Treating battlefield injuries and pain in veterans from Afghanistan and Iraq

The August issue of Pain Medicine features two original research studies on treating pain in veterans from Afghanistan and Iraq.

Along with an editorial that describes the physical and emotional challenges faced by returning veterans and long-term care necessary to help them achieve optimal function and reintegration necessary for leading a meaningful, productive life.

“Blast injuries may cause visual and hearing impairment, severe burns, and cognitive deficits as well as severe limb trauma,” says editorialist Rollin M. Gallagher, M.D., M.P.H., Editor-in-Chief of Pain Medicine when discussing the Stojadinovic et al article detailed further below. “Even without these comorbidities, soldiers surviving severe combat injuries are at high risk for developing post-traumatic stress disorder and chronic neuropathic pain. The priority of saving lives must be closely followed by the imperative to minimize the incidence and severity of these consequences, using aggressive pain management as early as possible and continuously, with the goal of maximizing the soldier’s chances of a useful and rewarding recovery, whether as a civilian or in the military.”

Dr. Gallagher also emphasizes that the Gironda et al study shows that persistent pain from many conditions, not just combat injury, is common amongst returning soldiers and often accompanied by psychiatric problems, considerable functional impairment, and difficulties readjusting to civilian life

Dr. Gallagher contends that soldiers deserve the best pain management available. The editorialists suggest legislators and policymakers expand health care service reimbursement and support pain research on and off the battlefield.

Battlefield Injuries Effectively Managed with Regional Anesthetic

Advanced regional anesthetic techniques allow effective management of complex injuries such as those sustained in war zones, according to a study from Walter Reed Army Medical Center (WRAMC) published in the August issue of Pain Medicine. The researchers studied 287 combat casualties with arm and leg injuries who received surgical care incorporating regional anesthesia to evaluate the safety of a new program of advanced regional anesthesia, developed by senior author Chester Buckenmaier, in meeting the anesthetic and pain management challenges inherent in treating soldiers with multiple injuries.

The study subjects were evacuated to WRAMC between March 2003 and December 2004. More than 900 operations were performed on the 287 casualties before arrival at WRAMC and 634 additional surgeries were performed at WRAMC. Approximately 35% of the casualties were amputees. A total of 646 advanced regional anesthesia procedures were performed on the patients with only minor complications. The researchers conclude that advanced regional anesthetic techniques allow for safe perioperative surgical anesthesia and pain control in the management of modern combat casualty.

The authors conclude, “Our personal experience seems to suggest that advanced regional anesthetic techniques are effective and provide improved pain control, facilitating frequent returns to the operating room and postoperative recovery. Advanced regional anesthetic techniques have been applied to 70% of our combat amputees and appear to be an effective way of contributing to early rehabilitation.”

The authors assert that improved methods of providing surgical anesthesia, perioperative analgesia, and effective pain control during evacuation and rehabilitation are essential in modern combat casualty care. The severity of wounds often precludes opioids as the sole pain modality because of side effects associated with excessive use. Regional anesthesia appears to be a desirable alternative. Changes in modern warfare and improvements in protective body armor are resulting in fewer deaths and fewer penetrating injuries to the chest and stomach; however, blast injuries are responsible for a multiple penetrating wounds to the extremities, including burns, and soft tissue and bone destruction. (Pain Medicine. 2006; 7(4):330-338)

Lead author: Alexander Stojadinovic, M.D., from Walter Reed Army Medical Center in Washington, DC.

Many Returning Veterans Predicted to Experience Significant Pain

A substantial percentage of Operation Enduring Freedom and Iraqi Freedom (OEF/OIF) veterans may experience clinically significant pain following their military service, according to an article from James A. Haley Veterans’ Hospital and University of South Florida published in the August issue of Pain Medicine. Pain is one of the most frequently reported symptoms by veterans returning from recent overseas military action. To provide a description of this new group of veteran pain patients, the researchers reviewed medical records from 100 randomly selected veterans who reported moderate to severe chronic pain while seeking treatment at Southeastern Veterans’ Affairs medical center. Approximately 47% of 793 veterans whose charts included pain scores reported at least a mild level of current pain.

Moderate to severe pain intensity was recorded for the 28% of those originally reporting moderate to severe chronic pain. Diagnoses of musculoskeletal and connective tissue disorders were recorded for 82% of those with chronic conditions with a duration of one month or more.

Lead investigator Ronald J. Gironda, Ph.D., states, “As early identification and treatment of pain are known to reduce the incidence and severity of chronic pain conditions and therefore to conserve healthcare resources, it is hoped that these data will help to stimulate a proactive approach to the problem of pain in this population.”

Lead author: Ronald J. Gironda, Ph.D., from James A. Haley Veterans’ Hospital and University of South Florida, Tampa.