An Effectiveness-Implementation Trial of Functional Restoration for Chronic Pain Management in Active Duty Military Personnel

Aug 11, 2023

Chronic pain has a major detrimental effect on operational readiness across all branches of the U.S. military and is the single greatest condition related to medical disability within the U.S. Department of Veterans Affairs.

Although there are several effective, evidence-based treatments for acute pain such as medications, injections, devices, and surgeries, most of them are not similarly effective for chronic pain. In addition, the military has been seeking alternatives to opioid medications, a mainstay of treatment, due to increasing rates of addiction and negative side effects.

Interdisciplinary, multicomponent, functional restoration programs (FRPs) targeting the biological, behavioral, psychological, and social aspects of chronic pain are the evidence-based treatments with the strongest scientific support for chronic pain management. FRPs use a rehabilitation model designed to increase physical functioning, improve pain coping skills, and increase the opportunity to return to work.

However, it has been difficult to achieve widespread implementation of these programs in the Military Health System (MHS), because the establishment of an FRP is clinically and administratively complex and very different from routine chronic pain management practices.

Working to bring effective chronic pain management to military clinics

Addressing the need for effective chronic pain management, STRONG STAR investigators have launched a project to accelerate the implementation of FPRs across the MHS, doing so under the leadership of partnering principal investigators by Alan Peterson, PhD (Lt Col, USAF Ret.), of The University of Texas Health Science Center at San Antonio and Katherine Comtois, PhD, of the University of Washington.

The study is an extension of two successful randomized clinical trials (RCTs) conducted by STRONG STAR researchers to evaluate an FRP called Functional and Occupational Rehabilitation for Troops (FORT). Investigators will test the effectiveness of FORT with active duty military personnel with chronic pain at six MHS clinics nationwide, where they also will test a strategy designed to promote implementation of this treatment approach at the six clinics. 

How the program works

FORT includes education about chronic pain, relaxation, and stress management; cognitive and behavioral therapies designed to improve pain coping and increase physical activity; individually tailored and gradually increasing physical and occupational therapy exercises; strategies for activity pacing and functional activation; and specialized modules for addressing pain-related concerns such as stigma, depression, and insomnia.

Some patients in the study will receive FORT plus the established treatment as usual for chronic pain. Their progress will be compared to another group that simply receives treatment as usual.

Aspects of FORT implementation that the team plans to develop at the military treatment facilities include establishment of support from clinical and administrative leadership, allocation of clinical space and personnel, use of effective criteria for screening patients, commitment of sufficient time for clinical treatment, and use of complementary and integrative medicine approaches. They later will assess for the extent that those elements have been adopted at the military clinics, along with the number of FORT programs offered per year.

Expected benefits

This research potentially could provide an effective way to implement improved treatment for chronic pain, help more affected service members maintain their careers, improve operational readiness, and decrease military and VA costs associated with military separation due to pain-related disability.

Written Exposure Therapy for Suicide Prevention: A Randomized Clinical Trial

Feb 06, 2023

Military personnel admitted to inpatient psychiatry for self-injurious thoughts and behaviors (SITBs) represent an at-risk group for continued SITBs and rehospitalizations following discharge. However, there is an absence of evidence-based interventions designed to be delivered on inpatient psychiatric units to reduce the risk of post-discharge SITBs.

To address this need, STRONG STAR investigators have developed Written Exposure Therapy for Suicide Prevention (WET-SP), a brief, suicide-specific psychotherapy based on Written Exposure Therapy, in which an individual writes about a personally stressful experience and the related thoughts and feelings. WET has shown to be effective in improving mental and physical health, and data from pilot study research suggests that it also helps to reduce SITBs.

However, no study has adapted WET-SP specifically to target distress associated with suicidal crises and examined whether the intervention reduces risk of subsequent SITBs and suicide-related hospitalizations. 

Testing the therapy at a military hospital

STRONG STAR investigators led by Brian Marx, PhD, with VA’s National Center for PTSD and Boston University School of Medicine, will address that research gap with a study involving 124 patients admitted for acute psychiatric care at Carl R. Darnall Army Medical Center at Fort Cavazos (formerly Fort Hood), TX. Half will be randomly assigned to receive WET-SP delivered by the study team, plus the psychiatric unit’s treatment as usual (TAU). The other half will be assigned simply to receive TAU, which includes daily contact and patient-centered care delivered by the acute psychiatric unit provider team. TAU also includes psychiatric assessment, initial stabilization, nurse case management, medication management, treatment of medical comorbidities, group and individual therapy, and discharge planning.

Assessments to measure the outcomes for both groups of patients will be administered at pretreatment, posttreatment, and 10-, 20-, and 30-week follow-ups. The investigators also will explore whether a computerized analysis of the narrative content of WET-SP can predict which patients will benefit from the treatment.

Expected benefits

If WET-SP demonstrates success, it will address a critical healthcare crisis by reducing suicidal ideation and preventing post-discharge suicidal behaviors and rehospitalization for suicide-related concerns.

Although WET-SP must be delivered by a clinician, it is easy to train, offering a relatively low-cost yet high-yield therapeutic approach for military settings.