Management of chronic musculoskeletal pain in veterans: a systematic review

Main Article Content

Alessandro Santini
Antonio Petruzzo
Noemi Giannetta
Antonio Ruggiero
Marco Di Muzio
Roberto Latina


veterans; military; nurses; pain; pain management; musculoskeletal pain; opioid therapy; post-traumatic stress disorder.


Background and aim of the work. Veterans are military with health problems due to military conditions. The improved body armor and operational conditions has reduced the number of deaths, but increased the number of veterans with severe injuries, affected by musculoskeletal pain and associated syndromes, such as post-traumatic stress disorder. Multimodal approaches are considered in USA the gold standard for the treatment of these problems, while in Europe and Italy the data are unknown. The aim of this review was to describe and summarize multimodal therapeutic approaches that apply to the veteran population for chronic musculoskeletal pain and relate syndromes management.Methods. A comprehensive systematic review of the literature on Cochrane Library, PubMed, CINAHL e PsycINFO databases was conducted, from 2001 to 2020.

Results. 228 papers have been found, 134 were selected after the first screening. 24 quantitative studies were included in the review, all from USA. Different multimodal interventions with different kind of treatment types emerged. The analyzed studies’ sample size was 11 million (mean age = 57.67 years; SD=±11.94). The multimodal approaches showed a significant improvement in all outcomes (pain reduction and control, opioid therapy reduction, psychosocial outcomes) compared to traditional therapy.

Conclusions. Multimodal therapeutic approaches seem to guarantee a good management chronic musculoskeletal pain and related mental disorders, and the reduction and control to opioid use. Military nurses emerged as professionals who have a central role in this approach. European and Italian authorities should consider veterans, in order to assess their expected increase in the future.


Download data is not yet available.
Abstract 419 | PDF Downloads 786


1. Cornell Law School Legal Information Institute - Electronic code of federal regulations; 2019. Available at: Accessed on July 4, 2019).
2. Ministero della Difesa: Esercito. Centro Veterani della Difesa [Ministry of Defense: Army, Defense Veterans Center]; 2018. Available at: Accessed on April 19, 2019.

3. Pardew J, Bennett C. North Atlantic Treaty Organization (NATO): Rivista della NATO. Operazioni: vecchie e nuove [NATO Magazine: Operations: old and new]; 2006. Available at: Accessed on November 27, 2019.
4. VA USA. Veteran Population Projections 2017-2037; 2019. Available at: Accessed on September 02, 2019.
5. Naliboff B. D., Wu S. M., Schieffer B., Bolus R., Pham Q., Baria A., & Shekelle P. A randomized trial of 2 prescription strategies for opioid. Treatment of chronic nonmalignant pain. J. Pain 2011, 12: 288-296.

6. Matthias M. S., Miech J. E., Myers L. J., Sargent C., & Bair M. J. An expanded view of self-management: patients’ perceptions of education and support in an intervention for chronic musculoskeletal pain. Pain Med. 2012, 13: 1018-1028.
7. Ministero della Difesa. Eventi del Ministro [Italian Ministry of Defense. Events of the Minister]; 2018. Available at: Accessed April 14, 2019.
8. Ministero della Difesa. Primo Piano [Italian Ministry of Defense. Focus]; 2019. Available at: Accessed on September 18, 2019.
9. North Atlantic Treaty Organization (NATO). Relations with Iraq; 2018. Available at: Accessed on April 24, 2019.

10. North Atlantic Treaty Organization (NATO). NATO and Afghanistan; 2019. Available at: Accessed on April 24, 2019.
11. Institute of Medicine. Returning Home from Iraq and Afghanistan: preliminary assessment of readjustment needs of veterans, service. U.S.: The National Academies, 2010
12. Gironda R. J., Clark M. E., Massengale J. P., Walker R. L. Pain among veterans of Operations Enduring Freedom and Iraqi Freedom. Pain Med 2006, 7: 339-343.
13. Bader C. E., Giordano N. A., McDonald C., Meghani S. H. & Polomano R. S. Musculoskeletal pain and headache in the active duty military population: An integrative review. Worldviews Evid Based Nurs 2018, 15: 264-271.
14. Treede R., Rief W., Barke A., Aziz Q., Bennett M., Benoliel R., & Svensson P. Chronic pain as a symptom or a disease: the IASP Classification of Chronic Pain for the International Classification of Diseases (ICD-11). IASP 2019, 160: 19-27.
15. Kaiser U., Arnold B., Pfingsten M., Johannes B. N., Sabatowski R. Multidisciplinary pain management programs. J. Pain Res 2013, 6: 355-358.
16. Peterson K., Anderson J., Bourne D., Mackey K., & Helfand M. Effectiveness of models used to deliver multimodal care for chronic musculoskeletal pain: a rapid evidence review. J. Gen. Intern. Med. 2018, 33: 71-81.
17. Centro for Effective Practice - Management of chronic non-cancer pain; 2018. Available at: Accessed on April 23, 2019.
18. Institute of Medicine. Treatment for posttraumatic stress disorder in Military and Veteran populations: Final Assessment. U.S: The National Academies, 2014.

19. National Institute of Mental Health. Mental Health Information- Post-Traumatic Stress Disorder; 2019. Available at: Accessed on August 05, 2019.
20. Outcalt S. Pain experience of Iraq and Afghanistan veterans with comorbid chronic pain and posttraumatic stress. J. Rehabil. Res. Dev. 2015, 51: 559-570.
21. Verweij D. Comrades or Friends? On Friendship in the Armed Forces. J. Mil Ethics 2007, 6: 280-291.
22. Lew H. L., Otis J. D., Tun C., Kerns R., Clark M. E., & Cif, D. X. Prevalence of chronic pain, posttraumatic stress disorder, and persistent postconcussive symptoms in OIF/OEF veterans: Polytrauma clinical triad. . Rehabil. Res. Dev. 2009, 46: 697-702.

23. Merrit B. P., Kretzmer T, McKenzie-Hartman T., Gootam P. Neurobehavioral management of the polytrauma veteran. Phys Med Rehabil Clin N Am 2019, 30: 133-154.
24. Randleman M. L., Douglas M. E., DeLane A. M., Palmer A. G. Measuring chronic pain intensity among veterans in a residential rehabilitation treatment program. J. Addict. Nurs. 2014, 2: 74- 80.
25. Outcalt S., Kroenke K.; Krebs E. E., Chumbler N. R., Wu J., Yu Z., Bair M. Chronic pain and comorbid mental health conditions: independent associations of posttraumatic stress disorder and depression with pain, disability, and quality of life. J. Behav. Med. 2015, 38: 535-543.
26. Seal K. H., Bertenthal D., Barnes D. E., Byers A. L., Gibson C. J., Rife T. S., Yaffe K. Traumatic brain injury and receipt of prescription opioid therapy for chronic pain in Iraq and Afghanistan veterans: do clinical practice guidelines matter? J. Pain 2018, 19: 931-941.
27. Kerns R., Philip E., Lee A., Rosemberger P. Implementation of the veterans health administration national pain management strategy. Transl. Behav. Med 2011, 1: 635-643

28. Toblin R. L., Quartana P. J., Riviere L. A., Walper K. C., & Hoge, C. W. Chronic pain and opioid use in U.S. soldiers after combat deployment. JAMA Intern. Med. 2014, 174: 1400-1401.

29. Butt L., & Caplan T. The rehabilitation team. Handbook of Rehabilitation Psychology (2nd ed.: pp. 451-457) New York, NY American Psychological Association, 2010.
30. Dobscha S., Corson K., Perrin N., Hanson G., Leibowitz R., & Gerrity M. Collaborative care for chronic pain in primary care: a cluster randomized Trial. JAMA 2009, 301: 1242-1252.

31. Manchikanti L., Cash K. A., Damron K. S., Manchukonda R., Pampati V., & McManus C. D. Controlled substance abuse and illicit drug use in chronic pain patients: An evaluation of multiple variables. Pain Physician 2006, 9: 215-225.
32. Gordon R. M., Corcoran G. R., Bartley-Daniele P., Sklenar D., Roach Sutton P., Cartwright F. A Transdisciplinary team approach to pain management in inpatient health care settings. Pain Manag Nurs 2014, 5: 426-435.

33. Ministero della Difesa – Operazioni Internazionali [Italian Ministry of Defense. International Operations]; 2019. Available at: Accessed April 2, 2019.

34. Frank J. W., Lovejoy T. I., Becker W. C., Morasco B. J. & Krebs E. Patient outcomes in dose reduction or discontinuation of long- term opioid therapy. A systematic review. Ann. Intern. Med. 2017, 167: 181-191.
35. Latina R, De Marinis MG, Giordano F, Osborn JF, Giannarelli D, Di Biagio E, et al. & Cattaruzza MS. Epidemiology of chronic pain in the Latium Region, Italy: a cross-sectional study on the clinical characteristics of patients attending pain clinics. Pain Manag Nurs 2019, 20: 373-381.
36. Liberati A., Altman D. G., Tetzlaff J., Mulrow C., Gotzsche P. C., Ioannidis J. P., & Moher D. PRISMA Statement per il reporting di revisioni sistematiche e meta-analisi degli studi che valutano gli interventi sanitari: spiegazione e elaborazione [Statement for reporting systematic reviews and meta-analyzes of studies evaluating health interventions: explanation and elaboration]. Gimbe 2015, 7: 1-36.
37. Schulz K. F., Altman D. G., Moher D. Improving the reporting of randomized trials: the CONSORT Statement and beyond. Stat Med 2012, 31: 2985-2997.

38. CONSORT. Statement; 2019. Available at: Accessed on August 2019.
39. Von Elm E, Altman DG, Egger M, Pocock SJ, Gotzsche PC, Vandenbroucke JP. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. Gac Sanit 2008, 22: 144-150.

40. O’Brien B. C., Harris I. B., Beckman T. J., Reed D. A., Cook D. A. Standards for reporting qualitative research: a synthesis of recommendations. Acad Med 2014, 9: 1245-1251.

41. Bair M. J., Ang D., Wu J., Outcalt S., Sargent C., Kempf C., & Kroenke K. Evaluation of stepped care for chronic pain (ESCAPE) in veterans of the Iraq and Afghanistan conflicts. A randomized clinic trial. JAMA 2015, 175: 682-689.
42. Groessl E. J., Liu L., Chang D. G., Wetherell J. L., Bormann J. E., Atkinson J. H., Baxi S., Schmalzi L. Yoga for Military Veterans with Chronic Low Back Pain: A Randomized Clinical Trial. Am J Prev Med 2017, 53 (5): 599-608

43. Kroenke K., Krebs E. E., Wu J., Yu Z., Chumbler N. R., Bair M. J. Telecare Collaborative Management of Chronic Pain in Primary Care: A Randomized Clinical Trial. JAMA 2014, 312 (3): 240-248.
44. Rosen M. I., Becker W. C., Black A. C., Martino S., Edens E. L., Kerns R. D. Brief Counseling for Veterans with Musculoskeletal Disorder, Risky Substance Use, and Service Connection Claims. Pain Med. 2019, 20: 528–542.
45. Herbert M. S., Malaktaris A. L., Dochat C., Thomas M. L. Wetherell L., Afari N. Acceptance and Commitment Therapy for Chronic Pain: Does Posttraumatic Stress Disorder Influence Treatment Outcomes? Pain Med. 2019, 0(0): 1-9.
46. Burgess H. J., Rizvydeen M., Kimura M., Pollack M. H., Hobfoll S. E., Rajan K. B., Burns J. W. An Open Trial of Morning Bright Light Treatment Among US Military Veterans with Chronic Low Back Pain: A Pilot Study. Pain Med. 2018, 0(0): 1-9.

47. King P. R., Beehler G. P., Wade M. J. Self-Reported Pain and Pain Management Strategies Among Veterans With Traumatic Brain Injury: A Pilot Study. Mil. Med. 2015, 180 (8): 863-868.
48. Goode A. P., Taylor S. S., Hastings S. N., Stanwyck C., Coffman C. J., Allen K. D. Effects of a Home-Based Telephone- Supported Physical Activity Program for Older Adult Veterans With Chronic Low Back Pain. Phys Ther 2018, 98 (5): 369-380.

49. Highland K. B., Schoomaker A., Rojas W., Suen J., Ahmed A., Zhang Z., & Buckenmaier C. Benefits of the Restorative Exercise and Strength Training for Operational Resilience and Excellence Yoga Program for Chronic Lower Back Pain in Service Members: A Pilot Randomized Control Trial. Arch Phys 2017, 1-22.

50. Anamkath N. S., Palyo S. P., Jacobs S. C., Lartigue A., Schopmeyer K., Stigo I. A. An Interdisciplinary Pain Rehabilitation Program for Veterans with Chronic Pain: Description and Initial Evaluation of Outcomes. Pain Res Manag 2018, 1-9.
51. Carey E. P., Nolan C., Kerns R. D., Ho P. M., Frank J. W. Association Between Facility-Level Utilization of Non-pharmacologic Chronic Pain Treatment and Subsequent. Initiation of Long-Term Opioid Therapy. J. Gen. Int. Med. 2018, 33(1): 38-45.
52. Edmond S., Moore B. A., Dorflinger L. M., Goulet J. L., Becker W. C., Heapy A. A. Sellinger J. J., & Kerns R. D. Project STEP: Implementing the veterans health administration stepped care model of pain management. Pain Med. 2018, 19: 30-37.

53. Han L., Goulet J. L., Skanderson M., Bathulapalli H., Luther S. L. Kerns R. D., Brandt C. A. Evaluation of Complementary and Integrative Health Approaches Among US Veterans with Musculoskeletal Pain Using Propensity Score Methods. Pain Med. 2019, 20, 90-102.
54. Herbert M. S., Afari N., Liu, L., Heppner P., Rutledge T., Williams K., & Wetherell L. Telehealth versus In-Person Acceptance and Commitment Therapy for Chronic Pain: A Randomized Non-Inferiority Trial. J. Pain 2016, 2-29.

55. Kay C., Wozniak E., Ching A., Bernstein J. Health care utilization by veterans prescribed chronic opioids. J. Pain Res. 2018, 11: 1779-1787.

56. Cummins D. M., Tobian R. Motivational Enhancement Therapy for Veterans with Chronic Pain and Substance Use. Health Soc Work 2018, 43(4): 269-273.
57. Koffel E., Kroenke K., Bair M. J., Laverty D., Polusny M. A., Krebs E. E. The bidirectional relationship between sleep complaints and pain: analysis of data from a randomized trial. Health Psychol 2016, 35: 41-49.
58. The British Army. Army the Best. Army Medical Service; 2019. Available at: . Accessed on September 11, 2019.
59. Nicolescu B., Manifesto of transdisciplinarity. N.Y: State Univ of New York, 2002

60. Carey E. P., Nolan C., Kerns R. D., Ho P. M., Frank J. W. Association Between Facility-Level Utilization of Non-pharmacologic Chronic Pain Treatment and Subsequent. Initiation of Long-Term Opioid Therapy. J. Gen. Intern. Med. 2018, 33(1): 38-45.
61. National Safety Council. Safety Topics Opioids; 2018. Available at: Accessed on July 25, 2019.

62. National Institute of Health. National Institute on Drug Abuse. Opioid Overdose Crisis; 2019. Available at: Accessed on November 27, 2019.
63. King P. R., Beehler G. P., Wade M. J. Self-Reported Pain and Pain Management Strategies Among Veterans With Traumatic Brain Injury: A Pilot Study. Mil. Med. 2015, 180(8): 863-868.

64. Herbert M. S., Malaktaris A. L., Dochat C., Thomas M. L. Wetherell L., Afari N. Acceptance and Commitment Therapy for Chronic Pain: Does Posttraumatic Stress Disorder Influence Treatment Outcomes? Pain Medicine 2019, 0(0): 1-9.

65. The Balance Careers. U.S. Military Careers. Age Limits Within Military Service Branches; 2019. Available at: Accessed on September 13, 2019.
66. Council Foreign Relations. Demographics of the U.S. Military; 2019. Available at: Accessed on September 13, 2019.
67. Hoffman J. M., Ehde D. M., Dikmen S., Dillworth T., Gertz K., Kincaid C., Lucas S., Temkin N., Sawyer K., Williams R. Telephone-delivered cognitive behavioral therapy for veterans with chronic pain following traumatic brain injury: Rationale and study protocol for a randomized controlled trial study. Contemp. Clinic.Trials 2019, 76: 112-119.

68. Denke L., Barnes D., An Ethnography of Chronic Pain in Veteran Enlisted Women. Pain management nursing 2013, 95 (14).
69. Kress HG., Aldington D., Alon, E., Coaccioli S., & C., SichÞre P. A holistic approach to chronic pain management that involves all stakeholders: change is needed. CURR MED RES OPIN 2015, 31: 1743-1754.

70. Latina R., Mastroianni C., Sansoni J., Piredda M., Casale G., D'Angelo D., Tarsitani G., De Marinis M.G. The use of complementary therapies for chronic pain in Italian hospices. Prof Inferm 2012, 65: 244-50.

71. Matthias M. S., Miech E. J., Myers L. J., Sargent C., Bair M. J. A qualitative study of chronic pain in Operation Enduring Freedom/Operation Iraqi Freedom Veterans: "a burden on my soul". Mil. Med. 2014, 179: 26-30.

Most read articles by the same author(s)

1 2 > >>