Mindfulness-Based Interdisciplinary Pain Management Program for Complex Polymorbid Pain in Veterans: A Randomized Controlled Trial.

OBJECTIVE: To evaluate the effects of interdisciplinary pain management on pain-related disability and opioid reduction in polymorbid pain patients with 2 or more comorbid psychiatric conditions. DESIGN: Two-arm randomized controlled trial testing a 3-week intervention with assessments at pre-treatment, post-treatment, 6-month, and 12-month follow-up. SETTING: Department of Veterans Affairs medical facility. PARTICIPANTS: 103 military veterans (N=103) with moderate (or worse) levels of pain-related disability, depression, anxiety, and/or posttraumatic stress disorder randomly assigned to usual care (n=53) and interdisciplinary pain management (n=50). All participants reported recent persistent opioid use. Trial participants had high levels of comorbid medical and mental health conditions. INTERVENTIONS: Experimental arm-a 3-week, interdisciplinary pain management program guided by a structured manual; comparison arm-usual care in a large Department of Veterans Affairs medical facility. MAIN OUTCOME MEASURES: Oswestry Disability Index (pain disability); Timeline Followback Interview and Medication Event Monitoring System (opioid use). Analysis used generalized linear mixed model with all posttreatment observations (posttreatment, 6-month follow-up, 12-month follow-up) entered simultaneously to create a single posttreatment effect. RESULTS: Veterans with polymorbid pain randomized to the interdisciplinary pain program reported significantly greater decreases in pain-related disability compared to veterans randomized to treatment as usual (TAU) at posttreatment, 6-month, and 12-month follow-up. Aggregated mean pain disability scores (ie, a summary effect of all posttreatment observations) for the interdisciplinary pain program were -9.1 (95% CI: -14.4, -3.7, P=.001) points lower than TAU. There was no difference between groups in the proportion of participants who resumed opioid use during trial participation (32% in both arms). CONCLUSION: These findings offer the first evidence of short- and long-term interdisciplinary pain management efficacy in polymorbid pain patients, but more work is needed to examine how to effectively decrease opioid use in this population.

Development of a Practice Tool for Primary Care Providers: Medication Management of Posttraumatic Stress Disorder in Veterans with Mild Traumatic Brain Injury.

Posttraumatic stress disorder (PTSD) and comorbid mild traumatic brain injury (mTBI) are highly prevalent in veterans who served in Iraq [Operation Iraqi Freedom/Operation New Dawn] and Afghanistan [Operation Enduring Freedom]. Complicated psychotropic medications are used for treatment of PTSD and comorbid mTBI symptoms lead to polypharmacy related complications. Primary care providers (PCPs) working in Community Based Outpatient Clinics (CBOCs) are usually burdened with the responsibility of managing this complicated medication regimen or relevant side effects. The PCPs do not feel equipped to provide this complicated psychopharmacological management. Thus, there is a need for a comprehensive yet concise tool for the medication management of PTSD in veterans with comorbid mTBI. (1) To conduct focus groups of interdisciplinary team of experts and other stake holders to assess need, (2) To carefully review current VA/Department of Defense practice guideline to identify content, (3) To develop an evidence based, user friendly, and concise pocket guide for the PCP's. Content was identified by review of current guidelines and available literature and was finalized after input from stakeholders, multidisciplinary team of experts, and review of qualitative data from focus groups/interviews of clinicians working in remote CBOCs. The pocket tool was formatted and designed by multimedia service. A pocket guide in the form of a bi-fold, 4″ × 5.5″ laminated card was developed. One thousand hard copies were distributed in the local VA medical center. This product is available online for download at the South-Central Mental Illness Research, Education, and Clinical Center website ( https://www.mirecc.va.gov/VISN16/ptsd-and-mtbi-pocket-card.asp ). This pocket card provides PCPs an easy to carry and user-friendly clinical decision-making tool to effectively treat veterans with PTSD and comorbid mTBI.

Developing a Therapeutic Approach Toward Active Engagement for Veterans With Mild Traumatic Brain Injury.

BACKGROUND: Treatment of chronic mild traumatic brain injury (mTBI) or postdeployment syndrome can be challenging to frontline providers who care for our nation's war heroes. There is ample guidance available for symptom-based interventions, but relatively little information regarding the structure and language of the clinical encounter. Dynamic patient education centered upon relatable language, accessible analogies, and brain health can move the visit beyond historical diagnostics into a shared understanding of postdeployment barriers to reintegration. OBJECTIVE: We aim to describe a practical, education-based clinical approach for chronic mTBI or postdeployment syndrome (mTBI/PDS). The foundation of this method is gathering the veteran's narrative, validating and normalizing his or her experience, highlighting neurobehavioral changes from combat that may represent barriers to full community reintegration, and transitioning to an emphasis on overall brain health. CONCLUSION: The chronic mTBI or PDS clinical encounter can be enhanced by empowering the patient with relatable terms and concepts to describe his or her reintegration challenges and emphasizing factors of brain health. This approach can provide the patient with a base of understanding regarding his or her current symptoms, promote focus on factors for cognitive health, and orient the clinical encounter toward improved community reintegration and long-term cognitive wellness.

Enhancing Access to Psychiatric Care for Posttraumatic Stress Disorder in Veterans with Mild Traumatic Brain Injury through Integrated Services.

(i) To describe an integrated model of psychiatric care for the treatment of posttraumatic stress disorder (PTSD) in veterans with mild traumatic brain injury (mTBI). (ii) To evaluate access to and engagement in psychiatric care among veterans with comorbid PTSD and mTBI after implementation of an Integrated Care (IC) model compared to the previous Usual Care (UC). 100 randomly selected charts, 50 from each of UC and IC were reviewed in this non-concurrent case- control study. Polytrauma Network Site (PNS), an outpatient rehabilitation clinic, for veterans who suffered from brain and other traumatic injuries at an urban VA Polytrauma Rehabilitation Center. Veterans receiving treatment for mTBI symptoms by the rehabilitation team were referred for medication management for PTSD to UC and IC. Co-located access to psychiatric care for medication management as part of the interdisciplinary team with the goal of expediting rehabilitation and functional recovery. Number of consults for psychiatric care for medication management scheduled and completed within 30 days, and number of veterans offered, initiating, and completing evidence-based psychotherapies for PTSD in UC compared to IC. After implementation of IC there were significant improvements in timely completion of consults and patient engagement with a psychiatrist. There also were improvements in number of referrals, initiation, and completion of evidence-based psychotherapies for the treatment of PTSD. IC within the PNS shows promise as an effective care model for increasing access and engagement in care for veterans with comorbid PTSD/mTBI. Future research is needed to examine the utility of this model in other sites.

How to Conduct an Outpatient Telemedicine Rehabilitation or Prehabilitation Visit.

The novel coronavirus pandemic is resulting in an accelerated conversion of in-person physician visits to virtual visits. As barriers to adoption of telemedicine are rapidly decreasing, it is important to recognize the need for practical and immediately deployable information that can improve doctor-patient interactions, facilitate accurate documentation, and increase confidence in the transition to virtual visits. In this article we aim to outline the components of an outpatient telemedicine visit for physiatrists, with a particular focus on an adapted virtual physical examination. Uses of telemedicine may include future large scale concerns such as natural disasters or climate change. We describe a general approach to the visit, review definitions of terms commonly used in telemedicine, and offer tips for optimizing the encounter.

Rehabilitation in the Department of Veterans Affairs Polytrauma System of Care: Historical Perspectives.

The purpose of this article is to inform the reader of the historical aspects of the Polytrauma System of Care, understand the solutions that were implemented in addressing the continuum of care needs for service members and veterans, and provide an understanding of ongoing research efforts that will inform future solutions to strategically identified future care needs.

Rehabilitation of Persistent Symptoms After Concussion.

One of the more challenging aspects beyond acute concussion management occurs when symptoms do not resolve as anticipated over time. The term postconcussion syndrome generally refers to a presentation of multiple ongoing symptoms months to years from injury, typically comprised of physical, cognitive, and emotional complaints such as headaches, poor sleep, poor concentration, dizziness, and irritability. Although individual factors vary, the condition is often regarded as multifactorial. Persistent issues can pose a threat to full community reintegration following concussion and reduce overall quality of life; thus early recognition and treatment are essential to optimize long-term outcomes.