As many as 66% of Veterans with post-traumatic stress disorder also report chronic pain, a prevalence rate far higher than that of the general population.1,2 The statistics raise significant concern for service members returning from recent conflicts abroad, as well as those suffering PTSD effects from decades ago. Eighty percent of Vietnam Veterans receiving treatment for PTSD reported suffering from chronic pain.3 More recent population sample studies of Veterans have shown that up to 50% of those seeking treatment for pain have a diagnosis of PTSD or significant PTSD symptoms, and 45% to 80% of those seeking treatment for PTSD suffer from chronic pain.4

 

Rising Rates of Polytrauma

Some of the reasons behind increasing rates of comorbid PTSD and pain have to do with advances in battlefield medicine and protective armor, which have led to increased survival rates in those enduring physical injuries that would have been fatal in prior wars.5,6 These sustained injuries coupled with PTSD have been coined as “polytrauma” by the Department of Veterans Affairs (VA). The specific definition is: “two or more injuries to physical regions or organ systems, one of which may be life-threatening, resulting in physical, cognitive, psychological, or psychosocial impairments and functional disability.”7

Further investigations related to PTSD, chronic pain and persistent post-concussive symptoms in Operation Iraqi Freedom and Operation Enduring Freedom (OIF/OEF) Veterans revealed a characteristic polytrauma clinical triad.8,9

This triad is characterized by:

  • pain
  • PTSD
  • traumatic brain injury (TBI)

To make matters more complicated, the co-occurrence of pain and PTSD symptoms predicts greater decreased life satisfaction and functioning than the effects of PTSD alone.10 Experiences of pain may act as reminders of the traumatic event when the injury was sustained.11

In terms of approaching care, the relationship between a patient’s PTSD symptoms and pain often differs among individual Veterans depending on the deployment-related injury status.12 Thus, how we look at and understand the mechanisms and relationships by which pain and PTSD symptoms co-exist is required to fully understand and treat both conditions effectively.

 

The Path to PTSD and Its Classifications

The VA describes the spectrum of conditions that may lead to PTSD as starting with an inciting traumatic event, which then leads to an acute stress reaction (ASR). This reaction may disappear within days or potentially hours. If not resolved, however, clinically significant impairment symptoms may lead to acute stress disorder (ASD), described as symptoms experienced 48 hours to one month following the traumatic event. 13,14

People with ASD commonly report sleeping problems, pain, and other somatic issues. ASD has been shown to be a strong predictor of PTSD.13,14

PTSD is recognized when clinically significant symptoms, causing major impairments in occupational, social, and other critical areas of functioning, persist past one month of the traumatic event. More specifically:

  • Acute PTSD is recognized as symptoms lasting greater than one month, but less than 3 months after the traumatic event.
  • Chronic PTSD is recognized as clinically significant symptoms lasting more than three months after trauma exposure. It is widely recognized that chronic PTSD commonly needs effective treatment to improve symptomatology.
  • Lastly, PTSD with delayed onset is recognized as the onset of clinically significant symptoms at least six months after trauma exposure.13

In this article, we consider PTSD collectively and will not differentiate proposed treatments based on various classifications of post-traumatic stress disorder.

Acute PTSD Conventional Treatments

A variety of treatment approaches have been proposed for acute PTSD. The VA and Department of Defense recommend early intervention – that is, within four days after trauma exposure. The triage and management of acute traumatic stress include psychological first aid (PFA) and meeting of physiological needs, such as safety, food, hydration, shelter, and so forth.

PFA is designed to “stop the psychological bleeding” through protection from further harm, minimizing physiological arousal, addressing immediate needs, and prioritizing those who are most distressed. Early conventional interventions that have been noted to have significant benefit include brief cognitive therapy of approximately four to five sessions.

In contrast, psychological debriefing and early medication intervention in the form of benzodiazepines and typical antipsychotics have been shown to provide no benefit, according to the VA Practice Guidelines for Post-Traumatic Stress.14 (More on pharmacological considerations below.)

Long-Term Conventional Treatments

Trauma-focused Psychotherapy

Collectively, the VA’s recommended approach for managing comorbid PTSD and pain includes a first-line treatment of psychotherapeutic intervention or trauma-focused therapy (eg, Eye Movement Desensitization and Reprocessing) with adjunctive individual or group psychosocial therapy. Adjunctive treatment may include symptom-specific management of pain, sleep disturbances, and anger.13,14

SSRIs

For patients who choose not to engage or cannot access trauma-focused psychotherapy, the VA recommends specific SSRIs, including sertraline, paroxetine, fluoxetine, or venlafaxine as a monotherapy option for PTSD. Potential adverse effects should be noted, including sexual dysfunction, increased sweating, gastrointestinal upset, drowsiness, and fatigue. With SSRI treatment also comes the increased risk of suicidal thinking and suicidality,  especially in those under age 24.13-16

Non-Opioid Treatments for Pain

Non-opioid treatments recommended by the VA for the treatment of chronic pain include topicals, such as diclofenac gel, and oral meds such as anti-inflammatories (for muscle or bone pain), antidepressants (for muscle, bone, and nerve pain), and anticonvulsants such as gabapentin (for nerve pain).17

Alpha-1 Adrenoreceptor Antagonists

It is important to note that hyperactivity of the noradrenergic system has been identified as an underlying neurobiological mechanism in PTSD. Alpha 1-adrenoreceptor antagonists such as prazosin and doxazosin have been shown to alleviate nightmares and sleep disturbances induced by PTSD in military Veterans. Several double-blinded RCTs among military Veterans revealed reductions of symptoms as measured on the PTSD Checklist (military version) and the CAPS Hyperarousal Scale.18-23

Of note, doxazosin has been associated with significant reduction in alcohol consumption and cravings among individuals with a significant family history of alcoholism. A limitation of prazosin is its short half-life, leading to challenges with medication adherence and stable therapeutic dose. 18-23

Contraindications in Conventional Treatments of PTSD

As the VA recognizes PTSD as a significant risk factor in the prevalence of chronic pain, it recommends against the use of benzodiazepines in the treatment of PTSD and recommends caution when prescribing benzodiazepines for Veterans with PTSD and comorbid chronic pain.

Benzodiazepines for treatment of acute anxiety manifestations are associated with a greater incidence of PTSD symptoms, as well as tolerance to increasing doses.24 Likewise, both benzodiazepines and opioids are associated with increased CNS depression. It should be noted that concurrent benzodiazepine use is a contraindication to the initiation of opioid therapy in the conventional treatment of comorbid chronic pain and PTSD. (More on the risks of co-prescribing benzodiazepines and opioids.)

Given the multitude of potential adverse effects and addictive qualities in pharmacologic treatments, an integrative approach to managing comorbid PTSD and pain should be strongly considered in the Veteran patient population. The authors describe such an approach in the following sections.

Integrative Treatments for PTSD

A variety of integrative treatments have shown to be beneficial in the treatment of co-existing PTSD and chronic pain. The following section focuses on the therapeutic effects of exercise, meditation, recreational therapy, and several forms of acupuncture.

Exercise

Exercise is known to be a supportive treatment. According to the Cross-Stressor Adaptation Hypothesis, participation in frequent exercise with adequate intensity and duration leads to habituation to exercise stressors, including rapid breathing, increased heart rate, and physiological arousal. Consequently, these physiological stressors of exercise can cause adaptations in the stress response system. These adaptations can lead to improved responses to non-exercise stressors and trauma-related stimuli associated with PTSD.254

Additionally, exercise can improve pain outcomes, which support the mind-body connection of PTSD. When paired with psychotherapy, exercise produces greater reduction in PTSD symptoms than psychotherapy as a standalone treatment. Another mechanism in which exercise improves PTSD symptoms is through sleep improvement.25,26

Meditation

Meditation comes in many forms, with the ultimate goal of achieving a more balanced and present-state mind. Transcendental Meditation, in particular, has shown to have a positive impact on the symptoms of PTSD in Veterans. The technique – practiced 20 minutes twice daily while sitting comfortably with eyes closed – promotes stress and anxiety relief and works to improve brain function and memory. Transcendental Meditation ­– which can be practiced by patients at home and guided by clinicians if necessary – can help to promote a deeper state of rest, which can promote greater energy, improve quality of life, and build stress resilience.27,28

Acupuncture

Acupuncture is a safe, cost-effective, and non-stigmatizing treatment with a vast body of literature demonstrating its benefits for PTSD symptoms and chronic pain.29,30 There are many forms of acupuncture, including body acupuncture, medical acupuncture, auricular acupuncture, Chinese scalp acupuncture, and auricular acupuncture, also referenced as battlefield acupuncture (BFA).

Modern physicians practice acupuncture in ways that capture traditional and mechanistic traditions. Neuroimaging and physiological studies have demonstrated effects on the cortical, limbic, and autonomic nervous systems. 29,30

For example, Engel et al30 explored the impact of PTSD symptoms when comparing usual PTSD care as defined by the VA/DoD Clinical Practice Guideline for the Management of PTSD,15 and usual care plus acupuncture. The acupuncture intervention consisted of 60-minute treatment sessions, two times per week, for a total of 4 weeks. Results demonstrated significantly greater improvement in secondary outcome measures of pain, depression, physical health function, and mental health function.

Auricular acupuncture, in particular, is organized according to the reflex somatotopic system on the surface of the external ear. The external ear, with an atypical embryological pattern, with tissue originating from endodermal, mesodermal, and ectodermal layers, is easy to access. Similar to the “little man” cortical homunculus, the external auricle shares a similar somatotopic map of body systems. Auricular zones enable acupuncture needle access to ectodermal and intracranial structures. Physicians have developed a specific point combination to target common symptoms, including for acute pain.31-32

Auricular acupuncture has a unique application in the military population, especially in deployed and operational situations where, unlike pain and sedative medications, auricular acupuncture does not hinder performance, cognition, or cause addiction. Compared to other forms of acupuncture, auricular acupuncture can be offered in stringent settings where military service members must remain in body armor and promptly return to duty upon treatment completion – thus, its reference to “battlefield acupuncture.” The robust treatment option can help to ease a variety of PTSD and pain-related conditions, such as back pain.33,34

Likewise, an auricular trauma protocol (ATP) is a six-point collection that is used to target acute stress and PTSD. The protocol influences brain structures, including the hippocampus, amygdala, hypothalamus, prefrontal cortex, and parasympathetic nervous system. The ATP has been successfully utilized as a treatment for mild TBI, acute stress, PTSD, and chronic pain. Additionally, acupuncture has shown to successfully treat PTSD-associated tinnitus in war Veterans.32-35

Overall, acupuncture offers a variety of cost-effective treatment options with a wide range of benefits and should be strongly considered in the treatment of PTSD and pain for active duty service members and Veterans alike.

Recreational Therapy

Recreational therapy as a form of treatment is designed to restore prior levels of functioning (such as after a traumatic injury) or to promote health, wellness, and quality of life. Recreational interventions can be customized to the needs of the patient and may include sports, crafts, gardening, dance, drama, bird-watching, and more.

With outdoor recreational activities, such as equine-related therapy or fly-fishing, the proposed mechanism or “active ingredient” in healing includes behavioral activation, social support, effects of exercise on mood, modified attentional focus, unique effects of interactions with animals, and increased exposure to sunlight with its physiological and emotional effects.36

Recreational therapy is often overlooked by providers and should be strongly considered as it offers unique benefits without the associated stigma and patient reluctance.36 A study published in Military Medicine demonstrated that outdoor recreational therapy is linked to significant elevations in attentiveness and positive mood states, as well as a marked reduction in depression, anxiety, somatic stress, and negative mood states. Later analysis demonstrated improvements in sleep quality and significant reductions in perceived stress and PTSD symptoms. Leisure coping strategies are postulated to distract individuals from trauma and assist reconnection with self, prior to trauma.37

Several organizations, such as the Wounded Warrior Project, provide funding for Veterans to receive complimentary recreational therapy through events such as Project Odyssey Veteran Retreat. These options should be fully explored and discussed in the Veteran population.38

 

Osteopathic Approach to PTSD

Anatomical and Physiological Considerations

Post-traumatic stress disorder has unique anatomical and physiological considerations that impact symptoms. A study conducted by the Center for Imaging of Neurodegenerative Diseases at the San Francisco VA Hospital found MRI evidence of ongoing brain tissue volume loss in Veterans with PTSD, specifically in the brainstem, as well as frontal and temporal lobes. Results also suggested that increased PTSD symptoms may signify further brain injury. Findings noted that brain atrophy was connected to increased rates of decline in verbal recall and delayed facial recognition. Such anatomical brain changes in PTSD are suggestive to a greater risk of future cognitive impairments and dementia.39

Additionally, other neural mechanisms have been identified as underlying neurophysiology involved in the manifestation of PTSD. A study conducted in 2017 examined the neurophysiology of PTSD using magnetoencephalography (MEG). Combat Veterans with and without PTSD were compared. Findings demonstrated that Veterans with PTSD had significantly stronger neural activity in prefrontal, sensorimotor, and temporal areas compared to the control group. Veterans with PTSD demonstrated stronger activity in the amygdala, hippocampus, and hippocampal gyrus brain areas, whereas Veterans without PTSD had stronger neural activity in the occipital cortex.40

Further research on the neurobiological impact of psychological trauma of PTSD demonstrated that chronic dysregulation of the autonomic nervous system “flight or fight” response may lead to functional impairment in people with PTSD.41 The hypothalamic-pituitary-adrenal (HPA) axis is the major coordinator of the neuroendocrine stress response and is adversely impacted after post-traumatic stress. Furthermore, neurobiological abnormalities such as altered mechanisms of learning and extinction, sensitization to stress and arousal have been identified in PTSD.41,42

PTSD may be associated with an increased allostatic load, which manifests as physical dysfunctions, such as chronic musculoskeletal pain, hypertension, hyperlipidemia, obesity, and cardiovascular disease.42,43 Thus, in many cases, the anatomical, physiological, and musculoskeletal considerations noted above may be essential for optimal outcomes in patients with PTSD.

Osteopathic medicine recognizes these intricate relationships and addresses a person as a whole in relation to physical, psychological, social, and spiritual aspects of health. The osteopathic approach seeks health and optimal function.44

To address somatic dysfunction and calm the dysfunctional autonomic response and dysregulated brain chemistry in those with PTSD, providers may consider osteopathic manipulation. The technique focuses on various systems, including the nervous and circulatory systems, spine, viscera, cranium, and thoracic and abdominal diaphragm, to restore homeostasis and normalize autonomic activity.44-50

To address the physiologic considerations indicated above, the authors recommend treatment of the head and neck to effect changes in vagus nerve tone, the thoracic spine to address sympathetic dysregulation, and the sacrum to address the parasympathetic tone of the lower GI tract. The following osteopathic techniques are examples that may be used on a case-by-case basis but.

Suboccipital Release51

The suboccipital release is a gentle, simple technique that is effective in calming the autonomic nervous system by balancing the parasympathetic tone via the vagus nerve. More specifically, suboccipital release reduces suboccipital myofascial tensions to achieve neurovegetative inhibition.

Frontal Lift

The frontal lift is a gentle, simple technique that affects the frontal cortex, a critical part of judgement and decision making. The frontal lift technique rebalances frontal bone dysfunction at the sutural level, including frontoparietal and frontal nasal sutures. The frontal lift technique supports the relaxation of the underlying dura mater.

Sacral Rocking

Sacral rocking is a gentle, simple technique that helps stimulate parasympathetic tone via S2-4, driving the body into a further “rest and digest” physiological function.

Rib Raising

Rib raising is a gentle, simple articulatory technique that addresses restricted excursion of the rib cage. Rib raising modulates the autonomic nervous system and helps decrease sympathetic tone in the area of the closely approximated sympathetic chain. Rib raising has been shown to decrease salivary α-amylase activity immediately after the technique and 10 minutes post-procedure, as well.52 Research demonstrates that salivary α-amylase levels increase in response to physical or psychological stress. As noted, the use of salivary biomarkers to examine autonomic activity is a widely accepted noninvasive approach.18-20

Rib raising has shown to decrease salivary α-amylase activity immediately after the technique and 10 minutes post-procedure, as well.53 Research demonstrates that salivary α-amylase levels increase in response to physical or psychological stress.17,18 Use of salivary biomarkers to examine autonomic activity is a widely accepted noninvasive approach.18

Osteopathic Manipulation Protocol Recommendations

The dosage of treatment depends upon the patient response, but generally speaking, we recommend osteopathic manipulation once per week over four to five consecutive weeks, re-evaluating somatic dysfunction and tissue tension before and after each treatment to determine patient response.

Care should be combined with other forms of integrative treatments as listed herein.

A Step Further: Biotensegrity and SomatoEmotional Release

There are many biological rationales for the concept of equivalence of mind and body, the living matrix. The living matrix has been described as the “first responder” when an organism is faced with a life-or-death experience and other traumas such as physical and emotional abuse. As such, military combat scenarios are characteristic of life-or-death experiences.

It is postulated that emotional trauma is first registered by this matrix, rather than the nervous system.54 This is a basis for the concept that traumatic memories affect the living matrix, leading to dysfunctions in the body, widely recognized as lesions and somatic dysfunction.55

It has been postulated that post-traumatic stress disorder is not mental but rather a biophysical manifestation. The living matrix encapsulates the traumatic memory in an effort to reduce further damage.54,55

Gentle hands-on methods, such as SomatoEmotional Release have been shown to resolve emotional trauma arising from interactions with tissues where the traumatic structural patterns and cellular memories occupy.55

Overall, the authors hold that osteopathic treatments can be highly effective at identifying anatomical dysfunction and considering the patient as a whole.

Professional Takeaways

  • A safe and effective medical approach to managing comorbid PTSD and chronic pain includes conventional treatments, integrative treatments, and osteopathic manipulative medicine.
  • Osteopathic treatments can successfully identify anatomical dysfunction and help to treat pain using a whole-person approach.  Biomarkers such as blood pressure, salivary amylase, and heart rate are inexpensive markers to further validate the extent of autonomic dysfunction, HPA axis function, and PTSD symptomatology.
  • Adverse risks associated with the integrative treatments discussed are extremely low. Given the potential upside in dysfunctional autonomic responses and dysregulated brain chemistry of the patient, the authors recommended integrated care in the management of PTSD in Veterans and in the general population.
  • Further research is needed to optimize a treatment protocol for improved clinical practice when treating comorbid PTSD and chronic pain, ideally to be conducted within the Veterans Health Administration.
  • Given the unique needs of Veterans with PTSD, a whole-person treatment approach should be implemented for this honorably deserving population.

 

 

Acknowledgments: The lead author would like to acknowledge Joshua Pendlebury, CPL, CTRS for his combat military service in Operation Iraqi Freedom and Operation Enduring Freedom with the United States Marine Corps. His military service and healing journey inspired an unwavering passion to address the critical needs of Veterans. Additional thanks are offered to Pendlebury for his valuable insight regarding his expertise on recreational therapy as a safe and effective treatment for Veterans with PTSD and comorbid chronic pain.

References
Last Updated: Nov 23, 2020