Mr Daniel Rhon

Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2019. Low back pain (LBP) is a common condition suffered by military personnel. Psychosocial factors play a role in LBP prognosis and can be addressed with self-management tools. This study's purpose was to (1) describe clinical changes in psychosocial factors of LBP following a self-management intervention and (2) explore the LBP experience of military trainees. Ten participants in Initial Entry Training (IET) were included in this mixed methods study. A self-management intervention of exercises and psychosocial education was provided. Quantitative instruments assessing psychosocial factors were delivered at baseline and 6 weeks. Qualitative data were gathered after treatment and analyzed using a phenomenological approach. Low levels of psychosocial risk factors were reported. Patient satisfaction (COPM-Satisfaction subscale) was the only outcome that achieved statistical significance at 6 weeks (p = 0.037). Three themes emerged from the qualitative results: the influence of the military culture on recovery from LBP, the LBP experience of a trainee, and promoting the self-management of LBP. While this cohort of IET soldiers exhibited low levels of psychosocial risk factors, qualitative reports indicate that LBP has a negative impact on participation in training, academics, and interpersonal relationships. The constraints of military training make seeking care and applying treatment strategies challenging.

© 2018 Arthroscopy Association of North America Purpose: Determine which proportion of active-duty service members return to duty (RTD), RTD without limitations, which surgical intervention returns these personnel at a better proportion and with the ability to perform their military duties after surgery compared with the pre-injury state. Methods: A computer-assisted search of MEDLINE, EMBASE and SCOPUS databases was performed with keywords related to RTD for femoroacetabular impingement (FAI) syndrome. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were used for study methodology. Methodologic quality of individual studies was assessed with the Methodological Index for Non-Randomized Studies scale. Results: A total of 5 studies (884 service members/886 hips) qualified for inclusion. Limited evidence from level III to IV studies indicates that service members RTD at a proportion ranging from 57% (95% confidence interval [CI]: 53% to 62%) to 84% (95% CI: 73% to 91%), but only 39% (95% CI: 35% to 44%) to 59% (95% CI: 49% to 69%) do so without limitations. Mean duration of follow-up was 33.2 ± 11.3 months. No studies reported on actual duty requirements before versus after surgery, RTD criteria, or career longevity. Only 1 of 5 studies reported the RTD time-frame (mean 5 months). Only 2 of 5 studies reported complications, with a rate of 9.4% ± 6.3%. Three of 5 studies reported failures at a rate of 7.2% ± 4.7%, respectively. Femoroplasty (mean 56% of procedures in 4 studies) and acetabuloplasty (mean 55% of procedures in 4 studies) were the most commonly used procedures in studies reporting. Conclusions: RTD is poorly defined in the included studies. Limited evidence substantiates that approximately 75% of service members remain on active duty for at least 1 to 2 years after surgery for FAI syndrome, whereas only approximately 47% do so without limitations at mid-term follow-up. Similarly, despite improvements in patient-reported outcome measures, service members still report continued pain and functional limitations after FAI syndrome surgery. Level of Evidence: Level IV, systematic review of Level III and IV studies.

© 2018 The Author(s). Background: Large healthcare databases, with their ability to collect many variables from daily medical practice, greatly enable health services research. These longitudinal databases provide large cohorts and longitudinal time frames, allowing for highly pragmatic assessment of healthcare delivery. The purpose of this paper is to discuss the methodology related to the use of the United States Military Health System Data Repository (MDR) for longitudinal assessment of musculoskeletal clinical outcomes, as well as address challenges of using this data for outcomes research. Methods: The Military Health System manages care for approximately 10 million beneficiaries worldwide. Multiple data sources pour into the MDR from multiple levels of care (inpatient, outpatient, military or civilian facility, combat theater, etc.) at the individual patient level. To provide meaningful and descriptive coding for longitudinal analysis, specific coding for timing and type of care, procedures, medications, and provider type must be performed. Assumptions often made in clinical trials do not apply to these cohorts, requiring additional steps in data preparation to reduce risk of bias. The MDR has a robust system in place to validate the quality and accuracy of its data, reducing risk of analytic error. Details for making this data suitable for analysis of longitudinal orthopaedic outcomes are provided. Results: Although some limitations exist, proper preparation and understanding of the data can limit bias, and allow for robust and meaningful analyses. There is the potential for strong precision, as well as the ability to collect a wide range of variables in very large groups of patients otherwise not captured in traditional clinical trials. This approach contributes to the improved understanding of the accessibility, quality, and cost of care for those with orthopaedic conditions. Conclusion: The MDR provides a robust pool of longitudinal healthcare data at the person-level. The benefits of using the MDR database appear to outweigh the limitations.

© 2018 Journal of Orthopaedic and Sports Physical Therapy. BACKGROUND: The influence of prior patterns of health care utilization on future health care utilization has had minimal investigation in populations with musculoskeletal disorders. UUOBJECTIVES: The purpose of this study was to explore the relationship between presurgical health care utilization and postsurgical health care utilization in a population of patients undergoing hip surgery in the US Military Health System. METHODS: In this observational cohort study, person-level data were collected for patients undergoing hip arthroscopy in the Military Health System from 2003 to 2015, capturing all encounters 12 months before and 24 months after surgery for every individual. Cluster analysis was used to categorize individuals with high and low health care utilization, based on preoperative health care visits. Unadjusted and adjusted Poisson and generalized linear models were generated. Health care utilization outcomes were targeted, including costs, visits, and medication use. RESULTS: There were 1850 individuals in the final cohort (mean age, 32.18 years; 55.4% male). The high health care utilization group averaged 57.69 ± 25.87 visits, compared to 20.43 ± 8.36 visits in the low utilization group. There were significant differences between groups for total health care visits (58.17; 95% confidence interval [CI]: 57.39, 58.58), total health care costs ($11 539.71; 95% CI: $10 557.26, $12 595.04), hip-related visits (12.77; 95% CI: 12.59, 12.96), hip-related costs ($3325.07; 95% CI: $2886.43, $3804.51), days' supply of pain medications (752.67; 95% CI: 751.24, 754.11), opioid prescriptions (48.83; 95% CI: 48.47, 49.21), and cost of pain medications ($1074.80; 95% CI: $1011.91, $1137.68). CONCLUSION: Presurgical patterns of health care utilization were associated with postsurgical patterns of health care utilization, indicating that those patients who used more care before surgery also used more care after surgery. Clinicians should consider prior patterns of health care utilization, including utilization unrelated to the index condition, when determining care plans and prognosis.

STUDY DESIGN: Randomized controlled trial. OBJECTIVE: The aim of this study was to compare early physical therapy versus usual care in patients with low back pain. SUMMARY OF BACKGROUND DATA: Early physical therapy (PT) has been associated with reduced downstream healthcare utilization in retrospective studies, but not investigated prospectively in the military health system. METHODS: Military service members seeking care from a general practitioner were recruited. Patients attended a 20-minute self-management class with focus on psychosocial resilience and then randomized to usual care only (UC) versus immediately starting a 3-week physical therapy program (PT). Primary outcome was the Oswestry Disability Index at 1 year. Secondary outcomes included Oswestry scores at 4- and 12-week follow-up, numeric pain rating scale, global rating of change, and healthcare utilization at 1 year. Analysis of covariance was used to compare differences between groups, significance set at 0.05. TRIAL REGISTRATION: clinicaltrials.gov: NCT01556581 RESULTS.: A total of 119 patients (mean age 27.2 years; mean BMI 27.8¿kg/m; 15.1% female) enrolled (61 randomized to UC; 58 to PT). No between-group differences found on the Oswestry after 1 year. A between-group difference in Oswestry was present at 4 weeks (mean difference¿=¿4.4; 95% CI: 0.41-10.1; P¿=¿0.042) favoring PT. Total 1-year mean healthcare costs did not differ significantly between groups (UC $5037; 95 CI $4171-$6082 and PT $5299; 95 CI $4367-$6431). The portion of total mean healthcare costs related to low back pain was lower for UC ($1096; 95% CI $855-$1405) compared to PT ($2016, 95% CI $1570-$2590). CONCLUSION: There was no difference between usual care and early PT after 1 year. PT provided greater improvement in disability after 4 weeks. As both groups improved, the impact of the education may have been underestimated. Patients in the PT group utilized greater back-pain-related healthcare resources, but overall healthcare costs did not differ compared to UC.2.

© 2018, © 2018 The Author(s). Background: Arthroscopic hip surgery has risen 18-fold in the past decade; however, there is a dearth of clinical trials comparing surgery with nonoperative management. Purpose: To determine the comparative effectiveness of surgery and physical therapy for femoroacetabular impingement syndrome. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: Patients were recruited from a large military hospital after referral to the orthopaedic surgery clinic and were eligible for surgery. Of 104 eligible patients, 80 elected to participate, and the majority were active-duty service members (91.3%). No patients withdrew because of adverse events. The authors randomly selected patients to undergo either arthroscopic hip surgery (surgery group) or physical therapy (rehabilitation group). Patients in the rehabilitation group began a 12-session supervised clinic program within 3 weeks, and patients in the surgery group were scheduled for the next available surgery at a mean of 4 months after enrollment. Patient-reported outcomes of pain, disability, and perception of improvement over a 2-year period were collected. The primary outcome was the Hip Outcome Score (HOS; range, 0-100 [lower scores indicating greater disability]; 2 subscales: activities of daily living and sport). Secondary measures included the International Hip Outcome Tool (iHOT-33), Global Rating of Change (GRC), and return to work at 2 years. The primary analysis was on patients within their original randomization group. Results: Statistically significant improvements were seen in both groups on the HOS and iHOT-33, but the mean difference was not significant between the groups at 2 years (HOS activities of daily living, 3.8 [95% CI, ¿6.0 to 13.6]; HOS sport, 1.8 [95% CI, ¿11.2 to 14.7]; iHOT-33, 6.3 [95% CI, ¿6.1 to 18.7]). The median GRC across all patients was that they ¿felt about the same¿ (GRC = 0). Two patients assigned to the surgery group did not undergo surgery, and 28 patients in the rehabilitation group ended up undergoing surgery. A sensitivity analysis of ¿actual surgery¿ to ¿no surgery¿ did not change the outcome. Twenty (33.3%) patients who underwent surgery and 4 (33.3%) who did not undergo surgery were medically separated from military service at 2 years. Conclusion: There was no significant difference between the groups at 2 years. Most patients perceived little to no change in status at 2 years, and one-third of military patients were not medically fit for duty at 2 years. Limitations include a single hospital, a single surgeon, and a high rate of crossover. Registration: NCT01993615 (ClinicalTrials.gov identifier).

Copyright © 2018 Journal of Orthopaedic & Sports Physical Therapy®. BACKGROUND: Musculoskeletal injuries during military service are a primary source of disability, resulting in 2.4 million annual health care visits and 25 million limited-duty days. While the injury incidence during basic training is well documented, there is little understanding of injury distribution by organization type in the US Army following initial training. OBJECTIVE: To compare injury incidence, distribution, and impact across various military units. METHODS: In this prospective observational cohort study, comprehensive injury data from subject questionnaires and medical chart reviews were collected over 12 months for 1430 initially healthy Army personnel, representing combat, combat support, combat service support, and ranger units. Health care utilization and time loss due to injury were also collected. RESULTS: Of 1430 soldiers, 481 (33.6%) had time-loss injury, 222 (15.5%) were injured without limited work, 60 (4.2%) reported an injury but did not seek medical care, and 667 (46.6%) were uninjured. Across the whole sample, injuries were responsible for 5.9 ± 14.4 medical visits per soldier, 21 902 days of limited work, and $1 337 000 ($1901 ± $6535 per soldier) in medical costs. Considering only those reporting injury, each person averaged 36.3 ± 59.7 limited-work days. The injury incidence was highest in combat service support units (65.6%), with a risk ratio 1.60 times that of the reference group (combat, 41.1%). CONCLUSION: Combat support and combat service support personnel were more likely to have 1 or more injuries compared to rangers and combat personnel. The higher relative risk of injury in support units should be explored further.

This is an open access article, free of all copyright, and may be freely reproduced, distributed, transmitted, modified, built upon, or otherwise used by anyone for any lawful purpose. The work is made available under the Creative Commons CC0 public domain dedication. Background The global burden of low back pain is growing rapidly, accompanied by increasing rates of associated healthcare utilization. Health seeking behavior (HSB) has been suggested as a mediator of healthcare utilization. The aims of this study were to: 1) develop a proxy HSB measure based on healthcare consumption patterns prior to initial consultation for spinal pain, and 2) examine associations between the proxy HSB measure and future healthcare utilization in a population of patients with spine disorders. Methods A cohort of 1,691 patients seeking care for spinal pain at a single military hospital were included. Cluster analyses were performed for the identification of a proxy HSB measure. Logistic regression was used to identify the predictive capacity of HSB on eight different general and spine-related high healthcare utilization (upper 25%) outcomes variables. Results The strongest proxy measure of HSB was prior primary care provider visits. In unadjusted models, HSB predicted healthcare utilization across all eight general and spine-related outcome variables. After adjusting for covariates, HSB still predicted general and spine-related healthcare utilization for most variables including total medical visits (OR = 2.48, 95%CI 1.09,3.11), total medical costs (OR = 2.72, 95%CI 2.16,3.41), and low back pain-specific costs (OR = 1.31, 95%CI 1.00,1.70). Conclusion Health seeking behavior prior to initial consultation for spine pain was related to healthcare utilization after consultation for spine pain. HSB may be an important variable to consider when developing an individualized care plan and considering the prognosis of a patient.

© 2018 Associação Brasileira de Pesquisa e Pós-Graduação em Fisioterapia Background: Physical therapists¿ familiarity, perceptions, and beliefs about health services utilization and health seeking behaviour have not been previously assessed. Objectives: The purposes of this study were to identify physical therapists¿ characteristics related to familiarity of health services utilization and health seeking behaviour, and to assess what health seeking behaviour factors providers felt were related to health services utilization. Methods: We administered a survey based on the Andersen behavioural model of health services utilization to physical therapists using social media campaigns and email between March and June of 2017. In addition to descriptive statistics, we performed binomial logistic regression analysis. We asked respondents to rate familiarity with health services utilization and health seeking behaviour and collected additional characteristic variables. Results: Physical therapists are more familiar with health services utilization than health seeking behaviour. Those who are familiar with either construct tend to be those who assess for health services utilization, use health services utilization for a prognosis, and believe that health seeking behaviour is measurable. Physical therapists rated need and enabling factors as having more influence on health services utilization than predisposing and health belief factors. Conclusion: Physical therapists are generally familiar with health services utilization and health seeking behaviour; however, there appears to be a disconnect between what is familiar, what is perceived to be important, and what can be assessed for both health services utilization and health seeking behaviour.

© Association of Military Surgeons of the U.S. All rights reserved. Background: Musculoskeletal injuries present a significant challenge to military readiness accounting for over 29% of ambulatory medical visits and 25 million limited duty days across the U.S. Army. Although U.S. Military Health Systems perform periodic general health and deployment assessments, there is no validated tool to determine when a service member is at increased risk of sustaining a musculoskeletal injury. Method: 292 U.S. Army basic training recruits completed a novel injury screening test called the Musculoskeletal Readiness Screening Tool (MRST). It consisted of six separate physical movements and asked one question regarding perceived risk of personal injury. The injury surveillance period covered the duration of the basic training program lasting from 9 to 20 weeks. An independent t test was performed to assess for differences in composite MRST scores between those who sustained an injury and those who did not. A Receiver Operator Characteristic curve analysis was completed to determine if an appropriate cutoff score existed to predict increased likelihood for sustaining an injury within this cohort. Results: Our results indicate that the difference in mean composite score between injured (n = 143) and noninjured subjects fell just short of being significantly different ( p = 0.053). The MRST is most specific with a cutoff score of 6 (out of a maximum score of 12) at 0.89 (95% confidence interval: 0.82, 0.93). Those scoring less than or equal to 6 on the screening tool were 2.05 times (95% confidence interval: 1.07, 3.9) as likely to sustain an injury as those scoring greater than 6. Additionally, the results indicate that the test can be applied to both male and female trainees, as scores were not significantly different between the sexes. Conclusion: The MRST shows potential as a tool for identifying service members at higher risk for sustaining a musculoskeletal injury. Further research is needed to assess the validity, reliability, and responsiveness of this novel screening tool.