Date of Award

Summer 2019

Document Type

Open Access Dissertation


Health Promotion, Education and Behavior

First Advisor

Christine E. Blake


Persistent pain is one of today’s most complex issues in healthcare. In the U.S. military, persistent pain affects close to half of the service members who have deployed overseas and up to 73.2% of service members and veterans experiencing persistent pain. Interdisciplinary pain management, considered one of the most effective ways to manage persistent pain, utilizes the biopsychosocial model that illustrates the dynamic interaction between the physiological, psychological and social factors involved in the experience of persistent pain. Effective interdisciplinary programs address all components of the model and result in better coping skills to self-manage persistent pain, decreased fear of pain and re-injury, decreased pain catastrophizing, improved physical and psychological functioning and overall quality of life.

The process of change, while in an interdisciplinary pain program, is multifaceted and difficult to assess using conventional unidimensional scales. Multidimensional scales are commonly used to assess the components of persistent pain such as attitudes, beliefs, specific body region disability and quality of life but they may still not capture the full impact of an intervention on the experience of pain. A variety of methods including patient narrative and observation, daily assessments using ecological momentary assessment and change in patient activation can provide additional insight into the process of change in those with persistent pain. The Patient Activation Measure (PAM) was developed to assess this construct which combines concepts of self-efficacy, locus of control and other psychosocial components and has been used in healthy individuals and those with chronic conditions. Ecological momentary assessment (EMA) can be a reliable method to track temporal changes and contextual associations in various settings and has been utilized in various forms to monitor daily pain or other symptoms.

Three specific aims were proposed in this dissertation. The research study included patient participants who were active duty military service members suffering from persistent pain who were determined eligible and were enrolled in the Intensive Outpatient Pain Program at the D.D. Eisenhower Army Medical Center. Staff members who were actively working in the IOP were also recruited for the qualitative portion of the study. Prospective data was collected between September 2018 and December 2018 for the analysis in specific aim 1 and 3. Retrospective data was extracted from January 2017 through August 2018 for the quantitative analysis in specific aim 2.

Specific aim 1 was to gain insight into the process of change in the understanding of persistent pain through consideration of past and present experiences, psychosocial factors, personal and work relationships and stressors, attitudes, goals and future expectations of U.S. military service members attending an intensive outpatient program. Patient participants were interviewed at four time points during the program. Staff participants were interviewed once and a researcher was a participant-observer during the group components of the program. Data was analyzed with a constant comparative method using a preliminary codebook with organizational and theoretical categories. Iterative coding was completed with themes identified across all interviews addressing changes in perception of pain, attitudes, barriers and enablers, impact of past and present experiences and effectiveness of the program on future goals. Categorization of patient participants by similarities in experience was concurrent with data collection and analysis. Staff interviews and observation notes were coded using patient participant codebook and used to triangulate the data.

Specific aim 2 was to examine the change in the Patient Activation Measure and assess its relationship with measures of fear of movement, pain intensity, pain interference, and physical function assessment in an intensive outpatient program for persistent pain. Pre and post-intervention measures included: The Patient Activation Measure-13 (PAM-13), Defense and Veterans Pain Rating Scale (DVPRS), Tampa Scale for Kinesiophobia-17 (TSK-17), and physical function assessment which included 1- minute of push-ups, deadlift and a shuttle run. Paired t-tests and Spearman rank correlation were computed to assess changes pre to post-program and relationships of PAM-13 with the other outcome measures.

Specific aim 3 was to test the feasibility and acceptability of using a mobile app to monitor daily self-reported pain, psychosocial indicators and attitudes in an intensive outpatient program for persistent pain. Commercially available PACO© app was used in the study. Participants downloaded the app to their smartphones and answered 12 questions daily including weekends. Descriptive statistics were calculated for compliance rates and all other variables. Means and standard deviations were calculated for continuous variables, frequencies and percentages were calculated for categorial variables. Pain trajectories and stress levels for all participants were graphed to assess any trends.

For specific aim 1, five categories of participants emerged during analysis based on the observed and reported process of change: (1) participants already well-versed in many of the biopsychosocial aspects of pain, fine-tuning their skills; (2) participants with life-altering realizations changing their lives in all aspects during the program; (3) participants with partial buy-in focused more toward the physical function and performance; (4) participant with partial buy-in focused more on the psychosocial changes; and (5) participants for whom the biomedical model prevailed and despite some positive changes, the end result was seen as a failure to satisfactorily address their condition.

For specific aim 2, the sample included 105 participants (70.5% male), majority were enlisted (95.2%). The average age of participants was 29.02 years and pain duration was 56.68 months. The average patient activation score increased from level 3 (59.51, SD=14.13) to level 4 (69.67, SD=16.50). The TSK-17 score for the entire sample decreased by 4.44 points to 35.63, below the commonly used cut-off score of 37. All DVPRS components (pain intensity in last 24 hours, pain interference with activity, pain interference with sleep, pain affecting mood, pain affecting stress) showed a statistically significant decrease, with the largest improvement reported for quality of sleep (MD=1.44, p<.001, d=.778). No significant correlations were detected between baseline PAM-13 scores and reported change on all outcome measures and physical function assessment. Significant negative correlations were found between PAM-13 and TSK-17 at both baseline and upon completion of the program.

For specific aim 3, 11 of the 22 participants completed 100% of the daily survey with overall compliance of 91.1%. Participants reported receiving social support 77.5% of the days reported and considered it beneficial 91.4% of the time. The most frequent types of social support received were esteem support (69.4%), informational support (56.5%), and emotional support (53.7%). Participants reported making progress toward their individual goals 73.0% of the days reported. Pain and stress level trajectories showed high variability in between and within-participants throughout the 3 weeks. Majority of passive and active components of the program were considered beneficial regardless of whether they increased or decreased pain.

The process of change in persistent pain varied among the military service members participating in IOP with majority describing benefits such as increased physical performance, improved mood and relationships, acceptance of pain, decreased pain and increased patient activation. Significant changes took place in as little as 3 weeks even for individuals who have had persistent pain for many years. Future research should focus on the on-going process of change following the completion of the treatment program to determine continued changes and whether the changes are related to physical and psychosocial function and return to full military duty. EMA using a smartphone application for monitoring various outcome measures during an intensive outpatient program for persistent pain may be a beneficial tool for additional monitoring of participant progress in the program and beyond.