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The newspaper of The Johns Hopkins University February 25, 2008 | Vol. 37 No. 23
Pain Treatment in the Field Makes Return-to-Duty Rate Soar

By Eric Vohr
Johns Hopkins Medicine

Noncombat-related acute and recurrent chronic pain is the leading cause of soldier attrition in modern war, with the return-to-duty rate as low as 2 percent when these soldiers are treated outside the theaters of operation. However, that rate jumps to 95 percent when troops and officers are treated and managed for pain in the field, according to a new study from a Johns Hopkins anesthesiologist.

"The main factor seems to be rapid diagnosis and treatment of pain syndromes," said study co- author Col. Steven Cohen, of the Department of Anesthesiology and Critical Care Medicine at the Johns Hopkins University School of Medicine.

"Establishing pain treatment centers in combat areas gets care to soldiers fast and could dramatically increase the military's ability to maintain troop levels and succeed militarily in places like Iraq," Cohen said.

The report, appearing in the December issue of Anesthesiology, shows that 107 of 113 soldiers suffering from noncombat-related pain were able to return to duty after being treated in Baghdad at the Ibna Sina Hospital between October 2005 and September 2006. In contrast, a previous study by Cohen and colleagues showed that of 162 soldiers with similar kinds of pain evacuated from Iraq for treatment at Walter Reed Army Medical Center in Washington, D.C., or the Landstuhl Regional Medical Center in Germany between April 2003 and July 2004, only three returned to active duty.

Noncombat pain was defined in both studies as conditions resulting from such things as physical training, sports and accidents.

Among those patients treated in the field, sciatica (leg pain and/or tingling, numbness or weakness that travels from the low back through the buttock and down the large sciatic nerve in the back of the leg) accounted for 55.7 percent of the cases; noncardiac chest pain, 11.5 percent; arm pain from a herniated disc in the neck, 7.1 percent; groin pain, 7.1 percent; leg pain, 7.1 percent; low back pain without leg symptoms, 6.2 percent; arm pain unrelated to a herniated disc, 1.8 percent; and neck pain/headache, 1.8 percent. All the patients were seen within 72 hours of their initial complaints by anesthesiologists who are pain specialists.

In the first study done in soldiers who were evacuated for treatment, the most common complaints were sciatica, low back pain, leg pain and arm pain. The majority of these cases did not receive definitive treatment until a few weeks after their initial complaints.

Treatments for both sets of patients were similar and included epidural steroid injections, trigger point injections, lumbar interarticular facet blocks, groin blocks and corticosteroid injections, as well as nonsteroidal anti-inflammatory drugs, neuropathic pain drugs, muscle relaxants and opioids.

"Early intervention is almost always associated with better outcomes," Cohen said. "The longer a pain complaint goes untreated, the worse the prognosis."

Cohen said it is also more difficult to redeploy soldiers once they are medically evacuated, for both logistical and psychological reasons. "Soldiers who stay with their units build on the strong ties with those units and wish to remain. Those bonds weaken when military personnel are stateside with their families, making these soldiers even less amenable to returning to the field," he said.

Cohen co-authored the study with Maj. Ron L. White, an anesthesiologist at the Uniformed Services University of the Health Sciences in Washington, D.C. White serves in the United States Army and Cohen in the United States Army Reserve.


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