War-Related Illness and Injury Study Centers: A Resource for Deployment-Related Health Concerns, The

Military Medicine, Jul 2006 by Lincoln, Andrew E, Helmer, Drew A, Schneiderman, Aaron I, Li, Mian, Et al

Combat veterans often return from deployment having experienced a wide range of exposures, symptoms, and medical conditions. The Department of Veterans Affairs established war-related illness and injury study centers to serve combat veterans with unexplained illnesses. We report the exposures, clinical status, and utilization of 53 combat veterans who participated in the National Referral Program (NRP) from January 2002 until March 2004. Participants were primarily male (81%) and served in the Persian Gulf War (79%). Common diagnoses were chronic fatigue syndrome (n = 23, 43%), neurotic depression (n = 21, 40%), and post-traumatic stress disorder (n = 20, 38%). Self-reported exposures related to weaponry, disease prophylaxis, environmental hazards, stress, and poor hygiene. A small increase in mean SF-36V mental component scores (2.8 points, p = 0.009) and use of rehabilitation therapies (1.6 additional visits, p = 0.018) followed the NRP referral. The small gain in mental function suggests that the NRP may benefit combat veterans with long and complex medical histories.

Introduction

Combat veterans often return from deployment having experienced a wide range of physical and psychological exposures, symptoms, and medical conditions.1-3 Furthermore, postcombat syndromes have been documented among veterans of major conflicts from the U.S. Civil War to current wars.4,5 Among the most prominent is the debilitating symptom-complex often referred to as "Persian Gulf War Illness," or "Persian Gulf Syndrome." This condition is generally defined by the existence of medically unexplained symptoms including memory/cognitive difficulties, musculoskeletal pain, fatigue, headache, and shortness of breath.15 Although no formal case definition has been accepted, these problems are estimated to affect thousands of the nearly 700,000 U.S. troops deployed to the Persian Gulf War region in support of Operation Desert Shield and Operation Desert Storm.7,8 The uncertainty surrounding the health problems of these veterans has led to great frustration among veterans as well as clinicians, researchers, and policy makers. Because of the importance of this issue, and based on the recommendations of the National Academy of Sciences, Congress mandated that the Department of Veterans Affairs create specialized centers devoted to the understanding and treatment of deployment-related health concerns from all deployments.9

In May 2001, two war-related illness and injury study centers (WRIISCs) were established to provide for the needs of veterans with deployment-related health concerns and medically unexplained symptoms. The centers, one located in East Orange, New Jersey, and one in Washington, DC, have a four-part mission: to provide service to combat veterans and their health care providers through (1) clinical consultation, (2) education. (3) research, and (4) risk communication addressing potential environmental exposures and adverse health outcomes. The purpose of this article was to describe (1) the components of the centers and how they operate as a specialized occupational health resource, (2) the combat veterans who have participated in the WRIISC National Referral Program during the first 2 years of operation, and (3) the performance of the clinical program.

Clinical Consultation

The first element of the centers is clinical care for veterans with medically unexplained conditions thought to be related to their military deployment and service-related injuries. The centers take a holistic, patient-centered approach to the in-depth evaluation of veterans with debilitating symptoms that remain unexplained after medical examinations at their local VA medical center. Veterans with medically unexplained illnesses are referred for evaluation at one of the centers by their primary care provider. Diagnoses are made when possible and, in all cases, recommendations for management of the veteran's medical problems are given to the patient and the referring provider. Particular attention is paid to management of symptoms and strategies to improve quality of life and function. Veterans of the Armed Forces, including reservists and National Guard personnel, may be eligible for the WRlISC clinical program services if they served in a theater of combat operations during a conflict or other armed hostilities, or during some peacekeeping operations.10 Other veterans with concerns about exposure to toxic substances or radiation may also be eligible.

The WRIISC clinical program provides thorough, evidencebased, clinical evaluations to combat veterans. Multidisciplinary clinical teams consist of neurologists, internists, physiatrists, psychologists, nurse practitioners, and health educators who specialize in postdeployment and medically unexplained health concerns. Although there is no standard clinical work-up for many medically unexplained symptoms, the VA and Department of Defense (DoD) have jointly adopted clinical practice guidelines for postdeplovment health evaluation, chronic unexplained pain and fatigue, and post-traumatic stress disorder" to guide the evaluation both before and after referral to the WRIISC.