Abstract-To identify the prevalence of traumatic brain injury (TBI), posttraumatic stress disorder (PTSD), and pain in Veterans from Operation Iraqi Freedom/Operation Enduring Freedom/Operation New Dawn (OIF/OEF/OND), Veterans who received any inpatient or outpatient care from Veterans Health Administration (VHA) facilities from 2009 to 2011 were studied. A subset of Veterans was identified who were diagnosed with TBI, PTSD, and/or pain (head, neck, or back) as determined by their International Classification of Diseases-9th Revision-Clinical Modification codes. Between fiscal years 2009 and 2011, 613,391 Veterans accessed VHA services at least once (age: 31.9 +/-9.6 yr). TBI diagnosis in any 1 year was slightly less than 7%. When data from 3 years were pooled, 9.6% were diagnosed with TBI, 29.3% were diagnosed with PTSD, and 40.2% were diagnosed with pain. The full polytrauma triad expression (TBI, PTSD, and pain) was diagnosed in 6.0%. Results show that increasing numbers of Veterans from OIF/ OEF/OND accessed VHA over a 3 year period. Among those with a TBI diagnosis, the majority also had a mental health disorder, with approximately half having both PTSD and pain. While the absolute number of Veterans increased by over 40% from 2009 to 2011, the proportion of Veterans diagnosed with TBI and the high rate of comorbid PTSD and pain in this population remained relatively stable.

The available data signal the need for the incorporation of early and aggressive pain management strategies into existing treatment models. Challenges to providing effective pain management for OEF/OIF veterans are numerous and include comorbid cognitive, medical, and emotional impairments that complicate readjustment to civilian life. It is likely that the problem of polytrauma pain and associated comorbid conditions such as posttraumatic stress disorder and postconcussive syndrome will require the development of integrated approaches to clinical care which bridge traditional subspecialty divisions. A proposed model of treatment is presented.

Blast injury may be associated with differential physical, emotional, and pain-related symptoms that pose increased challenges for successful treatment.

Due to the high rates of blast injuries sustained during operations in Iraq and Afghanistan, the number of soldiers returning with massive and multiple wounds is unprecedented. While casualty survival rates have improved dramatically, the extent and impact of these wounds on soldiers' functioning pose unique challenges for their rehabilitation. Pain is highly prevalent in these individuals with polytrauma injuries and is a source of suffering, as well as an impediment to rehabilitation. However, there are a number of obstacles to effective pain treatment in this group of war-injured, including their multiple and severe injuries, the high prevalence of brain injuries, cognitive impairments and emotional distress, the prolonged and intensive rehabilitation process, and the frequent need for repeated follow-up surgeries. As a result, we believe that a comprehensive, interdisciplinary approach to pain treatment is required. In this article we describe the model of pain care that has evolved at the Tampa Polytrauma Rehabilitation Center, which incorporates medical, rehabilitative, cognitive-behavioral, and interventional treatments targeting pain intensity as well as pain-related impairments and coping. We include a case study illustrating some key aspects of our approach.

The VHAs TBI screening and evaluation process is identifying individuals with ongoing neurobehavioural symptoms. Moderate-to-severe symptoms were more prevalent in veterans with TBI-specialty clinician determined TBI. However, the high rate of symptom reporting also present in individuals without a confirmed TBI suggest that symptom aetiology may be multi-factorial in nature.