Improving chronic pain care after TBI through paired holistic and traditional session: Results from a single-site VA quality improvement project.

Research Objectives: 1. To describe the importance of timing complementary and integrative health in one Veteran’s Administration Polytrauma System of Care site.
2. To discuss evidence supporting that patient goals and engagement alter outcomes in chronic pain after TBI.
3. To discuss results of a quality improvement that paired self-management with standard chronic pain treatment for chronic pain..
4. To discuss future steps indicated from this project.

Design: Mixed-method quality improvement project. Cohort design with longitudinal measures.

Setting: Captain James A. Lovell Federal Health Care Center (Lovell FHCC) outpatient rehabilitation department

Participants: Adults 18 years of age or older who are veteran, veteran dependent, or active military patients seen for Battlefield Acupuncture at Lovell FHCC for chronic pain after TBI.

Interventions: A 15-minute session of a selection of the Veteran Whole Health program was offered at the time and in the location of Battlefield Acupuncture for chronic pain. Veteran Whole Health materials and sessions included the patient's choice of one of the following: 1) Whole Health Intro, 2) Personal health goals, 3) Biofeedback, 4) Breathing, 5) Gratitude, 6) Forgiveness

Main Outcome Measures: Primary outcomes: Receptivity (opt-in and opt-out rates for the Whole Health Session immediately after BFA). Secondary outcomes: Perceived benefit (satisfaction, recommend, and free-text data. Tertiary outcomes: Pain and pain interference (activity, sleep, stress, and mood.

Results: Results will be analyzed based upon the collected data.

Conclusions: Patients who opted into WH were 50% female (n=12), 71% (n=17) veterans, 17% (n=4) active military, and 13% civilians (Figure 2); Pain was reported in Low back 36% (n=17) of session, 28% (n=13) head/neck, 12% (n=6) arms, 8% (n=4) legs, and 8% (4) anxiety (Figure 3). Whole Health was offered during 66-BFA sessions to 47 patients of whom 25 (52% Female) opted into WH. Half of patients (53%) who were offered WH opted to have a WH session. Of those opting to have WH, most had two or more BFA+WH sessions and 1 opted-in after opting out in prior sessions. WH materials chosen by patients included Progressive Relaxation (26%, n=12), Breathing (23%, n=12), Biofeed- back (21%, n=10), Introduction to Whole Health (9% n=4), Forgiveness (10%, n=5). Family & Friends (2%, n=1), and Mindful Awareness (2%,n=1). Most (95%, n=41) highly recommended BFA+WH were reported for mood, stress, anxiety, and pain, and 25% of patients in repeat BFA+WH sessions reported improved sleep; one report of “the best sleep I ever had [the night] after BFA+WH.” (Figure 5). Greater Mean pain score pre-BFA is seen in the in the ‘initial WH session’ group (n=25) did not reach statistical significance. ANOVA supported that there was equal variance in pain change across groups and t-test results did not support our hypothesis that there would be a significant group effect (opt-out, initial opt-in, repeat opt-in; all opt-ins versus opt-outs). A one-tailed t-test of post-pre BFA pain change for the combined groups supported that there was significant reduction in pain after BFA (Figure 6). Free-text responses reinforced participants’ sense of improved well-being and sense of value with the Whole Health sessions following BFA. Conclusions/

Discussion: These preliminary data support that pairing WH with BFA for patients with TBI merits further study. Pain scores improved significantly post BFA in all three groups. Patients who opted-in reported that they valued having Whole Health coordinated with their physician delivered pain treatment at Lovell FHCC. Of the patients who opted-out of WH, all but one continue to opt-out, which may suggest personal characteristics and or beliefs that differ in patients who would value Whole Health, which merits further study. Though not statistically significant, the ‘initial WH session’ group showed a trend of higher initial pain score that was not seen in the ‘Repeat WH session’ group, which is inconclusive as our study was underpowered and lacked measures for chronic pain ‘yellow flags’, self-efficacy, or objective measures of pain interference. These data are also limited by the lack of strong bias controls. Nearly all (95%) of patients who received WH after BFA (initial and repeat WH session groups) reported that they would highly recommend having BFA+WH. Many commented that they had not known what Veteran Whole Health program was or how to access it at Lovell FHCC. A secondary benefit of this QI study is the dissemination of Whole Health access to patients.