Pain-related musculoskeletal disorders, psychological comorbidity, and the relationship with physical and mental well-being in Gulf War veterans

Post-Traumatic Osteoarthritis, Psychological Health, and Quality of Life After Lower Limb Injury in U.S. Service Members

INTRODUCTION

The aims of this project were to assess (1) the prevalence and timing of post-traumatic osteoarthritis (PTOA) after a traumatic lower limb injury, (2) the risk of PTOA based on injury type, and (3) the association of PTOA with psychological health and quality of life (QoL).

MATERIALS AND METHODS

The Wounded Warrior Recovery Project (WWRP) database and the Expeditionary Medical Encounters Dataset were queried to identify service members injured during deployment. The Military Health System Data Repository was utilized to extract medical record data to identify individuals with PTOA. Data on PTSD, depression symptoms, and QoL were extracted from the WWRP.

RESULTS

Of the 2,061 WWRP participants with lower limb injuries, 124 (6%) were diagnosed with PTOA, with first PTOA diagnosis occurring 3.8 ± 3.1 years after injury. Of the injury categories identified, only fractures were associated with high odds of lower limb PTOA (adjusted odds ratio [OR] = 3.92, 95% confidence interval [CI]: 2.38, 6.44). Individuals with PTOA diagnoses reported lower QoL scores relative to those without PTOA (F(1,2057) = 14.21, B = -0.05, P < .05). Additionally, rates of PTSD and depression symptoms were high but not different between those with or without PTOA.

CONCLUSIONS

Despite a low prevalence of lower limb PTOA in our study, fractures increased the risk of PTOA after deployment-related injuries. Additionally, those with PTOA reported lower QoL scores relative to those without PTOA. The findings of this study highlight the personalized needs of patients with trauma beyond just the repair of the immediate injury.

What is well-being? A scoping review of the conceptual and operational definitions of occupational well-being

Well-being is a multifaceted construct that is used across disciplines to portray a state of wellness, health, and happiness. While aspects of well-being seem universal, how it is depicted in the literature has substantial variation. The aim of this scoping review was to identify conceptual and operational definitions of well-being within the field of occupational health. Broad search terms were used related to well-being and scale/assessment. Inclusion criteria were (1) peer-reviewed articles, (2) published in English, (3) included a measure of well-being in the methods and results section of the article, and (4) empirical paper. The searches resulted in 4394 articles, 3733 articles were excluded by reading the abstract, 661 articles received a full review, and 273 articles were excluded after a full review, leaving 388 articles that met our inclusion criteria and were used to extract well-being assessment information. Many studies did not define well-being or link their conceptual definition to the operational assessment tool being used. There were 158 assessments of well-being represented across studies. Results highlight the lack of a consistent definitions of well-being and standardized measurements.

The Role of Psychological Wellbeing in a Cross-Provider Worksite Healthcare Management Program for Employees with Musculoskeletal Disorders

Background: Musculoskeletal and mental disorders are often comorbid, with complex correlations of pain, impairment due to pain, disability, and psychological wellbeing. This study investigates the role of psychological wellbeing in a worksite healthcare program for employees within a German randomized controlled trial. Methods: For our analyses we used data of the module for minor musculoskeletal complaints (N = 180). The intervention included a workplace-related training and case manager support. Results: Changes over time were significant in the disability score (t(179) = 9.04, p < 0.001), pain intensity (t(179) = 9.92, p < 0.001), and psychological wellbeing (t(179) = −4.65, p < 0.001). Individuals with low vs. high psychological wellbeing showed significant differences in their disability scoret0,t1 (tt0(178) = −4.230, pt0 < 0.001, tt1(178) = −2.733, pt1 < 0.001), pain intensityt0,t1 (tt0(178) = −3.127, pt0 < 0.01, tt1(178) = −3.345, pt1 < 0.01, and motivationt0 (tt0(178) = 4.223, pt0 < 0.001). The disability score∆ mediates the impact of pain intensity∆ on psychological wellbeingt1 (beta = 0.155, p < 0.05). Psychological wellbeing∆ had an impact on the disability scoret1 (beta = −0.161, p < 0.01). Conclusions: The lower the psychological wellbeing is at an intervention’s beginning, the higher the potential is for its improvement, which might affect individuals’ experienced impairment due to pain. In order to achieve the best outcomes, interventions should include both pain-related and psychological aspects. Future research needs to explore the causality of the found interrelationships further.

Mental and physical health, and long-term quality of life among service members injured on deployment

Background

More than 52,000 casualties have been documented in post-9/11 conflicts. Service members with extremity injuries (EIs) or traumatic brain injury (TBI) may be at particular risk for long-term deficits in mental and physical health functioning compared with service members with other injuries.

Methods

The present study combined medical records with patient reports of mental health and health-related quality of life (HRQOL) for 2,537 service members injured in overseas contingency operations who participated in the Wounded Warrior Recovery Project. Combined parallel-serial mediation models were tested to examine the pathways through which injury is related to mental and physical health conditions, and long-term HRQOL.

Results

Results revealed that injury was indirectly related to long-term HRQOL via its associations with physical health complications and mental health symptoms. Relative to TBI, EI was associated with a higher likelihood for a postinjury diagnosis for a musculoskeletal condition, which were related to lower levels of later posttraumatic stress disorder (PTSD) symptoms, and higher levels of physical and mental HRQOL. Similarly, EI was related to a lower likelihood for a postinjury PTSD diagnosis, and lower levels of subsequent PTSD symptoms, and therefore higher physical and mental HRQOL relative to those with TBI. Despite this, the prevalence of probable PTSD among those with EI was high (35%). Implications for intervention, rehabilitation, and future research are discussed.

Does Pain Acceptance Buffer the Negative Effects of Catastrophizing on Function in Individuals With Chronic Pain?

OBJECTIVES

Pain catastrophizing and pain acceptance are psychological factors that have been shown to be associated with pain-related outcomes and predict multidisciplinary pain treatment outcomes. However, they are rarely examined in the same study. This study aimed to: (1) assess the independent roles of pain catastrophizingand pain acceptance as predictors of pain intensity, pain interference, and depression; and (2) evaluate the potential moderating role of pain acceptance on the association between pain catastrophizing and both pain and function.

MATERIALS AND METHODS

A sample of 467 adults with chronic pain completed an online survey including measures of pain intensity, pain interference, depression, pain catastrophizing, and pain acceptance.

RESULTS

Pain catastrophizing and pain acceptance were independent predictors of pain interference. Only pain catastrophizing and the activity engagement domain of pain acceptance were independent predictors of pain intensity and depression. Activity engagement moderated the association between pain catastrophizing and depression, indicating a buffering effect on the negative effects of catastrophizing on depression. Pain willingness moderated the association between pain catastrophizing and pain interference, such that endorsing low pain willingness may override any negative effects of pain catastrophizing.

DISCUSSION

The findings suggest that pain catastrophizing and pain acceptance are independently important to adjustment to chronic pain. Research is needed to determine if treatments that target both for change are more effective than treatments that target only one.

The impact of in-service physical injury or illness on the mental health of military veterans

BACKGROUND

Each year approximately 2000 UK service personnel are medically discharged with physical and/or psychological injury or illness. While there is much research on both psychological injury and physical injury, the challenges of transition relating to the intersection between the two has received less attention. This article reports on the first phase of a 2-year funded study with the aim to understand the lived experiences of veterans who have been discharged from service with a physical injury or illness and the impacts of this on their mental health.

METHODS

Using a qualitative methodology, 22 veterans who had been discharged from service within the last 8 years were interviewed to identify key aspects of their experience of the transition process.

RESULTS

The article highlights two key themes: how some veterans adjusted to life with a physical injury or condition; and, the intersections that became apparent between physical injury and mental health. The challenges that veterans faced were shaped by the transition process and by the way in which the medical discharge process was conducted.

CONCLUSIONS

Consideration of improvements to the medical discharge process could influence better outcomes for those who have left with a physical injury or illness and later find themselves struggling with mental health issues.

Chronic pain, posttraumatic stress disorder, and opioid intake: A systematic review

BACKGROUND

The literature suggests that there is a high degree of co-occurrence between chronic pain and posttraumatic stress disorder (PTSD). An association has been found between PTSD and substance abuse. PTSD is a severe disorder that should be taken into account when opioids are prescribed. It has been found that the prevalence of opioid use disorder (OUD) in chronic pain patients is higher among those with PTSD than those without this disorder.

AIM

To perform a systematic review on the association between PTSD, chronic non-cancer pain (CNCP), and opioid intake (i.e., prescription, misuse, and abuse).

METHODS

We conducted a systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The Patient, Intervention, Comparator, and Outcomes (PICOS) criteria were formulated a priori in the protocol of the systematic review. A search was conducted of the PROSPERO database. In March 2019, searches were also conducted of 5 other databases: PubMed, MEDLINE, PsycINFO, Web of Science, and PILOTS. The Scottish Intercollegiate Guidelines Network checklist for cohort studies was used to assess the selected studies for their methodological quality and risk of bias. Each study was evaluated according to its internal validity, participant sampling, confounding variables, and the statistical analysis.

RESULTS

A total of 151 potentially eligible studies were identified of which 17 were retained for analysis. Only 10 met the selection criteria. All the studies were published between 2008 and 2018 and were conducted in the United States. The eligible studies included a total of 1622785 unique participants. Of these, 196516 had comorbid CNCP and PTSD and were consuming opiates. The participants had a cross-study mean age of 35.2 years. The majority of participants were men (81.6%). The most common chronic pain condition was musculoskeletal pain: back pain (47.14% across studies; range: 16%-60.6%), arthritis and joint pain (31.1%; range: 18%-67.5%), and neck pain (28.7%; range: 3.6%-63%). In total, 42.4% of the participants across studies had a diagnosis of PTSD (range: 4.7%-95%). In relation to opioid intake, we identified 2 different outcomes: opioid prescription and OUD. All the studies reported evidence of a greater prevalence of PTSD in CNCP patients who were receiving prescribed opioids and that PTSD was associated with OUD in CNCP patients.

CONCLUSION

Opioid analgesic prescription as the treatment of choice for CNCP patients should include screening for baseline PTSD to ensure that these drugs are safely consumed.

Factors associated with persistently high-cost health care utilization for musculoskeletal pain

BACKGROUND

Musculoskeletal pain conditions incur high costs and produce significant personal and public health consequences, including disability and opioid-related mortality. Persistence of high-cost health care utilization for musculoskeletal pain may help identify system inefficiencies that could limit value of care. The objective of this study was to identify factors associated with persistent high-cost utilization among individuals seeking health care for musculoskeletal pain.

METHODS

This was a retrospective cohort study of Medical Expenditure Panel Survey data (2008-2013) that included a non-institutionalized, population-based sample of individuals seeking health care for a musculoskeletal pain condition (n = 12,985). Expenditures associated with musculoskeletal pain conditions over two consecutive years were analyzed from prescribed medicine, office-based medical provider visits, outpatient department visits, emergency room visits, inpatient hospital stays, and home health visits. Persistent high-cost utilization was defined as being in the top 15th percentile for annual musculoskeletal pain-related expenditures over 2 consecutive years. We used multinomial regression to determine which modifiable and non-modifiable sociodemographic, health, and pain-related variables were associated with persistent high-cost utilization.

RESULTS

Approximately 35% of direct costs for musculoskeletal pain were concentrated among the 4% defined as persistent high-cost utilizers. Non-modifiable variables associated with expenditure group classification included age, race, poverty level, geographic region, insurance status, diagnosis type and total number of musculoskeletal pain diagnoses. Modifiable variables associated with increased risk of high expenditure classification were higher number of missed work days, greater pain interference, and higher use of prescription medication for pain, while higher self-reported physical and mental health were associated with lower risk of high expenditure classification.

CONCLUSIONS

Health care delivery models that prospectively identify these potentially modifiable factors may improve the costs and value of care for individuals with musculoskeletal pain prone to risk for high-cost care episodes.

Chiropractic Integrated Care Pathway for Low Back Pain in Veterans: Results of a Delphi Consensus Process

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.

Pain is associated with reduced quality of life and functional status in patients with Myalgic Encephalomyelitis/Chronic Fatigue Syndrome

Background and aims Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) is challenging to live with, often accompanied by pervasive fatigue and pain, accompanied by decreased quality of life (QoL) as well as anxiety and/or depression. Associations between higher pain, lower QoL and higher anxiety and depression have been shown in patients with various chronic pain disorders. Few studies have however examined such associations in a sample of patients with ME/CFS. The aims of the current study were to examine the impact of pain levels and compare levels of pain, health related QoL, anxiety and depression between patients with ME/CFS and healthy controls. In addition, the study aimed and to examine these relationships within the patient group only. Methods This is a cross-sectional questionnaire based study comparing 87 well-diagnosed patients with ME/CFS with 94 healthy controls. The De Paul Symptom Questionnaire (DSQ), the Medical Outcomes Study Short-Form Surveys (SF-36) and the Hospital Anxiety and Depression Scale (HADS) were used to examine and compare pain, physical function, QoL, anxiety and depression in patients and healthy controls. Further the pain variables were divided into pain total, pain intensity and a pain frequency score for analyses of the above mentioned variables within the patient group only. Results Significantly higher levels of pain, anxiety and depression, and lower levels of QoL were found in the patient group compared with healthy controls. For the patient group alone, pain was significantly associated with lower QoL in terms of physical functioning, bodily pain, general health functioning, vitality and social functioning capacity. In this patient sample, only frequency of joint pain showed significant difference in psychological variables such as depression and anxiety - depression combined. Conclusions ME/CFS patients differ significantly from healthy controls in pain, health related QoL, anxiety and depression. Pain is significantly associated with reduced QoL and overall a lower level of functioning. The relation between pain and anxiety and depression appears less clear. Implications Pain is for many ME/CFS patients associated with reduced physical functioning and reduced QoL. A thorough pain assessment can therefore be essential for clinicians, and subsequent medical pain treatment combined with good pain coping skills may increase functioning level and QoL for these patients. The link between joint pain and psychological factors should also be focused in clinical practice in terms of mapping and counseling. Pain should be further examined to understand the importance it may have for functioning level as reduced function is a main criteria when diagnosing the patients.

Combat Posttraumatic Stress Disorder and Quality of Life: Do Somatic Comorbidities Matter?

A vast number of veterans with posttraumatic stress disorder (PTSD) have chronic somatic comorbidities. However, their relationship with quality of life (QoL) has received little attention. We aimed to compare QoL of veterans with similar intensity of PTSD but different number of chronic somatic disorders. Of 129 veterans, 78% had at least one somatic disorder, and they reported lower QoL across all domains than veterans without somatic comorbidities. The greatest effect size was observed on social relationship (d = 0.65), it was notable on environment (d = 0.4) and psychological health (d = 0.38), and it was not relevant on physical health (d = 0.05). There was a negative correlation between the number of somatic disorders and scores on psychological health (rs = -0.217, p = 0.014), social relationships (rs = -0.248, p = 0.005), and environment (rs = -0.279, p = 0.001). The QoL of war veterans decreases significantly with the number of comorbid somatic conditions, particularly on the nonphysical domains of QoL.

Evaluation of an equine-assisted therapy program for veterans who identify as 'wounded, injured or ill' and their partners

The aim of this study was to evaluate outcomes of an equine-assisted therapy program for Defence Force veterans and their partners across the psychological domains of depression, anxiety, stress, posttraumatic stress, happiness, and quality of life, as well as compare the outcomes of an Individual and Couples program. A non-controlled, within-subjects longitudinal design was utilized with assessment at three time points (pre-intervention, post-intervention, and three months follow-up). Between-subjects analysis with two groups was also conducted to compare the outcomes of the Individual and Couples programs. Participants were recruited from ten programs in 2016 with a total of 47 veterans and partners from both an Individual program (n = 25; veterans only) and a Couples program (n = 22). Outcome measures included the Depression Anxiety Stress Scale-21, Posttraumatic Stress Disorder Checklist for DSM-5, Oxford Happiness Questionnaire, and Quality-of-Life Enjoyment and Satisfaction Questionnaire-Short Form. Paired samples t-tests revealed that within both the Individual and Couples programs, there were significantly fewer psychological symptoms and significantly greater levels of happiness and quality of life at post-intervention compared to pre-intervention. Reduced psychological symptoms were maintained at the three months follow-up for participants of the Couples program only. Independent samples t-tests revealed participants in the Couples program reported significantly less symptoms of depression, stress, and posttraumatic stress disorder (PTSD) at follow-up compared to participants in the Individual program. These results indicate there may only be meaningful benefits for equine-assisted therapy in the reduction of depression, stress, and PTSD symptoms for veterans, if partners are integrated into the intervention.

Musculoskeletal Pain and Headache in the Active Duty Military Population: An Integrative Review

BACKGROUND

Since 2001, the U.S. Armed Forces' training and deployment have greatly increased, escalating the risk of injury and pain-related issues both at home station and deployment environments.

AIMS

This integrative review examines the incidence, prevalence, and risk factors for musculoskeletal pain (MSP) and headaches in active duty (AD) military populations.

METHODS

Peer-reviewed research published between 2001 and 2016 was identified relevant to MSP and headache in AD military personnel using MeSH terms in key biomedical databases. Inclusion criteria were: epidemiological studies examining MSP or headache as primary or secondary outcome; samples that included AD populations; and studies conducted in the theater of operations, at home station, and in military treatment or Veterans Health Administration facilities.

RESULTS

Twenty-six articles met inclusion criteria. Low back pain (LBP) was the most prevalent MSP diagnosis. The incidence of LBP was 40.5 per 1,000 person-years and was comparable to nonmilitary populations. Inflammation and pain from overuse comprised the largest proportion of injury mechanism, accounting for about 82% of all injuries among nondeployed military personnel. The risk of MSP was greater for AD, female, Army, enlisted personnel, and those with greater time in a motor vehicle. Evidence suggests posttraumatic headache, occurring in up to 92% of military personnel who have sustained a mild traumatic brain injury, is associated with chronic daily headaches.

IMPLICATIONS

Nurses must recognize the consequences military service can have on the development of pain. Nurses have an opportunity to positively impact the health and well-being of military and veteran populations through early recognition and treatment of pain.

LINKING EVIDENCE TO ACTION

The findings from this review underscore considerable magnitude of MSP in military personnel and expose modifiable risk factors and potential targets for designing nurse-led interventions to improve pain and symptoms in military subpopulations.

The Status of Musculoskeletal Disorders and Its Influence on the Working Ability of Oil Workers in Xinjiang, China

The purpose of this study was to investigate the status of musculoskeletal disorders (MSDs) and its influence on the working ability of oil workers, and to provide a theoretical basis for helping lessen the burden of MSDs and improve the man-machine environment of oil workers. The cluster sampling method was used to study 2000 workers who had been employed for more than 1 year in this field. We investigated the prevalence rate and the work ability index (WAI). A total of 1935 valid questionnaires were collected, a response rate of 96.75%. There were 1639 people who had suffered from MSDs in the past year, a prevalence rate of 84.7%. The damage detection rate in female oil workers was higher than in males, and the damage detection rate in workers aged 30 to 45 years was higher than that in the other two age groups. The detection rate in less highly-educated oil workers was higher than that in more highly-educated workers. The detection rate in divorced workers was higher than that in other groups. The detection rate in workers between the number of working years of 18 to 25 years was higher than in the other two groups. The detection rate in workers with a high professional title was significantly higher than that in lower-titled workers (p < 0.05). The results showed that the WAI scores of the subjects with MSDs were significantly lower than for subjects without MSDs (p < 0.05). In a logistic regression analysis, sex, number of working years and WAI index all had an impact on MSDs. We concluded that due to the demands of their role, the oil workers had serious MSDs that influenced their working ability.

Trends in the Use and Characteristics of Chiropractic Services in the Department of Veterans Affairs

OBJECTIVES

The purpose of this study was to analyze national trends and key features of the Department of Veterans Affairs' (VA's) chiropractic service delivery and chiropractic provider workforce since their initial inception.

METHODS

This was a serial cross-sectional analysis of the VA administrative data sampled from the first record of chiropractic services in VA through September 30, 2015. Data were obtained from VA's Corporate Data Warehouse and analyzed with descriptive statistics.

RESULTS

From October 1, 2004, through September 30, 2015, the annual number of patients seen in VA chiropractic clinics increased from 4052 to 37349 (821.7%), and the annual number of chiropractic visits increased from 20072 to 159366 (693.9%). The typical VA chiropractic patient is male, is between the ages of 45 and 64, is seen for low back and/or neck conditions, and receives chiropractic spinal manipulation and evaluation and management services. The total number of VA chiropractic clinics grew from 27 to 65 (9.4% annually), and the number of chiropractor employees grew from 13 to 86 (21.3% annually). The typical VA chiropractor employee is a 45.9-year-old man, has worked in VA for 4.5 years, and receives annual compensation of $97860. VA also purchased care from private sector chiropractors starting in 2000, growing to 159533 chiropractic visits for 19435 patients at a cost of $11155654 annually.

CONCLUSIONS

Use of chiropractic services and the chiropractic workforce in VA have grown substantially over more than a decade since their introduction.

Combat exposure, emotional and physical role limitations, and substance use among male United States Army Reserve and National Guard soldiers

PURPOSE

Combat-exposed soldiers are at an increased risk for health problems that diminish quality of life (QOL) and substance use. We explored the cross-sectional associations between combat exposure and two measures of QOL, and the effect of substance use on those associations.

METHODS

Data are from the baseline wave of Operation: SAFETY, an ongoing survey-based study of United States Army Reserve/National Guard (USAR/NG) soldiers and their partners. Our sample consisted of male USAR/NG soldiers with a history of deployment (N = 248). Limitations in usual activity due to physical and emotional problems were assessed using the 36-Item Short-Form Health Survey (SF-36).

RESULTS

Greater combat exposure was independently associated with limitations in usual activity due to physical (regression coefficient = -0.35, 95% CI -0.55 to -0.16, R ² = 0.09; p < 0.01) and emotional (regression coefficient = -0.32, 95% CI -0.56 to -0.09, R ² = 0.09; p < 0.01) problems. Combat exposure had a significant interaction with frequent heavy drinking on physical role limitations (regression coefficient = -0.65, 95% CI -1.18 to -0.12, R ² = 0.12; p < 0.05) and emotional role limitations (regression coefficient = -0.83, 95% CI -1.46 to -0.19, R ² = 0.12; p < 0.05). Combat exposure also had a significant interaction with lifetime non-medical use of prescription drugs on physical role limitations (regression coefficient = 0.81, 95% CI 0.18-1.45, R ² = 0.11; p < 0.05).

CONCLUSION

Combat is an unmodifiable risk factor for poor QOL among soldiers; however, frequent heavy drinking and non-medical use of prescription drugs modifies the relationship between combat exposure and QOL. Therefore, substance use is a potential point of intervention to improve QOL among soldiers.

Arthritis, comorbidities, and care utilization in veterans of operations enduring and Iraqi Freedom

Veteran populations are known to have frequencies of arthritis higher than civilian populations. The aim of this study is to define the prevalence of arthritis among a cohort of veterans from ongoing U.S. military operations. A retrospective cohort study using Veterans Administration data sources for service connected disability, comorbidities, clinic utilization, and pharmacy utilization was conducted including veterans who deployed in service to operations in Afghanistan or Iraq, comparing veterans with a diagnosis of arthritis, arthritis plus back pain, and veterans with no pain diagnoses. The frequency of arthritis was 11.8%. Veterans with arthritis and arthritis plus back pain had greater frequencies of diabetes, hyperlipidemia, hypertension, and obesity compare to veterans with no pain diagnosis. Veterans with arthritis plus back pain had the highest pain clinic utilization and prescription use of opioids and anti-inflammatories. Veterans with no pain diagnosis had higher frequencies of diagnosis and clinic utilization for mental health disorders. Arthritis is prevalent among the latest generation of combat veterans and is associated with diabetes, obesity, and cardiovascular comorbidities. The need for arthritis care and associated comorbidities is expected to increase as the Veterans Administration and the civilian health care sector assumes care of these veterans. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:682-687, 2017.

Association of Chronic Pain and Community Integration of Returning Veterans With and Without Traumatic Brain Injury

OBJECTIVE

To evaluate the association between community integration and pain in veterans with and without mild blast-related traumatic brain injury (TBI).

DESIGN AND PARTICIPANTS

A cross-sectional study of 198 Operation Enduring Freedom/Operation Iraqi Freedom veterans, 135 with mild TBI and 63 without TBI exposure.

MAIN MEASURES

Community Integration Questionnaire (CIQ), Community Reintegration of Injured Service Members Instrument, Brief Pain Inventory.

RESULTS

Pain interference was significantly associated with CIQ social integration (P = .037), and pain severity was significantly associated with CIQ home integration (P = .038) and CIQ social integration (P = .044). Pain interference and pain severity had a significant interaction as related to the CIQ total score (P = .046), CIQ job score (P = .034), and CIQ productivity score (P = .034). Pain interference (P = .042) and pain severity (P = .015) were associated with community participation, but not perceived limitations (P > .05) or satisfaction (P > .05) as measures by the Community Reintegration of Injured Service Members Instrument. There was a significant interaction between TBI status and pain severity (P = .021) with community participation.

CONCLUSIONS

Chronic pain has a negative association with the community integration of returning veterans. Although TBI status was associated with overall community integration ratings, depression had a stronger association with impairments. These findings suggest, above and beyond the treatment of depression, the importance of effectively managing TBI-related pain to foster improved social functioning and to promote the psychological and social well-being of returning veterans.

The Role of Psychosocial Processes in the Development and Maintenance of Chronic Pain

The recently proposed Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks (ACTTION)-American Pain Society (APS) Pain Taxonomy (AAPT) provides an evidence-based, multidimensional, chronic pain classification system. Psychosocial factors play a crucial role within several dimensions of the taxonomy. In this article, we discuss the evaluation of psychosocial factors that influence the diagnosis and trajectory of chronic pain disorders. We review studies in individuals with a variety of persistent pain conditions, and describe evidence that psychosocial variables play key roles in conferring risk for the development of pain, in shaping long-term pain-related adjustment, and in modulating pain treatment outcomes. We consider "general" psychosocial variables such as negative affect, childhood trauma, and social support, as well as "pain-specific" psychosocial variables that include pain-related catastrophizing, self-efficacy for managing pain, and pain-related coping. Collectively, the complexity and profound variability in chronic pain highlights the need to better understand the multidimensional array of interacting forces that determine the trajectory of chronic pain conditions.

PERSPECTIVE

The AAPT is an evidence-based chronic pain classification system in which psychosocial concepts and processes are essential in understanding the development of chronic pain and its effects. In this article we review psychosocial processes that influence the onset, exacerbation, and maintenance of chronic pain disorders.

Military Chronic Musculoskeletal Pain and Psychiatric Comorbidity: Is Better Pain Management the Answer?

Chronic musculoskeletal pain, such as low back pain, often appears in the presence of psychiatric comorbidities (e.g., depression, posttraumatic stress disorder (PTSD)), especially among U.S. military service members serving in the post-9/11 combat era. Although there has been much speculation about how to best address pain/trauma psychiatric symptom comorbidities, there are little available data to guide practice. The present study sought to examine how pre-treatment depression and PTSD influence outcomes in a functional restoration pain management program using secondary analysis of data from the Department of Defense-funded Functional and Orthopedic Rehabilitation Treatment (FORT) trial. Twenty-eight FORT completers were analyzed using a general linear model exploring how well depression and PTSD symptoms predict post-treatment pain (Visual Analog Scale (VAS) pain rating), disability (Oswestry Disability Index; Million Visual Analog Scale), and functional capacity (Floor-to-Waist and Waist-to-Eye Level progressive isoinertial lifting evaluation scores) in a sample of active duty military members with chronic musculoskeletal pain and comorbid depression or PTSD symptoms. Analysis revealed that pre-treatment depression and PTSD symptoms did not significantly predict rehabilitation outcomes from program completers. Implications of these findings for future research on trauma-related pain comorbidities are discussed.

Developing a brief depression screen and identifying associations with comorbid physical and psychological illness in Australian Gulf War veterans

OBJECTIVE

Major depression occurs frequently in veterans, and is associated with comorbid psychological and physical disorders and poorer quality of life. Depression can be difficult to detect in primary care, while lengthy assessment instruments can deter use. Our study aimed to develop a brief depression screen that could be used by veterans and caregivers, and then to compare the association between the brief screen and comorbidities and quality of life with that of a longer instrument.

METHODS

Our dataset comprised 1204 male Royal Australian Navy veterans of the 1990/91 Gulf War. Depressive symptoms were assessed using the General Health Questionnaire (GHQ-12), health-related quality of life by the Short-Form Health Survey (SF-12), major depression and comorbid psychiatric diagnoses such as posttraumatic disorder (PTSD) using Diagnostic and Statistical Manual (DSM-IV) criteria. Comorbid physical illnesses including musculoskeletal disorders, chronic fatigue and diabetes were examined.

RESULTS

A brief depression screen of three key self-reported symptoms was identified. Veterans with major depression present according to the screen were over four times more likely to have multisymptom illness or PTSD, and almost twice as likely to have musculoskeletal disorders. Having depression according to the brief screen and having at least one other physical or psychological condition was associated with poorer quality of life. Similar results were obtained for a longer screen based on all GHQ-12 items.

CONCLUSION

A 3 item depression screen performed as well as a 12 item one in identifying major depression, comorbid physical and psychological illness and poorer quality of life in veterans.

Multivariate assessment of health-related quality of life in Canadian Armed Forces Veterans after transition to civilian life

Introduction: The goal of this study was to identify factors associated with the SF-12 Physical Component Summary (PCS) and Mental Component Summary (MCS) measures of health-related quality of life (HRQOL) in former Canadian Armed Forces (CAF) Veterans after transition to civilian life. Methods: Data were taken from the 2010 Survey on Transition to Civilian Life, a national computer-assisted telephone survey of CAF Regular Force personnel who released during 1998–2007. Multivariate linear regression models were developed using a variety of socio-economic, military, health, and disability characteristics. Results: Mean age was 46 years (range 20–67 y), and 12% of the participants were women. Higher age was associated with lower PCS but higher MCS scores. High ratings of mastery and high satisfaction with life were strongly associated with higher scores on both the PCS and the MCS. Most chronic physical health conditions were associated with poorer PCS scores, in particular chronic pain, musculoskeletal conditions, cancer, gastrointestinal conditions, hearing problems and, to a lesser degree, chronic mental health conditions. The only chronic condition associated with poorer MCS scores was presence of one or more mental health conditions. Both activity limitation in major life domains and needing assistance with activities of daily living were negatively associated with PCS scores, whereas only the latter was negatively associated with MCS scores. Discussion: The models suggested protective factors and identified characteristics of subgroups vulnerable to poor HRQOL after accounting for confounding. Findings can be used to identify those at high risk who may benefit from targeted interventions and to develop health promotion and prevention strategies for Canadian Armed Forces personnel in transition to civilian life.

Musculoskeletal pain and limitations in work ability in Swedish marines: a cross-sectional survey of prevalence and associated factors

OBJECTIVES

To estimate the prevalence of self-rated musculoskeletal pain and pain limiting work ability in Swedish Armed Forces (SAF) marines, and to study factors potentially associated with pain limiting work ability for the most prevalent pain regions reported.

DESIGN

Population-based, cross-sectional survey.

PARTICIPANTS

There were 272 SAF marines from the main marine battalion in Sweden included in the study.

OUTCOMES

Self-assessed musculoskeletal pain and pain limiting the marines' work ability within a 6-month period, as obtained from structured questionnaires. The association of individual, health and work-related factors with musculoskeletal pain limiting work ability was systematically regressed with multiple logistic models, estimating OR and 95% CI.

RESULTS

Musculoskeletal pain and pain limiting work ability were most common in the back, at 46% and 20%, and lower extremities at 51% and 29%, respectively. Physical training ≤1 day/week (OR 5.3, 95% CI 1.7 to 16.8); body height ≤1.80 m (OR 5.0, 95% CI 1.6 to 15.1) and ≥1.86 m (OR 4.4, 95% CI 1.4 to 14.1); computer work 1/4 of the working day (OR 3.2, 95% CI 1.0 to 10.0) and ≥1/2 (OR 3.3, 95% CI 1.1 to 10.1) of the working day were independently associated with back pain limiting work ability. None of the studied variables emerged significantly associated with such pain for the lower extremities.

CONCLUSIONS

Our findings show that musculoskeletal pain and resultant limitations in work ability are common in SAF marines. Low frequency of physical training emerged independently associated with back pain limiting work ability. This suggests that marines performing physical training 1 day per week or less are suitable candidates for further medical evaluation and secondary preventive actions. While also associated, body height and computer work need further exploration as underlying mechanisms for back pain limiting work ability. Further prospective studies are necessary to clarify the direction of causality.

Posttraumatic stress disorder and somatic symptoms among child and adolescent survivors following the Lushan earthquake in China: A six-month longitudinal study

OBJECTIVE

To explore somatic conditions in a sample of 2299 child and adolescent survivors of an earthquake and their relationship to posttraumatic stress disorder (PTSD) symptoms.

METHODS

The Children's Revised Impact of Event Scale, the Patient Health Questionnaire (PHQ)-13 scale, a short version of PHQ-15 scale that omits two items involving sexual pain/problems and menstrual problems, and a project-developed questionnaire were administered to participants three and six months after the earthquake.

RESULTS

Among child and adolescent survivors, the prevalence rates of probable PTSD were 37.4 and 24.2% three and six months, respectively, after the earthquake. The most common somatic symptoms were trouble sleeping (58.4 and 48.4%), feeling tired or having low energy (52.0 and 46.1%), and stomach pain (45.8 and 45.4%) after three and six months, respectively. Several specific somatic symptoms evaluated three months after the earthquake including trouble sleeping, headache, and shortness of breath were predictors of the overall PTSD symptoms evaluated six months after the earthquake. Additionally, the symptom of hyperarousal evaluated after three months could predict the overall somatic symptoms evaluated after six months.

CONCLUSIONS

PTSD and somatic symptoms were common after the earthquake, and a longitudinal association between PTSD and somatic symptoms was detected among child and adolescent survivors. These findings have implications in China and possibly elsewhere.

Chronic pain and comorbid mental health conditions: independent associations of posttraumatic stress disorder and depression with pain, disability, and quality of life

Both posttraumatic stress disorder (PTSD) and depression are highly comorbid with chronic pain and have deleterious effects on pain and treatment outcomes, but the nature of the relationships among chronic pain, PTSD, and depression has not been fully elucidated. This study examined 250 Veterans Affairs primary care patients with moderate to severe chronic musculoskeletal pain who participated in a randomized controlled pain treatment trial. Baseline data were analyzed to examine the independent associations of PTSD and major depression with multiple domains of pain, psychological status, quality of life, and disability. PTSD was strongly associated with these variables and in multivariate models, PTSD and major depression each had strong independent associations with these domains. PTSD demonstrated similar relationships as major depression with psychological, quality of life, and disability outcomes and significant but somewhat smaller associations with pain. Because PTSD and major depression have independent negative associations with pain, psychological status, quality of life, and disability, it is important for clinicians to recognize and treat both mental disorders in patients with chronic pain.

Risk factors of depression after prolonged low-dose rate environmental radiation exposure

PURPOSE

More than 10,000 Taiwanese people were exposed to excessive protracted low-dose rate radiation from contaminated reinforcement bars, which were installed in buildings before 1992. This study was conducted to assess the prevalence of depression amongst the exposed and identify related determinants now that more than two decades have passed since this population was informed of their exposure to radiation.

MATERIALS AND METHODS

We used the Beck depression inventory (BDI)-1A questionnaire to survey 2143 eligible people during their annual physical examinations between March 2009 and December 2009. In total, 1621 people participated in the survey. We employed multivariate logistic regression models with generalized estimating equations method to identify the determinants of depression.

RESULTS

The prevalence of depression (BDI-IA score ≥ 12) was 18.7%. Those who exhibited higher cumulative exposure [adjusted odds ratio (OR): 1.46, 95% confidence interval (CI): 1.02-2.07] and a previous history of depression (adjusted OR: 2.49, 95% CI: 1.36-4.58) were significantly associated with the risk of depression, whereas education level was inversely related to depression (adjusted OR: 0.71, 95% CI: 0.50-0.99).

CONCLUSION

Long-term, low-dose rate radiation exposure early in life might cause subsequent psychological stress and an increased risk of depression decades later.