Early, Continuous, and Restorative Pain Management in Injured Soldiers: The Challenge Ahead

Saving the lives of soldiers who sustain traumatic injuries in military combat tests the ingenuity, resourcefulness, and courage of medical teams on the battlefield and during and after transport to theater hospitals and to military hospitals in the United States. When considering the human meaning of these life-saving interventions, enthusiasm must be tempered by the reality of the enormous challenge of restoring survivors to a meaningful and productive life. Rehabilitation must occur in the face of physical and psychological functional limitations, in some cases catastrophic, for which there are no easy solutions. Blast injuries may cause visual and hearing impairment, severe burns, and cognitive deficits. Even without these comorbidities, soldiers surviving combat injuries are at high risk for developing post-traumatic neurobehavioral consequences of battlefield trauma, such as neuropathic pain and post-traumatic stress disorder (PTSD). Thus, the priority of saving lives must be closely followed by the imperative to minimize the incidence and severity of these consequences, with the goal of maximizing the soldier's chances of a useful and rewarding life after recovery, whether as a civilian or in the military. The severest battlefield injuries rightly draw most of our attention. However, a far larger group of soldiers incur noncombat-related day-to-day injuries and psychological trauma when deployed to war theaters, which can themselves lead to disabling chronic pain and psychological morbidity. The day-to-day physical wear and tear of military duty may also be accompanied by emotional stress of daily or episodic exposures to hostile environments and horrendous injuries and death of fellow soldiers and civilians. These soldiers also deserve the longitudinal care that will increase their chances of a successful recovery to a reasonable quality of life. Two articles in this issue—one by Stojadinovic and colleagues [1] at the Walter Reed Army Medical Center, Washington, DC, and the other by Gironda and colleagues [2] at the James A. Haley Veterans Hospital, Tampa, Florida—describe the types of devastating wounds, injuries, and other causes of pain and comorbidities that military, community, and Veteran Affairs Hospital clinicians will be managing as our soldiers return home on leave or upon discharge from military duty. These articles also present the hope that innovative pain management, starting soon after injury and continuing into chronic pain management programs in the community, offers in reducing the incidence and severity of chronic painful conditions and their associated problems such as PTSD and depression. Emerging literature on battlefield casualties in Iraq and Afghanistan with Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) has to some degree characterized the types of injuries and elucidated the dramatic impact that advances in combat protective gear, air transport evacuations, aggressive battlefield medical interventions, and patient-tracking systems have had on saving the lives [3–6]. Advances in military capabilities have resulted in the earlier return of injured military personnel to the United States with a higher level of acuity than past military conflicts [5]. Despite marked progress in military operations and delivery of medical care, the emergent management of pain following battlefield injuries still remains a significant challenge for health care professionals. Equally concerning are obvious gaps in research addressing ways in which rapid control of pain can be accomplished in the battlefield and theater medical care units, and during air transport evacuation and hospitalization in Germany. Isolated reports underscore the importance of adequate pain control [7], but few studies of battlefield injuries actually address pain management issues. A recent case report by Dr. Buckenmaier and his team at Walter Read Army Hospital details the procedures for aggressive early intervention with regional anesthesia and continuous peripheral nerve block on the battlefield and during evacuation [8]. Their article in this issue by Stojadinovic et al. [1] describe the initial consecutive sample of wounded soldiers receiving these interventions, and the preliminary results of this care in terms of improvements in pain, safety, and complications. The longer-term impact of their efforts on the incidence and severity of post-traumatic experiences, such as neuropathic pain (e.g., complex regional pain syndrome 2 [causalgia] and phantom limb pain) and related combat-induced problems such as PTSD, remains unclear. The physiological and psychosocial consequences of severe pain and psychological distress, the aftermath of battlefield injury, have not been adequately studied in prospective, longitudinal research designs. Moreover, little is known about the important role that prompt and effective pain relief plays in alleviating long-term suffering and pain-related disabilities such as PTSD. Animal models suggest that traumatic nerve injury left untreated causes “central sensitization” or neural remodeling (neural plasticity) that can ultimately lead to a state of sustained or chronic neuropathic pain [9]. The neurobiological basis for understanding chronic pain states underscore the importance of work to determine the effectiveness of regional anesthesia to prevent or minimize the associated experiences of sensitivity to typically nonpainful stimuli (allodynia) and exaggerated responses to painful stimuli (hyperalgesia) often reported with neuropathic pain [10]. Moreover, central sensitization explains the lasting perceptions of pain long after tissue healing has occurred and in the absence of a documented cause for pain [11]. Animal models provide compelling evidence to support the use of effective anesthetic interventional techniques to block painful stimuli at the time of tissue damage, which subsequently prevents central sensitization and reduces associated pain behaviors [12,13]. Carr and Goudas [14] have elucidated the relationship of acute tissue trauma to chronic pain through a cascade of events that trigger neurotransmitter release, intracellular responses, and neuropsychological response. Often, the surgical advances learned through innovative applications of new technologies in the care of large cohorts of injuries incurred on the battlefield are then translated to surgical care of trauma in civilian life. The early interventions by Stojadinovic and colleagues [1] propose a model of secondary prevention in pain management that, if successful, can translate into dramatic changes in the way trauma-induced pain is managed by emergency personnel in hospitals, and even at accident scenes, in civilian life. At no time has this knowledge been more needed, especially given the threat of terrorism with improvised explosive devices that pose significant threats to civilians both in the United States and abroad. There are also far reaching implications for emergent treatment of military and civilians in other countries who encounter blast injuries from landmines as a result of the “collateral” impact of war. Gironda and colleagues [2], who studied an initial cohort of patients returning from the OIF/OEF war, suggest that our health care system may be ill prepared to not only deal with pain from catastrophic injuries, but also to contend with the possibility of large-scale widespread pain caused by a variety of noncombat-related injuries and conditions. Similar to the Gulf War, the majority of these patients did not sustain an initial combat injury, but rather suffered the onset of chronic painful conditions caused by or worsened by the day-to-day activities of military duty, such as they might incur as a civilian in highly strenuous physical labor. In many cases, their clinical presentation was confounded by the symptoms of psychological distress associated with deployment. These individuals will require the biopsychosocial rehabilitation approach, staffed by experience pain specialists, known to work best for any chronic pain population, be it a retired soldier or a laborer repetitively lifting heavy object on the job. Unfortunately, these programs are in short supply in the United States. Our soldiers deserve the best pain management practices that we have to offer. We hope that the imperative of caring for the soldiers who have served our country with dedication and courage, and who have incurred injuries in this service, will help galvanize political and societal support for the research needed to test more effective ways to treat acute and chronic pain. This will require expansion of reimbursed health care services to ensure access to the proper rehabilitative programs to achieve optimal function and reintegration with effective management of residual problems such as pain. Finally, we encourage legislators and policy-makers to allocate more funding to support investigations of pain control in the battlefield and early postinjury phase, and to recognize the valuable contributions that military personnel trained in pain management can make in preventing the development of long-term morbidity from traumatic injury.