Persistent pain in military veterans
Treating veterans is very complex, confronting and challenging but it is also extremely rewarding. Why? Because you may literally change their lives.
Due to inadequate Department of Veterans’ Affairs funding, allied health clinics are faced with a choice between closing their books to Department of Veterans’ Affairs patients or providing services for a fee that is unviable for their business.
It is disappointing to think that veterans may go without the help they need to get back on their feet because the department provides inadequate provider payment. This is a population that requires consistent treatment over a number of years.
Persistent pain in military and ex-military populations often does not improve within a couple of months, which is one of the reasons why it requires a different approach.
Pain and threat
Pain can be defined as ‘a distressing experience associated with actual or potential tissue damage with sensory, emotional, cognitive, and social components’ (Williams & Craig 2016).
Pain exists to protect and promote healing. In persistent pain, however, this response often leads to unhelpful biopsychosocial changes. Part of military training is vigilance about danger (Kimble et al 2013).
In military cohorts, training focuses on adapting instinctive threat responses to ensure that the decisions and actions of soldiers remain deliberate and rational regardless of the situation.
This ability to function under threat is reinforced regularly throughout military service. The body and mind become increasingly hypervigilant because survival may depend on this skill.
Resting hypervigilance is therefore present in the persistent pain experience (Bulcke 2015) and is challenging to address in the veteran population.
If there is a constant level of perceived threat, there is a constant upregulation of survival responses, including pain.
Dealing with the resting stress levels of veterans may lead to changes in levels of biological pain processing (Wippert & Wiebking 2018).
Taking the time to ensure that the veteran understands the role of their intrinsic hypervigilance and altered stress response is vital in the successful management of their persistent pain.
The veteran pain journey
The primary purpose of the military is to provide a national threat response capability.
Therefore, training soldiers to specialise in threat response is pertinent. Part of this training involves changing the identity and core values of military populations.
For example, honour in the military is more important than wealth; targeted aggression is an important asset; a warrior trains for adversity, therefore luxury and ease are considered unimportant; warriors are selfless—it’s all about the team and the job (Dixon 2014).
If you are injured or in pain and are unable to function in your unit, you may lose their respect and support and your status as a warrior may be questioned.
Because of this, soldiers learn to push through enormous amounts of pain and injury to avoid letting the team down.
Veterans retain the ability to push well beyond pain to get a job done, help a mate or aid their partner, to their own detriment.
This can be a barrier to persistent pain recovery, especially with graded exposure and pacing approaches.
A veteran may struggle to adapt their value system to align with the behaviours required to improve their persistent pain.
You are not just treating their persistent pain; you may also be adjusting their entire value system.
Pain rehabilitation for veterans
Pain rehabilitation in veterans is complex and requires multidisciplinary management.
Successful rehabilitation relies on ongoing support and behaviour change over time.
It is exceptionally important to empower and build agency with veteran patients because their recovery journey includes reshaping the way they operate within themselves, their community and the world outside the military.
Education needs to provide insight into how their pain experience has been shaped by their military training and draw links between their values, identity and purpose as a member of society.
This requires understanding and persistence from the entire management team when treating veterans’ persistent pain.
Common approaches to pain neuroscience education, graded exposure, pacing and other options for behaviour change management often fail to produce optimal outcomes in veteran populations.
This is because they don’t address the underlying differences in values and identity that commonly appear in ex-serving populations.
>> Damon Kerns-Stokes APAM has a special interest in veteran persistent pain management. Damon consults out of veteran medical centre GO2 Health in Brisbane, Queensland, where he manages the REFORGE veterans’ pain program (painprogram. reforge.com.au). His goal is to improve persistent pain management in Australian veterans through the education and empowerment of all healthcare professionals who work with veterans.
ADF report 2020-21. (n.d.).
Bulcke, C. vanden. (n.d.). Hypervigilance and pain: The role of bodily threat.
Damme, S., Crombez, G., & Eccleston, C. (2013). Hypervigilance and Attention to Pain. In Encyclopedia of Pain (pp. 1532–1535). Springer Berlin Heidelberg. https://doi.org/10.1007/978-3-642-28753-4_1825
Kimble, M. O., Fleming, K., & Bennion, K. A. (2013). Contributors to Hypervigilance in a Military and Civilian Sample. Journal of Interpersonal Violence, 28(8), 1672–1692. https://doi.org/10.1177/0886260512468319
Robert G. Dixon. (n.d.). Psychology and Basic Combat Training _ Small Wars Journal. Retrieved August 22, 2022, from https://smallwarsjournal.com/jrnl/art/psychology-and-basic-combat-training#_edn19
Williams, A., & Craig, K. (2016). Updating the definition of pain. PAIN, 157, 1. https://doi.org/10.1097/j.pain.0000000000000613
Wippert, P. M., & Wiebking, C. (2018). Stress and alterations in the pain matrix: A biopsychosocial perspective on back pain and its prevention and treatment. International Journal of Environmental Research and Public Health, 15(4). https://doi.org/10.3390/ijerph15040785
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