Neuromodulation is a rapidly growing field that has become increasingly important in the treatment of chronic pain. There is evidence that, in appropriately selected patients, neuromodulation therapies can decrease pain and improve function in individuals with chronic pain from various sources. Technologies such as spinal cord stimulation, peripheral nerve stimulation, and newer “restorative” muscle stimulation systems are now widely used in civilian and military medicine chronic pain practices.

Despite this growth, the absence of formal military guidelines has resulted in inconsistent access, variable decision-making, and unintended consequences for active-duty service members who receive these therapies.

Why This Guideline Is Needed – and Why Now

The need for these guidelines is both clinical and institutional. Pain medicine physicians in the military have long used neuromodulation to improve function and readiness in service members with refractory chronic pain. Yet, in the absence of policy or consensus standards, clinical and professional outcomes have often been at odds. Service members whose pain and function improved after implantation are sometimes rendered nondeployable, placed on restrictive profiles, or even medically separated solely because they have an implanted device. Part of this paradox is due to a lack of education among commanders and people who serve on medical boards, and a lack of policy within the US Department of War.

We sought to address these gaps and disparities via a new consensus document, published in the BMJ in late May.

A Recap of the New Guidelines and Their Development

The literature on neuromodulation is difficult to interpret because of heterogeneity in patient selection (eg, diagnoses), technical parameters (traditional vs newer forms of spinal cord stimulation, temporary vs permanent peripheral nerve stimulation), outcomes, and potential bias. The Military Neuromodulation Guidelines Committee was composed of subject matter experts, with no or minimal (and reconcilable) conflicts of interest, and the rigorous, 10-step Defense Health Agency (DHA) approval ensured recommendations devoid of significant bias.

In January 2025, the DHA Pain Management Clinical Support Service validated the need for consensus practice guidelines and endorsed their creation. Senior leaders in chronic pain management from the Army, Navy, and Air Force were assembled as part of the consensus panel. A steering committee was created, questions were devised that warranted answers by the steering committee and refinement by the full standing committee, and writing subcommittees were tasked with answering eight of the most salient questions.

We employed 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% or greater agreement was necessary to affirm a recommendation.

Gaps and Findings on Neuromodulation Therapy

Questions raised by the steering committee concerned:

  1. Patient selection (individual characteristics and conditions most likely to benefit from neuromodulation)

  2. Candidates for temporary (vs permanent) peripheral nerve stimulation (PNS), and factors associated with treatment outcome

  3. Whether the psychiatric contraindications, and requirement for mandatory psychological screening, should be the same as in non-military members

  4. Whether service members undergoing a medical board disposition determination should be eligible for permanent or temporary stimulators

  5. Who are the best candidates for multifidus muscle stimulation?

  6. Whether service members in certain military occupational specialties should not be implanted with permanent stimulators

  7. If active-duty service members with permanent implantable devices should be eligible for deployment and continued service on active duty

  8. Whether service members on opioid analgesics should be tapered prior to neuromodulation therapy

Findings that were specific to military personnel and that differ from civilian recommendations included:

  • We found insufficient evidence that neuromodulation can reliably reduce opioid use in service members.

  • There is evidence that temporary PNS can provide pain relief that lasts longer than the therapy is delivered.

  • There is insufficient evidence that service members with negative psychological screening and no prior history of such should require a routine psychological evaluation and approval.

  • Current neuromodulation devices have high levels of cybersecurity and can be safely operated in war settings.

  • For permanent but not temporary implantable devices, a joint decision model that includes a service member’s command should be employed prior to implant decisions.

  • Temporary, but not permanent, devices should be considered in service members undergoing medical boards who would like to remain on active duty.

  • Military service members who are candidates for multifidus muscle neurostimulation devices due to evidence of neuromuscular dysfunction should be allowed up to 6 months of rehabilitation time before duty disposition decisions.

  • If after 6 months, a service member is able to rehabilitate and return to full duty, they should be able to continue service as if a device had never been implanted, barring device-specific limitations.

  • Permanent implants are disqualifying for special operations, dive specialists, explosive ordnance disposal specialists, and may be disqualifying for aviation, combat arms, space, and submarine duty.

  • Although areas of responsibility may limit deployment, service members who are able to serve at full duty without restrictions for 3 months after treatment with an implanted device should be eligible for nonrestricted worldwide deployments.

  • Service Members on opioid analgesics should be informed of an increased likelihood of treatment failure, and those on > 90 oral morphine milliequivalents (MME) per day should be tapered to < 35 MME/day with the goal of having them discontinued prior to trial.

How the Guidelines Will Change Clinical Practice

The largest change to current practice may be an expanded awareness of neuromodulation therapy as an option for active-duty service members among patients themselves, their primary care managers, and their leadership, with clearer expectations and pathways for retention and deployment. The ability for patients to remain in full active-duty status will encourage pain physicians to use neuromodulation therapies more frequently for those patients deemed to be good candidates with otherwise refractory chronic pain.

Looking Ahead: Anticipated Approval and Impact

The DoD neuromodulation guidelines underwent formal review and revision in early 2026, with final approval granted in April. Their May publication and adoption marks a milestone in military pain medicine, offering the first comprehensive framework to guide clinicians, commanders, and service members navigating the complex intersection of chronic pain, advanced technology, and military service.

Ultimately, these guidelines are not intended to mandate care or replace clinical judgment. Instead, they provide a shared roadmap to promote consistency, fairness, and readiness – ensuring that service members who benefit from neuromodulation are supported, rather than penalized, for receiving effective treatment.