: Causes, phases, and early detection

When you arrive for your afternoon shift, you receive report from the day-shift nurse. He states he just admitted Marc Stevens, age 78, after a colostomy takedown. He reports that the patient’s blood pressure (BP) decreased in the operating room several times, with systolic BP dropping to 70 mm Hg, but he recovered with a fluid bolus. Mr. Stevens weighs 91 kg (200 lb). His BP has been on the low side, currently measuring 90/42 mm Hg, and his mean arterial pressure (MAP) is 58 mm Hg.

When you assess Mr. Stevens at 4 P.M., you find his urine output is 40 mL. When you return at 7 P.M. to check his vital signs and urine output, his BP is still a bit low (92/45 mm Hg), but otherwise he seems to be doing well; his urine output this hour is 82 mL. On your final check at 10 P.M., his output is 95 mL. Continue reading »

Special report – War on Pain: Resources for additional information

The organizations, websites, guidelines, and publications below are excellent resources for readers seeking more information on pain, pain management, and closely related topics.

Organizations and websites

Veterans Health Administration

This website aims to promote effective pain management by providing convenient, centralized access to the resources needed to provide pain-management services within the Veterans Administration (VA) healthcare system. Intended users of this site include veterans, their family members, caregivers, VA administrators, clinicians, and researchers with an interest in any aspect of pain management. The site provides quick access to relevant resources from both internal and external sources.

Clinical guidelines

Assessment and management of low back pain

This guideline describes critical decision points in diagnosingand managing low back pain. It provides clear, comprehensive evidence-based recommendations that incorporate current information and practices for practitioners throughout the Department of Defense (DoD) and VA healthcare systems.

Management of opioid therapy for chronic pain

Describing the critical decision points in managing opioid therapy in patients with chronic pain, this guideline provides evidence-based recommendations and workgroup consensus statements.

Management of postoperative pain

Besides detailing critical decision points in managing postoperative pain, this guideline makes evidence-based recommendations that incorporate current information and practices for practitioners in the DoD and VA healthcare systems.


Practitioner’s Manual: An Informational Outline of the Controlled Substances Act (2006)

The Drug Enforcement Administration established this comprehensive website for information and resources on drug diversion and misuse. Users can access the Practitioner’s Manual from this site.

Special report – War on Pain: Multimodal and multidisciplinary therapy for pain management

By Kevin T. Galloway, BSN, MHA; Chester C. Buckenmaier III, MD; Rollin M. Gallagher, MD, MPH; and Rosemary C. Polomano, PhD, RN, FAAN

An important initial step in pain management is setting goals, which differ for acute and chronic pain. Acute pain management aims to gain rapid, effective control of pain and eliminate further sources of pain. In contrast, management of chronic pain, such as low back pain or polytrauma pain, requires a biopsychosocial approach. The goals of chronic pain treatment include:

  • communicating realistic expectations (including the message that freedom from pain isn’t realistic)
  • improving the patient’s quality of life
  • increasing function and mobility
  • reducing the degree to which pain interferes with activities
  • relieving associated psychological stressors
  • minimizing the risk of opioid misuse, abuse, and addiction, which can be associated with long-term opioid analgesics.

Advances in treating combat-related pain

From the 1800s until recently, morphine was the sole pain-control method used by the military. One of the drug’s benefits, researchers recently found, is that morphine given during early resuscitation and trauma care may reduce the risk of posttraumatic stress disorder in military service members who don’t have serious traumatic brain injury. But in the modern combat environment, morphine has many undesirable—and at times deadly—properties. As the Iraq and Afghanistan conflicts continued and more military service members were treated, the need for alternative pain-management methods became increasingly obvious.

The destructiveness of the weapons used and the severity of combat injuries have been greater in Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) than in previous conflicts. Yet nearly 90% of OEF and OIF service members have survived their injuries, compared to a 76% survival rate during the Vietnam War. The higher survival rates stem from improvements in modern battlefield care, including advanced frontline surgical and resuscitation capabilities.

For wounded military patients who are hemodynamically stable and have isolated and uncomplicated orthopedic injuries or extremity wounds, oral transmucosal fentanyl citrate is an advance in acute pain management. This is particularly true in austere combat environments, such as those lacking ventilators, where multiple surgeries must be performed in one operating room, or where multiple patients must be placed on a single monitor. One oral fentanyl dose can provide rapid, sustained pain management for up to 5 hours, generally with only minor adverse effects (itching, nausea, vomiting, and light-headedness).

Austere environments challenge the traditional mindsets and training of surgeons, anesthesiologists, and nurses, who must adapt to environmental conditions and develop innovative anesthetic and analgesic plans as resources are consumed. In these environments, regional anesthesia is more common than general anesthesia, and anesthesia complications can be minimized with training and experience.

Rapid transport of wounded soldiers over great distances by air to increasingly sophisticated trauma-care levels contributes to the higher survival rate. Nonetheless, while rapid air transport to the next level of care is an advance, evacuation flights are crowded, light conditions are low, vibration and noise are high, monitoring resources are constrained, and healthcare personnel are limited. These limitations may contribute to the suboptimal pain relief during air transport reported by some military patients with polytrauma.

Regional anesthesia

Recent advances in treating combat related pain during evacuation flights and postoperatively include regional analgesia via continuous peripheral nerve blocks (CPNB) and patient-controlled analgesia (morphine or hydromorphone). Regional analgesia, which may be administered by certified registered nurse anesthetists, is a preventive strategy that yields improved analgesia, outcomes, and patient satisfaction. Regional analgesia with CPNB also provides pain relief during the frequent trips to the operating room that service members with polytrauma undergo at military treatment facilities and during multiple dressing changes and surgical debridements. Compared to patients who undergo general anesthesia,
those who receive CPNB have less pain, receive less analgesia, suffer less postoperative nausea, and experience fewer anesthesia-related complications. Risks of regional anesthesia include local anesthetic toxicity, nerve injury, and infection from the indwelling catheter.

Ongoing pain management

Optimal pain management requires a comprehensive strategy with a multimodal approach that includes pharmacologic therapy, psychological therapy, physical and occupational therapy, and procedural treatments. (See Multimodal treatments for optimal pain management by clicking the PDF icon above.)

The rationale for multimodal therapy is to improve analgesia by taking advantage of the synergistic action between drugs and the various techniques and delivery approaches that affect different mechanisms in the pain perception-modulation system, or that affect the same mechanism but in different parts of the peripheral nervous system (PNS) or central nervous system (CNS). Synergistic action may allow use of lower dosages and avoid complications of opioid-centered analgesia. A tenet of treating pain patients is that they have a right to have their pain assessed regularly and managed effectively—but they don’t have the right to abuse or violate the terms of their treatment programs.

Multimodal pharmacologic therapy

Many drugs other than opioids are available for treating pain. A rational approach to pharmacologic therapy is to consider a drug’s mechanism of action and the source or type of pain. Multimodal analgesia refers to the use of more than one agent from different pharmacologic analgesic classes that target different mechanisms of CNS or PNS pain. The goals of multimodal analgesia are to:

  • improve analgesia quality
  • achieve more balanced analgesia
  • reduce adverse events.

An example of multimodal pharmacologic therapy is use of an anticonvulsant (such as gabapentin or pregabalin) with an opioid for postoperative neuropathic pain. This combination reduces opioid requirements and adverse effects while providing better pain relief. Another multimodal strategy is to use a single agent with dual mechanisms of action. An example is monotherapy with tramadol or tapentadol; both drugs have mu-opioid receptor agonism and inhibit reuptake of neurotransmitters (primarily serotonin with tramadol and norepinephrine with tapentadol).

Nonpharmacologic strategies

Nonpharmacologic strategies for ongoing management of both acute and chronic pain include physical and occupational therapy, procedural techniques, and psychological measures. These strategies aim to restore function and mobility and to reduce psychosocial stressors that contribute to pain. An example of multidisciplinary, multimodal pain management is the treatment of military service members with polytrauma at entry to rehabilitation; all of these patients receive medication (opioids, 58%; nonsteroidal anti-inflammatory drugs [NSAIDs], 50%; anticonvulsants, 20%). Other forms of therapy are individualized and may include physical therapy (40%), occupational therapy (38%), individual psychotherapy (49%), and cognitive behavioral therapy (13%).

Chronic pain management

Intervening early and aggressively in the chronic pain cycle is crucial to favorably influencing pain and quality-of-life outcomes and preventing progression of disabling pain. The Veterans Administration (VA) developed a stepped-care approach to pain management in response to the changing veteran population and in an effort to standardize pain management throughout the VA. This approach became official policy in 2009. (See VA stepped pain-care approach by clicking the PDF icon above.)

Besides using the stepped-care approach, other aspects of managing patients with chronic pain include:

  • establishing a collaborative relationship with the patient to promote self-management
  • shifting the patient from a biomedical to a biopsychosocial treatment model
  • identifying long-term functional goals
  • supporting the patient’s efforts to address other life problems.

OEF and OIF veterans have a high frequency of pain of musculoskeletal or connective tissue origin (52%) with significant comorbidities, including mental disorders (48%), nervous-system or sensory-organ diseases (40%), and ill-defined signs and symptoms (46%). The most common pain diagnosis among deployed military service members is low back pain, which may be exacerbated by combat. Although 80% of patients with their first episode of nonspecific low back pain recover within 1 month and another 10% recover within 3 months, the remaining 10% go on to develop chronic pain.

A thorough physical examination and comprehensive history are the most important tools in evaluating low back pain. The physical examination includes a head-to-toe evaluation to determine which areas have structural abnormalities and to evaluate posture, inspect for skin changes (such as color), palpate muscles for knots and tender (trigger) points, assess reflexes, and evaluate range of motion. Patients also undergo neurologic and sensory exams and other special tests. The patient history includes the “5 Ps” of pain assessment—precipitation, pattern, prior treatments, patient beliefs, and predisposition. Diagnostic imaging isn’t necessary unless “red flags” are identified during the exam; imaging may be indicated if pain persists for 3 or more months after appropriate conservative treatment.

Conservative treatment

The goal of conservative treatment is to enable the patient to perform normal activities as soon as possible. Treatment measures include education and reassurance, brief rest (2 to 3 days), prevention of kinesiophobia (fear of movement) with gradual resumption of minimally painful activities, medications (NSAIDs plus muscle relaxants, which may promote a faster return to activity), and physical therapy.

Rational opioid prescribing

Over the last 30 years, use of opioid analgesics for treating chronic pain has increased. As a result, approximately 10% of American adults with chronic pain have a substance abuse disorder. An estimated 33% to 54% of persons with opioid addiction have chronic pain. This vulnerable population deserves effective pain control, but may require more stringent guidelines for opioid prescribing and monitoring. Brain circuits involved in drug abuse and addiction—reward, motivation, judgment, inhibitory control, and memory consolidation—also are involved in pain processing and perception.

Differentiating addiction, physical dependence, and tolerance

How do addiction, physical dependence, and tolerance differ? According to one definition, addiction is a chronic neurobiologic disease whose development and manifestations are influenced by genetic, psychosocial, and environmental factors. Addiction is characterized by one or more of the following:

  • impaired control over drug use
  • compulsive use
  • continued use despite harm
  • craving.

Physical dependence occurs with regular use of mu-opioid agonists and is to be expected. Serious consequences occur when the opioid is withdrawn abruptly or reversed with an opioid antagonist, such as naloxone. Sudden cessation or reversal can lead to a withdrawal syndrome characterized by physiologic responses, such as agitation, rapid pulse, sweating, and orthostatic hypotension. In rare cases, life-threatening seizures may accompany withdrawal, particularly when the patient also is withdrawing from barbiturates or benzodiazepines (which may be coprescribed in patients with chronic pain, although rarely indicated because of synergistic respiratory depression).

Tolerance refers to decreased response to a constant dose of a drug, or the need for increasing doses to maintain a constant effect.

The goal of rational opioid prescribing is to provide pain relief while preventing the potential adverse outcomes of addiction—but recognizing that physical dependence and tolerance may develop, which may necessitate changes in the treatment plan.

Risk-mitigation strategies

The rising use of opioids to treat chronic pain over the last 30 years is tied to a greater number of opioid prescriptions written by providers with limited training in pain management, psychiatry, or addiction. This trend in both the civilian and military sectors may have contributed to a rise in prescription drug abuse in military, VA, and civilian populations. It has prompted the creation of risk-mitigation strategies and programs to minimize the risk of misuse, abuse, and diversion. Risk-mitigation strategies should be used for patients with a history of opioid addiction who may receive opioids for pain management. Recommended strategies for these patients include:

  • prescribing long-acting or time contingent (rather than pain-contingent or as-needed) opioids
  • providing small quantities of opioids that necessitate frequent visits to reassess pain and function
  • prescribing the minimum dosage that relieves pain and maintains function
  • continuing to educate the patient about opioids
  • seeking specialists’ opinions and care when indicated by clinical complexity, comorbidities, treatment refractoriness, and higher risk.

When caring for patients who take opioids regularly before surgery, remember that they may require significantly higher opioid doses postoperatively to control pain.

Opioid Renewal Clinic

In 2002-2003, the Opioid Renewal Clinic (ORC) was established at the Philadelphia VA Medical Center to mitigate the risk of opioid misuse, addiction, and diversion. Developed by a nurse practitioner and clinical pharmacist (and supported by a multidisciplinary pain-management team that included an addiction psychiatrist, rheumatologist, neurologist and orthopedist), ORC is modeled on an anticoagulation clinic model. It uses various strategies to mitigate risk, including an opioid treatment agreement (and second-chance agreement), frequent visits, opioid prescribing on a short-term (weekly or biweekly) basis, periodic urine drug testing, pill counts, and comanagement with addiction services.

Several measures demonstrate ORC’s success in reducing the risk of opioid misuse, addiction, and diversion. Most primary-care providers report they’re more comfortable managing patients with chronic pain (89%) and receive fewer complaints from patients regarding pain medications (77%). A 2-year assessment showed use of opioid treatment agreements and urine drug testing increased markedly; emergency department visits decreased by 73% and unscheduled visits to the primary-care provider dropped 60%. In addition, at 1 year, 49% of at-risk ORC patients demonstrated 100% adherence with the program and no aberrant behavior. The ORC has been deemed a best practice by the VA and is being established in various forms throughout the administration and in some civilian settings as well.

National opioid pain care agreement policy

Using a multidisciplinary task force composed of clinicians, ethicists, lawyers, and educational specialists, the VA embarked on a 3-year process to develop a national opioid pain care agreement policy that aimed to standardize and optimize the use of opioid analgesia in pain management. The proposed policy, which takes an informed and shared decision-making approach to risk management, was presented for review in 2009. It recommends routine use of a standardized opioid pain care agreement between provider and patient when chronic opioid therapy is instituted. Patient information resources include a patient guide, which details what the patient needs to know about opioids and pain care in the VA, and a brochure outlining policies and expectations. More recent discussions of this procedure have led to consideration of a standardized informed consent process to replace the opioid pain care agreement policy.

Complementary and alternative medicine for pain management

Complementary and alternative medicine (CAM) encompasses a diverse group of healthcare systems, practices, and products not generally considered part of conventional medicine. The following definitions are useful for understanding CAM terms:

  • Complementary medicine is the use of CAM together with conventional medicine.
  • Alternative medicine is the use of CAM in place of conventional medicine.
  • Integrative medicine refers to a practice that combines conventional and CAM treatments for which evidence of safety and effectiveness exists.

For a summary of CAM techniques commonly used to manage pain, see CAM techniques used in pain management by clicking the PDF icon above.

Nurse’s role in pain management

The Army Pain Management Task Force, chartered by the Army Surgeon General in 2009, emphasizes the need for early and aggressive multimodal therapy for acute pain with coordinated transition of care from one level to the next. (For more information on this Task Force, see “Pain management across the military continuum” in this supplement.) At all levels, care is an interdisciplinary team effort in which nurses play a central role that includes:

  • communicating with team members and injured military service members
  • educating patients about pain management strategies
  • assessing and documenting pain and pain treatments.

Nurses develop unique and sustaining relationships with patients and families, engendering lasting trust that can be instrumental in achieving satisfaction with care and established goals in managing acute or chronic pain. The high survival rate after serious combat injuries in the current conflicts will increase the population of military service members and veterans with acute and chronic pain. Nurses can make a profound contribution to their recovery and return to duty or active civilian life.

Selected references

Buckenmaier CC 3rd, Lee EH, Shields CH, Sampson JB, Chiles JH. Regional anesthesia in austere environments. Reg Anesth Pain Med. 2003;28(4):321-327.

Buckenmaier CC 3rd, Rupprecht C, McKnight G, et al. Pain following battlefield injury and evacuation: a survey of 110 casualties from the wars in Iraq and Afghanistan. Pain Med. 2009;10(8):1487-1496.

Clark ME, Bair MJ, Buckenmaier CC 3rd, Gironda RJ, Walker RL. Pain and combat injuries in soldiers returning from Operations Enduring Freedom and Iraqi Freedom: implications for research and practice. J Rehabil
Res Dev
. 2007;44(2):179-194.

Gallagher RM. Rational integration of pharmacologic, behavioral, and rehabilitation strategies in the treatment of chronic pain. Am J Phys Med Rehabil. 2005;84(suppl3):S64-S76.

Gallagher RM, Polomano R. Early, continuous, and restorative pain management in injured soldiers: the challenge ahead. Pain Med. 2006;7(4):284-286.

Holbrook TL, Galarneau MR, Dye JL, Quinn K, Dougherty AL. Morphine use after combat injury in Iraq and post-traumatic stress disorder. N Engl J Med. 2010;362(2):110-117.

Polomano RC. Concepts in Acute Pain Management: A Nurse’s Guide to Multimodal Approaches to Drug Therapy: INROADS into Pain Management Initiative. Accessed July 22, 2011.

Malchow RJ, Black IH. The evolution of pain management in the critically ill trauma patient: emerging concepts from the global war on terrorism. Crit Care Med 2008; 36(suppl 7):S346-S357.

Wiedemer NL, Harden PS, Arndt IO, Gallagher RM. The opioid renewal clinic: a primary care, managed approach to opioid therapy in chronic pain patients at risk for substance abuse. Pain Med. 2007;8(7):573-584.

Yauger YJ, Bryngelson JA, Donohue K, et al. Patient outcomes comparing CRNA-administered peripheral nerve blocks and general anesthetics: a retrospective chart review in a US Army same-day surgery center. AANA J. 2010;78(3):215-220.

Kevin T. Galloway, is Chief of Staff of the Army Pain Management Task Force of the Office of the Army Surgeon General in Alexandria, Virginia. Chester C. Buckenmaier III is director of the Defense and Veterans Center for Integrative Pain Management and an associate professor at the Uniformed Services University of the Health Sciences in Rockville, Maryland. Rollin M. Gallagher is Deputy National Program Director for Pain Management in the Veterans Affairs Health System at the Philadelphia Veterans Affairs Medical Center in Philadelphia, Pennsylvania; he is also a clinical professor of psychiatry, anesthesiology, and critical care and Director of Pain Policy Research and Primary Care at Penn Pain Medicine at the University of Pennsylvania School of Medicine in Philadelphia. Rosemary C. Polomano is an associate professor of pain practice at the University of Pennsylvania School of Nursing and an associate professor of anesthesiology and critical care (secondary) at the University of Pennsylvania School of Medicine in Philadelphia.

Special report – War on Pain: Pain management across the military continuum

By Kevin T. Galloway, BSN, MHA; Chester C. Buckenmaier III, MD; and Rollin M. Gallagher, MD, MPH

In the military healthcare system, the need for aggressive management of acute pain associated with combat injuries and trauma is obvious. An equally important and possibly greater issue facing military medicine is how to treat military service members who develop significant pain caused by mechanical injuries related to wearing body armor, repeatedly jumping from vehicles, and riding for many hours in vibrating vehicles or helicopters. This population requires ongoing surveillance to identify the prevalence and nature of their pain syndromes and to assess for and manage chronic pain, which generally is of musculoskeletal origin.

The Defense and Veterans Pain Management Initiative (DVPMI), established in 2003 as the Army Regional Anesthesia & Pain Management Initiative, seeks to improve pain management in military and civilian medicine. Through research and clinical care, DVPMI dedicates experts and resources to address pain across the military’s continuum of care from level 1 (combat medic/buddy aid at the point of injury) to level 2 (forward surgical team or aid station) to level 3 (combat support hospital) and on to level 4 (major hospital outside the theater of war), with transition to services of the Veterans Health Administration (VHA) and ultimately the civilian community.

In 2009, the Army Surgeon General chartered a Pain Management Task Force to assess current pain management delivery in the military and provide recommendations for a comprehensive pain-management strategy that takes a holistic, interdisciplinary, multimodal approach. With additional representation from the Air Force, Navy, and national Veterans Administration (VA), the Task Force was directed to include all appropriate science technologies and approaches to pain management that would broaden the goals to optimizing quality of life and function for military service members and veterans with acute and chronic pain. The Task Force report, completed in May 2010, concluded that while the military meets accepted standards of care for pain management, the orientation, practice, and resourcing of pain management varies. Task Force members compiled more than 100 recommendations to advance a comprehensive pain-management strategy for military medicine.

Needed: Integrated care

Although managing pain is one of the most fundamental and basic responsibilities of healthcare professionals, clinicians and researchers continue to wrestle with evidence based and best practices to achieve effective pain management and reduce physical and psychological morbidity associated with suffering. The understanding of and approach to pain management by healthcare personnel are influenced significantly by their education and training, respective pain curricula, mentors, cultural beliefs, and personal experiences with pain. Thus, considerable variability exists in pain-management practices. To a degree, this has contributed to needless suffering, delayed access to pain experts, ineffective or inappropriate pain treatments, and financial burdens to the healthcare system.

Many patients and providers believe pain management falls within one of two categories:

  • intervention-centered (for instance, nerve blocks, joint injections, or acupuncture)
  • medication-centered (for example, pills and capsules).

However, neither of these unimodal approaches adequately meets the needs of many patients, who have complicated pain etiologies and histories. Instead, an effective strategy typically requires a comprehensive, integrated approach that incorporates the perspectives of various disciplines and professions, along with multimodal approaches to pain and individualized plans of care. The tools to implement this strategy fall outside of what insurance providers normally reimburse or what’s available in the average pain-management practice. Besides a physician, effective pain care may require nurses, physical therapists, behavioral health specialists, pharmacists, and other providers. Standard use of
medications and procedural interventions often requires the complementary use of acupuncture, massage therapy, mind-body techniques, and other integrative modalities.

While the military healthcare system’s pain-management challenges resemble those of civilian healthcare systems, military and VA facilities face unique challenges because of their distinctive mission, structure, and patient population. Caring for service members and their families involves responsibilities that extend beyond the usual relationship between a healthcare system and its patients. During times of war, the importance of optimizing care is heightened. The likelihood that military patients will have their health care coordinated by a single primary-care manager is relatively low because of the transience of military personnel (patients) and military healthcare providers.

Less-than-optimal continuity of care is extremely problematic when attempting to develop and implement long-term treatment plans for pain management and other chronic medical conditions. As a result, patients may face duplicate appointments, laboratory tests, and diagnostic and treatment procedures. Veteran populations commonly need care from multiple specialists and services, both within the VA system and the community. Access to consistent providers and services is paramount to continuity of care and reducing delays in care, confusion regarding point-of-care providers, and frustration encountered in navigating complex healthcare systems.

Fortunately, due to advances in combat technologies, such as improved body armor and combat casualty care, most military service members survive wounds that usually proved fatal in previous military conflicts. Survivors of complex polytrauma, however, must contend with significant life-altering challenges and pain, along with comorbid conditions, such as postconcussive syndrome, mild traumatic brain injury (TBI), and posttraumatic stress disorder (PTSD). These conditions require integrated approaches to clinical care that cross the traditional organization of healthcare specialties and patient care.

Pain assessment

Army Pain Task Force interviews with healthcare professionals across all specialties found variability in how pain is assessed and the perceived value placed on patients’ pain scores in directing pain care. While military physicians, nurses, and medics all reported they vigilantly assess pain during each patient encounter, usually using the numeric rating scale (0–10) and the visual analog scale, significant variations occurred in how patients were instructed to report their pain levels. Also, the healthcare professionals perceived pain-assessment scales as vague and highly subjective, with few functional anchors to help patients quantify and qualify their pain.

In response to these findings, the Task Force developed a revised pain scale, called the DoD/VA Pain Rating Scale, which uses a combination of validated pain-assessment scales and functional anchors incorporated to standardize reporting of pain levels. After a comprehensive validation research study is completed, this pain scale is expected to become the standard for all Department of Defense (DoD) and VA healthcare settings. Use of a common patient-reported pain instrument is expected to promote consistency in pain-assessment practices and offer a common understanding of pain in terms of severity, function, and impact on key biopsychosocial areas. With this improved pain reporting scale, the actionable value of pain assessments should increase exponentially. (See Pain rating scale by clicking the PDF icon above.)

Another product from the DVPMI is The Military Advanced Regional Anesthesia and Analgesia Handbook. (See “Resources for additional information.”) The first textbook written specifically for management of battlefield pain in military service members, it was developed based on a recommendation by the Joint Theater Trauma System Clinical Practice Guideline that all healthcare providers be trained and focused on pain management far forward on the battlefield and in military hospitals. The book contains 32 chapters, many of which address regional anesthesia techniques and the associated care of patients receiving this therapy. This text is an outstanding resource for all nurses who collaborate with anesthesiologists to develop regional anesthesia programs.

Transitions to other healthcare systems

Another finding from the Pain Task Force highlighted the importance of coordinating care among the multiple healthcare systems used by the military. Military service members and their families often receive care across a continuum of facilities in the DoD (Army, Navy, and Air Force), VA, and civilian hospitals. The “warm hand-off” between the transferring and accepting teams is a critical component in preventing duplicate laboratory tests and unnecessary medical procedures, as well as ensuring continuity of ongoing effective treatments.

This process depends on a recently developed network of military case managers, most of them registered nurses. Case managers are part of a clinical and administrative team that coordinates communications and care among patients, families, the clinical care team, and military commands. The role of case managers is extremely important as patients move between healthcare systems that may have different formularies, equipment, and treatment protocols for treating pain.

Considerations for acute pain management

The primary objective of acute pain management is to treat pain early and aggressively. For military service members, this means starting pain management far forward on the battlefield. Those who receive prompt, aggressive treatment from an acute pain service experience a greater degree of pain relief, decreased pain intensity, and improved outcomes.
Survey data found that among those treated by an established acute pain service at a combat support hospital in Afghanistan, approximately 30% experienced pain relief in the first 1 to 3 hours, increasing to more than 80% in 7 to 10 hours. Coalition forces deployed to Iraq who received far forward treatment with early and aggressive pain management at an
interventional pain service at a Baghdad hospital had a 95% rate of return to duty; more than 90% were treated for less than 48 hours with multimodal therapy. The most common diagnosis was radiculopathy (63%), which was treated with epidural steroid injections, physical therapy, and pharmacotherapy (primarily nonsteroidal anti-inflammatory drugs), or a combination.

The Pain Outcomes for Warriors Experiences Research initiative demonstrated that more effective painmanagement strategies are needed to prepare injured military service members for long evacuation flights. A survey completed by 110 wounded military service members evacuated from Iraq and Afghanistan to a regional medical center in Germany found that only 65% reported 50% or less pain relief during transport. Pain relief scores improved at the regional medical center, with only 33% indicating 50% or less pain relief.

For military nurses deployed to combat support hospitals, pain management begins at the point of injury. Nurses working in military hospital settings assist in developing effective analgesic regimens. (See Mission of nursing in acute pain management by clicking the PDF icon above.) Raising the pain assessment to the level of the “fifth vital sign” and using standardized assessment and documentation tools greatly improve pain-management care.

Acute pain management relies on a systematic approach to treatment. (See Acute pain management: Key considerations by clicking the PDF icon above.) For nurses, an integral component of patient care is performing regular physical pain assessments and reassessments. These detailed, concise evaluations provide important data for all healthcare team members and serve as the basis for treatment plans. Elements secondary to the pain process, such as psychosocial factors, the patient’s coping mechanisms, family dynamics, and variable levels of patient and family understanding, require nurses to establish trust and a working relationship with patients and families.

Considerations for chronic pain management

For military service members, the rapid transition from being a soldier in a combat zone to returning home to the previous role as spouse, parent, or both is difficult at best. Sustaining serious polytrauma, emotional distress, and psychological exhaustion during military service significantly complicates this transition. At the outset of the current military conflicts, neither DoD nor VA was accustomed to treating survivors of serious blast injuries with significant polytrauma and other associated comorbidities. VHA directive 2009-053 calls for early and continuous treatment of military service members within the DoD, with transition of care to the VA and an integrated stepped pain-management program. Transition to the VA is promoted by a local or regional team to ensure timely initial health assessments, and by coordinators who advocate for care.

Challenges of complex polytrauma

The more complex polytrauma patients with their broader spectrum of physical injuries and comorbidities— including the triad of chronic pain, PTSD, and persistent postconcussive symptoms (the “3 Ps”)—challenge not only current perspectives of the pain continuum and its association with tissue damage and healing. They also challenge pain-management models.

For example, wounded warriors with painful injuries and postconcussive cognitive impairments may require a much more structured environment for successful use of a complex multimodal pain treatment approach. PTSD activates neuropathic pain and worsens cognitive and behavioral controls. Patients with PTSD have higher rates of psychiatric and social problems and less improvement in pain compared to those without PTSD. An effective treatment plan addresses physical and emotional signs and symptoms while providing on-going assessments for and treatment of TBI, PTSD, chronic pain, and substance abuse.

A new disorder, postdeployment multisymptom disorder, has been identified to address the prevalence and greatly increased symptom burden of patients whose pain is clustered with PTSD, mild TBI, PTSD with mild TBI, or substance abuse in patients with polytrauma. To effectively treat these patients requires not just managing individual symptoms but using multifaceted care approaches that focus on function, reintegration into family and social systems, and quality of life.

Currently, DoD and VA are evaluating a new transdisciplinary, stepped, and integrated mental healthcare model centered on maximizing quality of life for patients with postdeployment multisymptom disorder. Core treatments in this model address aspects of daily living and psychosocial functioning; specialty programs are designed to deal with specific diagnoses. Future directions include refining the model, enhancing efficiency of therapy, increasing the consumer focus (such as expanding hours for access to care), and conducting research to determine how interactions among comorbid states affect pain and identify the most effective treatments for these conditions.

Nurse’s role in chronic pain management Nurses are instrumental in achieving the goals of chronic pain therapy by helping patients navigate all aspects of treatment. Specific nursing actions include medication management, counseling (including adherence to therapy), promoting lifestyle changes (such as smoking cessation, physical  therapy, and nutrition counseling), and assisting with complementary and alternative therapies. Of course, nurses are uniquely positioned to conduct pain assessments and monitor responses to analgesic therapies.

Nurses must apply the principles of multimodal analgesia and understand the rationale for both pharmacologic and nonpharmacologic approaches to pain control. Targeted pain treatments, especially multiple analgesics, require knowledge of drug mechanisms of action, dosing parameters for optimal pain relief, synergistic effects that may potentiate adverse drug effects, and guidelines for safe patient monitoring.

In both military and civilian settings, nursing is contributing to improved pain management through clinical practice and research. Nurses are integral to the success of research programs on pain at military and VHA facilities and have made substantial contributions to advancing pain science in such roles as research coordinators and associate or principal investigators. Nurses also serve as primary patient advocates in both military and civilian healthcare systems.

Selected references

Brown ND. Transition from the Afghanistan and Iraqi battlefields to home: an overview of selected war wounds and the federal agencies assisting soldiers regain their health. AAOHN J. 2008;56(8):343-346.

Buckenmaier CC 3rd, Rupprecht C, McKnight G, et al. Pain following battlefield injury and evacuation: a survey of 110 casualties from the wars in Iraq and Afghanistan. Pain Med. 2009;10(8):1487-1496.

Clark ME, Bair MJ, Buckenmaier CC 3rd, et al. Pain and combat injuries in soldiers returning from Operations Enduring Freedom and Iraqi Freedom: implications for research and practice. J Rehabil Res Dev. 2007;44(2):179-194.

Clark ME, Walker RL, Gironda RJ, et al. Comparison of pain and emotional symptoms in soldiers with polytrauma: unique aspects of blast exposure. Pain Med. 2009; 10(3):447-455.

Lamb D. The documentation of pain management during aeromedical evacuation missions. Nurs Clin North Am. 2010;45(2):249-260.

Lew HL, Otis JD, Tun C, et al. Prevalence of chronic pain, posttraumatic stress disorder, and persistent postconcussive symptoms in OIF/OEF veterans: polytrauma clinical triad. J Rehabil Res Dev. 2009;46(6):697-702.

Office of the Army Surgeon General. Pain Management Task Force. Providing a Standardized DoD and VHA Vision and Approach to Pain Management to Optimize the Care for Warriors and Their Families. Final Report; May 2010. Pain_Management_Task_Force.pdf. Accessed July 21, 2011.

Kevin T. Galloway, is Chief of Staff of the Army Pain Management Task Force of the Office of the Army Surgeon General in Alexandria, Virginia. Chester C. Buckenmaier III is director of the Defense and Veterans Center for Integrative Pain Management and an associate professor at the Uniformed Services University of the Health Sciences in Rockville, Maryland. Rollin M. Gallagher is Deputy National Program Director for Pain Management in the Veterans Affairs Health System at the Philadelphia Veteran Affairs Medical Center in Philadelphia, Pennsylvania; he is also a clinical professor of psychiatry, anesthesiology, and critical care and Director of Pain Policy Research and Primary Care at Penn Pain Medicine at the University of Pennsylvania School of Medicine in Philadelphia.

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