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WRNMMC Providers Urge Holistic Approach to Pain Management

Three hands; one set putting a needle into another Tim Iliff, a licensed acupuncturist with the 673d Surgical Operations Squadron pain clinic at Joint Base Elmendorf-Richardson in Alaska, provides care to a patient. Acupuncture is of the many modalities used in pain management. (Photo by Air Force Staff Sgt. Sheila deVera)

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According to Army Capt. (Dr.) Bryan Stepanenko, a family physician with the Defense Health Agency, pain is an experience with four components. They include tissue signal, transmission and interpretation, metabolic and hormonal environment, and mental and emotional state.

Healing also has four components – trusting and cooperative partnership, shared understanding, ritual [care] and improved well-being, Stepanenko continued. Those components are sequential, he added.

Stepanenko, a paramedic for nearly six years prior to earning his medical degree from the University of Miami, Miller School of Medicine in 2015, served as a featured speaker during the virtual three-day 10th Annual Pain Care Skills Training in September, annually recognized as Pain Awareness Month. 

The National Capital Region (NCR) Pain Care and Wounded Warrior Pain Care Initiatives at Walter Reed National Military Medical Center (WRNMMC), hosted the training.

The annual training brings together subject matter experts to discuss and learn more about optimizing care and integrative approaches to pain management within the Department of Defense (DoD), stated Dr. Christopher Spevak, director of the Prescription Medication Misuse Program and deputy director of the NCR Pain Care and Wounded Warrior Pain Care Initiatives at WRNMMC. He explained how the training focused on sharing best practices, conducting hands-on training and learning integrative approaches. “The overall goal of the [annual training] is to promote readiness, restoration of function and relief of pain while reducing the misuse of opioids,” he stated.

Stepanenko teaches functional medicine pathway through the NCR Pain Care Initiative out of WRNMMC. He also serves as an outpatient clinician, providing primary care to service members, dependents, veterans and DoD beneficiaries. He explained functional medicine as an operating system encompasses a number of modalities “to deliver personalized holistic and integrative care empowering the patient and clinician working to heal chronic pain.”

“The most impactful and the most rewarding part of my job is when I get to witness true healing happening,” Stepanenko said. “That might be [a person] losing 15 pounds so this person’s arthritis is better [and he or she] can play with the grandkids,” he added.

Regarding pain, Stepanenko said, “Every person’s experience is uniquely different.” He described the experience of pain triggered by a tissue signal, followed by a transmission of that signal up the nerves and then interpreted by the brain. The experiences also encompasses the pain receiver’s metabolic and hormonal environment, which along with his or hers mental and emotional state, impacts pain (“because you slept poorly, so nothing is going to be right”).

Stepanenko explained how there are opportunities to change one’s experience with pain. “We can always move the needle. We will never run out of options.” He explained this is so because functional medicine as a “person-oriented medical approach for better patient outcomes, better utilization of resources, and empowerment for self-care strategies.”

The Military Health System’s efforts to address chronic pain includes a holistic strategy that’s multidisciplinary and multimodal, and decreases reliance on medications, Sepanenko explained. He said the efforts of the MHS is to “incorporate integrative and alternative therapeutic modalities into a patient-centered care plan.” This includes looking at lifestyle, nutrition and empowering the patient.

Army Master Sgt. Geoffrey Dardia, who also spoke at the event, discussed his empowerment as a patient. After serving in the Special Forces, Dardia now helps service members and others such as himself who’ve faced challenges with pain and their care. His goal is to help them understand the impact of the operational environment and the effects it can have on them. He’s also an advocate for expanding access to functional medicine.

Discussing his experience, Dardia explained providers had difficulty with a diagnosis when he began to experience fatigue, migraines, short-term memory loss, vision problems, brain fog, weight gain, no libido, itchy rashes, and graying and hair loss in 2011. Because of the challenges in determining a diagnoses, Dardia began studying medical literature and if his operational environment was impacting his health. He found that he possibly had symptoms of neurotoxicity and needed diagnostic testing. 

The Green Beret received an evaluation for traumatic brain injury in 2012, and a number of other signs and symptoms were disclosed that Dardia described as indicators of “Operator Syndrome,” including light sensitivity and other vision challenges, ringing in the ears, balance issues, aches and pains (gout-like symptoms), calcium deposits subdermal (head and extremities), intolerance to stress (short fuse) and gastrointestinal issues (bloating, constipation, diarrhea, blood, mucus). 

During Dardia’s two decade military career, he trained and served in a number of environments exposing him to numerous rounds of ammunition, explosions, blasts and toxins.

He went to the Cleveland Clinic’s Center for Functional Medicine, and his multi-disciplinary treatment included a detoxification program to help clear his body of some of the toxins he was exposed to during his military service. The program also focused on improving his nutrition and other lifestyle modifications. 

Dr. Scott Engel, a clinical psychologist who serves as the director of the Fort Hood Intrepid Spirit Center (ISC), agreed with Dardia that care providers “be willing to enter the culture of the warrior, learn customs and traditions, and integrate the military lexicon into how [the provider] communicates and intervenes [with the warrior],” to better outcomes. Engel is also officer in charge of the Fort Hood Traumatic Brain Injury Clinic, and the Fort Hood Site Director for the Defense and Veterans Brain Injury (DVBIC) in Texas.

He provided the Dr. Anita Hickey Memorial Lecture during the training, stated the “war fighter is the subject matter expert who can teach the provider [about the warrior’s personal situation], and the provider should acknowledge what he or she doesn’t know, be humble and teachable, while amplifying what [he or she] knows and how [he or she] can help the war fighter,” he stated.

“We are really doing a disservice if we don’t look at the whole person,” Engel stressed.

Dr. Anthony Panettiere, who addressed the relationship between sleep and pain, agreed. The neurologist and sleep medicine physician at the National Intrepid Center of Excellence at the WRNMMC, stated 67 to 88% of pain patients have sleep complaints, and 50% of sleep patients have chronic pain. He stated sleep contributes to the restorative process affecting pain.

A retired Navy captain, Panettiere explained pain affects sleep in a number of ways, including contributing to insomnia, insufficient delta sleep, less total sleep time and increased nighttime awakenings. People who experience pain “fixate” on it, which can hamper sleep. “Pain can keep sympathetic nervous system at a heightened level [decreasing sleep],” Panettiere stated. He added pain medicine can also reduce sleep.

“Sleep and pain states have bi-directional impact. Multi-disciplinary treatments for both the pain and sleep issues likely have a greater impact on overall well-being,” Panettiere stated.

Workshops during the training focused on nutrition and pain; resiliency; pain research; physical exams and assessments for pain; regenerative medicine; drug testing for pain; art therapy for pain; fascia techniques; headaches; (pain) anxiety and depression; hypnosis; osteopathic manipulation for physicians; and more.

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