Management of Post-traumatic Stress Disorder in Veterans and Military Service Members: A Review of Pharmacologic and Psychotherapeutic Interventions Since 2016.

PURPOSE OF REVIEW: It is vitally important that providers treating post-traumatic stress disorder continue to stay abreast of research advances in the treatment of this disorder. This article updates the reader about advances in research in PTSD treatment in the past four years as well as the evolving recommendations of clinical practice guidelines. RECENT FINDINGS: One of the most important developments is that trauma-focused therapy (TFT) has emerged as the first-line treatment for PTSD with pharmacologic options often being noted as second-line or adjunctive. The quality and quantity of research into the treatment of PTSD continue to grow; however, the pace of research into treatment options lags behind our understanding of the development, course, and prognosis of the disorder. The development of new research-based evidence in the treatment of PTSD, both pharmacologic and psychotherapeutic, is needed and likely to necessitate frequent updates and re-evaluations of clinical practice guidelines.

A randomized controlled trial of an online self-management program for adults with arthritis pain.

The objective of this RCT was to assess the efficacy of an online pain self-management program with adults who had a self-reported doctor diagnosis of arthritis pain (N = 228). Participants were recruited via flyers and online postings then randomized to the experimental condition or the wait-list control condition. Individuals in the experimental condition reported significantly (1) increased arthritis self-efficacy and (2) reduced pain catastrophizing from baseline to follow up compared to those in the control condition. High user engagement (>204.5 min on the website) was also significantly associated with improved self-management outcomes. These findings suggest that use of an online self-management program may positively impact self-efficacy and catastrophizing among adults with arthritis pain at 6 month follow up. Nonsignificant findings for hypothesized variables such as pain intensity and health behaviors are also discussed. Future longitudinal research is needed to assess if cognitive changes associated with participation in an online self-management program leads to reduced pain.

Judging pain sensitivity with subcutaneous lidocaine injections.

OBJECTIVE: Pain perception is affected by psychological, social, medical, and environmental conditions, and contributes to the patient's treatment satisfaction and response. Better understanding of pain perception will likely improve pain assessment and treatment selection. The objective of this study was to define a range of verbal and nonverbal pain responses to a clinical stimulus in a clinical population. DESIGN: Subjects were 165 patients with chronic pain conditions. The patients were scheduled for elective interventional pain procedures on the lumbar spine including lumbar interlaminar epidural steroid injections, lumbar transforaminal steroid injections, lumbar facet injections, lumbar medial branch nerve blocks, radiofrequency ablation of lumbar medial branch nerves, and lumbar discography. Intervention. Prior to the procedure, subjects rated anxiety on a numerical rating scale (NRS) from 0 (no anxiety) to 3 (extreme anxiety), and received standardized subcutaneous injections of lidocaine (using 25-G needle to infiltrate 2 cc 1% lidocaine) as local anesthesia. Following the lidocaine injection, pain was rated on an NRS scale. Body movement detected during the injection was rated by an independent observer and recorded as none, less than 1 in., and more than 1 in. Body movement was defined as torso moving away from original prone position. RESULTS: Patients were 37% men and 63% women, with average age of 53 years. The range of pain intensity responses fell within a normal curve (P < 0.01), with average pain intensity of 4.9 (standard deviation = 2.7). Patients with more body movement reported higher pain (P < 0.01). Anxiety predicted pain intensity ratings (P < 0.01). Use of opioids did not predict pain intensity, body movement, or anxiety. CONCLUSION: This study shows normal distribution of verbal pain response to a clinical pain stimulus in a clinical population. Body movement and anxiety correlated with verbal pain intensity ratings. Subcutaneous injections of lidocaine may be a useful model for exploration of pain sensitivity in a clinical population.

painACTION-back pain: a self-management website for people with chronic back pain.

OBJECTIVE: To determine whether an interactive self-management Website for people with chronic back pain would significantly improve emotional management, coping, self-efficacy to manage pain, pain levels, and physical functioning compared with standard text-based materials. DESIGN: The study utilized a pretest-posttest randomized controlled design comparing Website (painACTION-Back Pain) and control (text-based material) conditions at baseline and at 1-, 3, and 6-month follow-ups. PARTICIPANTS: Two hundred and nine people with chronic back pain were recruited through dissemination of study information online and at a pain treatment clinic. The 6-month follow-up rates for the Website and control groups were 73% and 84%, respectively. MEASUREMENTS: Measures were based on the recommendations of the Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials and included measures of pain intensity, physical functioning, emotional functioning, coping, self-efficacy, fear-avoidance, perceived improvement with treatment, self-efficacy, and catastrophizing. RESULTS: Compared with controls, painACTION-Back Pain participants reported significantly: 1) lower stress; 2) increased coping self-statements; and 3) greater use of social support. Comparisons between groups suggested clinically significant differences in current pain intensity, depression, anxiety, stress, and global ratings of improvement. Among participants recruited online, those using the Website reported significantly: 1) lower "worst" pain; 2) lower "average" pain; and 3) increased coping self-statements, compared with controls. Participants recruited through the pain clinic evidenced no such differences. CONCLUSIONS: An online self-management program for people with chronic back pain can lead to improvements in stress, coping, and social support, and produce clinically significant differences in pain, depression, anxiety, and global rates of improvement.

Mediators and moderators of chronic pain outcomes in an online self-management program.

OBJECTIVES: Little is known about the moderators and mediators of change in online pain interventions based on cognitive-behavior therapy (CBT). We hypothesized that the effects of painACTION.com, an online pain self-management program, on pain-related outcomes would be mediated by changes in depression, anxiety, and stress, as well as the use of coping strategies. We also examined potential moderators of change. METHODS: First, the efficacy of painACTION.com and moderators of the intervention effects were evaluated using a pooled sample from previous back, neuropathic, and arthritis pain studies. Next, we explored whether the intervention effect on the primary outcomes, pain severity, and patient global impression of change (PGIC), was mediated by coping strategies or emotional functioning. RESULTS: Compared with controls, experimental participants evidenced significant improvement in pain, emotional functioning, and coping strategies from baseline to follow-up. There were no clear moderators of intervention effects. Changes in emotional factors, particularly stress levels, mediated the relationship between the intervention and outcome (pain severity) over time. DISCUSSION: This study supports the effectiveness of online interventions when CBT and self-management targets pain levels, emotional factors, and wellness-focused coping. The importance of stress as a mediator of pain severity is discussed. The absence of moderators may indicate that the intervention is effective for a wide variety of patients with chronic pain.

Raising the clinical standard of care for suicidal soldiers: an army process improvement initiative.

From 2004 to 2008, the suicide rate among US Army Soldiers increased 80%, reaching a record high in 2008 and surpassing the civilian rate for the first time in recorded history. In recent years, the rate of Army suicides rose again; the year 2012 reflects the highest rate of military suicides on record. There is a need to assess current behavioral health practices to identify both effective and ineffective practices, and to adapt services to meet the needs of the Army behavioral health patient population. This paper discusses a process improvement initiative developed in an effort to improve clinical processes for suicide risk mitigation in an Army behavioral health clinic located in the catchment area of the US Army Southern Regional Medical Command.

Pain at presentation and survival in hepatocellular carcinoma.

UNLABELLED: Pain is a common feature of most human cancers, including hepatocellular carcinoma (HCC). The reported frequency is quite variable, however, and the prognostic significance is not clear. In this report, we examine the incidence of pain in a large HCC database derived from unresectable patients whom we have treated and examine the prognostic and clinical correlates. We report that HCC patients with pain at presentation have a worse prognosis and adverse tumor characteristics. PERSPECTIVE: This article presents one of the first looks at correlates of pain and survival in HCC. Results of this study could inform future research and clinical investigations regarding the importance of pain at presentation in patients with HCC, which impacts qualify of life and survival.

What arthritis pain practitioners and patients want in an online self-management programme.

OBJECTIVE: Self-management of pain is a critical component of arthritis care; however, limited mobility can restrict access to resources. Although the internet has become a primary source of health information, few studies address what patients want and need from a self-management website. METHODS: Thirty-two people diagnosed with arthritis and 12 practitioners a) participated in individual one-hour interviews and b) sorted and rated a list of 88 unique statements that were derived from the interviews. Qualitative data were analysed using concept mapping procedures. RESULTS: The six-cluster map provided the best discrimination between statements. Follow-up analyses suggested that although patients with arthritis and practitioners generally agree on the categories of content on a self-management website about arthritis, they appear to disagree on the importance of each category. CONCLUSIONS: These findings about patient and provider desired content can be used by health educators to develop a curriculum for health education of patients with arthritis pain.

Managing cancer pain with nonpharmacologic and complementary therapies.

Nonpharmacologic interventions are important adjuncts to treatment modalities for patients with cancer pain. A variety can be used to reduce pain and concomitant mood disturbance and increase quality of life. Physicians may feel relatively uninformed about which modalities have been used for patients with cancer and have scientific support. This article reviews several nonpharmacologic and complementary and alternative modalities commonly used by patients with cancer pain. It focuses on those having empirical support or promising preliminary evidence, with the goal of familiarizing physicians with therapies that may complement regular oncologic care. This review updates an article published in November 2005. An anecdotal case study has been added to illustrate incorporation of nonpharmacologic and complementary therapies in the treatment of a patient with cancer-related pain.