Academic journal article Journal of Rehabilitation Research & Development

Pain and Combat Injuries in Soldiers Returning from Operations Enduring Freedom and Iraqi Freedom: Implications for Research and Practice

Academic journal article Journal of Rehabilitation Research & Development

Pain and Combat Injuries in Soldiers Returning from Operations Enduring Freedom and Iraqi Freedom: Implications for Research and Practice

Article excerpt


Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) commenced in October 2001 and May 2003, respectively, as part of the global war on terror. To date, more than 1 million military personnel have been deployed to Afghanistan or Iraq. Approximately 21,000 of those deployed have been wounded in combat, and about 46 percent of these casualties have been medically evacuated ( Blast-related injuries predominate; wounds from improvised explosive devices (IEDs), land mines, shrapnel, and other blast phenomena account for 65 percent of combat injuries [1]. Approximately 60 percent of these injured soldiers have symptoms of traumatic brain injury (TBI) ( Nevertheless, despite the number of casualties and the wound severity, the U.S. military medical system has been remarkably successful in the management of combat trauma during these conflicts, as evidenced by the >90 percent survival rate following injury [2]. This success has been attributed to multiple factors, including improved body armor [3-4], surgical care deployed far forward on the battlefield [5], and rapid evacuation to major hospitals via military aircraft equipped with sophisticated medical equipment [6]. The advantages of these innovations for survival following combat trauma are clear, but this success has created other unforeseen medical challenges. One of the most significant has been the management of pain immediately following combat trauma, during subsequent acute medical treatment, and throughout initial rehabilitation efforts.

In this article, we introduce the subject of trauma-related pain and describe several innovative approaches for improving the pain care provided to OEF and OIF military personnel during acute stabilization, transport, medical-surgical treatment, and rehabilitation. Next, we identify some of the pain assessment, classification, and treatment challenges emerging from work with this population and, where possible, provide associated clinical practice suggestions. Finally, we close with a discussion of related research priorities. Throughout, we should note that empirical data in this area, while provocative, are limited. Therefore, the conclusions and implications we provide should be viewed as tentative and subject to modification as additional data become available.


Because trauma patients are often seriously injured and have multiple body regions involved, they commonly experience significant levels of pain [7-8]. Since the initial care of the trauma patient involves stabilization of cardiovascular and respiratory status, employment of life-saving procedures (e.g., chest tube, endotracheal intubation), and assessment of multiple and severe injuries, pain may not be appropriately assessed and thus not adequately treated [9]. Compounding the problem of pain treatment in the trauma setting are provider concerns that opioids may lead to hypotension, respiratory depression, clouding of mental status, and obfuscation of changes in clinical status [7].

When adequate pain control is not achieved, individuals suffer unnecessarily, adding to concerns about their ability to recover and function normally after the trauma. Unfortunately, most trauma-care algorithms, even at major trauma centers, do not include a systematic approach to pain assessment. Furthermore, empirical studies of pain assessment in trauma patients are virtually nonexistent. This lack is unfortunate given that pain may be constantly present for trauma patients from the time of the initial injury through the acute treatment phase and may continue into rehabilitation and the return to the community [10].

Edwards has categorized the continuum of trauma care into three phases: (1) emergency, (2) acute or healing, and (3) rehabilitation [10]. The emergency phase begins at the time of injury and ends after resuscitation and emergency stabilization are complete. …

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