Chronic pain after a traumatic orthopedic injury and posttraumatic stress disorder (PTSD) are each major concerns for the U.S. military in their own right. Both conditions have a direct impact on military readiness and are leading causes of medical discharges from active duty, as well as long-term VA disability, according to a 2006 report by the U.S. Department of Defense and the U.S. Department of Veterans Affairs. When these conditions become chronic, they can lead to a lifetime of pain and suffering for veterans and potentially contribute to an array of socioeconomic difficulties. In financial terms, the costs associated with the treatment of these conditions exceed hundreds of billions of dollars annually.

As different as these two conditions are, they are not necessarily separate problems that can be addressed in isolation from each other, because they frequently come together in one “unwanted package,” and each adversely affects the other. An increasing body of evidence from civilian studies suggests that individuals who experience physical trauma are likely to experience symptoms of significant psychosocial distress as well. In fact, one specific study published by A.J. Starr and colleagues in 2004 identified over half of a civilian sample of orthopedic trauma patients who met criteria for PTSD after their injury. To date, these studies have not been replicated in a military population, but it is suspected that the rates of comorbid orthopedic trauma and PTSD would be similar to those found in civilians, if not higher. The problem is not just that physical trauma can lead to the development of PTSD. Studies have also shown that PTSD affects patients’ reports of physical complaints, and PTSD is among the variables that are most predictive of functional outcome following injury.

Making matters worse, recent research by M.J. Bosse and colleagues suggests that individuals experiencing comorbid chronic pain and traumatic stress may respond poorly to treatment targeting only one diagnosis, contributing to the chronicity and severity of both PTSD and pain. On the positive side, data from other studies suggest that early interventions for orthopedic trauma pain and related traumatic stress can be effective in preventing chronic pain or PTSD syndromes.

The potential of cognitive therapy in treating both PTSD and pain: A STRONG STAR investigation

Robert Gatchel, PhD, of The University of Texas at Arlington hopes to build on these positive findings through a novel study he has designed for STRONG STAR to examine the effects of combining preventive pain and PTSD treatments for trauma patients. As part of their investigation, Dr. Gatchel and his co-investigators will identify the comorbidity of orthopedic trauma and traumatic stress in an active-duty military population, and they will evaluate a preventive behavioral health treatment strategy aimed at helping to retard or halt the development of PTSD and/or chronic pain syndromes. The study will examine the efficacy of multiple treatment options, utilizing a four-group randomized experimental design to measure the effects of cognitive behavioral therapies targeting pain treatment only, PTSD treatment only, and the treatment of both pain and PTSD compared to treatment as usual.

Evaluations of these four groups will be conducted at pretreatment, immediately at posttreatment, and at 6- and 12-month follow-up periods in order to determine differential outcomes on numerous variables. The investigators hypothesize that treating individuals with chronic pain and PTSD symptoms (e.g., lasting 12 weeks or more) through a proven psychosocial model will help to improve psychological, socioeconomic and physical symptoms of these chronic clinical syndromes. They further aim to demonstrate the efficacy of these early treatments in facilitating the return to active duty of military personnel living with pain and traumatic stress. Finally, they also expect to have a positive impact on other psychosocial and socioeconomic outcomes, such as work retention, additional health-care utilization, depression symptoms, health-related quality of life, and perceived disability.

The benefits of success

If Dr. Gatchel and his colleagues successfully demonstrate that integrating pain and PTSD treatments leads to improved outcomes for wounded warriors, the payoff will be substantial: affected military personnel could potentially enjoy a greatly improved quality of life; the U.S. Department of Defense could save billions of dollars in elevated treatment costs attributable to comorbid pain and PTSD; and thousands of civilian trauma patients could benefit from this improved treatment method.