Stepped Care Helps Vets With Musculoskeletal Pain

A new study has found that a stepped-care strategy improved function and decreased pain severity in veterans of Iraq and Afghanistan, producing at least a 30% improvement in pain-related disability. The researchers, from the Richard L. Roudebush VA Medical Center in Indianapolis, the Regenstrief Institute and the Indiana University School of Medicine, led the randomized controlled ESCAPE trial (Evaluation of Stepped Care for Chronic Pain).

“Pain is disabling and interferes with daily living as well as the ability to work, ” said Matthew Bair, M.D., the VA and Regenstrief Institute investigator and IU associate professor of medicine who led the randomized controlled ESCAPE trial, in the March 9, 2015 news release. “It is a critical health issue among veterans, many of whom had multiple, often lengthy deployments.”

Dr. Bair, an internist who treats veterans in primary care and is a health services researcher, was a U.S. Army physician for eight years. “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 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 nine months.”

This study included 241 veterans of Operations Enduring Freedom, Iraqi Freedom and New Dawn who suffer from musculoskeletal pain of the back, knee, neck or shoulder. The two-step program, created by Dr. Bair and colleagues, involved analgesics, self-management strategies and cognitive behavioral therapy. Nurse care managers phoned the veterans, helping them develop healthier thought patterns. They also helped the veterans better understand that while their pre-deployment level of activity wasn’t possible at the time, a substitute activity like swimming might be within their reach and may decrease their pain.

Veterans enrolled in the ESCAPE program experienced an improvement in their function and a decrease in their pain severity and pain interference (how pain interferes with mood, physical activity, work, social activity, relations with others, sleep and enjoyment of life).

According to the news release, “The authors report that patients randomized to the innovative two-step approach spoke of an evolving understanding of their pain experience during the trial, and of how this new understanding helped them manage their pain more effectively.”

Asked about evidence-based psychological treatments used, Dr. Bair told OTW, “There were six sessions of nurse-delivered cognitive behavioral therapy.”

As for whether the patients will continue using the tools they acquired if left without support, Dr. Bair noted, “Some will continue using these tools without support, but based on our previous studies many need the support, encouragement, and accountability from a care manager to continue to use the tools.”