News and Reports

By Ronessa Dass, Tom Hoppe, & Lindsay Rite

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Chronic Pain in Veterans

Chronic pain impacts the entire human experience (1). Canadian veterans, however, are disproportionately impacted as 41% to 64% of them experience chronic pain (2). This may be due to various factors that are unique to the lived experience of veterans with chronic pain (2). For example, veterans are more likely to experience service-related physical and/or mental health traumas, such as post-traumatic stress disorder (2,3).

Moreover, veterans are trained through their service to develop “a military mindset.” This mindset influences how veterans perceive their environment and themselves, thus constructing a significant portion of their identity (4). Military mindset is a complex experience but overall refers to a mission first, self last ideology (5). Veterans experience a shift in identity once they return to civilian communities and may experience a loss of purpose and camaraderie, as well as confusion with their own social roles (2,6,7). This mindset can influence how veterans approach traditional physical rehabilitation treatments (6).

Issues in Veteran Chronic Pain Management

Currently, access to interdisciplinary chronic pain services in Canada is inadequate to meet the national demand. Accurately evaluating the need for resources is challenging due to inconsistency in research and clinical data collection (1). However, one cross-sectional study assessing access to multidisciplinary pain treatments in Canada reported that 50% of Canadians with chronic pain wait approximately six months prior to accessing a multidisciplinary pain clinic (8). Furthermore, specialized veteran-specific services within current pain programs are limited in scheduling availability and geographic location (2,9,10).

Many rehabilitation specialists (e.g., occupational therapists and physiotherapists) use pain education tools (e.g., cognitive behavioral therapy, pain neuroscience education) to help persons with chronic pain understand their condition and to promote pain-reducing techniques (1,11). Pain education sessions are limited in their utility if they are not specifically adapted to an individual’s unique needs (1). This limitation is clear in veteran pain management, as military identity is rarely discussed within clinical settings and has an impact on how pain management is received (2,6,7,10).

Exercise therapy is a common intervention used in chronic pain management (4,12). Exercise therapy requires 1) identifying a personal functional goal, and 2) pacing, both of which can be challenging for veterans (4,7,13). Mission first identity can obstruct veterans from establishing individual goals as they often put the needs of others before themselves (7). In addition, pacing supports pain patients in achieving their personal goals and requires establishing safe functional baselines and then implementing a progressive overload (4,7). Many veterans may experience cognitive dissonance, as veterans may dissociate from their physical symptoms of pain and push through any pain sensitivity, which obstructs pacing in exercise therapies (14). The engrained mission first mindset, however, is contradictory to the slow progressions emphasized in pacing and functional goal attainment (4,12).

Lastly, many healthcare professionals (HCPs) lack the training and tools to identify and treat the complexities of veteran identity, history, and current socioeconomic concerns. In this way, HCPs may have difficulty building trust and rapport with veterans (2). To summarize, there are many unique barriers to adequate chronic pain care for veterans.

The Military Veteran Alpine Challenge

The Military Alpine Challenge demonstrates how chronic pain rehabilitation specialists can modify their approaches to target the unique concerns of veterans with chronic pain. The Military Alpine Challenge is a hiking experience organized by Tom Hoppe, a decorated veteran involved in military identity research, and Dr. Lindsay Rite, the Director of Integrative Health at CHANGEpain Clinic and Chiropractor specializing in chronic pain management. The hike was sponsored by the Chronic Pain Centre of Excellence for Canadian Veterans. The hike was developed to address the gap in veterans’ understanding of available resources and strategies to improve pain management and quality of life. The purpose of the original Military Alpine Challenge was to provide pain education, develop a sense of accomplishment, and build awareness for veterans suffering with chronic pain. During the hike, veterans were immersed in nature and discussed strategies to understand their pain and military identity. Although no formal data was collected after the hike, some members reported having reflections on military identity and the impact it has on their transition and pain.

The next Military Alpine Challenge, which is scheduled for August 2023, will be a formal event supported by ten virtual pain education courses discussing topics including pain science, safe movement, military mindset, yogic breath work, sleep, and pain. Aside from the actual hike, additional supports including resources for veterans’ local active rehabilitation team, coaching, and regular group check-ins to promote social support. Prior to and following participation, participants will partake in standardized fitness tests assessing whether they are physically capable to participate and complete a reflective journal. Three months after the hike, participants will receive an informal check-in to verify their well-being and continued progress. A summary of key observations of the 2023 Military Alpine Challenge will be disseminated later this year.

Implications for the Field of Rehabilitation

Rehabilitation HCPs and researchers working with veteran populations can incorporate the strengths of the Military Alpine Challenge into their own practice.

Implications for Rehabilitation HCPs

Rehabilitation HCPs are encouraged to consider military identity in their approach to chronic pain care for veterans (1). Pain education should be tailored to the needs and concerns of veterans (2,6,7,10). For example, mission first mindsets can override the importance of pacing in pain therapies, thus pain education programs should address how to work within the confines of the mission first mindset (4,12). Pain educators should also consider common veteran health comorbidities (e.g., post-traumatic stress disorder and cognitive dissociation; 11). Incorporating comorbidities may require unique environments (e.g., nature) to establish safe settings for rehabilitation. Lastly, since veterans are both goal- and team-driven, treatments should include family- or team-based approaches to assist veterans in engaging with care (5,9,15). To conclude, the consideration of military identity in veteran chronic pain management promotes personalized care.

Implication for rehabilitation researchers

Rehabilitation researchers have an important role in supporting rehabilitation HCPs in providing effective care for veterans with chronic pain (1). Though there have been studies exploring the influences of military identity in veterans with chronic pain, their specific effects on treatment are unclear (1). Researchers should continue to investigate these effects, as well as the effects of intersectionality of identities (e.g., sex, gender, ethnicity, and sexuality) in veterans, which is another important area of veteran research that remains understudied (1). Rehabilitation researchers can utilize these findings to develop educational materials to aid HCPs in treating veterans with chronic pain.

The inclusion of culture and identity in veteran rehabilitation research cannot be done without the help of the lived experiences of veterans (16). The authors recommend that researchers study veteran identity before beginning a project. It is also important to 1) determine what type of engagement and knowledge is needed from their veteran partner, and 2) establish clear expectations of timeline and contributions.

Conclusion

To summarize, the Military Alpine Challenge provides lessons for rehabilitation HCPs and researchers in incorporating knowledge of military culture and adapting to the needs of a population, which helps rehabilitation specialists meet the needs of the communities they intend to help.

Acknowledgements

Featured illustration by Catherine George for rehabINK.

To refer to this article, it can be cited as:

Dass R, Hoppe T, Rite L. The Military Veteran Alpine Challenge: Implications for the field of rehabilitation. rehabINK. 2023:Issue#15. Available from: https://rehabinkmag.com

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References

1. Government of Canada. Canadian pain task force report: March 2021. Government of Canada. 2021.
2. Perera E, Thompson JM, Asmundson GJG, El-Gabalawy R, Sareena J, et al. Chronic pain: The canadian armed forces members and veterans mental health follow-up survey. J Mil Veteran Fam Heal. 2023;8(1):1–107.
3. Leung KK, Carr FM, Russell MJ, Bremaulg-Phillips S, & Triscott JAC. Traumatic brain injuries among veterans and the risk of incident dementia: A systematic review and meta-analysis. Age Ageing. 2021;51(1):301–14.
4. Chronic Pain Centre of Excellence. Overview. Chronic Pain Centre of Excellence for Canadian Veterans. 2023.
5. Hitch CMHCM, Harper B, Armour C, Waterhouse-Bradley B. How army veterans cope with chronic pain: A grounded theory approach. J Veteran Stud. 2020;6(1):122–34.
6. Grimell J. Revisiting living in limbo to illustrate a pastoral psychological understanding of transition from military to civilian life. Pastoral Psychol. 2019;68(1):393–405.
7. Heidi Cramm, Deborah Norris, Kelly Dean Schwartz, Linna Tam-Seto A, Mahar W& A. Impact of canadian armed forces veterans’ mental health problems on the family during the military to civilian transition. Mil Behav Heal. 2020;8(2):148–58.
8. Choinière M, Peng P, Gilron I, Buckley N, Williamson O, Janelle-Montcal A, et al. Accessing care in multidisciplinary pain treatment facilities continues to be a challenge in canada. Reg Anesth Pain Med. 2020;45(1):943–8.
9. Kithulegodaa N, Strachan PH, Zachariasc R, Buckleyc N, Bussec JW. Exploring canadian veterans’ priorities regarding chronic pain research: A qualitative study. J Mil Veteran Fam Heal. 2021;7(2):106–15.
10. Jones C, Smith-MacDonald L, & Bremaul-Phillips S. Perceptions of canadian armed forces health services health care professionals on cognitive assessment processes. J Mil veteran Fam Heal. 2021;7(3):6–19.
11. Joypaul S, Kelly F, Sara S. McMillan M. Multi-disciplinary interventions for chronic pain involving education: A systematic review. PLoS One. 2019;15(10):1–24.
12. Veterans Affairs of USD. Common challenges during re-adjustment to civilian life. U.S. Department of Veterans Affairs. 2021.
13. Kang E, Kim MY, Lipsey KL, Foster ER. Person-centered goal setting: A systematic review of intervention components and level of active engagement in rehabilitation goal-setting interventions. Phys Med Rehabil. 2022;103(1):121–30.
14. Maunder L, Marriott E, Katz J, Salomons T V. Mechanisms of heightened pain-related disability in canadian armed forces members and veterans with comorbid chronic pain and PTSD. J Mil Veteran Fam Heal. 2022;8(3):32-44.
15. Tracy S. Herrmann, Joanna E. Bettmann, Caroline Sweeney WR, Marchand JC& AWH. Military veterans’ motivation and barriers to outdoor recreation participation. Leis Stud. 2022;1–18.
16. Knight SJ, Haibach JP, Hamilton AB, Whittle J, Ono SS, Butler J, Flower M, Ray CD, Pugh MJ ZS. Veteran engagement in health services research: A conceptual model. J Gen Intern Med. 2022;37(1):94–8.