Vulnerable Population: Chronic Pain and Combat Veterans

Since 2001, 2.6 million Americans have been deployed to Iraq or Afghanistan as a U.S. service member.  The Washington Post recently reported that more than 600,000 soldiers experience physical or mental health related disability resulting directly from combat with more than 51,000 being classified as “wounded in action.”  The report stressed that this classification only includes those individuals wounded in combat and not back pain, knee injuries, persistent headaches, or lingering coughs, among other side effects of war.  Furthermore, 1.1 million veterans attested that they were in worse physical health due to their service with 470,000 having severe injuries such as amputation, burns, and brain damage. A report that came out in 2013 in the International Business Times, detailed that 1 million veterans have been injured in combat operations in Afghanistan and Iraq.  That same year, Forbes magazine reported that 270,000 brain injuries have been diagnosed since 2001, 1 in 5 veterans experienced post-traumatic stress disorder (PTSD), and 50,000 soldiers were classified as polytrauma: 1,600 moderate or severe brain injuries, 1,400 amputees, and 900 burned.  It is apparent that this is one of the populations at highest risk for developing life-long chronic pain issues and a priority that should be addressed by chronic pain advocates.

There are a multitude of reasons why so many service members return from combat with grave disabilities that cause daily and enduring pain elucidated in research journals and newspapers alike. These reasons include but are not limited to: multiple deployments, 13 year-long conflicts, improvements in armor, medic transportation, and military medicine, prolonged exposure to fighting on current tours, shorter breaks between tours than previous wars, and blasts from suicide bombers and improvised explosive devises (IEDs).  When these factors combine, the prevalence for serious morbidities and co-morbidities arise.

Within chronic pain research, much attention has been paid to the relationship between chronic pain, traumatic brain injury (TBI), and posttraumatic stress disorder (PTSD).  US Veterans, returning from Iraq and Afghanistan, report experiencing chronic pain to a substantial degree with 50% of male and 78% of female veterans stating that they endure pain on a consistent basis (Otis et al., 2011).  In fact, pain among combat veterans is so high that the prevalence surpasses the rate of all diagnosed mental health conditions combined (Kerns et al., 2011).  In addition, it is the most common complaint presented at the Veterans Health Administration (VHA) and it is growing at a fast pace with each passing year (Kerns et al., 2011). Due to the dangerous forces veterans are exposed to in combat operations that result in serious injury, those that return from war often suffer from pain in the head, back, legs and shoulders (Otis et al., 2011).  As with so many of us that cope with chronic pain on a continuing basis, veterans report that their pain impedes their occupational, social, and recreational life.  As a result, they experience feelings of isolation, depressed mood, and worthlessness; which, in turn, lead to diminished physical capabilities intensifying the pain experience (Otis et al. 2011).

However, those exposed to war are not only coping with extreme life-long pain but a high prevalence of PTSD and post-concussive symptoms due to injury sustained on the battlefield.  It has been difficult to locate the exact causal relationship between PTSD and chronic pain. The key symptoms associated with PTSD, heightened arousal, fear, and the traumatic experience of the battlefield, is suspected to help fuel, maintain, exacerbate, and evolve the chronic pain state by increasing activity in the central and autonomic nervous and musculoskeletal systems (Turk, 2011).  The distinguishing mark of PTSD follows a traumatic experience that either endangers an individual’s life or threatens to cause serious injuries leading to reactions of tremendous fear, feelings of helplessness and loss of control, and horror.  A person then recollects the traumatic experience through repeated thoughts, nightmares, flashbacks, or triggers from their daily life.  The symptoms of PTSD are often emotionally and physically debilitating leading to sleep disorders, difficulty in attention, withdrawal, hyper vigilance, irritability, anger, and quick to startle (Otis et al., 2011).  Obviously, due to the extreme brutality of war, individuals on the front-line of combat are at a substantial risk of developing PTSD with one study of 103, 788 veterans from the wars in Iraq and Afghanistan reporting a 13% diagnostic rate at VA facilities (Otis et al., 2011).

Mild Traumatic Brain Injury (mTBI) occurs when a physical injury and interference to the brain results from an external blow to the head.  The hallmark signs that this type of injury has occurred include loss of consciousness, memory, confusion, disorientation, weakness, loss of balance, changes in vision, and sensory loss among other debilitating symptoms (Otis et al., 2011).  Considered to be the signature injury of the last two wars, TBI is the primary cause of disability among service members (Spelman et al., 2012). According to The Department of Defense, 73% of all military casualties in Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) were caused by explosive devices (Otis et al., 2011). The risks of injury are monumental due to IEDs, flying debris, the force of blasts to the body, and inhaling toxic fumes (Otis et al., 2011).  Painful headaches in the wake of such exposure are the most commonly reported symptom with PTSD and the inability to sleep exacerbating the disability (Patil et al., 2011).

While PTSD and TBI are the most frequently reported and studied co-morbidities with chronic pain, other serious consequences of combat occur leading to a life-long struggle with pain such as burns, spinal cord injuries and amputations. Within the amputation population, amputees often experience phantom limb pain. They are also at a significant risk for pain in the hip and back due to gait patterns accommodating prosthesis. The resulting depression and grieving that occurs from losing a limb also plays a role in continuing a cycle of pain.

Providing the best possible pain care to the many individuals returning wounded from deployment requires utilizing a multidisciplinary approach to treat both physiological and psychological related disorders. The complicated scope of health risks experienced by veterans requires practitioners to pull from a variety of disciplines including: physical medicine and rehabilitation, physical therapy, anesthesiology, psychology, and social work (Spelman et al. 2012). With pain being among the most complex and costly disorders treated by the Veterans Health Administration (VHA), this is no easy feat. The VHA has implemented several innovative ideas into caring for veterans. For example, veterans living in rural areas of the country can access the VHA initiated telehealth technology so that veterans can more readily connect with experts in pain care in neighboring larger cities (Kerns et al., 2011). However, the VHA is continuously running into problems of space and staffing limitations because of the sizable volume of individuals who require care, the cost of delivering these services, and the available amount of practitioners who have the expertise to treat complex and varied medical conditions (Kerns et al., 2011).  In the recent Washington Post article it was reported that 60 % of veterans believe that the VA is doing only a fair to poor job in assisting them as they return to civilian life with 1.5 million veterans feeling that the needs of their fellow military personnel are not being met. Furthermore, the report noted that health problems and stress from combat has resulted in an exorbitant cost yet to be fully determined.  While major improvements in neuroscience and prosthetics have opened up the possibilities for better long-term care, treatment and understanding of disabilities like TBI still lags behind.  With the largest combat operation since the Vietnam War, service members are returning home with a multitude of internal and external combat injuries, approximately 1 million of them, about the population size of Dallas or San Jose—a new city of wounded.

Read the full reports from Forbes, Washington Post, and International Business Times:

http://www.forbes.com/sites/rebeccaruiz/2013/11/04/report-a-million-veterans-injured-in-iraq-afghanistan-wars/

http://www.ibtimes.com/va-stops-releasing-data-injured-vets-total-reaches-grim-milestone-exclusive-1449584

http://www.washingtonpost.com/sf/national/2014/03/29/a-legacy-of-pride-and-pain/?clsrd

A few resources for returning veterans:

https://www.nrd.gov/

http://afterdeployment.t2.health.mil/

http://www.vetcenter.va.gov/

http://www.oefoif.va.gov/

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4 Comments Add yours

  1. Great article. Good work !!!

  2. Lotenna says:

    the pain: both physical, emotional and mental torture these war veterans go through is so deep. trauma, sleep disorders, nightmares….

    1. You are so right, Lotenna. While PTSD is most commonly discussed, the physical chronic pain that accompanies trauma is not so commonplace and that is why I decided to write a piece about it. Thanks for reading and keep up the great work with your blog. It is so important to bring light to these issues in this world and your words certainly do that!

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