Integrated Pain Management and
Complementary and Alternative
Medicines in the Military
How the Arts Can Be Integrated
g
into Military
y Interdisciplinary
p
y
Pain Research
Don McGeary,
McGeary PhD
PhD, ABPP
Assistant Professor
Department of Psychiatry
U i
University
i off T
Texas Health
H l h Science
S i
Center
C
San
S A
Antonio
i
Overview
• The Arts and the Military
• The Arts and Pain/Trauma
/
• Military Polytrauma
• Integration of Arts in Intervention
• An Example
• Future Directions
The Arts and the Military
(Music)
• Art and Music have been a part of
military life for 1000’s
1000 s of years
• Side drums were carried into battle
as early as the 1400
1400’ss
• Military bands have been a part of
the
h U
U.S.
S military
l
since our nation’s
’
inception
• Military bands are used for ceremony
and to boost morale
Dobney, Jayson Kerr. "Military Music in American and European Traditions". In Heilbrunn Timeline
of Art History. New York: The Metropolitan Museum of Art, 2000–.
http://www.metmuseum.org/toah/hd/ammu/hd_ammu.htm
Standard
S
d d Bearer
B
and
d Drummer
D
Hans Sebald Beham, 1544
Metropolitan Museum of Art
htt //
http://www.metmuseum.org/toah/
t
/t h/
works-of-art/41.1.90
The Arts and the Military
(Visual)
• Visual arts
(e g painting,
(e.g.,
painting drawing,
drawing sculpti
ng) provide insight about early
military life
• Create and show art for
morale and Esprit de Corps
• U.S. Army Illustrators of Ft.
Custer Michigan “to
Custer,
to enliven
Army life with art.”
Park MP, Park RH. Art in wartime: The First Wounded, London Hospital, August
1914. 2011 Jun;37(1):23-6. doi: 10.1136/jmh.2010.006478.
BG John S. Brown.. Organizational History [pamphlet]. U.S. Army Center of
Military History. 1999. accessed online:
http://www.history.army.mil/html/forcestruc/ohpam.html
1st Infantry Division
The Big Red One
One”
“The
US Army Institute of Heraldry
The Arts and Pain/Trauma
• Art can be diagnostic
• Paintings from one of
my patients
• Renoir’s “The Farm at
Les Collettes”
Reprinted with permission from:
www.thecanvassolider.com
The Metropolitan Museum of Art. Collection
Online
http://www.metmuseum.org/collection/thecollection-online/search/437433
The Arts and Pain/Trauma
• Art can be therapeutic
• Music can promote sleep for pain patients
• Art therapy may relieve pain by addressing
emotional distress
• Sensory art therapies are easy to implement and
may have a detectable effect
• Group-based
G
b
d music
i therapy
h
improves
i
PTSD
• More well-designed
g
research is needed
Crawford BA, Lee C, Bingham J, PACT Working Group. Pain Practice 2014;15:S66-S76.
Theorell T,
T Konarski K,
K Westerlund H,
H et al. Psychother Psychosom 1998;67:50
1998;67:50-56.
56.
Reprinted with permission from:
www.thecanvassolider.com
Picard LM, Bartel LR, Gordon AS, Cepo D, Wu Q, Pink LR. Pain Res Manag 2014;19:97-101.
Carr C, d’Ardenne P, Sloboda A, Scott C, Wang D, Priebe S. Psychol Psychother 2012;85:179-202.
Chronic Musculoskeletal Pain
• Pain was originally conceived
as a simple phenomenon
• Mind and body were separate
systems
• There is a mountain of
evidence
d
disproving
d
this
h
• Dualism still dominates
colloquial concepts of pain
(and some medical concepts!)
http://en.wikipedia.org/wiki/Dualism_%28philosophy_of_mind%
29#mediaviewer/File:Descartes-reflex.JPG
Chronic Musculoskeletal Pain
Cognitive
Emotional
Ph i l
Physical
Behavioral
PAIN
S i l
Social
Engel G. Science 1977;196:129-136.
Military Polytrauma
Pain
PTSD
P l
Polytrauma
Pain becomes
complex when
accompanied by
other trauma
conditions
McGeary et al. 2011
TBI
http://www.backpainsacramento.com/wp-content/uploads/2010/05/back-pain.gif
http://kidsandmeds.umwblogs.org/files/2010/10/ptsd-300x200.jpg
Military Polytrauma
70
60
58 6
58.6
54.7
50
42.1
2
40
30
20
10
0
Pain and PTSD
Pain and TBI
Polymorbid Pain
Lew H, Otis JD, Tun C, Kerns RD, Clark ME, Cifu DX. JRRD 2009;46:697-702
Integration of Arts in Intervention
• A complex phenomenon requires a
complex intervention
Pain
P i
R i
Ratings
• Simple interventions (e.g., opioid
medications surgery) can fail or
medications,
create additional problems
• R
Rehabilitation
h bl
should
h ld b
be
emphasized over pain relief
Gatchel RJ, McGeary DD, McGeary CA, Lippe B. American
Psychologist 2014;69:119-130.
Integration of Arts in Intervention
• The best pain intervention
should be:
–
–
–
–
–
Interdisciplinary
Functional
Outcome-Oriented
Biopsychosocial
Intensive
• Programs like this can:
–
–
–
–
Increase function
Decrease emotional distress
Decrease opioid use
Decrease pain intensity
Gatchel RJ, McGeary DD, McGeary CA, Lippe B. American Psychologist 2014;69:119-130.
Gatchel RJ, McGeary DD, Peterson AL, et al. Military Medicine 2009;174:270-277.
http://www.canvassoldier.com/canvas-soldier-paintings.html
Integration of Arts in Intervention
PT
Depression
PSY
?
BFB
MD
PTSD
TBI
Integration of Arts in Intervention
PT
Although there is a great deal of support for
CBT, a component
p
study
y showed a very
y small
effect of CBT in generating outcomes
desired for interdisciplinary pain
management
PSY
CBT
BFB
MD
Depression
PTSD
TBI
Integration of Arts in Intervention
PT
Motivation
Depression
PSY
?
Inspiration
BFB
MD
PTSD
TBI
An Example
PT
PSY
Mind
Fulness
BFB
MD
An Example – NCCIH Study
• NCCIH: R01 AT008422
AT008422-01
01
• Project Title: Establishing
efficacy of a functionalrestoration-based CAM pain
management program
• PI: Don McGeary, PhD
• A collaboration between the
STVHCS PRC and STRONG STAR
An Example – Clinical Question
FORT-A
FORT-A Psychotherapy Group
((4 days/wk
/ x 3 wks))
FORT-A Physical Therapy Group
(4 days/wk x 3 wks)
Individual Psychotherapy
(2 days/wk x 3 wks)
Biofeedback
(4 days/wk x 3 wks)
Homework:
Group
Individual Psychotherapy
PT
PRC (Treatment As Usual)
Diagnostics (Imaging, ESR)
S lf Care,
Self
C
Ad
Advice
i to
t R
Remain
i A
Active
ti
Education, Books, Handouts
ed cat o : Acetaminophen,
ceta
op e , NSAIDs
S
s
Medication:
Antidepressants (TCA), Benzodiazepines
Opioids
Physical Therapy
Other Non-Pharmacological Therapy:
Spinal Manipulation, Exercise, CBT
Relaxation
An Example - Participants
• Both genders, all racial/ethnic groups, and ages 18-72.
• Present with chronic musculoskeletal pain (CMP) as a primary pain complaint
• CMP is accompanied by at least moderate disability
• Consistent with NIH Task Force recommendations, "chronic" CMP has been a problem for the
Veteran for at least half the days in the last 3 months and was acquired or exacerbated as
part of active duty U.S.
U S military service in the Operations Iraqi Freedom (OIF)
(OIF), Enduring
Freedom (OEF), or New Dawn (OND) war eras.
• CMP p
presents in the context of comorbid trauma
• Demonstrate “chronic” opioid use (using opioid medication for 20/30 days over 3+ months.
• S
Speak
k and
d read/understand
d/ d
d English
E li h wellll enough
h to fully
f ll participate
i i
in
i the
h intervention
i
i and
d
to reliably complete assessment measures.
• The Veteran will be eligible to be a PRC patient
An Example - Outcomes
Assessments
Medical History Interview
Domain Assessed
previous pain treatments
comorbid pain/medical conditions
Concomitant Medications
medications that may impact pain/mood
Timeline Follow-back Interview
opioid medication use
Oswestry Disability Index
self-report disability
Beck Depression
p
Inventory
y– 2
depression
p
PTSD Checklist – 5
PTSD
Beck Scale for Suicide Ideation
suicide risk
Functional Capacity Evaluation
objective disability
Pain Catastrophizing Scale
pain coping
Future Directions
• More tightly controlled studies of art as an intervention and
diagnostic tool
• Integrating art into more complex interventions as a “force
multiplier
multiplier”
• Inspiration going beyond the patient into significant others and
support personnell (perhaps
( h
even their
h providers)
d )