Chronic Pain in Canadian Veterans: Current Understanding and Future Trends

When I took the decision to embark on the graduate studies journey, it never occurred to me that I would be spending so much time reflecting and understanding the population that I serve.  As a military physiotherapist, I have sometimes found it difficult to engage in discussion about my professional identity and reality when attending conferences, courses or even simply with my physio friends.  I felt like people were curious about what I do but also that I could not personally relate to their day to day struggles in the Canadian healthcare scene.  I just did not get it. MHST 601, Critical Foundations in Health Disciplines, allowed me to better understand the Canadian healthcare system and the factors that influence it.  It has been refreshing and a great learning opportunity for me to bounce back ideas with the professionals from our small class. 

At the start of my military physio career, healthcare colleagues would talk to me about Ottawa (the posting) as being full of ‘’old people with chronic pain riding their desk’’ and that I should never ask to go there.  When they offered me the position of rehabilitation physio in Ottawa about 10 years later and an opportunity to work with providers who specialize in chronic pain, despite the initial warning, I could not say no.  Although I only spent a couple years there, I have not regretted this choice in my career.  The twenty months I worked in the National Capital not only shaped me as a physiotherapist but also as a person.  Therefore, I chose to discuss chronic pain in my final blog post for this course with my new knowledge.

Chronic pain was only recently recognized by the World Health Organization as a disease in its own right (Canadian Pain Task Force Report, 2019).  For researchers and policy makers this step is huge as it will allow better data collection by establishing a clear diagnosis on what was not well understood in the past.  Thinking about the population I serve; this is a crucial step for active duty military personnel and for Veterans who previously did not have an explicit diagnosis when it came to their pain.  The media may influence Canadians to think that mental health problems have the most impact on the overall well-being of Veterans.  However, looking at the determinant of health of Veterans, those suffering from chronic pain and musculoskeletal pain have the greatest odds of disability when it comes to health-related quality of life questionnaire (Rebeira, Grootendorst & Coyte, 2015).

Following an analysis of the Survey on Transition to Civilian Life, VanDenKerkhof et al (2015) reported a forty one percent prevalence in chronic pain for Canadian veterans. This is twice the amount presented in the Canadian Pain Task Force Report (2019) in the general population.  Sadly, this figure goes up even more, as much as 85%, for veterans suffering from at least one mental health condition. This strengthen the idea that pain is multidimensional. 

In my blog post on chronic pain (Lambert, 2019), I presented the biopsychosocial model, a great tool for anyone suffering from chronic pain or working with this clientele.  Using this simple diagram from Jull’s paper (2017), I also illustrated how each component of the model could weigh in differently on the pain experience.

Copied from Jull (2017)

When it comes to chronic pain with active duty military or veterans, each member presents with a different story, regardless of their background.  In this course, I learned more about the concept of storytelling in the unit studying indigenous health.  My sister who works with the Cree Community in Chisasibi, Quebec, insisted that I looked up the NUKA system of care.  This relationship-based system puts emphasis on the story given from the patient to the clinician.  Talking about storytelling, Dr. Terry Simpson says to Danny Preston in an interview (2019): ‘’ It's something that's been lost in western medicine, and we're bringing it back’’.  The Southcentral Foundation has been hosting conferences annually for the past decade sharing information about their award-winning model of care.  Their statistics are impressive and should spark interest not only in the indigenous communities across the country but also in the Canadian health care at large. Stakeholders involved in healthcare should know of this system and be intrigued and humbled by their prowess.

Copied from: https://scfnuka.com/

The biopsychosocial model is a form of storytelling: it allows healthcare providers to better understand the factors influencing the pain experience of their patients and target their intervention.  The teacup analogy can be empowering for both the patient and the clinician. Greg Lehman sees the teacup as an ‘’actionable analogy’’ (2018) as there are two ways one suffering from chronic pain can help themselves: they can decrease the stressors we put in the cup and/or they can build a bigger cup.

Both methods are important and relate to resiliency which is a relatively new concept discussed in the Canadian Army Forces (CAF). The Merriam-Webster dictionary (2019) defines resilience as ‘’ the capability of a strained body to recover its size and shape after deformation caused especially by compressive stress and an ability to recover from or adjust easily to misfortune or change’’.  In the CAF, resilience applies in garrison, in training, during operational deployments and in an individual's personal life. It includes the physical and psychological ability to cope with, recover quickly from, and potentially thrive in, challenging environments (Canadian Army Integrated Performance Strategy, Annex F, 2015.).  How does this concept translate into life after military service? Are we relying too much on our peers and supervisors when we are in and lose this ability to bounce back when we get out? 

Hellewell and Cernak (2018) recently published a study where they measured resilience to operational stress in CAF personnel. They were able to demonstrate that changes in the panel of salivary biomarkers characterize soldiers and in turn may help identify military personnel who are at low, moderate, or high risk of developing maladaptive stress response to operationally demanding situations. In the last unit of this course, we researched new trends in healthcare: is this something that will routinely be monitored in combat in the future or throughout military members’ career? Could it be of use in the management of chronic pain? 

No matter what the future holds, I will continue to research, be curious and innovate in my daily physiotherapy practice: I will strive to deliver the best possible care to military members, especially those transitioning towards civilian life.  Even if it may be tempting to take shortcuts and turn towards new technologies, thanks to this course, I will remember the powerful healing potential of storytelling and that it empowers both the patient and the provider. Off to new challenges now, thank you for reading. 

References

Canadian Army Integrated Performance Strategy (2015.) Leader’s Guide to Readiness and Resilience Annex F.  Retrieved from: https://strongproudready.ca/missionready/wp-content/uploads/4500-1_caips_annex_f_en.pdf

Canadian Pain Task Force Report. (June 2019) Chronic Pain in Canada: Laying a Foundation for Action. Retrieved from:https://www.canada.ca/en/health-canada/corporate/about-health-canada/public-engagement/external-advisory-bodies/canadian-pain-task-force/report-2019.html

Hellewell, S. C. and Cernak, I. (2018), Measuring Resilience to Operational Stress in Canadian Armed Forces Personnel. Journal of Traumatic Stress, 31: 89-101.

Jull, G. (2017). Biopsychosocial model of disease: 40 years on. Which way is the pendulum swinging? British Journal of Sports Medicine, (16), 1187. Retrieved from http://0-  search.ebscohost.com.aupac.lib.athabascau.ca/login.aspx?direct=true&db=edsgih&AN=edsgcl.505809083&site=eds-live

Lambert, A.M. (2019, October 29). What fills your cup? A Biopyschosocial Approach to Chronic Pain [Blog post]. Retrieved from: https://alambert202.wixsite.com/website/post/overflowing-cup

Lehman, G. (2108, May 2). Do our patient’s need fixing? Or do they need a bigger cup?  [Blog post]. Retrieved from: http://www.greglehman.ca/blog/2018/5/1/do-our-patients-need-fixing

Preston, D. (Interviewer) & Simpson, T. (Interviewee). (2019). Storytelling is the best medicine, doctor touts Nuka System of Care[Interview transcript]. Retrieved from KNBA-KBC website: https://www.knba.org/post/storytelling-best-medicine-doctor-touts-nuka-system-care

Rebeira M, Grootendorst P, Coyte PC. (2015) Determinants of chronic physical health conditions in Canadian Veterans. J. Mil Vet Fam Health.;1(2):32–42

Resilience. 2019. In Merriam-Webster.com. Retrieved November 27, 2019  from: https://www.merriam-webster.com/dictionary/resilience

Southcentral Foundation, (n.d.) Nuka system of care. Retrieved from : https://www.southcentralfoundation.com/nuka-system-of-care/

VanDenKerkhof, E. G., VanTil, L., Thompson, J. M., Sweet, J., Hopman, W. M., Carley, M. E., & Sudom, K. (2015). Pain in Canadian Veterans: analysis of data from the Survey on Transition to Civilian Life. Pain research & management, 20(2), 89–95. doi:10.1155/2015/763768