Complicating Factors Associated with Mild Traumatic Brain Injury: Impact on Pain and Posttraumatic Stress Disorder Treatment

  • John D. Otis
  • Regina McGlinchey
  • Jennifer J. Vasterling
  • Robert D. Kerns


The nature of combat in Iraq and Afghanistan has resulted in high rates of comorbidity among chronic pain, posttraumatic stress disorder (PTSD), and mild traumatic brain injury (mTBI) in Veterans of Operations Enduring Freedom and Iraqi Freedom (OEF/OIF). Although separate evidence-based psychological treatments have been developed for chronic pain and PTSD, far less is known about how to approach treatment when these conditions co-occur, and especially when they co-occur with mTBI. To provide the best care possible for OEF/OIF Veterans, clinicians need to have a clearer understanding of how to identify these conditions, ways in which these conditions may interact with one another, and ways in which existing evidence-based treatments can be modified to meet the needs of individuals with mTBI. The purpose of the present paper is to review the comorbidity of pain, PTSD, and mTBI in OEF/OIF Veterans, and provide recommendations to clinicians who provide care to Veterans with these conditions. First, we will begin with an overview of the presentation, symptomatology, and treatment of chronic pain and PTSD. The challenges associated with mTBI in OEF/OIF Veterans will be reported and data will be presented on the comorbidity among all three of these conditions in OEF/OIF Veterans. Second, we will present recommendations for providing psychological treatment for chronic pain and PTSD when comorbid with mTBI. Finally, the paper concludes with a discussion of the need for a multidisciplinary treatment approach, as well as a call for continued research to further refine existing treatments for these conditions.


Pain Posttraumatic stress disorder Traumatic brain injury Polytrauma Integrated intervention 


  1. Alexander, M. P. (1995). Mild traumatic brain injury: Pathophysiology, natural history, and clinical management. Neurology, 45, 1253–1260.PubMedGoogle Scholar
  2. American Congress of Rehabilitation Medicine. (1993). Definition of mild traumatic brain injury. Journal of Head Trauma Rehabilitation, 8, 86–87.CrossRefGoogle Scholar
  3. American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author.Google Scholar
  4. Barrow, I. M., Collins, J. N., & Britt, L. D. (2006a). The influence of an auditory distraction on rapid naming after a mild traumatic brain injury: A longitudinal study. Journal of Trauma, 61, 1142–1149.PubMedCrossRefGoogle Scholar
  5. Barrow, I. M., Hough, M., Rastatter, M. P., Walker, M., Holbert, D., & Rotondo, M. F. (2006b). The effects of mild traumatic brain injury on confrontation naming in adults. Brain Injury, 20, 845–855.PubMedCrossRefGoogle Scholar
  6. Belanger, H. G., Curtiss, G., Demery, J. A., Lebowitz, B. K., & Vanderploeg, R. D. (2005). Factors moderating neuropsychological outcomes following mild traumatic brain injury: A meta-analysis. Journal of the International Neuropsychological Society, 11, 215–227.PubMedCrossRefGoogle Scholar
  7. Bigler, E. D. (2008). Neuropsychology and clinical neuroscience of persistent post-concussive syndrome. Journal of the International Neuropsychological Society, 14, 1–22.PubMedCrossRefGoogle Scholar
  8. Bilmes, L. (January, 2007). Soldiers returning from Iraq and Afghanistan: The long-term costs of providing Veterans medical care and disability benefits. John F. Kennedy School of Government, Harvard University; RWP07-001.Google Scholar
  9. Bruner, E. F. (2006). Military forces: What is the appropriate size for the United States?. Washington, DC: Congressional Research Service.Google Scholar
  10. Bryant, R. A., Moulds, M., Guthrie, R., & Nixon, R. D. (2003). Treating acute stress disorder after traumatic brain injury. American Journal of Psychiatry, 160, 585–587.PubMedCrossRefGoogle Scholar
  11. Buffum, M. D., Hutt, E., Chang, V. T., Craine, M., & Snow, A. L. (2007). Cognitive impairment and pain management. Journal of Rehabilitation Research and Development, 44, 315–330.PubMedCrossRefGoogle Scholar
  12. Cernak, I., & Noble-Haeusslein, L. J. (2010). Traumatic brain injury: An overview of pathobiology with emphasis on military populations. Journal of Cerebral Blood Flow and Metabolism, 30, 255–266.PubMedCrossRefGoogle Scholar
  13. Chard, K. M., Schumm, J. A., McIlvain, S., Bailey, G., & Parkinson, R. B. (2010). Examining the effectiveness of CPT-C in a residential program for Veterans with PTSD and TBI. Paper presented at the ISTSS 26th Annual Meeting, Montréal, Québec, Canada.Google Scholar
  14. Chibnall, J. T., & Tait, R. C. (2001). Pain assessment in cognitively impaired and unimpaired older adults: A comparison of four scales. Pain, 92, 173–186.PubMedCrossRefGoogle Scholar
  15. Clark, M. E., Bair, M. J., Buckenmaier, C. C., Gironda, R. J., & Walker, R. L. (2007). Pain and combat injuries in soldiers returning from Operations Enduring Freedom and Iraqi Freedom: Implications for research and practice. Journal of Rehabilitation, Research and Development, 44, 179–194.CrossRefGoogle Scholar
  16. Defense Manpower Data Center. (n.d.). Global war on terrorism—Operation Iraqi Freedom by casualty category within service, March 19, 2003 through December 6, 2008. Retrieved from Department of Defense Personnel & Procurement Statistics website
  17. DePalma, R. G., Burris, D. G., Champion, H. R., & Hodgson, M. J. (2005). Blast injuries. New England Journal of Medicine, 352, 1335–1342.PubMedCrossRefGoogle Scholar
  18. Dikmen, S., Machamer, J., Rann, J. R., & Temkin, N. R. (2010). Rates of symptom reporting following traumatic brain injury. Journal of the International Neuropsychological Society, 16, 401–411.PubMedCrossRefGoogle Scholar
  19. Dikmen, S. S., Machamer, J. E., & Winn, H. (1995). Neuropsychological outcome at 1-year post head-injury. Neuropsychology, 9, 80–90.CrossRefGoogle Scholar
  20. Fisher, S., Burgio, L., Thorne, B., Allen-Burge, R., Gerstle, J., Roth, D., et al. (2002). Pain assessment and management in cognitively impaired nursing home residents: Association of Certified Nursing Assistant pain report, Minimum Data Set pain report, and analgesic medication use. Journal of the American Geriatrics Society, 50, 152–156.PubMedCrossRefGoogle Scholar
  21. Galarneau, M. R., Woodruff, S. I., Dye, J. L., Mohrle, C. R., & Wade, A. L. (2008). Traumatic brain injury during Operation Iraqi Freedom: Findings from the United States Navy-Marine Corps Combat Trauma Registry. Journal of Neurosurgery, 108, 950–957.PubMedCrossRefGoogle Scholar
  22. Gironda, R. J., Clark, M. E., Massengale, J. P., & Walker, R. L. (2006). Pain among Veterans of Operation Enduring Freedom and Iraqi Freedom. Pain Medicine, 7, 339–343.PubMedCrossRefGoogle Scholar
  23. Haskell, S. G., Heapy, A., Reid, M. C., Papas, R., & Kerns, R. D. (2006). The prevalence and age-related characteristics of pain in a sample of women veterans receiving primary care. Journal of Women’s Health, 15, 864–871.CrossRefGoogle Scholar
  24. Haskell, S. G., Ning, Y., Krebs, E., Goulet, J., Mattocks, K., Kerns, R. D., et al. (in press). The prevalence of painful musculoskeletal conditions in female and male Veterans in 7 years after return from deployment in Operation Enduring Freedom/Operation Iraqi Freedom. Clinical Journal of Pain.Google Scholar
  25. Heinrich, R. L., Choen, M. J., Naliboff, B. D., Collins, G. A., & Bonebakker, A. D. (1985). Comparing physical and behavioral therapy for chronic low back pain on physical abilities, psychological distress and patients’ perceptions. Journal of Behavioral Medicine, 8, 61–78.PubMedCrossRefGoogle Scholar
  26. Herr, K., Coyne, P. J., Key, T., Manworren, R., McCaffery, M., Merkel, S., et al. (2006). American Society for Pain Management Nursing. Pain assessment in the nonverbal patient: Position statement with clinical practice recommendations. Pain Management Nursing, 7, 44–52.PubMedCrossRefGoogle Scholar
  27. Hoffman, B. M., Papas, R. K., Chatkoff, D. K., & Kerns, R. D. (2007). Meta-analysis of psychological interventions for chronic low-back pain. Health Psychology, 26, 1–9.PubMedCrossRefGoogle Scholar
  28. Hoge, C. W., Castro, C. A., Messer, S. C., McGurk, D., Cotting, D. I., & Koffman, R. L. (2004). Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. New England Journal of Medicine, 351, 13–22.PubMedCrossRefGoogle Scholar
  29. Hoge, C. W., McGurk, D., Thomas, J. L., Cox, A. L., Engel, C. C., & Castro, C. A. (2008). Mild traumatic brain injury in U.S. Soldiers returning from Iraq. New England Journal of Medicine, 358, 453–463.PubMedCrossRefGoogle Scholar
  30. Holroyd, K. A., O’Donnell, F. J., Stensland, M., Lipchik, G. L., Cordingley, G. E., & Carlson, B. (2001). Management of chronic tension-type headache with tricyclic antidepressant medication, stress-management therapy, and their combination: A randomized controlled trial. JAMA, 285, 2208–2215.PubMedCrossRefGoogle Scholar
  31. Horgas, A. L., Elliott, A. F., & Marsiske, M. (2009). Pain assessment in persons with dementia: Relationship between self-report and behavioral observation. Journal of the American Geriatrics Society, 57, 125–132.CrossRefGoogle Scholar
  32. Iverson, G. I., Zasler, N. D., & Lang, R. T. (Eds.). (2007). Postconcussion disorder. New York: Demos.Google Scholar
  33. Keane, T. M., Fairbank, J. A., Caddell, J. M., & Zimering, R. T. (1989). Implosive (flooding) therapy reduces symptoms of PTSD in Vietnam combat Veterans. Behavior Therapy, 20, 245–260.CrossRefGoogle Scholar
  34. Keane, T. M., & Kaloupek, D. G. (1982). Imaginal flooding in the treatment of posttraumatic stress disorder. Journal of Consulting and Clinical Psychology, 50, 138–140.PubMedCrossRefGoogle Scholar
  35. Kerns, R. D., Otis, J. D., Rosenberg, R., & Reid, C. (2003). Veterans’ concerns about pain and their associations with ratings of health, health risk behaviors, affective distress, and use of the healthcare system. Journal of Rehabilitation, Research and Development, 40, 371–380. PMID: 15080222.Google Scholar
  36. Kessler, R. C., Bergland, P., Demler, O., Jin, R., & Walters, E. E. (2005). Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62, 593–602.PubMedCrossRefGoogle Scholar
  37. King, N. S., Crawford, S., Wenden, F. J., Moss, N. E., & Wade, D. T. (1995). The Rivermead Post Concussion Symptoms Questionnaire: A measure of symptoms commonly experienced after head injury and its reliability. Journal of Neurology, 242, 587–592.PubMedCrossRefGoogle Scholar
  38. King, L. A., King, D. W., Bolton, E. E., Knight, J. A., & Vogt, D. S. (2008). Risk factors for mental, physical, and functional health in Gulf War veterans. Journal of Rehabilitation Research and Development, 45, 395–407.PubMedCrossRefGoogle Scholar
  39. Lew, H., Otis, J. D., Tun, C., Kerns, R. D., Clark, M. E., & Cifu, D. X. (2009). Prevalence of chronic pain, posttraumatic stress disorder and persistent post-concussive symptoms in OEF/OIF Veterans: The polytrauma clinical triad. Journal of Rehabilitation, Research and Development, 46, 697–702. PMID: 20104399.CrossRefGoogle Scholar
  40. Lew, H. L., Poole, J. H., Vanderploeg, R. D., Goodrich, G. L., Dekelboum, S., Guillory, S. B., et al. (2007). Program development and defining characteristics of returning military in a VA Polytrauma Network Site. Journal of Rehabilitation, Research and Development, 44, 1027–1034.CrossRefGoogle Scholar
  41. Linton, S. J., & Ryberg, M. (2001). A cognitive-behavioral group intervention as prevention for persistent neck and back pain in a non-patient population: A randomized controlled trial. Pain, 90, 83–90.PubMedCrossRefGoogle Scholar
  42. Lippa, S. M., Pastorek, N. J., Benge, J. F., & Thornton, G. M. (2010). Postconcussive symptoms after blast and nonblast-related mild traumatic brain injuries in Afghanistan and Iraq War Veterans. Journal of the International Neuropsychological Society, 16, 856–866.PubMedCrossRefGoogle Scholar
  43. Lundin, A., de Boussard, C., Edman, G., & Borg, J. (2006). Symptoms and disability until 3 months after mild TBI. Brain Injury, 20, 799–806.PubMedCrossRefGoogle Scholar
  44. McAllister, T. W., Flashman, L. A., McDonald, B. C., & Saykin, A. J. (2006). Mechanisms of working memory dysfunction after mild and moderate TBI: Evidence from functional MRI and neurogenetics. Journal of Neurotrauma, 23, 1450–1467.PubMedCrossRefGoogle Scholar
  45. McCrea, M. (2008). Mild traumatic brain injury and post-concussion syndrome: The new evidence base for diagnosis and treatment (pp. 84–87). New York: Oxford University Press.Google Scholar
  46. Merskey, H., & Bogduk, N. (1994). IASP task force on taxonomy (pp. 209–214). Seattle, WA: IASP Press.Google Scholar
  47. Monson, C. M., Schnurr, P. P., Resick, P. A., Friedman, M. J., Young-Xu, Y., & Stevens, S. P. (2006). Cognitive processing therapy for veterans with military-related posttraumatic stress disorder. Journal of Consulting and Clinical Psychology, 74, 898–907.PubMedCrossRefGoogle Scholar
  48. Moser, R. S., Schatz, P., & Jordan, B. D. (2005). Prolonged effects of concussion in high school athletes. Neurosurgery, 57, 300–306. discussion 300–306.PubMedCrossRefGoogle Scholar
  49. Omalu, B. I., DeKosky, S. T., Minster, R. L., Kamboh, M. I., Hamilton, R. L., & Wecht, C. H. (2005). Chronic traumatic encephalopathy in a National Football League player. Neurosurgery, 57, 128–134.PubMedCrossRefGoogle Scholar
  50. Otis, J. D. (2007). Managing chronic pain: A cognitive-behavioral therapy approach. New York, NY: Oxford University Press.Google Scholar
  51. Otis, J. D., Keane, T., Kerns, R. D., Monson, C., & Scioli, E. (2009). The development of an integrated treatment for Veterans with comorbid chronic pain and posttraumatic stress disorder. Pain Medicine, 10, 1300–1311.PubMedCrossRefGoogle Scholar
  52. Owens, B. D., Kragh, J. F., Jr., Wenke, J. C., Macaitis, J., Wade, C. E., & Holcomb, J. B. (2008). Combat wounds in operation Iraqi Freedom and operation Enduring Freedom. Journal of Trauma, 64, 295–299.PubMedCrossRefGoogle Scholar
  53. Pautex, S., Michon, A., Guedira, M., Emond, H., Le Lous, P., Samaras, D., et al. (2006). Pain in severe dementia: Self-assessment or observational scales? Journal of the American Geriatrics Society, 54, 1040–1045.PubMedCrossRefGoogle Scholar
  54. Report of VA Consensus Conference. (2010). Practice recommendations for treatment of Veterans with comorbid TBI, Pain, and PTSD.Google Scholar
  55. Resick, P. A., Jordan, C. G., Girelli, S. A., Hutter, C. K., & Marhoefer-Dvorak, S. (1988). A comparative outcome study of behavioral group therapy for sexual assault victims. Behavior Therapy, 19, 385–401.CrossRefGoogle Scholar
  56. Resick, P. A., Nishith, P., Weaver, T. L., Astin, M. C., & Feuer, C. A. (2002). A comparison of cognitive-processing therapy with prolonged exposure and a waiting list condition for the treatment of chronic posttraumatic stress disorder in female rape victims. Journal of Consulting and Clinical Psychology, 70, 867–879.PubMedCrossRefGoogle Scholar
  57. Resick, P. A., & Schnicke, M. K. (1993). Cognitive processing therapy for rape victims: A treatment manual. Newbury Park: Sage Publications.Google Scholar
  58. Ruff, R. (2005). Two decades of advances in understanding of mild traumatic brain injury. Journal of Head Trauma Rehabilitation, 20, 5–18.PubMedCrossRefGoogle Scholar
  59. Ruff, R. L., Ruff, S. S., & Wang, X. (2009). Improving sleep: Initial headache treatment in OIF/OEF veterans with blast-induced mild traumatic brain injury. Journal of Rehabilitation, Research and Development, 46, 1071–1084.CrossRefGoogle Scholar
  60. Sayer, N. A., Cifu, D. X., McNamee, S., Chiros, C. E., Sigford, B. J., Scott, S., et al. (2009). Rehabilitation needs of combat-injured service members admitted to the VA polytrauma rehabilitation centers: The role of PM&R in the care of wounded warriors. Physical Medicine and Rehabilitation, 1, 23–28.Google Scholar
  61. Schneiderman, A. I., Braver, E. R., & Kang, H. K. (2008). Understanding sequelae of injury mechanisms and mild traumatic brain injury incurred during the conflicts in Iraq and Afghanistan: Persistent postconcussive symptoms and posttraumatic stress disorder. American Journal of Epidemiology, 167, 1446–1452.PubMedCrossRefGoogle Scholar
  62. Seal, K. H., Bertenthal, D., Miner, C. R., Sen, S., & Marmar, C. (2007). Bringing the war back home: Mental health disorders among 103, 788 US Veterans returning from Iraq and Afghanistan seen at Department of Veterans Affairs facilities. Archives of Internal Medicine, 167, 476–482.PubMedCrossRefGoogle Scholar
  63. Sheedy, J., Geffen, G., Donnelly, J., & Faux, S. (2006). Emergency department assessment of mild traumatic brain injury and prediction of post-concussion symptoms at one month post injury. Journal of Clinical and Experimental Neuropsychology, 28, 755–772.PubMedCrossRefGoogle Scholar
  64. Soo, C., & Tate, R. (2007). Psychological treatment for anxiety in people with TBI. Cochrane Database of Systematic Reviews, 3, CD005239.Google Scholar
  65. Tanielian, T., & Jaycox, L. H. (2008). Invisible wounds of war: Psychological and cognitive injuries their consequences, and services to assist recovery. Santa Monica, CA: RAND Corporation.Google Scholar
  66. Terrio, H., Brenner, L. A., Ivins, B. J., Cho, J. M., Helmick, K., Schwab, K., et al. (2009). Traumatic brain injury screening: Preliminary findings in a US Army Brigade Combat Team. Journal of Head Trauma Rehabilitation, 24, 14–23.PubMedCrossRefGoogle Scholar
  67. Van Tulder, M. W., Ostelo, R., Vlaeyen, J. W. S., Linton, S. J., Morley, S. J., et al. (2000). Behavioral treatment for chronic low back pain: A systematic review with the framework of the Cochrane Back Review Group. Spine, 25, 2688–2699.PubMedCrossRefGoogle Scholar
  68. Vasterling, J. J., Proctor, S. P., Friedman, M. J., Hoge, C. W., Heeren, T., King, L. A., et al. (2010). PTSD symptom increases in Iraq-deployed soldiers: Comparison with nondeployed soldiers and associations with baseline symptoms, deployment experiences, and postdeployment stress. Journal of Traumatic Stress, 23, 41–51.PubMedGoogle Scholar
  69. VA/DoD Evidence Based Guideline: Evaluation and Management of Concussion/mTBI-Subacute/Chronic. (Conus).Google Scholar
  70. VHA Handbook 1160.01. (2008). Uniform mental health services in VA Medical Centers and Clinics. Washington, DC: Department of Veterans Affairs, Veterans Health Administration.Google Scholar
  71. Wade, D. T., King, N. S., Wenden, F. J., Crawford, S., & Caldwell, F. E. (1998). Routine follow up after head injury: A second randomised controlled trial. Journal of Neurology, Neurosurgery and Psychiatry, 65, 177–183.CrossRefGoogle Scholar
  72. Wall, S. E., Williams, W. H., Cartwright-Hatton, S., Kelly, T. P., Murray, J., Murray, M., et al. (2006). Neuropsychological dysfunction following repeat concussions in jockeys. Journal of Neurology, Neurosurgery and Psychiatry, 77, 518–520.CrossRefGoogle Scholar
  73. Warden, D. (2006). Military TBI during the Iraq and Afghanistan wars. Journal of Head Trauma Rehabilitation, 21, 398–402.PubMedCrossRefGoogle Scholar
  74. Warden, V., Hurley, A. C., & Volicer, L. (2003). Development and psychometric evaluation of the Pain Assessment in Advanced Dementia (PAINAD) Scale. Journal of the American Medical Directors Association, 4, 9–15.PubMedCrossRefGoogle Scholar
  75. Wasserberg, J. (2002). Treating head injuries. BMJ, 325, 454–455.PubMedCrossRefGoogle Scholar
  76. Wilk, J. E., Thomas, J. L., McGurk, D. M., Riviere, L. A., Castro, C. A., & Hoge, C. W. (2010). Mild traumatic brain injury (Concussion) during combat: Lack of association of blast mechanism with persistent postconcussive symptoms. Journal of Head Trauma Rehabilitation, 25, 9–14.PubMedCrossRefGoogle Scholar
  77. Wong, D. L., & Baker, C. (1998). Pain in children: Comparison of assessment scales. Pediatric Nursing, 14, 9–17.Google Scholar
  78. Wood, R. L. (2004). Understanding the ‘miserable minority’: A diasthesis-stress paradigm for post-concussional syndrome. Brain Injury, 18, 1135–1153.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC (outside the USA) 2011

Authors and Affiliations

  • John D. Otis
    • 1
    • 4
    • 5
  • Regina McGlinchey
    • 6
    • 8
    • 9
  • Jennifer J. Vasterling
    • 2
    • 4
  • Robert D. Kerns
    • 3
    • 7
  1. 1.Research ServiceVA Boston Healthcare SystemBostonUSA
  2. 2.Psychology Service and National Center for PTSDVA Boston Healthcare SystemBostonUSA
  3. 3.VA Connecticut Healthcare SystemWest HavenUSA
  4. 4.Department of PsychiatryBoston University School of MedicineBostonUSA
  5. 5.Department of PsychologyBoston UniversityBostonUSA
  6. 6.Department of PsychiatryHarvard Medical SchoolBostonUSA
  7. 7.Department of PsychiatryYale UniversityWest HavenUSA
  8. 8.Geriatric Education, Clinical, and Research CenterVA Boston Healthcare SystemBostonUSA
  9. 9.VA RR&D Translational Research Center for TBI and Stress Disorders (TRACTS)VA Boston Healthcare SystemBostonUSA

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