Coping with persistent pain
Having served 12 years in the Australian army and deployed three times to Iraq, Dave was medically discharged from the military at age 30 with injuries to his lumbar spine, cervical spine, bilateral shoulders, bilateral elbows, bilateral hips, bilateral knees, bilateral ankles, and right wrist. He had significant sciatic symptoms in his left leg and was struggling with tinnitus and sensorineural hearing loss. After separating from the Australian Defence Force (ADF), he also developed major depressive disorder, adjustment disorder and generalized anxiety disorder.
Dave was now entering a completely different world; he would need to apply for a Medicare card, find a place to live, make his own medical appointments, schedule his own activities, plan his own future, all of which he had not done before as he had enlisted at 18 years of age.
He had operated in some of the most dangerous places in the world and felt more comfortable there than where he was currently.
Dave was one of 1914 involuntary separations from the ADF that year (ADF Report 2020-21, n.d.).
Dave has persistent pain
Treating veterans is very complex, confronting, and challenging; but it is also extremely rewarding. Why? Because you may literally change their life.
Many allied health clinics are having to close their books to DVA patients due to insufficient funding that comes with treating this population. It is disappointing to think that they will go without the help they need to be able to get back on their feet because of complexities around DVA provider payment. These patients require consistent treatment over years: often they do not improve over a couple of months. This is also why persistent pain in military and ex-military populations requires a different approach.
Pain and Threat
Pain can be defined as: ‘a distressing experience associated with actual or potential tissue damage with sensory, emotional, cognitive, and social components (Williams & Craig, 2016).’ Pain exists to protect and promote healing, however, in persistent pain, this response often leads to unhelpful biopsychosocial changes.
A part of training in the military is the vigilance of danger (Kimble et al., 2013). In military cohorts, training focuses on adapting instinctive threat responses to ensure that the decisions and actions of soldiers remain deliberate and rational regardless
of the situation.
This ability to function under threat is reinforced regularly throughout military service. The body and mind become increasingly hypervigilant, as their survival may depend on this skill.
This resting hypervigilance is present in the persistent pain experience (Bulcke, n.d.) and is challenging to address in a veteran population. If there is a constant level of perceived threat, there is a constant upregulation of survival responses, including pain.
Dealing with resting stress levels of veterans may lead to changes in levels of biological pain processing (Wippert & Wiebking, 2018). Taking the time to ensure that the veteran understands the role of their intrinsic hypervigilance and altered stress response is vital in the successful management of their persistent pain.
The Veteran Pain Journey
The purpose of the military is first and foremost to provide a national threat response capability. Therefore, training soldiers to specialise in threat response is pertinent. Part of this training involves changing the identity and core values of military populations. For example, honor in the military is more important than wealth, targeted aggression is an important asset, a warrior trains for adversity therefore luxury and ease are considered unimportant, warriors are selfless: it’s all about the team and the job
(Robert G. Dixon, n.d.).
If you are injured or in pain and unable to function in your unit, often you lose the respect and support of your unit, and your status as a warrior may be questioned. Because of this, soldiers may push through enormous amounts of pain and injury to avoid letting
the team down.
Due to this value system, veterans retain the ability to push well beyond pain to get a job done, help a mate aid their partner to the detriment of themselves.
This can be a barrier to persistent pain recovery, especially with graded exposure
and pacing approaches.
A veteran may struggle to adapt their value system to align with the behaviours required to improve their persistent pain.
You are not just treating their persistent pain; you may be adjusting their entire value system.
Pain Rehabilitation for Veterans
Pain rehabilitation in veterans is complex and requires multidisciplinary management. Successful rehabilitation relies on support and behaviour change over time. It is exceptionally important to empower and build agency with veteran patients, as their recovery journey includes reshaping the way they operate within themselves, their community, and the world outside the military.
Education needs to provide insight into how their pain experience has been shaped by their military training, and draw links between their values, identity, and purpose as a member of society. This requires understanding and persistence from the entire management team when treating their persistent pain.
Often, conventional approaches to pain neuroscience education, graded exposure, pacing, and other behaviour change management options fail to produce optimal outcomes in veteran populations as they don’t address the underlying differences in values and identity that commonly appear in
In 2022, Painaustralia released a submission report to the Royal Commission into Defence and Veteran Suicide (Painaustralia, n.d.) outlining several recommendations to improve the management of Australian military and ex-military populations. REFORGE Veteran Care has also submitted recommendations and solutions (Martin & Mccarthy, n.d.) to the commission that align with the recommendations from Painaustralia. These recommendations address the need for specialised and targeted care approaches to veterans to improve treatment outcomes. The future management of veterans like Dave relies on acceptance and action around these recommendations.
Dave requires multidisciplinary tailored support and empowerment to navigate the persistent pain recovery journey. He requires a treatment team that understands where he has come from to help guide where he wants to go. He requires improved recognition of his pain condition and access to appropriate management services that have been specially trained to treat veterans.
Dave is a veteran with persistent pain.
REFORGE Veteran Care challenges all clinics and practitioners involved in persistent pain management to get on board with the Pain Revolution Go the Distance challenge and help raise vital funds to support rural Australians and veterans living with pain.
ADF report 2020-21. (n.d.).
Bulcke, C. vanden. (n.d.). Hypervigilance and pain: The role of bodily threat.
Damme, S., Crombez, G., & Eccleston, C. (2013). Hypervigilance and Attention to Pain. In Encyclopedia of Pain (pp. 1532–1535). Springer Berlin Heidelberg. https://doi.org/10.1007/978-3-642-28753-4_1825
Kimble, M. O., Fleming, K., & Bennion, K. A. (2013). Contributors to Hypervigilance in a Military and Civilian Sample. Journal of Interpersonal Violence, 28(8), 1672–1692. https://doi.org/10.1177/0886260512468319
Martin, R., & Mccarthy, K. (n.d.). Forging Ahead-A Solutions Focussed Submission. www.go2health.com.au
Painaustralia. (n.d.). Painaustralia Submission-Royal Commission into Defence and Veteran Suicide.
Robert G. Dixon. (n.d.). Psychology and Basic Combat Training _ Small Wars Journal. Retrieved August 22, 2022, from https://smallwarsjournal.com/jrnl/art/psychology-and-basic-combat-training#_edn19
Williams, A., & Craig, K. (2016). Updating the definition of pain. PAIN, 157, 1. https://doi.org/10.1097/j.pain.0000000000000613
Wippert, P. M., & Wiebking, C. (2018). Stress and alterations in the pain matrix: A biopsychosocial perspective on back pain and its prevention and treatment. International Journal of Environmental Research and Public Health, 15(4). https://doi.org/10.3390/ijerph15040785