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BackgroundThe NIH-DOD-VA Pain Management Collaboratory (PMC) supports 11 pragmatic clinical trials (PCTs) on nonpharmacological approaches to management of pain and co-occurring conditions in U.S. military and veteran health organizations. The Stakeholder Engagement Work Group is supported by a separately funded Coordinating Center and was formed with the goal of developing respectful and productive partnerships that will maximize the ability to generate trustworthy, internally valid findings directly relevant to veterans and military service members with pain, front-line primary care clinicians and health care teams, and health system leaders. The Stakeholder Engagement Work Group provides a forum to promote success of the PCTs in which principal investigators and/or their designees discuss various stakeholder engagement strategies, address challenges, and share experiences. Herein, we communicate features of meaningful stakeholder engagement in the design and implementation of pain management pragmatic trials, across the PMC.DesignOur collective experiences suggest that an optimal stakeholder-engaged research project involves understanding the following: i) Who are research stakeholders in PMC trials? ii) How do investigators ensure that stakeholders represent the interests of a study's target treatment population, including individuals from underrepresented groups?, and iii) How can sustained stakeholder relationships help overcome implementation challenges over the course of a PCT?SummaryOur experiences outline the role of stakeholders in pain research and may inform future pragmatic trial researchers regarding methods to engage stakeholders effectively.

Active-duty military fathers are frequently away from their families throughout their military career and are faced with readjusting to family and garrison life after each separation. For fathers of very young children, reintegration can have unique challenges due to the tremendous developmental progression occurring in early childhood and the impact of lengthy deployment separations. While much of the research on military families focuses on extreme negative experiences (e.g., reactions to war injuries and posttraumatic stress disorder), little is known about the common experiences of military families. This qualitative study explores the reintegration experiences of 15 active-duty U.S. Army fathers with a child under six in their home during the deployment. Homecoming experiences were coded and analyzed to distinguish four adjustment factors and five adaptation challenges. Most fathers described having mixed experiences during reintegration, with 93% referencing at least one factor making adjustment easier (e.g., communication with their spouse during deployment), and 80% referencing at least one factor making adjustment difficult (e.g., child's initial hesitation or perceived rejection). Adjustment facilitators included: spending quality time with family, individual and family growth, quality communication during deployment, and the service member's parental perspective taking. Challenges to adjustment included negative postdeployment reactions of children, difficulty readjusting to family and civilian life, and service member psychological changes. These findings expand our understanding of the reintegration experience of active-duty fathers with young children and identify common challenges and facilitators that can be addressed through culturally informed supportive services across the deployment cycle. [ABSTRACT FROM AUTHOR]

Cognitive processing therapy (CPT) is an effective treatment for posttraumatic stress disorder (PTSD); however, some patients do not improve to the same extent as others. It is important to understand potential factors that can be modified for better patient outcomes. This clinical trial implemented a three‐arm, equipoise‐stratified randomization design to allow for the accommodation of patient preference before randomization to one of three CPT treatment modalities: in‐home, in‐office, or telehealth. This study examined whether satisfaction with the modality, perceived stigma, expectations of therapy, and credibility of the therapist differed between modalities and whether these factors impacted treatment outcomes. We hypothesized that the contributions of these variables would depend upon whether participants opted out of any treatment arms and that these factors would predict treatment outcomes. Participants who endorsed less perceived stigma demonstrated larger reductions in PTSD symptom severity than those with similar levels of perceived stigma in the telehealth and in‐office conditions, η2 =.12–.18. Participants who endorsed lower satisfaction with their treatment modality and were assigned to the in‐home condition experienced larger PTSD symptom reductions than those with similar dissatisfaction in the telehealth and in‐office conditions, η2 =.20. The results show the robustness of evidence‐based therapies for PTSD given that dissatisfaction did not impede treatment success. In addition, they demonstrate that it is important for clinicians to address stigma before initiating evidence‐based therapies for PTSD. Strategies to address these factors are discussed. [ABSTRACT FROM AUTHOR]

Objective: To explore whether the association between change in headache management self‐efficacy and posttraumatic headache–related disability is partially mediated by a change in anxiety symptom severity. Background: Many cognitive–behavioral therapy treatments for headache emphasize stress management, which includes anxiety management strategies; however, little is currently known about mechanisms of change in posttraumatic headache–related disability. Increasing our understanding of mechanisms could lead to improvements in treatments for these debilitating headaches. Methods: This study is a secondary analysis of veterans (N = 193) recruited to participate in a randomized clinical trial of cognitive–behavioral therapy, cognitive processing therapy, or treatment as usual for persistent posttraumatic headache. The direct relationship between headache management self‐efficacy and headache‐related disability, along with partial mediation through change in anxiety symptoms was tested. Results: The mediated latent change direct, mediated, and total pathways were statistically significant. The path analysis supported a significant direct pathway between headache management self‐efficacy and headache‐related disability (b = −0.45, p < 0.001; 95% confidence interval [CI: −0.58, −0.33]). The total effect of change of headache management self‐efficacy scores on change in Headache Impact Test‐6 scores was significant with a moderate‐to‐strong effect (b = −0.57, p = 0.001; 95% CI [−0.73, −0.41]). There was also an indirect effect through anxiety symptom severity change (b = −0.12, p = 0.003; 95% CI [−0.20, −0.04]). Conclusions: In this study, most of the improvements in headache‐related disability were related to increased headache management self‐efficacy with mediation occurring through change in anxiety. This indicates that headache management self‐efficacy is a likely mechanism of change of posttraumatic headache–related disability with decreases in anxiety explaining part of the improvement in headache‐related disability. [ABSTRACT FROM AUTHOR]

There is acknowledgment that deployments can be stressful for military spouses; however, less is known about their experiences post-deployment. This qualitative study examined the post-deployment experiences of 16 female spouses, whose active duty Army husband had returned from deployment within the previous 2 years and who had a young child during the deployment. Spouses reported that the time surrounding their husbands' return was one of the great transitions, often accompanied by stress. Most families were able to work through challenges and show positive adjustment over time. However, some spouses described severe post-deployment challenges marked by disconnect from their partners; three of these were spouses whose husbands had posttraumatic stress disorder. The findings address how spouses prepared for their husband's return, their reunion experiences, the process of reintegrating their husband into family life, and individual changes in the partners post-deployment. Facilitators and challenges to adjustment were identified as potential targets for interventions. [ABSTRACT FROM AUTHOR]

Objective: To characterize the relationship between head trauma types (blast injury, blunt injury, combined blast+blunt injury) with subsequent headache presentations and functioning. Background: Posttraumatic headaches (PTHs), the most common sequelae of traumatic brain injury (TBI), are painful and disabling. More than 400,000 veterans report having experienced a TBI, and understanding the predictors of PTHs may guide treatment developments. Methods: This study used a nested‐cohort design analyzing baseline data from a randomized clinical trial of cognitive behavioral therapy for PTH (N = 190). Participants had PTH (from blast and/or blunt head trauma) and symptoms of posttraumatic stress disorder (PTSD). The Structured Diagnostic Interview for Headache‐Revised and Ohio State University Traumatic Brain Injury Identification Method were used to phenotype headaches and head injury histories, respectively. Results: Individuals with persistent PTHs after a combined blast and blunt head trauma were more likely (OR =3.45; 95% CI [1.41, 8.4]) to experience chronic (vs. episodic) PTHs compared with the blunt trauma only group (23/33, 70% vs. 26/65, 40%, respectively); and they were more likely (OR =2.51; 95% CI [1.07, 5.9]) to experience chronic PTH compared with the blast trauma only group (44/92, 48%). There were no differences between head injury type on headache‐related disability, depression symptoms, or severity of PTSD symptoms. Conclusion: The combination of blast and blunt injuries was associated with headache chronicity, but not headache disability. Considering the refractory nature of chronic headaches, the potential added and synergistic effects of distinct head injuries warrant further study. [ABSTRACT FROM AUTHOR]