Two-Step Treatment Approach Significantly Decreases Pain in Wounded Veterans


A two-step treatment plan that combines pharmaceutical analgesics, self-management strategies, and cognitive behavioral therapy is associated with greater improvements in pain severity and pain-related disability in veterans compared with usual care.

Pain severity in veterans was reduced and function was improved after implementing a two-step treatment program, according to findings published in JAMA Internal Medicine.

Researchers from Indiana University School of Medicine observed 241 veterans recruited from Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Darn with chronic and disabling musculoskeletal pain in order to determine whether a stepped care intervention is more effective than usual care. The researchers hypothesized that this two-step program would be effective in reducing pain-related disability, pain interference, and pain severity.

The veterans’ pain was located in the cervical or lumbar spine or extremities (shoulders, knees, and hips) and was monitored from December 2007 to June 2011. A 9-month follow-up period was concluded by April 2012. The patients received treatment at a post-deployment clinic and 5 general medicine clinics at a Veterans Affairs medical center.

The first step in the program was 12 weeks of analgesic treatment and implementation of pain self-management strategies. The next step was 12 weeks of cognitive behavioral therapy. All of the intervention steps were delivered by nurse care managers.

After 9 months follow up, the patients who received the two-step intervention (121 patients) demonstrated decreased pain severity and pain interference (how pain interferes with mood, physical activity, work, social activity, relations with others, sleep, and enjoyment of life), as well as an improvement in overall function.

“Pain is disabling and interferes with daily living as well as the ability to work,” study leader Matthew Bair, MD, who previously served for 8 years as a US Army physician, explained in a press release. “It is a critical health issue among veterans, many of whom had multiple, often lengthy deployments. Many have significant long term pain. We know that medications alone are only modestly successful in helping them; current pain treatments haven’t made much of a dent.”

The usual care group (120 patients) received educational handouts about musculoskeletal pain. They were additionally advised to discuss their pain with their physicians. The patients continued medications, clinic visits, specialty referrals, and other care as usual.

“The decrease in pain severity and 30 percent improvement in pain-related disability we achieved in the ESCAPE study are clinically significant, and we found that improvement lasted for at least 9 months,” Bair concluded.

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