US Department of Defense consensus guidelines on neuromodulation for pain management in an active-duty military population from a tri-service, multispecialty working group

Military pain medicine physicians often treat Service Members with chronic pain with implantable neural stimulators in the spine and near peripheral nerves. These procedures are performed to improve readiness, restore function and deployability; however, there are no consensus practice guidelines on the use of these devices, which has led to inequities in their application and the disposition of patients who receive them. In January 2025, the Defense Health Agency Pain Management Clinical Support Service validated the need for consensus practice guidelines and endorsed their creation. Senior leaders in pain management from the Army, Navy and Air Force were assembled as part of the consensus panel. A small ad hoc steering committee drafted preliminary questions which were modified and approved by the committee-at-large. A modified Delphi approach was employed using modified US Preventive Services Task Force grading of evidence guidelines. Greater than 50% agreement among committee members was the predetermined threshold to declare a statement, but > 75% agreement was necessary to affirm a recommendation. Eight questions were selected for guideline development with 100% consensus achieved by committee members. Differences between treatment recommendations for military (vs non-military) personnel include a joint decision process involving a Service Member’s Command prior to implanting a permanent device intended to improve their suitability for continued service; active-duty Service Members may be less likely to require muscle (eg, multifidus) neurostimulation due to their active lifestyles, but if they do receive a device they should be placed on limited duty for a 6-month time period to allow for improved function; an implanted neurostimulator is disqualifying for induction into the military and military occupational specialty testing is recommended before retention decisions are made; and that opioid therapy be tapered prior to trialing a patient for a permanent implant. Although the committee noted that some areas of responsibility limit deployment for personnel with implanted devices and agreed that Service Members should be tested in simulated environments before deployment, we found insufficient evidence to recommend that Service Members serve at full duty for >3 months without restrictions after treatment to be eligible for non-restricted worldwide deployments. Neuromodulation can provide a transformative opportunity for some military personnel, enabling them to maintain performance in challenging conditions. Considerations that should be addressed before deciding on the use of neuromodulation include the likelihood of success, the disposition of the Service Member (eg, medical board, separation from service), and military occupation-specific requirements such as anticipated duty in combat, underwater, flight, electronically secure areas, and in austere environments without support services.