Reports From the Field

Evaluation of the Empower Veterans Program for Military Veterans With Chronic Pain

Journal of Clinical Outcomes Management. 2022 March;29(2):88 - 95 | 10.12788/jcom.0089

References

2. Bastian LA, Heapy A, Becker WC, et al. Understanding pain and pain treatment for veterans: responding to the federal pain research strategy. Pain Med. 2018;19(suppl_1); S1-S4. doi:10.1093/pm/pny1433

3. Engle GL. The need for a new medical model: a challenge for biomedicine. Science. 1977;196(4286):129-136. doi:10.1126/science.847460

4. Bevers K, Watts L, Kishino ND, et al. The biopsychosocial model of the assessment, prevention, and treatment of chronic pain. US Neurology. 2016;12(2):98-104. doi:10.17925/USN.2016.12.02.98

5. Bair MJ, Ang D, Wu J, et al. Evaluation of stepped care for chronic pain (ESCAPE) in veterans of the Iraq and Afghanistan conflicts: A randomized clinical trial. JAMA Intern Med. 2015;175(5):682-689. doi:10.1001/jamainternmed.2015.97

6. Veterans Health Administration. Pain Management. VHA Directive 2009-053. Washington, DC: Department of Veterans Affairs; 2009.https://www.va.gov/painmanagement/docs/vha09paindirective.pdf

7. Moore BA, Anderson D, Dorflinger L, et al. Stepped care model for pain management and quality of pain care in long-term opioid therapy. J Rehabil Res Dev. 2016;53(1):137-146. doi:10.1682/JRRD.2014.10.0254

8. Institute for Healthcare Improvement. How to improve. Accessed March 14, 2022. http://www.ihi.org/resources/Pages/HowtoImprove/default.aspx

9. Saenger M. Empower Veterans Program. APA PCSS-O Webinars. Evidence CAM LBP 2016.

10. Gaudet T, Kligler B. Whole health in the whole system of the Veterans Administration: How will we know we have reached this future state? J Altern Complement Med. 2019;25(S1):S7-S11. doi:10.1089/acm.2018.29061.gau

11. Veterans Health Administration. Whole health: Circle of health. Updated April 1, 2021. Accessed March 14, 2022. https://www.va.gov/WHOLEHEALTH/circle-of-health/index.asp

12. Krebs EE, Carey TS, Weinberger M. Accuracy of the pain numeric rating scale as a screening test in primary care. J Gen Intern Med. 2007;22(10):1453-1458. doi:10.1007/s11606-007-0321-2

13. Veterans Health Administration. Pain as the 5th vital sign toolkit. October 2000, revised edition. Geriatrics and Extended Care Strategic Healthcare Group, National Pain Management Coordinating Committee. https://www.va.gov/PAINMANAGEMENT/docs/Pain_As_the_5th_Vital_Sign_Toolkit.pdf

14. McKillop JM, Nielson WR. Improving the usefulness of the Multidimensional Pain Inventory. Pain Res Manag. 2011;16(4):239-244. doi:10.1155/2011/873424

15. Kerns RD, Turk DC, Rudy TE. The West Haven-Yale Multidimensional Pain Inventory (WHYMPI). Pain.1985;23(4):345-356. doi:10.1016/0304-3959(85)90004-1

16. Verra ML, Angst F, Staal JB, et al. Reliability of the multidimensional pain inventory and stability of the MPI classification system in chronic back pain. BMC Musculoskelet Disord. 2012;13:155. doi:10.1186/1471-2474-13-155

17. Development of the World Health Organization WHOQOL-BREF quality of life assessment. The WHOQOL Group. Psychol Med. 1998;28(3):551-558. doi:10.1017/s0033291798006667

18. World Health Organization. Division of Mental Health. WHOQOL-BREF: introduction, administration, scoring and generic version of the assessment: field trial version, December 1996. Accessed March 14, 2022. https://apps.who.int/iris/handle/10665/63529

19. Guay S, Fortin C, Fikretoglu D, et al. Validation of the WHOQOL-BREF in a sample of male treatment-seeking veterans. Mil Psychol. 2015;27(2):85-92. doi:10.1037/mil0000065

20. Skevington S, Lotfy M, O’Connell K, WHOQOL Group. The World Health Organization’s WHOQOL-BREF quality of life assessment: Psychometric properties and results of the international field trial. A Report from the WHOQOL Group. Qual Life Res. 2004;13(2):299-310. doi:10.1023/B:QURE.0000018486.91360.00

21. Stratton KJ, Bender MC, Cameron JJ, Pickett TC. Development and evaluation of a behavioral pain management treatment program in a Veterans Affairs Medical Center. Mil Med. 2015;180(3):263-268. doi:10.7205/MILMED-D-14-00281.

22. Sullivan MJ, Thorn B, Haythornthwaite JA, et al. Theoretical perspectives on the relation between catastrophizing and pain. Clin J Pain. 2001;17(1):52-64. doi:10.1097/00002508-200103000-00008

23. Sullivan JL. The Pain Catastrophizing Scale: User manual. Accessed March 14, 2022. https://studylib.net/doc/8330191/the-pain-catastrophizing-scale---dr.-michael-sullivan

24. Darnall BD, Sturgeon JA, Cook KF, et al. Development and validation of a daily pain catastrophizing scale. J Pain. 2017;18(9):1139-1149. doi:10.1016/j.jpain.2017.05.003

25. Osman A, Barrios FX, Kopper BA, et al. Factor structure, reliability, and validity of the Pain Catastrophizing Scale. J Behav Med. 1997;20(6):589-605. doi:10.1023/a:1025570508954

26. Sullivan MJL, Bishop S, Pivik J. The Pain Catastrophizing Scale: development and validation. Psychol Assessment. 1995;7(4):524-532. doi:10.1037/1040-3590.7.4.524

27. Walker R, Clark M, Gironda R. Psychometric characteristics of the Pain Treatment Satisfaction Scale. J Pain. 2015;6(3Suppl.):S76.

28. Emerson RW. Bonferroni correction and type I error. J Vis Impair Blind. 2020;114(1):77-78. doi:10.1177/0145482X20901378

29. Cohen J. Statistical power analysis for the behavioral sciences. 2nd ed. Routledge; 1988. doi:10.4324/9780203771587

30. Craner JR, Lake ES, Bancroft KA, George LL. Treatment outcomes and mechanisms for an ACT-based 10-week interdisciplinary chronic pain rehabilitation program. Pain Pract. 2020;20(1):44-54. doi:10.1111/papr.12824

31. Han L, Goulet JL, Skanderson M, et al. Evaluation of complementary and integrative health approaches among US veterans with musculoskeletal pain using propensity score methods. Pain Med. 2019;20(1):90-102. doi:10.1093/pm/pny027

32. Herman PM, Yuan AH, Cefalu MS, et al. The use of complementary and integrative health approaches for chronic musculoskeletal pain in younger US veterans: an economic evaluation. PLoS One. 2019;14(6):e0217831. doi:10.1371/journal.pone.0217831

33. National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Board on Global Health; Board on Health Sciences Policy; Global Forum on Innovation in Health Professional Education; Forum on Neuroscience and Nervous System Disorders; Stroud C, Posey Norris SM, Bain L, eds. The Role of Nonpharmacological Approaches to Pain Management: Proceedings of a Workshop. National Academies Press (US); April 12, 2019.

34. Richmond H, Hall AM, Copsey B, et al. The effectiveness of cognitive behavioural treatment for non-specific low back pain: a systematic review and meta-analysis. PLoS One. 2015;10(8):e0134192. doi:10.1371/journal.pone.0134192

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36. Khoo E, Small R, Cheng W, et al. Comparative evaluation of group-based mindfulness-based stress reduction and cognitive behavioral therapy for the treatment and management of chronic pain: a systematic review and network meta-analysis. Evid Based Ment Health. 2019;22(1):26-35. doi:10.1136/ebmental-2018-300062

37. Khusid MA, Vythilingam M. The emerging role of mindfulness meditation as effective self-management strategy, Part 2: clinical implications for chronic pain, substance misuse, and insomnia. Mil Med. 2016;181(9):969-975. doi:10.7205/MILMED-D-14-00678

38. la Cour P, Petersen M. Effects of mindfulness meditation on chronic pain: A randomized controlled trial. Pain Med. 2015;16(4):641-652. doi:10.1111/pme.12605

39. Zou L, Zhang Y, Yang L, et al. Are mindful exercises safe and beneficial for treating chronic lower back pain? A systematic review and meta-analysis of randomized controlled trials. J Clin Med. 2019;8(5):628. doi:10.3390/jcm8050628

40. Hughes LS, Clark J, Colclough JA, et al. Acceptance and commitment therapy (ACT) for chronic pain: a systematic review and meta-analyses. Clin J Pain. 2017;33(6):552-568. doi:10.1097/AJP.0000000000000425

41. Kemani MK, Olsson GL, Lekander M, et al. Efficacy and cost-effectiveness of acceptance and commitment therapy and applied relaxation for longstanding pain: a randomized controlled trial. Clin J Pain. 2015;31(11):1004-1016. doi:10.1097/AJP.0000000000000203

42. Scott W, Daly A, Yu L, McCracken LM. Treatment of chronic pain for adults 65 and over: analyses of outcomes and changes in psychological flexibility following interdisciplinary acceptance and commitment therapy (ACT). Pain Med. 2017;18(2):252. doi:10.1093/pm/pnw073

43. Veehof MM, Trompetter HR, Bohlmeijer ET, Schreurs KMG. Acceptance- and mindfulness-based interventions for the treatment of chronic pain: a meta-analytic review. Cogn Behav Ther. 2016;45(1):5-31. doi:10.1080/16506073.2015.1098724

44. Matthias MS, McGuire AB, Kukla M, et al. A brief peer support intervention for veterans with chronic musculoskeletal pain: a pilot study of feasibility and effectiveness. Pain Med. 2015;16(1):81-87. doi:10.1111/pme.12571

45. Anamkath NS, Palyo SA, Jacobs SC, et al. An interdisciplinary pain rehabilitation program for veterans with chronic pain: description and initial evaluation of outcomes. Pain Res Manag. 2018;2018(3941682):1-9. doi:10.1155/2018/3941682

46. Kamper SJ, Apeldoorn AT, Chiarotto A, et al. Multidisciplinary biopsychosocial rehabilitation for chronic low back pain. Cochrane Database Syst Rev. 2014;9: CD000963. doi:10.1002/14651858.CD000963.pub3

47. Penney LS, Haro E. Qualitative evaluation of an interdisciplinary chronic pain intervention: Outcomes and barriers and facilitators to ongoing pain management. J Pain Res. 2019;12:865-878. doi:10.2147/JPR.S185652

48. Murphy JL, Cordova MJ, Dedert EA. Cognitive behavioral therapy for chronic pain in veterans; Evidence for clinical effectiveness in a model program. Psychol Serv. 2022;19(1):95-102. doi:10.1037/ser0000506

49. Katz L, Patterson L, Zacharias R. Evaluation of an interdisciplinary chronic pain program and predictors of readiness for change. Can J Pain. 2019;3(1):70-78. doi:10.1080/24740527.2019.1582296

50. Majumder SMM, Ahmed S, Shazzad N, et al. Translation, cross-cultural adaptation and validation of the Pain Catastrophizing Scale (PCS) into Bengali I patients with chronic non-malignant musculoskeletal pain. Int J Rheum Dis. 2020;23:1481-1487. doi:10.1111/1756-185X.13954

51. Margiotta F, Hannigan A, Imran A, et al. Pain, perceived injustice, and pain catastrophizing in chronic pain patients in Ireland. Pain Pract. 2016;17(5):663-668. doi:10.1111/papr.12

52. Bras M, Milunovic V, Boban M, et al. Quality of live in Croatian Homeland war (1991-1995) veterans who suffer from post-traumatic stress disorder and chronic pain. Health Qual Life Out. 2011;9:56. doi:10.1186/1477-7525-9-56

53. Liu C-H, Kung Y-Y, Lin C-L, et al. Therapeutic efficacy and the impact of the “dose” effect of acupuncture to treat sciatica: A randomized controlled pilot study. J Pain Res. 2019;12:3511-3520. doi:10.2147/JPR.S210672

Discussion

The purpose of this quality improvement project was to abstract and analyze previously collected data from veterans with high-impact chronic pain who attended the EVP. Comparison of pre-intervention and postintervention data obtained from 67 veterans who completed the program revealed improvements in pain intensity, pain interference, negative cognition (catastrophizing), and quality of life. The differences were statistically significant and clinically meaningful, with medium and large effect sizes. In addition, veterans reported high satisfaction with the EVP.

The EVP includes CIH approaches that have demonstrated effectiveness among veterans and other populations with chronic pain. A wealth of studies, for example, support the effectiveness of CIH approaches among veterans.^30-34 Other studies focus on specific CIH approaches that are components of the EVP. Evidence supports, for example, the efficacy of mindfulness-based stress reduction,^35-39acceptance and commitment therapy,^40-43 brief peer support intervention,⁴⁴ and interdisciplinary biopsychosocial rehabilitation.^45,46

While empirical evidence supports components of the EVP, only one study focused on the outcomes of the Atlanta VA EVP among veterans with chronic pain. Results of a qualitative study conducted by Penney and Haro⁴⁷ described the experience of veterans with the EVP. Those veterans reported adopting new self-care or lifestyle practices for pain management and health, accepting pain, being better able to adjust and set boundaries, feeling more in control, participating in life, and changing their medication use.

The mean baseline scores from the current sample were similar to samples of patients with chronic pain in other studies (NPRS,⁴⁸ MPI,⁴⁸ and PCS^48-51). After converting scores on the WHOQOL-BREF from those that ranged from 4 to 20 to those that ranged from 0 to 100,¹⁸ the scores from the current sample were similar to those of other studies of patients with chronic pain.^48,52,53Several strengths of the project should be noted. Data were collected using well established measurement tools that had previously demonstrated reliability and validity. All the tools used in data collection demonstrated good internal consistency reliabilities in the current sample of veterans. Weaknesses of the project include the use of a convenience sample of veterans and small sample size. Data were not available on the number of veterans who were offered participation or on how many veterans declined enrollment. The sample of veterans who chose to participate in the EVP may or may not have been representative of the population of veterans with high-impact chronic pain. As a pre- and postintervention design with no comparison group, the results are subject to multiple threats to internal validity, including the Hawthorne effect, maturation in the form of healing, and attrition. Reasons for leaving the program had not been recorded, so the investigators had no way of knowing factors that may have contributed to attrition. Also, data on when veterans left the program were unavailable. Research is needed with a control group to reduce the effect of confounding variables on the outcome measures. This project used data collected at a single VA facility, which limits its generalizability.

While completers and noncompleters of the EVP were similar on age, gender, and baseline measures, there may have been unidentified characteristics that influenced program completion. The investigators noticed the presence of more missing data among noncompleters compared to completers on the pre-intervention PCS; thus, noncompleters may have scored lower than completers on this instrument simply because there were more individual items that were unanswered/missing among this group of noncompleters.

Data were analyzed using a limited number of outcome measures that had previously been collected. Other outcome measures might include whether EVP participants reduced their use of medications, clinical resources, and personnel. Future projects, for example, could determine whether the EVP is effective in reducing opioid analgesic medication use and decreasing primary care and emergency department visits. Cost-benefit analyses could be completed to determine whether EVP is associated with financial savings.

Because no follow-up assessments were made to determine whether improvements were maintained over time, the project focus was limited to an evaluation of the short-term changes in the outcome measures. Future projects could include a follow-up assessment of the veterans 1- or 2-years post completion of the EVP.

Data for the project were collected prior to the COVID-19 pandemic, when the EVP was implemented through face-to-face meetings with participants and their peers. It is not clear how changes to the delivery of the program (such as offering it through telehealth) might impact veterans’ satisfaction with the program, willingness to complete it, and other variables of interest.

The results of this project were made available to stakeholders with recommendations for program expansion both at the current location and at other VA facilities, including the recommendation to hire additional personnel that would implement the program. As the VA network of facilities expand the EVP program and adapt it for telehealth delivery, the investigators recommended a similar analysis of data be performed following telehealth delivery. If delivery through telehealth is shown to improve outcome measures, the EVP could provide pain management treatment options for patients challenged by transportation barriers, including rural veterans.

Conclusion

This quality improvement project provided evidence of improvement in measures of pain severity, pain interference, negative cognition (catastrophizing), quality of life, and patient treatment satisfaction among veterans with chronic high-impact pain. Findings have been well received by the northeastern VA as well as the Veterans Integrated Systems Network 5. The results of the analyses were used to inform decisions regarding the future of the program.

Disclaimer: This material is the result of work supported with resources and the use of facilities at the VA Maryland Health Care System, Baltimore, Maryland. The views expressed are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs or the United States Government.

Acknowledgments: The authors thank Dr. Arianna Perra, the recent past coordinator of the Empower Veterans Program (EVP), who provided initial insights and support that motivated the decision to evaluate the program. We also thank the veterans and VA EVP clinicians who contributed data for the evaluation, and Dr. Michael Saenger (Director, TelePain-EVP: EVP) and Dr. Robert Lavin for their ongoing support, care, and concern for veteran patients. We also thank Dr. Beverly Bradley and the neurology service administrative team for their guidance in the process of obtaining necessary VA approvals for this project.

Corresponding author: Jessica U. Uche, DNP, CRNP-Family; jessica.uche@va.gov

doi:10.12788/jcom.0089

References

1. Institute of Medicine (US) Committee on Advancing Pain Research, Care, and Education. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. The National Academies Press (US); 2011.

2. Bastian LA, Heapy A, Becker WC, et al. Understanding pain and pain treatment for veterans: responding to the federal pain research strategy. Pain Med. 2018;19(suppl_1); S1-S4. doi:10.1093/pm/pny1433

3. Engle GL. The need for a new medical model: a challenge for biomedicine. Science. 1977;196(4286):129-136. doi:10.1126/science.847460

4. Bevers K, Watts L, Kishino ND, et al. The biopsychosocial model of the assessment, prevention, and treatment of chronic pain. US Neurology. 2016;12(2):98-104. doi:10.17925/USN.2016.12.02.98

5. Bair MJ, Ang D, Wu J, et al. Evaluation of stepped care for chronic pain (ESCAPE) in veterans of the Iraq and Afghanistan conflicts: A randomized clinical trial. JAMA Intern Med. 2015;175(5):682-689. doi:10.1001/jamainternmed.2015.97

6. Veterans Health Administration. Pain Management. VHA Directive 2009-053. Washington, DC: Department of Veterans Affairs; 2009.https://www.va.gov/painmanagement/docs/vha09paindirective.pdf

7. Moore BA, Anderson D, Dorflinger L, et al. Stepped care model for pain management and quality of pain care in long-term opioid therapy. J Rehabil Res Dev. 2016;53(1):137-146. doi:10.1682/JRRD.2014.10.0254

8. Institute for Healthcare Improvement. How to improve. Accessed March 14, 2022. http://www.ihi.org/resources/Pages/HowtoImprove/default.aspx

9. Saenger M. Empower Veterans Program. APA PCSS-O Webinars. Evidence CAM LBP 2016.

10. Gaudet T, Kligler B. Whole health in the whole system of the Veterans Administration: How will we know we have reached this future state? J Altern Complement Med. 2019;25(S1):S7-S11. doi:10.1089/acm.2018.29061.gau

11. Veterans Health Administration. Whole health: Circle of health. Updated April 1, 2021. Accessed March 14, 2022. https://www.va.gov/WHOLEHEALTH/circle-of-health/index.asp

12. Krebs EE, Carey TS, Weinberger M. Accuracy of the pain numeric rating scale as a screening test in primary care. J Gen Intern Med. 2007;22(10):1453-1458. doi:10.1007/s11606-007-0321-2

13. Veterans Health Administration. Pain as the 5th vital sign toolkit. October 2000, revised edition. Geriatrics and Extended Care Strategic Healthcare Group, National Pain Management Coordinating Committee. https://www.va.gov/PAINMANAGEMENT/docs/Pain_As_the_5th_Vital_Sign_Toolkit.pdf

14. McKillop JM, Nielson WR. Improving the usefulness of the Multidimensional Pain Inventory. Pain Res Manag. 2011;16(4):239-244. doi:10.1155/2011/873424

15. Kerns RD, Turk DC, Rudy TE. The West Haven-Yale Multidimensional Pain Inventory (WHYMPI). Pain.1985;23(4):345-356. doi:10.1016/0304-3959(85)90004-1

16. Verra ML, Angst F, Staal JB, et al. Reliability of the multidimensional pain inventory and stability of the MPI classification system in chronic back pain. BMC Musculoskelet Disord. 2012;13:155. doi:10.1186/1471-2474-13-155

17. Development of the World Health Organization WHOQOL-BREF quality of life assessment. The WHOQOL Group. Psychol Med. 1998;28(3):551-558. doi:10.1017/s0033291798006667

18. World Health Organization. Division of Mental Health. WHOQOL-BREF: introduction, administration, scoring and generic version of the assessment: field trial version, December 1996. Accessed March 14, 2022. https://apps.who.int/iris/handle/10665/63529

19. Guay S, Fortin C, Fikretoglu D, et al. Validation of the WHOQOL-BREF in a sample of male treatment-seeking veterans. Mil Psychol. 2015;27(2):85-92. doi:10.1037/mil0000065

20. Skevington S, Lotfy M, O’Connell K, WHOQOL Group. The World Health Organization’s WHOQOL-BREF quality of life assessment: Psychometric properties and results of the international field trial. A Report from the WHOQOL Group. Qual Life Res. 2004;13(2):299-310. doi:10.1023/B:QURE.0000018486.91360.00

21. Stratton KJ, Bender MC, Cameron JJ, Pickett TC. Development and evaluation of a behavioral pain management treatment program in a Veterans Affairs Medical Center. Mil Med. 2015;180(3):263-268. doi:10.7205/MILMED-D-14-00281.

22. Sullivan MJ, Thorn B, Haythornthwaite JA, et al. Theoretical perspectives on the relation between catastrophizing and pain. Clin J Pain. 2001;17(1):52-64. doi:10.1097/00002508-200103000-00008

23. Sullivan JL. The Pain Catastrophizing Scale: User manual. Accessed March 14, 2022. https://studylib.net/doc/8330191/the-pain-catastrophizing-scale---dr.-michael-sullivan

24. Darnall BD, Sturgeon JA, Cook KF, et al. Development and validation of a daily pain catastrophizing scale. J Pain. 2017;18(9):1139-1149. doi:10.1016/j.jpain.2017.05.003

25. Osman A, Barrios FX, Kopper BA, et al. Factor structure, reliability, and validity of the Pain Catastrophizing Scale. J Behav Med. 1997;20(6):589-605. doi:10.1023/a:1025570508954

26. Sullivan MJL, Bishop S, Pivik J. The Pain Catastrophizing Scale: development and validation. Psychol Assessment. 1995;7(4):524-532. doi:10.1037/1040-3590.7.4.524

27. Walker R, Clark M, Gironda R. Psychometric characteristics of the Pain Treatment Satisfaction Scale. J Pain. 2015;6(3Suppl.):S76.

28. Emerson RW. Bonferroni correction and type I error. J Vis Impair Blind. 2020;114(1):77-78. doi:10.1177/0145482X20901378

29. Cohen J. Statistical power analysis for the behavioral sciences. 2nd ed. Routledge; 1988. doi:10.4324/9780203771587

30. Craner JR, Lake ES, Bancroft KA, George LL. Treatment outcomes and mechanisms for an ACT-based 10-week interdisciplinary chronic pain rehabilitation program. Pain Pract. 2020;20(1):44-54. doi:10.1111/papr.12824

31. Han L, Goulet JL, Skanderson M, et al. Evaluation of complementary and integrative health approaches among US veterans with musculoskeletal pain using propensity score methods. Pain Med. 2019;20(1):90-102. doi:10.1093/pm/pny027

32. Herman PM, Yuan AH, Cefalu MS, et al. The use of complementary and integrative health approaches for chronic musculoskeletal pain in younger US veterans: an economic evaluation. PLoS One. 2019;14(6):e0217831. doi:10.1371/journal.pone.0217831

33. National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Board on Global Health; Board on Health Sciences Policy; Global Forum on Innovation in Health Professional Education; Forum on Neuroscience and Nervous System Disorders; Stroud C, Posey Norris SM, Bain L, eds. The Role of Nonpharmacological Approaches to Pain Management: Proceedings of a Workshop. National Academies Press (US); April 12, 2019.

34. Richmond H, Hall AM, Copsey B, et al. The effectiveness of cognitive behavioural treatment for non-specific low back pain: a systematic review and meta-analysis. PLoS One. 2015;10(8):e0134192. doi:10.1371/journal.pone.0134192

35. Kearney DJ, Simpson TL, Malte CA, et al. Mindfulness-based stress reduction in addition to usual care is associated with improvements in pain, fatigue, and cognitive failures among veterans with Gulf War illness. Am J Med. 2016;129(2):204-214. doi:10.1016/j.amjmed.2015.09.015

36. Khoo E, Small R, Cheng W, et al. Comparative evaluation of group-based mindfulness-based stress reduction and cognitive behavioral therapy for the treatment and management of chronic pain: a systematic review and network meta-analysis. Evid Based Ment Health. 2019;22(1):26-35. doi:10.1136/ebmental-2018-300062

37. Khusid MA, Vythilingam M. The emerging role of mindfulness meditation as effective self-management strategy, Part 2: clinical implications for chronic pain, substance misuse, and insomnia. Mil Med. 2016;181(9):969-975. doi:10.7205/MILMED-D-14-00678

38. la Cour P, Petersen M. Effects of mindfulness meditation on chronic pain: A randomized controlled trial. Pain Med. 2015;16(4):641-652. doi:10.1111/pme.12605

39. Zou L, Zhang Y, Yang L, et al. Are mindful exercises safe and beneficial for treating chronic lower back pain? A systematic review and meta-analysis of randomized controlled trials. J Clin Med. 2019;8(5):628. doi:10.3390/jcm8050628

40. Hughes LS, Clark J, Colclough JA, et al. Acceptance and commitment therapy (ACT) for chronic pain: a systematic review and meta-analyses. Clin J Pain. 2017;33(6):552-568. doi:10.1097/AJP.0000000000000425

41. Kemani MK, Olsson GL, Lekander M, et al. Efficacy and cost-effectiveness of acceptance and commitment therapy and applied relaxation for longstanding pain: a randomized controlled trial. Clin J Pain. 2015;31(11):1004-1016. doi:10.1097/AJP.0000000000000203

42. Scott W, Daly A, Yu L, McCracken LM. Treatment of chronic pain for adults 65 and over: analyses of outcomes and changes in psychological flexibility following interdisciplinary acceptance and commitment therapy (ACT). Pain Med. 2017;18(2):252. doi:10.1093/pm/pnw073

43. Veehof MM, Trompetter HR, Bohlmeijer ET, Schreurs KMG. Acceptance- and mindfulness-based interventions for the treatment of chronic pain: a meta-analytic review. Cogn Behav Ther. 2016;45(1):5-31. doi:10.1080/16506073.2015.1098724

44. Matthias MS, McGuire AB, Kukla M, et al. A brief peer support intervention for veterans with chronic musculoskeletal pain: a pilot study of feasibility and effectiveness. Pain Med. 2015;16(1):81-87. doi:10.1111/pme.12571

45. Anamkath NS, Palyo SA, Jacobs SC, et al. An interdisciplinary pain rehabilitation program for veterans with chronic pain: description and initial evaluation of outcomes. Pain Res Manag. 2018;2018(3941682):1-9. doi:10.1155/2018/3941682

46. Kamper SJ, Apeldoorn AT, Chiarotto A, et al. Multidisciplinary biopsychosocial rehabilitation for chronic low back pain. Cochrane Database Syst Rev. 2014;9: CD000963. doi:10.1002/14651858.CD000963.pub3

47. Penney LS, Haro E. Qualitative evaluation of an interdisciplinary chronic pain intervention: Outcomes and barriers and facilitators to ongoing pain management. J Pain Res. 2019;12:865-878. doi:10.2147/JPR.S185652

48. Murphy JL, Cordova MJ, Dedert EA. Cognitive behavioral therapy for chronic pain in veterans; Evidence for clinical effectiveness in a model program. Psychol Serv. 2022;19(1):95-102. doi:10.1037/ser0000506

49. Katz L, Patterson L, Zacharias R. Evaluation of an interdisciplinary chronic pain program and predictors of readiness for change. Can J Pain. 2019;3(1):70-78. doi:10.1080/24740527.2019.1582296

50. Majumder SMM, Ahmed S, Shazzad N, et al. Translation, cross-cultural adaptation and validation of the Pain Catastrophizing Scale (PCS) into Bengali I patients with chronic non-malignant musculoskeletal pain. Int J Rheum Dis. 2020;23:1481-1487. doi:10.1111/1756-185X.13954

51. Margiotta F, Hannigan A, Imran A, et al. Pain, perceived injustice, and pain catastrophizing in chronic pain patients in Ireland. Pain Pract. 2016;17(5):663-668. doi:10.1111/papr.12

52. Bras M, Milunovic V, Boban M, et al. Quality of live in Croatian Homeland war (1991-1995) veterans who suffer from post-traumatic stress disorder and chronic pain. Health Qual Life Out. 2011;9:56. doi:10.1186/1477-7525-9-56

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Relax. The dog-tor will see you now

Evaluation of the Empower Veterans Program for Military Veterans With Chronic Pain

References

Discussion

Conclusion

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