Explanatory models for chronic pain have shifted away from simplistic biomedical models dating back to the time of Descartes toward more comprehensive biopsychosocial models stemming from the early works of George Engel (1980). As our understanding of chronic pain became increasingly complex, so too did treatment recommendations. Treatments limited to medical interventions or psychotherapy have now given way to integrated, interdisciplinary programs including physical interventions (pain medicine, orthopedics, physical therapy), cognitive and behavioral interventions (activity pacing, cognitive-behavioral treatment [CBT]-based psychotherapy, stress management), and social interventions (improved communication). The treatment effectiveness of interdisciplinary pain management programs has been well documented in the scientific literature (e.g., Gatchel & Okifuji, 2006) for addressing musculoskeletal disorders. Interdisciplinary care consists of coordination of services in a comprehensive program and frequent communication among healthcare professionals, all providing care “under one roof” at the same facility. All healthcare providers work together in one facility, without the need for outside consultants. The key ingredients for interdisciplinary care are the following: a common philosophy of rehabilitation, constant daily communication among on-site healthcare professionals, and active patient involvement. A truly integrated pain management program ensures the best patient care by emphasizing the regular coordination of services. Indeed, there must be constant communication among all treatment team members, and the team members need to ingrain the treatment philosophy in their patients to ensure effective comprehensive treatment.

Although there is no standard composition for an interdisciplinary chronic pain management team, there are solid recommendations available in the extant research literature (see Sanders, Harden, & Vicente, 2005). Most interdisciplinary pain programs are developed to directly address the complexity of pain based on the biopsychosocial model. Physical interventions are overseen by a medical director (usually a physician or nurse) who is responsible for assessing and defining the needs and limits of physical rehabilitation. Physical and Occupational Therapists then design and implement a physical rehabilitation program in coordination with the medical director and pain physicians who use medical interventions (e.g., medications and injections) to enhance participation in rehabilitation. Psychologists and Counselors typically oversee psychosocial rehabilitation designed to help the patient overcome motivational, emotional (e.g., depression and anxiety), and cognitive obstacles (e.g., fear avoidance, pain acceptance, pain catastrophization) to rehabilitation.

Cognitive and behavioral therapies are a central feature of the psychotherapeutic component of interdisciplinary treatment for chronic pain. The primary aims of CBT are to identify and replace maladaptive patient cognitions, emotions, and behaviors with more adaptive ones. By addressing both cognitive and behavioral aspects, chronic pain patients receive a more comprehensive treatment that may facilitate adjustment to issues, ranging from mood concerns to maladaptive pain behaviors. Within interdisciplinary chronic pain management programs, CBT has emerged as the psychosocial treatment of choice for chronic pain. In their meta-analysis, Morley, Eccleston, and Williams (1999) found that “CBT produced significant changes in measures of pain experience, mood/affect, cognitive coping and appraisal (reduction of negative coping and increase in positive coping, pain behavior and activity level, and social role function)” (p. 8). Specific examples of cognitive areas addressed by CBT include catastrophizing, acceptance of the pain condition, avoidance of activity due to unrealistic concerns about harm (i.e., fear avoidance, kinesiophobia), and expectations of pain treatment (Vowles, McCracken, & Eccleston, 2007). Additional CBT methods include relaxation training, attention control, motivation (i.e., motivational interviewing), and activity management training (i.e., pacing). The overarching goal for these various techniques is to help the patient identify and address maladaptive thoughts and behaviors. Pain behaviors may include fostering dependence, assuming the sick role, or missing inordinate amounts of time from work for recovery. CBT is often short term and skill oriented, two valuable aspects with regard to treatment of chronic pain patients in the context of these intensive and relatively brief programs.

McCracken and Turk (2002) reported numerous controlled clinical trials of CBT in interdisciplinary chronic pain intervention contexts and found these treatments to be successful at helping patients manage their chronic pain conditions and reduce disability. Additionally, a review by Gatchel and Rollings (2008) offers further support regarding the efficacy of CBT intervention in chronic pain. Gatchel and Robinson (2003) have also provided a comprehensive overview for CBT intervention with chronic pain populations based on the extensive support for the use of CBT found in the literature. Group CBT psychotherapy has also been widely identified and recommended as an important treatment for persistent musculoskeletal conditions (e.g., Keefe, Rumble, Scipio, Giordano, & Perri, 2004; Morley et al., 1999).

With current evidence-based clinical research overwhelmingly supportive of the use of interdisciplinary chronic pain management, clinicians should familiarize themselves with the various facets that comprise this approach. Functional restoration, individual CBT, and group CBT each offer frontline treatments within the context of interdisciplinary treatment for chronic pain. Providers must be aware that communication and collaboration among team members is a requisite element of effective interdisciplinary treatment. Essentially, the sum of the collective medical, psychological, and physical rehabilitation processes represents an improved treatment option, as compared to their worth as isolated treatments. The extensive and ever-growing literature in support of interdisciplinary treatment approaches for chronic pain reflects a collective affirmation for superior patient care.

Functional restoration, the first evidence-based form of interdisciplinary pain management for chronic musculoskeletal pain disorders, was initially developed by Mayer and Gatchel (1988). Since that time, it has been demonstrated to be an extremely effective approach in the diagnosis, intervention, and management of chronic musculoskeletal pain (Gatchel & Mayer, 2008). It requires an interdisciplinary team of clinicians to enact its goals of restoring physical functional capacity and psychosocial performance. This comprehensive approach requires excellent communication among providers in order to address physical, psychological, and vocational challenges during patient recovery. A systematic review by Guzman et al. (2001) revealed that intensive interdisciplinary rehabilitation with functional restoration achieved its goal of pain reduction and functional restoration, relative to usual care. Support for the robustness of the findings on functional restoration programs includes the fact that studies across different economic and social conditions have produced positive and comparable outcomes, not only in the United States but also in other countries such as Denmark (Bendix & Bendix, 1994; Bendix et al., 1996), Germany (Hildebrandt, Pfingsten, Saur, & Jansen, 1997), Canada (Corey, Koepfler, Etlin, & Day, 1996), France (Jousset et al., 2004), and even Japan (Shirado et al., 2005). Thus, Gatchel and Okifuji (2006) concluded “The fact that different clinical treatment teams, functioning in different states and different countries, with markedly different economic and social conditions and workers’ compensation systems produced comparable positive results speaks highly for the robustness of the research findings and the utility, as well as the fidelity, of this approach to pain management…” (p. 782). Moreover, the success of the functional restoration approach has been thoroughly documented, with over 40 studies now available through MEDLINE supporting the approach, with dissemination worldwide, including into the US military.

The US House of Representatives (2008) drafted H.R. 5465, the Military Pain Care Act, which identified pain as a prevalent and significant problem for the US military and encouraged broad changes in how chronic pain and musculoskeletal disorders are managed within the military. Recently, both the US Army and the US Air Force have implemented functional restoration (FR) pain clinics based on a model developed through a Department of Defense-funded research initiative that began in 2003: the Functional Occupational Restoration Treatment (FORT) program. The purpose of the FORT study was to evaluate the effectiveness of an interdisciplinary FR pain program for the first time in a military population. It was designed to decrease chronic musculoskeletal pain, increase functioning, and retain military members on active duty. The major hypothesis was that the FORT intervention would significantly increase the likelihood that active-duty military personnel suffering from musculoskeletal disorders would remain on active duty and be fully qualified to perform all of their military duties, as well as positively impact other socioeconomic outcomes. All participants were active-duty military members recruited from all four branches of the military and treated at Wilford Hall Medical Center at Lackland Air Force Base, Texas. This was a pre- to posttreatment evaluation design, with evaluations conducted immediately before and after treatment, as well as at 6-, 12-, and 18-month follow-up periods, in order to determine differential outcomes on variables such as return to full duty status, work retention, and additional healthcare utilization. The specific aims of the study were to evaluate the efficacy of the FORT program in reducing patient-reported pain symptoms, unnecessary healthcare utilization, healthcare costs, and number of military members on medical profile, disability, or separated from active duty. Additional aims included improving functioning, increasing the number of military members remaining fit for duty and worldwide qualified, and increasing military members’ ability to pass their physical fitness test for their respective military service. In summary, this research project addressed the clear need for clinical research to develop evidence-based assessment and treatment approaches to decrease the enormous cost associated with chronic musculoskeletal conditions within the US Armed Forces.

Data analyses to date have shown a variety of desirable outcomes associated with FORT treatment (Gatchel et al., 2009). The FORT intervention resulted in significant improvements for functional capacity, health-related quality of life, and military retention. In contrast, a treatment-as-usual group showed no significant change in physical or psychosocial outcomes over the 1-year assessment span. Furthermore, participants who completed treatment as usual were three times more likely to have received a medical discharge from active-duty service compared to FORT participants and were more likely to seek increased levels of pain-related healthcare and medication use. The success of this research project proved the efficacy of the interdisciplinary FR approach even when they are translated into a military medical environment. More work is needed, however, to examine the cost effectiveness of this military approach.

There have been significant advancements in military pain analgesia since the onset of the current war effort in 2001. In 2009, the then US Army Surgeon General, LTG Eric Schoomaker, recognized that chronic pain management was a significant problem for military medical providers without any clear guidance for providers on analgesic and opioid medication prescription (Plunkett, Turabi, & Wilkinson, 2012). LTG Schoomaker assembled the Army Pain Management Taskforce to address these concerns, and the taskforce published a comprehensive report in 2010 outlining the best available evidence and most notable gaps in military analgesia and pain management (Pain Management Taskforce, 2010). One of the most notable gaps identified by the Pain Management Taskforce Final Report was the need for increased guidance on opioid medication prescription for active-duty service members and veterans. Opioid medications are often a frontline treatment option for chronic musculoskeletal pain. Despite their benefit to the pain sufferer, these medications often come with deleterious side effects (e.g., drowsiness, difficulty concentrating) that erode an individual’s ability to complete military work. Unfortunately, the increasing trend in military musculoskeletal disorders has been accompanied by a similar increase in the frequency of opioid medication prescription and use (Kent & Ong, 2011). Opioid dependence has risen among active-duty service members as opioid medications have become more prolific in treating military chronic pain. The DMED reveals a dramatic increase in the frequency of ambulatory visits for opioid dependence among active-duty service members from 2001 (when the current war effort began) to 2011 (the most recent available data). According to the DMED, there were 1,147 ambulatory visits among active-duty service members from all service branches with a primary diagnosis of opioid dependence (ICD-9 code 304.0). This number consistently increased over the next decade up to 22,211 visits in 2011 (Fig. 8.2).

The US Army Pain Management Taskforce Final Report (Pain Management Taskforce, 2010) stressed the addition of complementary and alternative medicine (CAM) approaches for use in military and veterans affairs (VA) treatment facilities. Top-tier CAM interventions addressed by the report include acupuncture, yoga, biofeedback, and massage. Although various other CAM modalities are recommended as second-tier treatment options, the Report does little to illuminate the data supporting (or dissuading) the use of these interventions (many of which are already heavily utilized in DoD and VA treatment facilities). Data addressing the potential efficacy of these treatments are included below.

The military attempts to treat disabling injuries in hopes of returning members to full capacity and enabling them to perform all duties required for continued active-duty status. Sometimes, despite best efforts, military members are no longer capable of carrying out their assigned job duties due to disability. When service members are no longer capable of performing their military duties due to physical or mental defect, they are put on a medical profile. This is the first step in a long process of establishing disability within the military. The military’s profile system is meant to allow a service member time to recuperate and return to duty. If recuperation does not occur, the military member is referred to the Medical Evaluation Board (MEB)/Physical Evaluation Board (PEB) to determine ability to remain in the military and compensation for disability. This is a lengthy process that ends with the military member either being returned to active-duty status or being discharged/retired from the military. If the service member leaves the military, many enter the Veterans Affairs (VA) system to treat ongoing disability. The following section of this chapter will provide a discussion of the physical profile serial system, which is necessary to introduce the disability evaluation system (DES). This discussion will include the MEB/PEB and the VA disability system encompassing the four branches of the military that fall under the jurisdiction of the Department of Defense (e.g., Army, Air Force, Navy, Marines). The information in this section provides an overview of these procedures, for specifics regarding a particular service branch the reader should consult appropriate military regulations and instructions specific to that service branch.

Physical profile system: The military’s physical profile serial system was established to determine whether soldiers were physically capable of performing assigned duties and to classify individuals based upon physical functional abilities. This information was then used to establish suitability for different career fields. These standards were developed to ensure readiness of military personnel while preserving health and preventing injury (United States Department of the Air Force [U.S. Dept of AF], 2010, June 25).

The physical profile system classifies military members according to physical functioning which determines the availability for worldwide duty (i.e., deployment). The military’s Physical Profile Serial Chart system falls within six categories that represent different areas of physical functioning. These categories are designated “P-U-L-H-E-S” (Karpinos, 1960). Each letter signifies a different medical area:

Numerical designations from one to four are used to reflect different levels of functional capacity within the P-U-L-H-E-S system. These numerical designations allow a physician to rate service members’ functional capacity within each category and make recommendations for duty limitations based on current problems or defects. Each number corresponds to the following:

Physicians will put military members who are injured or suffer a medical problem on a medical profile. A medical profile is a way to communicate with command about illnesses and duty limitations suffered by service members that could affect the military mission. Whether a defect affects the military mission is often dependent upon the military members’ occupational specialty. A defect that is limiting in one career field may not have mission impact in another career field. When an individual is initially put on a profile, it is generally under the assumption that the service member will recover, return to duty, and continue to meet medical retention standards developed by the military. When recuperation is expected, a service member is put on a temporary profile, which is designated with the letter “T” after the number in the P-U-L-H-E-S system (i.e., P4T). A temporary profile is only valid for 12 months from the initial profile date. After 6 months, if the service member has not recovered, a referral to a specialist will be made. The specialist will determine if recovery is likely. If it is, the temporary profile will be extended and treatment will continue until the profile is reviewed in another 6 months. If the service member is not likely to recover and does not meet medical retention standards, the service member is entered into the DES and must be referred to a MEB/PEB.