DoD Program Applies Chronic Pain and Trauma Care Approaches to Treat Gulf War Veterans with Idiopathic Illnesses

Ann Norwood, MD

Walter Reed Army Medical Center, the Uniformed Services University of the Health Sciences and the Henry M. Jackson Foundation for the Advancement of Military Medicine have teamed to provide innovative care for Gulf War veterans with unexplained physical symptoms, sometimes referred to as Gulf War Syndrome. The unique service, called the Specialized Care Program (SCP), utilizes a multidisciplinary mix of medical, physical and psychosocial modalities during an intensive three-week partial hospital program aimed at improving veterans' outlook, overall functioning and quality of life. A 1992 meta-analysis in the journal Pain summarized 65 controlled studies of multidisciplinary chronic pain programs and found they were associated with significant improvements in pain, mood, health-care use and return-to-work rates -- improvements that persisted over time. There may be important parallels between chronic pain patients and Gulf War veterans with idiopathic symptoms.

"Typically, we see Gulf War veterans who have looked to the medical system for answers to their health concerns, but have come up empty," says Major Charles Engel, a psychiatrist, epidemiologist and Gulf War veteran who is the SCP director. "As providers, it bothers us when we don't have clear answers for our patients' concerns. Sometimes, we become overzealous, shotgunning tests and medicines even when we don't expect them to help, an approach that yields false positive results and iatrogenic complications. Other times, we become frustrated and then reduce, label or even deny their concerns, essentially rejecting them. This frequently leaves them angry with the medical system and, in our setting, a military that they perceive has let them down. In the SCP, we emphasize joining with the veteran around his or her health concerns and searching with them for a middle medical ground."

The goal of the SCP is to empower veterans to take charge of their health concerns, rather than wait passively on a medical system that in many cases simply does not have the answers they seek. The multidisciplinary staff helps them develop an individualized program of gradually increasing exercise, provides them education on how to collaborate with providers and communicate with loved ones and employers regarding their health limitations, and offers them cognitive-behaviorally based therapies for traumatic experiences and idiopathic symptoms. Prior to entering SCP, veterans typically complete the Department of Defense Comprehensive Clinical Evaluation Program (CCEP), a program designed to provide timely, accessible, and systematic medical evaluations for individuals with Gulf War-related health concerns. During the SCP, veterans work closely with their internists to arrange lasting primary care follow-up and address their questions about past medical testing.

The SCP has seen 63 veterans to date and is experiencing an increasing demand for services. The numbers of veterans seeking care in the CCEP has decreased in the past two months, but SCP inquiries continue to increase. Many are from non-DoD beneficiaries, such as like reservists and veterans no longer in the military. The SCP is working on ways to offer them care. Over the past six months, the SCP has launched an aggressive effort to examine outcomes. It has developed a detailed database measuring multiple aspects of patients' health status, including satisfaction, and has recently begun using computer-assisted telephone interviews for tracking veterans' status over time. In the future, Engel hopes to launch a larger-scale program evaluation to help policy-makers decide whether the SCP approach might benefit veterans of future deployments.