**Transcript of Cyberseminar**

**Spotlight on Pain Management**

**The Veteran Experience of Chronic Pain from Musculoskeletal Injuries: Lessons from the War-Related Illness and Injury Study Center**

**Presenters:  Drew A. Helmer, MD, MS; Canaan Heard, BA**

**June 4, 2013**

**The Veteran Experience of Chronic Pain from Musculoskeletal Injuries: Lessons from the War-Related Illness and Injury Study Center**

**June 4, 2013**

*This is an unedited transcript of this session. As such, it may contain omissions or errors due to sound quality or misinterpretation. For clarification or verification of any points in the transcript, please refer to the audio version posted at www.hsrd.research.va.gov/cyberseminars/catalog-archive.cfm or contact:**drew.helmer@va.gov**.*

Dr. Robert Kerns:Good morning, everybody. This is Bob Kerns, National Program Director for Pain Management and Director of the Pain Research Informatics Medical Comorbidities in Education Center at VA Connecticut. It is my pleasure to welcome you to this month’s spotlight on pain management. We are looking forward to a presentation today on The Veteran Experience of Chronic Pain from Musculoskeletal Injuries: Lessons from the War Related Illness and Injury Study.

Before I introduce our speakers, I do want to acknowledge our partnership with the HSR&D Center for Information, Dissemination and Educational Resources. They have been terrific in partnering with our program office and the prime center in putting on this monthly webinar series I hope that you have been attending monthly. If this is your first time, please know that this is a monthly series on pain management in this time slot, so please stay tuned for information about future sessions.

Let me go ahead and introduce today’s speakers. Dr. Drew Helmer is director of the New Jersey War Related Illness and Injury Study Center, pronounced WRIISC. He assumed this responsibility in December of 2011. He was trained as a general internist and he worked at the Michael E. DeBakey VA Medical Center in Houston from 2007 to 2011 where he was the lead clinician for the Post Deployment Health Clinic and for the South Central Veterans Integrated Service Network. He was also Associate Director of Research for PrimeCare and Assistant Director of the Neurorehabilitation Neurons to Networks VA Rehabilitation Research and Development Traumatic Brain Injury Research Center of Excellence located there. Dr. Helmer conducted research focused on several issues important to veterans including chronic pain, exposure concerns, depression and suicide ideation, maltraumatic brain injury, and sexual health concerns. During his first stint in New Jersey between 2001 and 2007, Dr. Helmer was the medical director at the New Jersey WRIISC and a VA Health Services Research and Development Center Career Development Awardee. He developed the structure and processes for the risk and national referral evaluation for veterans with multi-symptom illness and was engaged in research and educational efforts related to deployment health issues and diabetes quality of care and utilization. He had received his medical degree from Columbia University College of Physicians and Surgeons and his master of science in health policy and management from Columbia University School of Public Health.

He is joined today by Mr. Canaan Heard. Canaan is a graduate of Louisiana State University in Baton Rouge, Louisiana, and is currently a doctoral candidate in public health at the LSU Health Sciences Center. He has served nine years as a U.S. Marine and is currently a Reserve Sergeant. While in the Marine Corps, he was assigned to Weapons Company 323 and the Martial Arts Center of Excellence and deployed to Iraq. He has worked with various populations on physical fitness, resiliency and deployment health. His work has been published in the Journal of Military Medicine, National Sports and Conditioning Association, Tactical Strength and Conditioning Report, and the Marine Corps Gazette. He is the owner of Next Generation Fitness, a corporation offering physical fitness, personal fitness and corporate wellness training to clients. It was due to Sergeant Heard’s persistence and passion that the Combat Conditioning Assessment Program, the preliminary results of which are first to be presented publicly today, was successfully completed. 

So welcome Dr. Helmer and Mr. Heard for their presentation on The Veteran Experience of Chronic Pain from Musculoskeletal Injuries: Lessons from the War Related Illness and Injury Study Center. Drew?

Dr. Drew A. Helmer:Yeah. Thank you very much, Bob. Heidi, do you have me ... what? There we go.

Moderator:Nope. Yep. You just needed to click on it first and now you have got control. So you are good to go.

Dr. Drew A. Helmer:Sorry about that. Today we are going to talk about our experience at the WRIISC, as we like to call it with chronic pain and we have a couple interesting things to share with you. In terms of learning objectives, I am going to start by describing the prevalence and range of musculoskeletal injuries in an active duty military population. We are going to talk about some common risk factors for musculoskeletal injuries and how those might differ in a military population. And then we are going to relate the lifelong impact of musculoskeletal injuries experienced by servicemembers to what we do in the VA.

I was told to have a couple poll questions and so we are going to ask you to complete this question on your screen. What is your primary role in VA? Are you a student, trainee or fellow? Clinician, researcher, or a manager or policy-maker or other?

Moderator:And responses are coming in. We will give just a few more seconds before I close it out here and show the results ... There we go.

Dr. Drew A. Helmer:Okay.

Moderator:Now it looks for today’s session we are staying about 53 percent clinician; 18 percent researcher; 8 percent manager; 4 percent student, trainee or fellow; and 17 percent other.

Dr. Drew A. Helmer:Okay. And in terms of an outline—thank you, everybody, for responding—we are going to start by talking about musculoskeletal injuries and then transition into injuries in the military population, particularly with regard to physical training and fitness. Then we are going to talk about our experience with a pilot project that we conducted on active duty Marines last fall. Sergeant Heard is going to do that part of the presentation. Then I will wrap up at the end with a WRIISC perspective on how to manage some of the long-term impacts of musculoskeletal injuries.

So just to make sure we are kind of all on the same page, I have a very simple, basic definition of a musculoskeletal injury. It is basically damage to the muscles, bones or connective tissues and related to them.

And I wanted to make sure we are talking about some of the same characteristics of injuries—and this is not meant to be comprehensive. I think these are just anchor points for us to use in our conversation in the rest of the presentation.

So we are focused in this presentation on two particular mechanisms, an overuse sort of mechanism and a traumatic mechanism of injury.

We have categorized our results from our Combat Conditioning Assessment Program in terms of core or axial injuries, upper extremity and lower extremity locations; and in terms of the severity or the damage related to the injuries. We talked about alteration of structure and loss of function. Obviously, these are not the only way of thinking of injury characteristics, but I think it is helpful to have the same frame of reference that we are using for today.

In terms of the impact in musculoskeletal injuries, you experience an injury. Let us say you are a soccer player or you play soccer on the weekends. You are running around on the field and you twist your leg and have a knee injury. You may have an alteration in the actual body structure. That is deformity. It may or may not be visible.

And you also have a loss of function. So you may not be able to bend your knee or stand on your leg in terms of your ability to function.

That loss of function, then, can contribute to a limitation in activities, so you no longer have the same ability to walk, run or kick a ball; and that can lead to limitations in your participation. So if you have that injury on Saturday, you are no longer able to play your soccer game on Sunday. So your participation with your teammates is going to be altered. 

This is where you start to get into the more meaningful impact of injuries like this. It is a loss of the fun stuff, right; you cannot play the game. You have to do something different.

Perhaps it is actually serious enough that it interferes with your employment or your ability to function in your everyday life: a loss of income.

Another impact of musculoskeletal injuries that we think is pretty significant is your increased exposure to healthcare, which also just takes time away from your other activities, costs money and can result in other complications related to the healthcare intervention.

I also wanted to just make sure we are talking about the prospects of recovery. So if the injury occurs, you need to recover from the injury. The likelihood of recovery varies and some of the critical elements in this are the injury characteristics themselves, the degree of deformity or alteration in structure, the location, other aspects of the severity of the injury.

It also depends on timely recognition and assessment, the appropriate treatment and allowing adequate time for the injury to heal and the appropriate return to activities progression.

So separate from those critical elements, there are the facilitators, the things that make it easier to recover from an injury, things that maybe enhance the timely recognition and assessments or the appropriate treatment. Some of these things might include insurance coverage. It might include the setting or the context of the injury.

There are also barriers that can get in the way of recovery, particularly the timely recognition, assessment. For example, if you do not have access to medical care or you do not have timely access because you are in a combat zone, you may or may not recover as optimally as you would like.

Also, if you have to work and continue to use the injured body parts, you may not have the ability to heal.

And then finally, there are other barriers, other health conditions such as mental health condition, perhaps substance abuse, that may make it less likely that you will have an optimal recovery from injuries.

I think what we see is that there are some common patterns which can perpetuate less-than-optimal outcomes or inhibit recovery. One pattern is a failure to take time to rest and actually allow yourself to recover. This leaves you prone to reinjury and perhaps more persistent pain. Also maybe put you at higher risk for accumulating new injuries as you try to compensate for the injured body part or the dysfunction by using your body in a slight less appropriate or efficient way.

Another pattern which can perpetuate negative outcomes or inhibit recovery is failure to substitute activities. If you go back to the soccer player analogy, if somebody really blows out their ACL or something and is unable to participate in their activity and their soccer team for a long time, they may not seek out alternative ways of staying fit and they may end up gaining weight. They feel isolated through the disruption in their ability to participate. This can lead to depression symptoms and this is another negative pattern that we sometimes see.

And then finally I think there is an example of somebody who has an over-reliance on healthcare and is seeking an unrealistic cure for their problems. Perhaps that is related to medication use and often medications are not going to suffice or are not enough to make the recovery happen. And then there is also the risk of iatrogenic complications.

I am now going to transition a little bit and talk about musculoskeletal injuries in the context of physical fitness training. 

So in order to stay physically fit, you have to be physically active; and with more activity, there is greater risk for musculoskeletal injuries. You have more time off the couch and are more likely to experience a trauma or an overuse injury.

Activities can be performed more or less safely. So if you know what you are doing and you are doing proper techniques, safer free weight lifting, you are less likely to be injured doing that activity. If you are just going in for the first time and throwing stuff around, you are more likely to be injured.

And then, of course, some activities are more risky than others.

Conversely, musculoskeletal injuries can impact fitness, and we already kind of talked about this. They can limit your function and activity. They can contribute to the deconditioning and weight gain and negatively impact your mood and motivation. They can also contribute to other injuries. So this relationship between musculoskeletal injuries and physical activity—they are two separate constructs, but they are very intimately related.

And of course, separate from the injuries, which are the last three bullets on this slide, you have other barriers to physical fitness. If you are trying to improve your fitness, it is actually dependent upon where you are at this time. And then there are competing demands for the time it takes to participate in physical training, the imperfect knowledge and difficulty motivating yourself to engage in physical training, and then some other negative behaviors that can compete with physical fitness.

And now we are going to go on to poll question two: Have you served in the military? You need to select one.

Moderator:And responses are coming in. We will give just a few more seconds before I bring those up ... Okay, there you go ... We are seeing around 83 percent no; 14 percent yes, in the past; and 3 percent yes, currently. Thank you for those responses.

Dr. Drew A. Helmer:Great. And the reason we asked that question now is I am going to transition to ask about physical training in the military and how the physical training relates to the musculoskeletal injuries.

There is this model, this idea of the “Healthy Warrior” where active duty servicemembers are physically and mentally fit and resilient, and physical training is a core part of the military experience.

I reviewed the U.S. Marine Corps Order, which talks about physical training in the Marine Corps, and it basically says we use this to promote healthy lifestyles and combat readiness. It mandates five 30-minute sessions per week of physical training. And it was interesting to me that this is rather decentralized just how the physical training happens. What physical training actually occurs is up to the decision that is under the direction of the unit commander. The directive specifically says that the Marine Corps makes available many resources, but the decision on how Marines get trained is actually done at the unit level.

In working with the Marine Corps on this project that Sergeant Heard is going to describe in a second, we realized that exercise and physical training are not just about fitness in the military. We kind of encountered some situations where these other roles of exercise were more predominant: for discipline purposes, to maintain discipline, establish discipline, as punishment. If somebody did something wrong, it was “give me 50 pushups.” 

It was also a way to fill time. There can be a lot of down time in your active duty military service. It is also a social activity. We saw Marines working out in the gym and participating in physical fitness activities for social purposes, just for fun. It is also a way to demonstrate excellence. So people are awarded for being physically fit and performing well on fitness tests.

So all of these things actually played a role in our experience with the Combat Conditioning Program, and also kind of inform the risk of musculoskeletal injury as well as the setting and the context.

In this slide, I have kind of done a schematic of the military lifecycle. So you have got a pre-military phase, the first 18 years of life. You go to boot camp. If you are on active military duty you spend three to 20 years in this part of the lifecycle alternating perhaps between time in garrison, which is at your base here in the States or somewhere else versus being deployed to a combat zone. And then eventually you become a veteran and you probably spend most of your life in that phase of the military lifecycle.

But you have encountered or experienced different things during your military career that may affect your life. And thinking about physical fitness and musculoskeletal injuries in this context, your military experience with fitness and risk of injury is at least partially determined by your pre-military experience. So obviously, if you are fitter or if you are more physically active, you are going to come into boot camp and you are going to have probably a lower risk of injury and it will be less challenging to achieve the fitness standards required in boot camp.

Then once you finish with boot camp and you go into kind of the routine of active military duty life and you still have to meet your standards of fitness performance, as I mentioned already, it is up to the unit commander in terms of how diligently those are enforced or how much the physical training is emphasized. 

When you are deployed, it is a whole different scenario; and obviously, not every deployment is the same. However, you may or may not have the same time available for physical training. You may be under a more stressful situation where there is no time for training but you are getting a lot of physical activity. Or it could be that there is no time for training but there is not a lot of physical activity. So these are some of the different settings in which exercise can happen. And depending on where you are, the patterns of injuries can be different.

And then once you leave the military, you have these experiences. Perhaps you still have injuries that are in the recovery mode. Perhaps you have some of the longer-term impacts already setting in from previous injuries; and that is where we, as VA providers, then need to kind of take the baton and run with it.

So that schematic and our discussion from earlier in this presentation kind of led me to this framework for musculoskeletal injuries in the military population. You can see across the top I have this setting and context, the setting being Basic Training, Deployment or in Garrison; and the context being a training activity versus a leisure activity; or in the case of a deployment setting, a combat activity.

And then you can see how this allows you to kind of tease out different injury mechanisms that might be more or less prevalent depending on your setting and context, the location of the injury. And you could actually extend this to look at other characteristics of musculoskeletal injuries.

When we reviewed the literature to look at rates of injury in active duty populations, I broke it out into the three settings, Training, Garrison and Deployment. You can see that the rates of injuries are 6-12 per 100 male recruits per month in Basic Training and then 25 percent of men and 55 percent of women report to sick call with an injury during basic training in the army.

You could also see that even in Garrison, in the Army, you still have a fairly high rate of injury, 10-12 injuries per 100 soldier/months, and that 80-90 percent of limited-duty days were related to physical training. 

In a separate study, we had 51 percent of soldiers in the Army were injured in a six-month period for a rate of 142 injuries per 100 soldiers/year.

Then if you jump down here to Deployment, among soldiers deployed to Afghanistan, 45 percent were injured in 12 months with the most common sites of injury being low back, knee and shoulder; and 8 percent of these actually occurred in physical training, not in combat.

This is just to show that this is actually a pretty prevalent problem in the military, as you would expect, as we talked about. This is an active occupation, an active calling. With physical activity comes risk and actual experience of injury.

At this point I am going to allow Sergeant Heard to talk about the Combat Conditioning Program, which will shed a little more light on our own experience with this from a research setting, and then I will come back and talk about the implications for VA providers after this.

Sergeant Canaan Heard:So thank you, Dr. Helmer. We are going to talk about the Combat Conditioning Assessment Program, and our research question was, “Does a more systematic approach to physical training reduce musculoskeletal injuries?”

Our study design was this: we randomized 29 Marines to a moderate or high-moderate 11-week training program. Our volunteers came from an active duty United States Marine Corps population and it was a clerical unit.

The Combat Conditioning Program was an 11-week intervention and each week we had three one-hour sessions, and each session took place on Monday, Wednesday and Friday. The exercises were adapted from a Combat Conditioning Manual taken from the U.S. Marine Corps Martial Arts Center for Excellence.

The intensity and the volume of activity progressed from week one through all the way through week 11.

We looked at musculoskeletal injuries. Every participant got a daily log which they filled out. The log recorded if they were injured and what type of injury did they have. If they were injured, I confirmed the injury with the participant. The log also recorded if they missed because of the injury.

From all this information, we recorded a rate per 100 person/month and the injuries of the daily log also allowed us to look upon the location of the injury such as knee, back, hip.

The characteristics that we looked were demographics; health behaviors; prior health issues; body stuff such as height, weight, body fat; baseline fitness. We used the physical fitness tests and a combat fitness test which were routine in the U.S. Marine Corps, and then we also looked at adherence to regimen. So we had attendance rates and we had a dropout rate.

Our participants at baseline were relatively young. They had been in the Marine Corps for less than four years, so they were on their first enlistment. The responses we got from the PHQ 15, the CD-RISC and the VR-36 indicated we had an overall relatively healthy population. The majority of our participants were males. Only four had been deployed in a combat theatre and one of the things we thought was interesting was that half of them took supplements.

Baseline fitness and performance: we had a low body fat percentage and we had a relatively active population, and that is indicated by the total METS per week. 

The fitness performance, again, we got from the physical fitness test and the combat fitness test, which you can see from the bottom part of the table: pull ups, hang time, crunches, three-mile runs, ammo can lifts and half-mile runs.

Next we are going to talk about adherence. We had a total of 29 enrolled. Out of that 29, six dropped out. Two were transferred to different units. Two were not adherent; they missed more than seven sessions. One was deployed to Afghanistan. And one broke his wrist during leisure time activities, so his injury had nothing to do with the program.

Attendance as a whole: 29 participants completed 744 sessions, giving us a 90.4 percent on all the sessions. We had 23 complete the whole entire program and they attended 677 sessions.

The reasons for missing sessions were conflicting duties, leave or other, injury or they were too tired/sick. We will talk about some of the conflicting duties later on in this presentation.

We had eight participants who recorded musculoskeletal concerns in 13 daily log entries. Eleven notations did not impede successful completion of the session for which the injury was noted, and only 12 injury notations did not prompt medical attention.

This is interesting because the injuries we got were very minor and we only had one that missed a complete session because she was injured. We will talk about her in the next slide. Of the two that missed, we had one that had shin splints and the other one we will talk about next.

Our injury rate was 14.9 injuries/100 person months, and then we had 9.2 injured participants/100 person months.

The bivariate associations between baseline factors and any musculoskeletal injuries: the overall healthier you were—so you had like a lower body fat percentage—the less likely you were to get injured. So if you had a lower body fat percentage, you could do more pull ups or you did more crunches, you were less likely to get injured. This was also interesting: if you had a slower three-mile run time, you were less likely to get injured.

And again I want to point out supplement use. If you took supplements, you were more likely not to get injured.

And the two illustrative injuries that I would like to talk about: the first participant who was injured broke his wrist, but it was not related to the program itself. He broke his wrist while on the weekend and he was reluctant to receive medical care. It was not until after I urged him to seek medical care that he actually did see a corpsman. The initial diagnosis was that he sprained he his wrist, so they gave him a wrist brace. He wanted to continue to participate in the program, so I let him continue. It was not until the following week that he went for his followup and it was determined that he had a broken wrist.

The next participant I would like to talk about was the participant who missed the one training session because she pulled her groin. This is interesting because she was running outside of the program. She ran eight to 12 miles and we believe that this extracurricular running may have added to the injury that she got. She sought medical attention over the weekend and she also ran during the weekend. So the extra running could have prompted her injury. And also in addition to this pulled groin, she reported three additional injuries on daily logs.

So to summarize everything, the incidence of injuries was similar to published rates. Most were lower extremity injuries. Most were very minor in nature. So they all became back to 100 percent. Towards the end of the program, they all completed the program except for the guy who broke his wrist.

The risk factors for injuries were mostly expected: baseline physical fitness. If you were improved, if you had less body fat and you were more physically fit so that you had a higher vertical jump and you could do more pull ups and you could do more crunches, then you were less likely to get injured. We found that guys who took supplements were less likely to become injured.

The limitations of our study were you had limited generalizability. Our small sample size limited our power to test out our hypotheses.

But throughout doing this program, you realized that it is extremely hard to work with a population like this. They have competing duties and there is also a lot of pressure put on them by their chain of command to exercise outside of the program. One of the problems I faced was the command did not think I was training these guys enough. So they encouraged some of them to work out, outside of the program, and the program was not designed to do that. And with that, I will turn it back to Dr. Helmer.

Dr. Drew A. Helmer:Thank you, Canaan. I did the same thing. Here we go. So from my perspective, this project offered a tremendous opportunity to gain some insights on where the chronic pain issues in our veterans come from. So I want you to think a little bit about your VA patients, the veterans sitting in the room waiting for you to see them right now.

When we see the patients, even with the recent combat veterans, it is often a lifetime of pain and negative impacts on health and function. This is a very helpful exercise to think about where did these things come from. By the time you see them, they have been out of the military typically at least a year, and for our older veterans, decades. And yet they still have pain from these injuries. Often the injuries did occur during their military experience, and they are often multiple, so it is not just one injury, but they have accumulated injuries over their life and they have never really recovered.

I think the other really important thing that this provided me was much more contextual background about where these injuries happened, why they happened, why they did not recover, and the challenges they experienced trying to recover from these injuries. And then that gives me an idea of what I can do to help the veteran move forward.

At this point, I am going to have our final poll question before I start talking about the WRIISC. And the question is, before this presentation, had you heard of the War Related Illness and Injury Study Center (WRIISC)? Select one of the following. 

Moderator:The responses are coming in. We will give it just a few more seconds here ... Okay, and here are your results: 62 percent said no; 16 percent said yes, I’ve referred one or more patients; 13 percent have interacted directly; and 9 percent are not sure. Thank you for responding to the poll question.

Dr. Drew A. Helmer:Great. Thank you, everybody. 

I am going to tell you a little bit about the WRIISC. The WRIISCs were established in 2001, were congressionally mandated, and we are supposed to look at deployed veterans because they have unique healthcare issues and concerns. We serve veterans from any conflict with a war-related illness or injury through clinical assessments, education and research. And we kind of came out of the 1990s experience with Gulf War Illness, but we were always meant to look at more than just Gulf War Illnesses, so that is what we do.

The three parts of our mission are research, education and clinical care, and we work very hard to make sure that these three components work together and that we derive synergies between them. So for example, our patients that we see are invited to participated in research activities. Our research activities inform the clinical care and the assessments that we do. And then we take what we learn from both our research activities and our clinical and try to package it up into educational products for dissemination.

There are three WRIISC sites. I am based in East Orange, New Jersey. Then we have our site in Palo Alto and the site in Washington, DC. And we divide the country between the three of us for purposes of referring patients for clinical evaluation. I will tell you a little bit more. 

This figure represents where we fit in the deployment healthcare system of the VA. So if you think about a system of care, a stepped-care approach to deployment health issues, we have kind of the basic public health surveillance and then primary care providing the bulk of services. If somebody has a specific issue, then they might get referred for local specialty care, perhaps even going to somebody with more experience in post-deployment health. And then finally being referred to the WRIISC because of our expertise in deployment-related health and exposure concern, particularly those that are difficult to diagnose or medically unexplained, kind of more like the Gulf War Illness, scenario.

The patients that we see at the WRIISC are complex, generally quite symptomatic with health problems, often with multiple diagnoses, often not functioning well with poor quality of life. We require that a basic workup has been done so that appropriate tests and even trials of treatment have been attempted at the referring facility before the patient is referred to us. And we do tend to focus on patients who have either specific or even vague but definitely deployment-related environmental or occupational exposure concerns.

What we do when the patient comes to us is we review the medical records to make sure that we have not missed anything and to kind of assess where the workup is, and then we perform a very comprehensive, multidisciplinary evaluation over multiple days. This is the same sort of evaluation offered at all three WRIISC sites. It includes a history and physical, psychological evaluation, neuropsych, environmental and occupational exposure assessment. And then we also look at the whole person; we have our social worker talk to them and get some other components of their life.

I am going to talk a little bit more in detail about our experience with chronic pain, so this is probably the most prevalent problem that we see in our patients, our complex patients with multiple diagnoses and difficult-to-diagnose problems. But it is also the most common problem in all veterans. Chronic pain is, I think, probably the number one reason people go to the doctor.

In our population or our sample, it is most often musculoskeletal in nature and it is often in multiple locations. Sometimes the question is, is this chronic pain fibromyalgia, and that is something that we try to ease out; but often it is just pain in multiple locations. And it is often traceable. You can trace it back and say, well, when did it start? And the patient can attribute it to a specific injury, often with a very vivid recollection of the context and the setting.

If he cannot do that, it is often presumed to be due to overuse or strain; and then what we have found in our experience is that that context of the injury often matters in terms of how the patient perceives our ability to help and their likelihood of recovery.

That gets us into the barriers to recovery. One of the more common ones, and I alluded to this earlier, is that pattern of being or that situation of being unable to modify your activities despite the pain, knowing about the injury, and that allows the injury to persist and inhibits recovery and healing. 

We also hear a lot about difficulty accessing not so much primary care but other desired and appropriate services, perhaps complementary and alternative modalities, perhaps physical medicine and rehabilitation, physical therapy. We hear a lot about difficulty with access.

We also hear a lot—we do not hear it from the patient, we hear it in talking to the patient—about ineffective interactions with healthcare providers. So we will often see patients who have come to rely probably too much on pain medicines at the exclusion of other ways of managing pain and perhaps looking for a quick or easier fix to their problems than the sometimes long haul of working on rehabilitation of the injured body part.

In terms of ineffective interactions, we see communication problems between patients and providers an awful lot and we spend a lot of time talking to patients about that.

And then, of course, particularly in our patients, it is never just a knee, a knee problem. It is always complicated by comorbidities, most often depression; PTSD; substance abuse; sometimes just sleep disruption without an underlying cause, sometimes with sleep apnea,; other musculoskeletal injuries or dysfunction; and of course other medical problems related to the GI system or the pulmonary system. But it is never just chronic pain, at least in terms of the patients that we see.

So what do we do for these patients when they come here? We really do take a holistic approach to the care of these patients with the assessments. We acknowledge and address the other aspects of chronic pain including the origin of the pain and the injury and the history of the injury. Like I mentioned, we have a multidisciplinary team. We have physicians, internal medicine physicians, occupational and environmental medicine physicians, nurse practitioners, psychologists, neuropsychologists, social worker. We kind of have a super PACT. It is the corps of the social worker, physician and nurses, but then we supplement it with some of the other expertise that we commonly use for our particular patient population.

We very, very much focus on optimizing health and function, and we emphasize self-management, in particular have the patient set some goals and ways of measuring their progress for those goals and also looking at things they can do for themselves, including some of the complementary and alternative techniques.

Probably the most concrete thing that we do with the patient, because we are primarily an assessment center, is we take our evaluation and work with the patient to craft the goals and the next steps, and that is what we call the road map. We provide this road map to the patient and to the referring provider, and then encourage the patient and primary care provider or PACT team to meet with the patient and say, well, what are we going to do about this, try to implement it, maybe adapt it. Maybe things have changed since they were here in New Jersey, but to take that road map and try to work with it and move it forward.

We spend a lot of time educating the patient about how to work with their PACT and provider team. We emphasize the importance of communication to the patient and we encourage the patient to assess themselves with the symptom log and share these results with the PACT.

In terms of our followup, at this point, we do check-in phone calls at one, six, and 12 months. Our social worker calls and does an assessment on how they are doing with the road map and then tries to help problem solves barriers that the patient might have encountered.

We are in the process of trying to upgrade our followup assessments and we want to do that in conjunction with stronger partnership with the referring PACT. Actually, I was pleasantly surprised at the number of people who have referred patients to us. And so if you have done that in the past, what we are looking to do moving forward is partnering a little bit more with the referring provider and trying to find out how else we can help, what other resources we can link them up with.

And in particular, we also want to get a better sense of whether we have made a difference. We want to look at the patients’ achievement of their own personal goals as written down on the road map, look at their overall participation as a global measure of function and then look at some of the process measures of progress toward their goals. Did they schedule and actually attend the appropriate appointments that they were looking for?

So I am going to sum it all up at this point and just emphasize that musculoskeletal injuries are very common in military service. The setting, context and injury characteristics may vary; but those characteristics and the context may be quite significant. In particular, there are barriers to healing and recovery that are common in the military population and some may be relatively unique to the military population.

But the next bullet point is that these injuries may persist and their negative impact may persist; and we may, as VA providers, be taking the time and trying to work with the veterans to ameliorate some of those problems. I am going to say at the WRIISC we advocate for a holistic, multidisciplinary approach that focuses on self-management, goal-setting and optimizing health and function. We think it is achievable although we know we have a pretty special place in the VA.

However, I did work in a PACT in Houston for several years and I think we want to work with everybody and try to figure out how to better do this for patients.

I think with that and some contact information, then that is the end of our presentation. So I understand we have time for some questions and answers.

Moderator:We have a little bit of time here, so for the audience, if you do have a question, please use the Q&A pane and go to Webinar to submit those into us. I am just going to start with the first one we received here and work our way through. What supplements were used, referring to the WRIISC Factors slide?

Sergeant Canaan Heard:That was a very mixed bag, so we saw some supplements that were intended to promote energy and wakefulness. We saw some supplements that were more intended to promote muscle hypertrophy, strengthening supplements and some vitamins.

Moderator:Great. Thank you. The next question here: I may have missed it in the beginning—was age correlated to those measured factors and scores?

Sergeant Canaan Heard:So we did the bivariate analysis and we did look at age, and it was not statistically associated with injury in the sample. However, in previous literature it is associated, although it can go either direction. But the age range of our sample was quite narrow and we also had a small sample and so that is why we think it did not hit the benchmark of statistical significance. We did look at most of those baseline characteristics, and the ones that we reported were the ones that either reached statistical significance or approached statistical significance. But as I mentioned, this really was our first crack at looking at the data, and so we will be refining our analytic plan as we move forward.

Moderator:Okay, great. Thank you. I have two questions here that are kind of similar, so I am going to ask them together. Are patients of WRIISC only those who have served in deployed war zones or any who have served during a documented wartime? And, do you see any veteran from any war?

Sergeant Canaan Heard:So to answer the second one, yes, we see any veteran from any war. There are some eligibility criteria. For example, it has to be safe for the veteran to travel to us; and in terms of being able to reimburse them for their travel they need to be service-connected and eligible for VA travel benefits. With regards to the first question, our mission is explicitly to help veterans who have been deployed to combat zones. So while we sometimes answer questions about stateside exposure concerns, for example whether that is related to Camp Lejeune water contamination or some other specific question, that is part of we do as a WRIISC in terms of our expertise. So we mostly see patients, veterans, who were deployed to combat zones.

Moderator:Great, thank you. The next question that I have here: I have been thinking of referring an OIS veteran to WRIISC. He has been struggling with intractable dizziness since his second deployment to Iraq. He also has severe neck pain and migraines. I recently read about cervicogenic dizziness. What has been your experience with this in combat veterans?

Sergeant Canaan Heard:That is a great question. I am not going to be able to speak to our overall experience. We have not looked at that particular condition in detail. However, that does sound like if the patient has already been evaluated at their home VA, perhaps seen the polytrauma TBI clinic, perhaps talked to physical medicine/rehabilitation  about a more granular characterization of their dizziness problem, that does sound like the sort of patient that we would see. We would basically review what has been done for the patient, do our assessment and then dig into the literature around this and look at not just that as a possible diagnosis but the whole differential diagnosis, and try to help the veteran understand what is going on and make some concrete recommendations about next steps. In that particular case, we would look at the factors that might be contribute to the dizziness, perhaps the contribution of the cervical injuries, but we might also look at other things, perhaps the vestibular system, perhaps other possible causes or contributing factors. And then we would get the veteran to think about well, what can I do to make this better and how can I work with my team to make sure that we know enough so that we can move forward so that I get better.

Moderator:Great. Thank you. 

Dr. Robert Kerns:This is Bob Kerns. I wanted to jump in for a second. I apologize. I do have to leave the call and I wanted to not miss the opportunity to thank Drew and Canaan and offer their wonderful presentation today. I hope the Q&A will continue in my absence. I also want to thank all our participants today for their interest and their support for this program; and I want to thank Heidi Schleuter and all her colleagues at Cyber for their support again. I look forward to speaking with all of you on next month’s call. Take care, mate.

Moderator:Thank you.

Dr. Robert Kerns:Bye-bye.

Moderator: For Drew and Canaan, we do still have maybe about a half-dozen pending questions out here. Do you have the time to stay on for a little bit longer, or do you want to handle some of these offline? I am not sure about your schedules.

Dr. Drew A. Helmer:I am happy to stay on.

Moderator:Okay, fantastic. The next question I have here: It sounded like Sergeant Heard’s study used modifications of USMC combat conditioning exercises. What prompted the modifications?

Sergeant Canaan Heard:I can answer this. There were no modifications. There are guidelines that are put out by commanders as far as physical fitness programs, and like Drew stated, it is up to every single commander. So we did not really modify it. I just used a linear periodization system to create a program for that unit to follow. So I took the guidelines that were prescribed in the Marine Corps Order 6100.13 and utilized those guidelines to create a program geared towards that unit.

Dr. Drew A. Helmer:Jeff, I can jump in here. One of the things that surprised me when we were planning this project was I really expected that physical training would be of the utmost importance and what became really quickly apparent was that that was not the most important thing for a unit commander. And so as you saw from our experience, 80 percent of the missed sessions were because the Marines got pulled to do something else. And before we started doing this, when we were looking at what we wanted to do, we thought, okay, we will get three days a week. We will have one-hour session; that should be easy to grab the participants and really make sure that they commit to that schedule. And what we heard was that oh, no, if I need that person to go to the range to practice firing, or if I need them to go do some sort of dress ceremony responsibility, they were going to go do that. And so I think what Canaan is saying is the program we created basically was trying to make it systematic, whereas the baseline normal was that it was a little more catch as catch can in terms of physical training.

Moderator:Okay, great. Thank you. The next question I have here: If we were to make a referral to your center, how long does the veteran stay at your center for the evaluation?

Dr. Drew A. Helmer:So in New Jersey, we have the veteran here for three nights. They are not admitted to the hospital. They stay in a hotel like a Hoptel sort of situation, and we spend two-and-a-half days evaluating the patient. The other two sites are slightly different. California, the Palo Alto WRIISC, treats patients as outpatients. I believe they arrive on a Monday morning and they stay through a Friday, or perhaps they leave Thursday night. And in Washington, DC, they are actually admitted to the hospital and they spend about four days admitted to the hospital and have all their evaluations and testing done during that period. So the bottom line is the three sites vary a little bit, but it is three to five days for the length of the evaluation.

Moderator:Okay, great. Thank you. And the next question here: Do you have the service available in all of the VAs, and I am assuming it is just at the three locations that you mentioned there.

Sergeant Canaan Heard:So we have these three sites and they are where the WRIISC programs sit. We have an inter-facility consult that is supposed to be implemented at every VA medical center and CBOC and is part of your consult order screen, and you can look at the IFC, a portion of that, and identify the WRIISC to place a consult. And then we receive the consult at the appropriate facility based on where the referral is coming from. Then each site processes their referrals on their own and evaluates the consults and has a conversation with the referring provider and with the patient about expectations and appropriateness of the referral.

Moderator:Okay, great, thank you. And the next question here: Concerning your pilot study, did you conclude that a more systematic approach to physical training reduces musculoskeletal injuries, and are there implications for healthcare delivery in the VA?

Sergeant Canaan Heard:So did we conclude that. So like I said, this was our preliminary analysis and we are really not powered to answer that question definitively. However, I believe that our findings, as we presented them today, indicate that this systematic approach, compared to much larger published studies, does seem to indicate that the intensity or severity of the musculoskeletal concerns in our population were less than what have been published. I think the implications for the VA are that when you see a patient with a chronic pain problem, we need to do a better job of understanding where that came from. We need to do a better job of talking to the patient about some of those less biomedical characteristics of the pain and the injury and a little bit more about the psychosocial context and in particular the impact of the original injury and how it has been managed over the years. I would say that is the implication for the VA.

Moderator: Great, thank you. And that is all of the submitted questions that we have, so we did not run over too long on time. Drew, Canaan, I want to thank both of you so much for taking the time to put this together and present. We really appreciate the time that you put into this. To the audience, thank you very much for joining us today. As you leave today’s session, you will be prompted with a feedback survey. If you could take a few moments to fill that out, we really do read through all of your feedback. We really do appreciate that you take a few moments to fill that out. Drew, Canaan, I do not know if either of you have any closing remarks you would like to make before we close down today’s session?

Dr. Drew A. Helmer:No, thank you very much for listening, everybody.

Sergeant Canaan Heard:No.

Moderator:Thank you, everyone, for joining us today. We do have our Spotlight on Pain Management session scheduled in July and we will be sending out registration information on that to everyone within the next couple weeks. Thank you, everyone, for joining us today, and we hope to see you at a future Spotlight on Pain Management Cyber Seminar. Thank you.

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