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Table 1 Characteristics of studies that have investigated the association between deployment to the Gulf War and symptoms of pain amongst veterans

From: Pain in veterans of the Gulf War of 1991: a systematic review

Study Sample Study design Measured outcomes Response rate and bias Confounding Notes
Sutker 1993 215 GWV
44 NGV
Sampled from 5 National Guard and Army Reserve units as part of debriefing programme
Questionnaire administered by VA staff 4–10 months after return from Operation Desert Shield/Storm General aches and pains as measured by the Health symptom checklists 70% GWV response (306 eligible)
91 GWV excluded from analysis for failure to complete the majority of measures administered, however, they 'did not differ on descriptive variables' from those that were analysed.
Number of eligible NGVs unclear
Bonferonni adjustment showed no sig. effects for sex/race although women and non-white participants tended to report more health complaints Symptom presence included the report of the symptom at least once a week over the past 30 days
Sostek 1996 57 GWV
44 NGV
members of a single National Guard Unit
Questionnaire survey Joint pain
Abdominal pain (infra or supra umbilical location)
62% GWV (92 sampled)
100% NGV (44 sampled)
Unclear what percentage of the unit was sampled
No adjustments were made for confounding.
Groups were said to be similar on a range of socio-demographic variables with the exception of age. Gulf veterans were significantly older.
Authors suggest that bias may be present in their study as a significantly higher proportion (p≤0.05) of Gulf veterans report experiencing a 'change in the colour of fingernails' (a control symptom)
Iowa 1997 1896 GWV
1799 NGV
DoD Manpower Data Center used to create a stratified random sample from 28,968 military personnel from Iowa
Cross-sectional telephone interview survey
Sept 1995 – May 1996
Bodily pain 78% GWV (2421 eligible)
73% NGV (2465 eligible)
Those who were regulars, enlisted, navy or coast guard, aged up to 25 years and black or other ethnic background less likely to participate
Controlled for stratification variables: military service (regular/National Guard), age, sex, race, branch of service and rank Response reliability for 165 interviews kappa 0.39–0.79
Doebbeling 2000 see Iowa 1997 see Iowa 1997 Pain or aches in more than 1 joint
Back pain
see Iowa 1997 see Iowa 1997  
Voelker 2002 See Iowa 1997 see IOWA 1997 Bodily pain on SF-36 see Iowa 1997 See Iowa 1997 Effect size is the standardised mean difference on the bodily pain subscale of the SF36
Peloso 2002 See Iowa 1997 See Iowa 1997 Chronic widespread pain See Iowa 1997 See Iowa 1997 Outcome – pain present in last year and last month, moderate or greater severity and involvement of upper and lower extremities and trunk
Fukuda 1998 1163 GWV
2538 NGV
Sampled veterans were active duty members of the Air Force, from Florida or Pennsylvania and who were on base at the time of the survey
Cross-sectional population survey
Jan – March 1995
Joint pain
Muscle pain
Chest pain
Veterans were not sampled according to Gulf status so no differential response rates are given.
Unit response rate 35% – 73%
No report of adjustment made for potential confounders.  
Goss Gilroy 1998 3113 Canadian GWV
3439 Canadian NGV
Sampled from Department of National Defence human resources data files
Cross-sectional survey Serious trouble with back pain 73% GWV (4262 eligible)
60% NGV (5699 eligible)
NGVs matched on sex, age group and regular/reserve status Only data for male veterans is presented.
Proctor 1998 186 GWV from Fort Devens
66 GWV from New Orleans
48 Germany deployed veterans
Cohort study
Spring 1994 – Autumn 1996
Joint pain
Chest pain
53% Fort Devens (353 sampled, 2949 eligible)
34% New Orleans (194 sampled, 928 eligible)
51% Germany deployed.
Participants were recruited after taking part in a previous study
Published odds ratios were weighted for sampling design and adjusted for age, sex and education  
Proctor 2001 See Proctor 1998 See Proctor 1998 Chronic back pain
Bodily pain on SF-36
See Proctor 1998 See Proctor 1998  
Ishoy 1999 686 GWV
231 NGV
Selected from Danish Armed Forces personnel database
Cross-sectional survey Feb 1997-Jan 1998 Joint pain
Muscle pain
84% GWV (821 eligible)
58% NDV (400 sampled)
Non-response meant GWV more likely to be older males
Controls matched for gender, age and profession  
Unwin 1999 3284 GWV
1815 Bosnia veterans
2408 Era controls
Random sample taken from the UK
MoD database Service men only
Cross-sectional postal survey
August 1997-Nov 1998
Pain without redness or swelling in several joints
Chest pain
70% GWV (4250 eligible)
62% Bosnia (4250 eligible)
63% Era (4246 eligible)
Responders were significantly older and more likely to be in service but didn't differ on SF36 ratings
Sample was stratified by service, status, sex, age, rank and fitness.
Analyses restricted to male veterans. Potential confounders (age, marital status, rank, education, employment, still serving or discharged, smoking, alcohol consumption and GHQ score) are adjusted for by logistic regression
Unwin 2002 236 GWV
217 Bosnia veterans
192 Era controls
Service women only
See Unwin 1999 Pain without redness or swelling in several joints 72% GWV
66% Bosnia
58% Era
Analyses restricted to female veterans.  
Kang 2000 11441 GWV
9476 NGV
Stratified random sample taken from the DoD Manpower Data Center
Population based survey 1995–1997 Joint pain
Muscle pain
Back pain
Abdominal pain
76% GWV (15000 eligible)
63% NGV (15000 eligible)
Non responders were more likely to be younger, unmarried, non-white and enlisted
Estimates were weighted to control for stratification variables: gender and unit component  
Knoke 2000 524 GWV
935 NGV
Sampled from active duty US Naval mobile construction battalion personnel (Seabees). Personnel had to be in residence at either Port Hueneme or Gulfport
Questionnaire survey carried out in 1994 Pains in lower back
Pains in heart/chest
Moving joint pain
Unusual muscle pain
Chest pain
Abdominal pain
Earlobe pain
65% GWV
46% NGV
Analyses restricted to male veterans. 'Earlobe pain' was included as a validity symptom as it was thought not to have a physiologic basis
Steele 2000 1435 GWV
409 NGV
DoD Manpower Data Center used to create a stratified random sample from 16,566 military personnel from Kansas
Population based telephone survey
Feb – Aug 1998
Joint pain
Muscle pain
Body pain (hurts all over)
Abdominal pain or cramping
Moderate/multiple pain symptoms
65% response (3138 eligible)
Overall, Gulf and female veterans were more likely to respond.
Published odds ratios are adjusted for sex, age, income level and education level. Women and reservists deliberately over sampled due to increased reporting of ill health in those groups. Veterans had to be either separated or retired from military or currently serving in the reserves.
Cherry 2001 8210 GWV
3981 NGV
Random sample taken from the UK MoD database
Cross-sectional survey
Dec 1997-Sept 1999
Stomach pain
Pain in your chest
Widespread pain
86% GWV (9505 eligible)
84% NGV (4749 eligible)
Non responders were younger
NGV sample stratified by sex, age, service and rank to frequency match GWV sample. Widespread pain defined as "axial skeletal and contra lateral body pain" for at least 24 hours in the past month
Gray 2002 3831 GWV
4933 deployed elsewhere
3104 non-deployed
All active duty Seabees regardless of whether still in service at time of study identified through Defense Manpower Data Center
Cross-sectional survey
May 1997 – May 1999
Unusual muscle pain
Joint pain
Chest pain
Stomach pain/ulcer
Total eligible 18,945
64% response
Respondents more likely to be reservists, married, Caucasian, and deployed elsewhere.
Published odds ratios adjusted for age, gender, active-duty/reserve status, ethnicity, smoking, alcohol use. Reliability for self-reported physician-diagnosed medical conditions in 519 subjects retested 6 months apart: Kappa = 0.6
Simmons 2004 23,358 GWV
17,730 NGV
Stratified random sample from UK MoD database
Cross-sectional postal survey
Aug 1998-March 2001
Muscular pain/weakness
Chest pains/tightness
48% response overall.
Pain data available for:
45% GWV (51581 eligible)
34% NGV (51688 eligible)
Analysis restricted to male veterans.
Published odds ratios adjusted for age, service, rank, service status at time of survey, alcohol and smoking
Kelsall 2004 1456 GWV
1588 NGV
Stratified random sample from Australian Defence Force database
Cross-sectional postal survey
Aug 2000-April 2002
General muscle pain
Pain without redness or swelling in several joints
Low back pain
78% GWV (1871 eligible)
54% NGV (2924 eligible)
Non responders were younger and of lower rank.
Analyses restricted to male veterans.
Published odds ratios adjusted for sex, 3 yr age band, service and rank.
  1. GWV – Gulf War veteran
  2. NGV – Non-Gulf veteran
  3. DoD – US Department of Defense
  4. MoD – British Ministry of Defence