Easing the pain

Pain is everywhere. It can be dull and fleeting muscle aches or fiery, chronic back pain. It can be the result of day-to-day life or stem from a specific injury-in other words, pain is unavoidable.

However, pain does not have to been chronic, debilitating or life altering. Recognizing that there is no all-encompassing strategy for pain management, Army Medical Command created the Pain Management Task Force to improve current pain management methods, and identify new ones.

"The surgeon general and the senior leadership in MEDCOM identified a gap in strategies and current MEDCOM practices of pain management," Col. Kevin Galloway, chief of staff for the PMTF at the Office of the Surgeon General, said. "While we made tremendous efforts over the years to utilize available medications and procedures to treat pain, there was no universal understanding of pain in our organization."

The task force, chartered in 2009 by the Army's surgeon general, Lt. Gen. Eric Schoomaker, made the assessment that the current system lacked a comprehensive strategy to ensure the optimization of care, Galloway explained. The PMTF works to develop a holistic, multi-disciplinary, comprehensive pain strategy, focusing as much on pain management as on quality of life for Soldiers and their Families.

"It's not enough to take someone's pain away, if in the process we leave them, in essence, disabled on a couch, unable to get up and interact," Galloway said. "We wanted to make sure we optimized what was available out there...giving the right combinations, the right modalities, and we had a plan to do that across our entire health care system.... That's no small challenge. Others have tried and given up over the years."

Pain management for both psychological and physical injuries encompasses everything related to eliminating or reducing pain, while also maximizing functionality throughout treatment and avoiding additional disabilities that may arise due to inadequate care, Galloway explained.

The PMTF took a close look at the prevalence of chronic pain, post-traumatic stress disorder and traumatic brain injury and their shared symptoms. Task force members identified overlapping symptoms and recommended no longer dividing patients into pieces for different specialists, and instead initiated a communicative, team approach to health care.

"The P3 combination of symptoms and overlap tells us there is no way we can be effective by attempting to (concentrate on one injury). It's trying to float one boat in harbor. It just doesn't work, and at the expense of the other boats, you'll try to float only your condition, your problem, your specialty.

"It's much more effective for us to concentrate on the harbor, as opposed to the boat," Galloway said.

This is not the health care model of traditional medicine. The challenge for the Army is to transform from the old, piecemeal model to the new, comprehensive care model.

After six months the PMTF, in collaboration with the Air Force, Navy and Veterans Administration, produced a 160-page report containing more than 100 recommendations to create a comprehensive pain management system. Schoomaker approved the report, and the task force moved forward with implementation under the Pain Management Campaign Plan.

"It's a huge undertaking," Galloway said, noting that the task force has to operationalize all those recommendations into a form the Army can execute.

"We've not only got to retrain and redo the culture with our medical staff, we have to standardize the culture and the understanding of our patients and make sure everybody on both sides understands what they bring to the table, what their responsibilities are," Galloway said. "We have to resource this in a way that's constant across the organization, and also build on the best practices that are out there, and make sure that we identify them, standardize them, and make sure that they're available across the organization."

The campaign plan includes a uniform approach for pain care providers, identifying capabilities, resources and services that will be needed. Other primary goals include improving rehabilitation, reintegration and recovery for the patient, establishing pain management as a priority, and making sure the Army message on comprehensive pain care is effectively developed and communicated across organizations.

"It's a dynamic, living plan for the Army," he said.

Pain is very individualized, and there is great variability in the way medical personnel assess pain, Galloway said. Currently, pain is measured on a zero to 10 scale, 10 being the worst pain a patient has ever felt. But one patient's 10 may be another's five, Galloway pointed out. One of the up-front goals of the PMCP is to standardize how that scale is analyzed.

"We (will) provide functional, reproducible anchors in that 10-scale that (ask): 'Are you able to concentrate' Are you able to go to work' Can you enjoy watching a TV show with this pain, or are you unable to have any pleasurable activity because of the pain'' That way, we can start being a little bit more effective at getting (you to zero)."

The task force also acknowledged the correlation between chronic pain and depression. The PMCP hopes to provide the tools and education to assist providers, improve treatment and continue decreasing the stigma of behavioral health treatment.

"A lot of our pain medicine and behavioral health initiatives involve integrating this care at the primary care level," Galloway said. "The majority of our patients will likely have occasional issues with pain and stress in the normal course of their lives. We want to provide as much of this care as appropriate in the primary care environment, so it should not be out of the norm for patients to see a variety of services in primary care, including behavioral health."

Galloway added that reinforcing this expectation will allow care providers to refer patients to a behavioral health specialist, when necessary, without feeling like they are adversely labeling those patients.

The Army is paving the way in military medicine with this new, comprehensive plan, so there aren't any existing models or examples to follow, Galloway explained. Because of the size and scope of the undertaking, it will take time. However, MEDCOM hopes to coordinate with representatives from other Army initiatives, like Comprehensive Soldier Fitness and the Army Suicide Prevention Task Force, to reinforce and complement their messages, Galloway added. That will help avoid disconnects with the audience they are all trying to reach.

"We just have to make sure that in implementation we stay synchronized, that there is a constant message," he said.

Better pain management will mean not only better overall care for Soldiers, but improved retention rates for the Army, because Soldiers won't leave military service as a result of pain, Galloway noted.

There have been some major advances in battlefield and post-injury pain management over the last several years. Galloway highlighted the significance of increased use of regional anesthesia in military hospitals in Iraq and Afghanistan. This approach often allows patients with severe extremity injuries to be relatively pain free as they are transported from the battlefield to Landstuhl, Germany, and on to the United States.

The task force also traveled to civilian medical centers to learn about non-traditional medicines for possible inclusion in the new comprehensive system, Galloway said.

"We have to look at things like acupuncture or yoga, biofeedback, as things we fully need to integrate into our health care system and have available. They are very effective, if not (as) sole treatment for some conditions, (as) complementary treatment to some of the existing things that we are doing," Galloway explained.

Though there are some civilian facilities on the cusp of having a comprehensive and holistic approach to pain management, this practice is not yet part of military or civilian medicine practices, Galloway said. The Army would be leading the way with the introduction of these treatments in a structured and responsible way.

"We're very proud of that. I think that shows part of the transformation that we're undertaking as part of the campaign plan," he added.

"Of all the things that I've been associated with in 23-24 years in the Army, this is the most exciting. It has the opportunity to transform medicine in and outside of the military."