November 16, 2009

Back pain permanently sidelines soldiers at war, study finds

Military personnel evacuated out of Iraq and Afghanistan because of back pain are unlikely to return to the line of duty regardless of the treatment they receive, according to research led by a Johns Hopkins pain management specialist.

In a study published Nov. 9 in the Archives of Internal Medicine, researchers found that just 13 percent of service members who left their units with back pain as their primary diagnosis eventually returned to duty in the field. Women, officers, those deployed in Afghanistan and those with previous back pain had better outcomes but only marginally. Aside from combat injuries sustained during battle, the return-to-duty rate for spinal pain and other musculoskeletal disorders is lower than for any other disease or noncombat injury category except for psychiatric illness, the researchers said.

“The whole mission of the medical corps for the military is to preserve unit strength, to keep people doing what they’re doing,” said study leader Steven P. Cohen, associate professor of anesthesiology at the Johns Hopkins School of Medicine and a colonel in the U.S. Army Reserve. “If you have only a 13 percent success rate, this is a failure. There’s a systemic problem.”

Cohen and his team looked at data from 1,410 soldiers who were medically evacuated out of war zones complaining chiefly of back pain from 2004 through 2007. More than 95 percent of the service members were taken to the U.S. military’s treatment facility in Landstuhl, Germany. Researchers assessed how many were returned to their stationed units within two weeks and how many were sent to the United States unable to perform their duties.

A previous study done by Cohen, who is also director of chronic pain research at Walter Reed Army Medical Center, showed that when soldiers with back pain were taken to a pain clinic in Iraq, all patients returned to their units. When they were sent to pain clinics in Germany or in Washington, D.C., fewer than 2 percent did. Both this previous study and the new research suggest that the farther away evacuees are treated, the less likely they are to return to their units. Cohen noted that it can be difficult for certain soldiers to return to their jobs, particularly those in physically demanding combat-related roles. “It’s the rule in war: People will have back pain because you have to go on these long road marches and carry heavy equipment, wear body armor,” he said. “The roads are not paved. Riding in these vehicles while wearing body armor, it hurts your back.”

Cohen said that the reason why few military personnel return to their units after leaving with back pain may simply be a reflection of the outcomes for back pain in civilian life. “Back pain has notoriously low success rates for treatment,” he said.

The biggest predictors of a poor outcome, he said, are psychosocial factors. People who are depressed or anxious, cope poorly with stress, are unhappy in their jobs or have psychological issues are more likely to remain disabled by back pain. Cohen said that those with back pain who remain in the country where they are deployed may be more motivated to stay on the job or are more satisfied with their role in the military.

The military needs to find a way to get soldiers with back pain back to their units wherever possible, said Cohen, suggesting that could be accomplished if there were more pain management options in Iraq or Afghanistan, following the model used for soldiers with symptoms of combat stress. When those symptoms are treated at mental health clinics on base, approximately 95 percent of service members returned to their units. When treated in a transitional unit in nearby Kuwait, the figure was around 50 percent. When sent to Germany, fewer than 10 percent returned.

Other researchers on the study are Shruti G. Kapoor, a resident in the Department of Anesthesiology at the Johns Hopkins School of Medicine; Maj. Conner Nguyen, chief of Physical Medicine and Rehabilitation at Landstuhl Regional Medical Center in Germany; and Col. Leslie Foster and Maj. Anthony Plunkett, both of Walter Reed Medical Center.

The research was funded in part by a congressional grant from the John P. Murtha Neuroscience and Pain Institute, Johnstown, Pa.; the U.S. Army; and the Army Regional Anesthesia & Pain Medicine Initiative, Washington, D.C.

Related Web site: Steven P. Cohen