Pain neuroscience education improves post-traumatic stress disorder, disability, and pain self-efficacy in veterans and service members with chronic low back pain: Preliminary results from a randomized controlled trial with 12-month follow-up.

Post-traumatic stress disorder (PTSD) and chronic low back pain (CLBP) are frequently co-morbid. Some research suggests that PTSD and CLBP may share common neurobiological mechanisms related to stress. Traditional biomedical education may be ineffective for PTSD and CLBP, especially when co-morbid. The purpose of this study is to determine if pain neuroscience education (PNE) is more effective than traditional education in reducing PTSD, disability, pain, and maladaptive beliefs in patients with CLBP. Participants with CLBP and possible PTSD/PTSD-symptoms were recruited for this study. Participants were randomly allocated to a PNE group or a traditional education group. The intervention included 30 minutes of education followed by a standardized exercise program once a week for 4-weeks with a 4 and 8-week follow-up and healthcare utilization assessed at 12-months. Forty-eight participants consented for this research study with 39 allocated to treatment (PNE n = 18, traditional n = 21). PNE participants were more likely to achieve a clinically meaningful reduction in PTSD symptoms and disability at short-term follow-up. At 12-months, the PNE group utilized healthcare with 76% lower costs. In participants with CLBP, PNE may reduce hypervigilance toward pain and improve PTSD symptoms. Participants who received PNE were more confident body-tissues were safe to exercise. These beliefs about pain could contribute to a decrease in perceived disability and healthcare consumption for CLBP.

The Effect of Cautionary Versus Resiliency Spine Education on Maximum Deadlift Performance and Back Beliefs: A Randomized Control Trial.

ABSTRACT: Scott, KM, Kreisel, BR, Florkiewicz, EM, Crowell, MS, Morris, JB, McHenry, PA, and Benedict, TM. The effect of cautionary versus resiliency spine education on maximum deadlift performance and back beliefs: A randomized control trial. J Strength Cond Res 38(7): e341-e348, 2024-The purpose of this study was to determine the effect of cautionary information about the spine vs. a message of spine resiliency on maximum deadlift (MDL) performance and beliefs regarding the vulnerability of the spine. This cluster randomized control trial involved 903 military new cadets (n = 903) during their mandatory fitness test in cadet basic training (mean age 18.3 years, body mass index 23.8 kg·m-2, 22% female). Subjects were cluster randomized to 3 groups. The cautionary group received a message warning them to protect their backs while deadlifting, the resiliency group received a message encouraging confidence while deadlifting, and the control group received the standardized Army deadlift education only. The outcome measures were MDL weight lifted and perceived spine vulnerability. Significance was set at alpha ≤0.05. There were no between-group differences in weight lifted (p=0.40). Most subjects believed that the spine is vulnerable to injury. Three times as many subjects who received the resiliency education improved their beliefs about the vulnerability of their spines compared with those receiving the cautionary education (p<0.001). This study demonstrated the potential for brief resiliency education to positively influence beliefs about spine vulnerability, whereas cautionary education did not impair performance.

The Convergent Validity of the SWAY Balance Application to Assess Postural Stability in Military Cadets Recovering from Concussion.

Background: Concussions are often accompanied by balance disturbances. Clinically accurate evaluation systems are often expensive, large, and inaccessible to most clinicians. The Sway Balance Mobile Application (SWAY) is an accessible method to quantify balance changes. Purpose: To determine the known groups and convergent validity of the SWAY to assess balance after a concussion. Study Design: Case-Control Study. Methods: Twenty participants with acute concussion and twenty controls were recruited. At initial, one-week, and final return to activity (RTA) evaluations, all participants completed the Sports Concussion Assessment Tool (SCAT-5), and balance control measured by SWAY mBESS and NeuroCom Balance Master Sensory Organization Test (SOT). Mixed model ANOVAs were used to detect differences in SWAY mBESS and NeuroCom SOT scores with time (initial, one-week, final RTA) as the within-subjects factor and group (concussed, healthy) as the between-subjects factor. Spearman's Rho correlations explored the associations between NeuroCom SOT scores, SWAY scores, SCAT-5 symptom scores, and time in days to final RTA. Results: The sampled population was predominantly male and age (20 ± 1), and BMI differences were insignificant between groups. The SWAY did not detect differences between healthy and concussed participants and did not detect change over time [F(2,40) = .114, p = 0.89; F(2,40)= .276, p =0.60]. When assessing the relationship between the SWAY and the SOT, no correlation was found at any time point (r = -0.317 to -0.062, p > 0.05). Time to RTA demonstrated a moderate correlation with both SCAT-5 symptom severity score (r = .693, p < 0.01) and SCAT-5 total symptom score (r = .611, p < 0.01) at the one-week follow-up. Conclusion: The SWAY mBESS does not appear to be a valid balance assessment for the concussed patient. The SWAY mBESS in patients with concussion failed to demonstrate convergent validity and did not demonstrate an ability to validate known groups. When assessing the time to final RTA, the one-week post-initial assessment SCAT-5 symptom severity and total scores may help determine the length of recovery in this population. Level of Evidence: Level 3.

Demographic, psychosocial, and physical fitness predictors of successful graduation from U.S. Army Ranger School.

U.S. Army Ranger School is an arduous 64-day leadership training course designed to simulate the stressors of combat. Although physical fitness has been shown to be an important predictor of successful graduation for Ranger School, psychosocial characteristics like self-efficacy and grit have not been examined. The purpose of this study is to identify personal, psychosocial, and fitness characteristics associated with successful completion of Ranger School. This study was a prospective cohort examining the association of baseline characteristics of Ranger School candidates with a primary outcome of graduation success. Multiple logistic regression was performed to determine the contribution of demographics, psychosocial, fitness and training characteristics to graduation success. Out of 958 eligible Ranger Candidates, this study obtained graduation status for 670 students, 270 (40%) of which graduated. Soldiers who graduated were younger, more likely to come from units with a higher proportion of previous Ranger School graduates, had higher self-efficacy and faster 2-mile run times. The results from this study suggest that Ranger students should arrive in optimal physical conditioning. Furthermore, training programs that optimize student self-efficacy and units with a high proportion of successful Ranger graduates may confer advantage for this challenging leadership course.

Physical and behavioral characteristics of soldiers acquiring recommended amounts of sleep per night.

OBJECTIVES: Only one-third of U.S. Army Soldiers meet the recommended sleep guideline of 7 or more hours per night. Soldiers meeting the recommended sleep guideline are more likely to perform better on cognitive and physical tasks. The purpose of this analysis was to compare the physical and behavioral characteristics of Soldiers who met and did not meet the sleep recommendation guideline and determine associations between physical and behavioral characteristics and the acquisition of recommended amounts of sleep per night. METHODS: A survey was administered to U.S. Army Soldiers. Adjusted odds ratios and corresponding 95% confidence intervals were calculated to determine associations between achieving the recommended number of hours of sleep per night and age, physical characteristics, health behaviors, physical training, and physical performance. RESULTS: A survey was completed by 4229 men and 969 women. Male Soldiers who met the recommended sleep requirement had lower estimated body fat [20.3 ± 4.2% vs. 21.1 ± 4.4%], were less likely to use tobacco [11.5% vs. 16.2%] and exercised more [259 ± 226 vs. 244 ± 224 min/wk] compared with those who did not obtain 7 hours of sleep per night. Female Soldiers who met the recommended sleep requirement had lower estimated body fat [31.4 ± 4% vs. 32.1 ± 4.6%] and exercised more [258 ± 206 vs. 241 ± 216 min/wk] compared with those who did not obtain 7 hours of sleep per night. CONCLUSION: Soldiers who choose to adopt healthy lifestyle characteristics may be more likely to meet the recommended sleep duration guideline.

Translating Public Health Recommendations Using the Army Design Methodology.

The U.S. Army employs over 470,000 active duty soldiers throughout the world. Although the Army also employs hundreds of public health professionals, public health recommendations are often not framed in ways that are readily actionable to senior Army leaders. This case study shows how public health findings were translated into actionable recommendations using the Army Design Methodology (ADM) and subsequently implemented by installation leadership. Following a perceived increase in suicides at Fort Wainwright, Alaska, in 2019, installation leadership requested that the U.S. Army Public Health Center conduct an epidemiological consultation. A mixed-methods approach was used to gather qualitative and quantitative data. The ADM was used to translate the findings and provide actionable recommendations for senior Army leaders. Many recommendations were implemented within a year of the report's release and included modifications to gym facilities, dining halls, and sleeping areas. Key improvements included the installation of $900,000 worth of new gym equipment in existing physical fitness facilities, increasing the basic daily food allowance by 44% to facilitate the purchase of healthy options, and the installation of blackout blinds in all barracks to ensure more restful sleep during times of peak sunlight. The ADM is well understood by senior Army leaders. Use of the ADM in future military-specific public health studies could ensure a more effective uptake and implementation of public health recommendations.

Development of a pain neuroscience education program for post-traumatic stress disorder and pain.

Introduction: Individuals with co-morbid post-traumatic stress disorder (PTSD) and pain have higher disability, pain, and pain catastrophizing beliefs than patients without PTSD. Pain neuroscience education (PNE) may be an effective tool to help those with PTSD and pain reduce maladaptive beliefs about pain. The purpose of this paper is to report the development and evaluation of a PNE curriculum for participants with PTSD and pain. Methods: After writing an initial draft of PNE for PTSD and pain, a panel of medical experts in PNE, PTSD, and rehabilitation reviewed the booklet. After addressing recommendations from the medical panel (n = 29), individuals with (n = 13) and without (n = 20) PTSD reviewed the booklet. Results: Overall, 89% of participants recommended the PNE booklet and 90% thought it would help patients with PTSD and pain. Although patients with PTSD rated the PNE booklet more critically than other participants, a particular support group (n = 4) rated the PNE booklet significantly different (p < .05) than remaining participants with PTSD (n = 9). Individuals with PTSD and pain were able to comprehend the PNE booklet at a comparable rate to an expert medical panel and participants without PTSD after adjusting for education levels (p = .12). Conclusions: Many patients with PTSD and pain avoid painful activities because they believe they are harmful. This research demonstrates that individuals with PTSD and pain can comprehend PNE that challenges these beliefs. The PNE curriculum developed by this research may provide a logical explanation for the link between PTSD symptoms and pain and should be tested for clinical effectiveness.

Post-Traumatic Stress Disorder Symptoms Contribute to Worse Pain and Health Outcomes in Veterans With PTSD Compared to Those Without: A Systematic Review With Meta-Analysis.

INTRODUCTION: Post-traumatic stress disorder (PTSD) and chronic pain are frequently co-morbid conditions in the U.S. veteran population. Although several theories about the cause of increased pain prevalence in individuals with PTSD have been presented, no synthesis of primary data informing the impact of co-morbid PTSD and pain has been completed. The purpose of this study was to systematically review the literature and quantify disability, function, and pain-related beliefs and outcomes in veterans with PTSD compared to veterans without PTSD. MATERIALS AND METHODS: A systematic search of three electronic databases was conducted. Inclusion criteria required pain-related comparison of veterans with PTSD to those without PTSD. Primary outcome measures and standardized mean differences (SMDs) were assessed for pain, function, disability, pain beliefs, and healthcare utilization using a random effects model. RESULTS: 20 original research studies met inclusion criteria and were assessed for quality and outcomes of interest. The majority of studies were cross-sectional. Veterans with PTSD and pain demonstrated higher pain (SMD = 0.58, 95% CI 0.28-0.89), disability (SMD = 0.52, 95%CI 0.33-0.71), depression (SMD = 1.40, 95%CI 1.2-1.6), catastrophizing beliefs (SMD = 0.95, 95% CI 0.69-1.2), sleep disturbance (SMD = 0.80, 95% CI 0.57-1.02), and healthcare utilization; they had lower function (SMD = 0.41, 95% CI 0.25-0.56) and pain self-efficacy (SMD = 0.77, 95% CI 0.55-0.99) compared to veterans without PTSD. CONCLUSION: In veterans with chronic pain, PTSD symptomology has a large effect for many negative health-related outcomes. This review supports the need for clinicians to screen and understand the effects of PTSD symptoms on patients with pain. Clinicians should recognize that veterans with PTSD and pain likely have elevated pain catastrophizing beliefs and decreased self-efficacy that should be targeted for intervention.

Effect of Chronic Low Back Pain and Post-Traumatic Stress Disorder on the Risk for Separation from the US Army.

INTRODUCTION: Co-morbid post-traumatic stress disorder (PTSD) and low back pain (LBP) are common reasons for increased disability in the Veteran communities. Medical discharge from the military represents a considerable financial cost to society. Little is currently known about the impact of LBP and PTSD as longitudinal risk factors for medical discharge from Active Duty military service. MATERIALS AND METHODS: A retrospective analysis of US Army Active Duty Soldiers from 2002 to 2012 was performed to determine the risk for medical discharge. Four levels of exposure for were identified as independent variables: no chronic LBP or PTSD, chronic LBP only, PTSD only, and co-morbid PTSD present with chronic LBP. Statistical analysis utilized modified Poisson regression controlling for sex, age, rank, time in service, deployment, mental health, sleep disorders, alcohol use, tobacco use, obesity, and military occupation. This study was approved by a Department of Defense Institutional Review Board. RESULTS: After controlling for potential confounding variables, the RR for chronic LBP and PTSD independently was 3.65 (95% CI: 3.59-3.72) and 3.64 (95% CI: 3.53-3.75), respectively, and 5.17 (95% CI: 5.01-5.33) when both were present. CONCLUSIONS: This is the first study to identify a history of both chronic LBP and PTSD as substantial risk factors for medical discharge from the US Army. PTSD and chronic LBP may mutually reinforce one another and deplete active coping strategies, making Soldiers less likely to be able to continue military service. Future research should target therapies for co-morbid PTSD and chronic LBP as these conditions contribute a substantial increase in risk of medical discharge from the US Army.

Effects of sit-up training versus core stabilization exercises on sit-up performance.

PURPOSE: Core stabilization exercises target abdominal and trunk muscles without the excessive loading that occurs during sit-ups. However, core stabilization exercise programs (CSEP) have not been widely adopted in the US Army partially because of the perceived deleterious impact they would have on performance during the Army Physical Fitness Test. The purpose was to determine whether performing CSEP in lieu of sit-ups during unit physical training would have detrimental effects on sit-up performance and passing rates on the fitness test. METHODS: Soldiers (N = 2616) between 18 and 35 yr of age were randomized to receive a traditional exercise program (TEP) with sit-ups or CSEP. Subjects with a previous history of low back pain or other injury precluding participation in training were excluded. The training programs were completed four times per week for 12 wk. Performance was assessed at baseline and after 12 wk. RESULTS: Both groups demonstrated significant improvements in sit-up performance and overall fitness scores over time (P < 0.001). There were no significant between-group differences in overall fitness scores (P = 0.142) or sit-up performance (P = 0.543). However, CSEP resulted in a significant improvement in sit-up passing rates by 5.6% compared with 3.9% for the TEP group (P = 0.004). CONCLUSIONS: CSEP did not have a detrimental impact on sit-up performance or overall fitness scores or pass rates. There was a small but significantly greater increase in sit-up pass rate in the CSEP (5.6%) versus the TEP group (3.9%). Incorporating CSEP into Army physical training does not increase the risk of suboptimal performance on the Army's fitness test and may offer a small benefit for improving sit-up performance.