1
|
Mowery HC, Campello M, Ziemke G, Oh C, Hope T, Jansen B, Weiser S. Psychological Risk Factors for Delayed Recovery Among Active Duty Service Members Seeking Treatment for Musculoskeletal Complaints at a Navy Shore-Based Military Medical Treatment Facility. Mil Med 2024; 189:12-17. [PMID: 39160797 DOI: 10.1093/milmed/usae019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 01/02/2024] [Accepted: 01/31/2024] [Indexed: 08/21/2024] Open
Abstract
INTRODUCTION Musculoskeletal injuries (MSIs) are a leading cause of separation from the U.S. Navy. Data have shown that several psychological responses to MSI are associated with treatment outcomes. Yellow flags are maladaptive psychological responses to injury and predict delayed recovery, whereas pink flags indicate resilience after MSI and are associated with good treatment outcomes. Identifying these factors in patients with MSI would permit early targeted care to address factors that may delay their readiness for deployment and enhance factors that support recovery. MATERIALS AND METHODS Active duty service members with MSI who reported to physical therapy outpatient services at a naval hospital were recruited for the study. Yellow flags were assessed at baseline as part of a larger study. Participants completed the Fear Avoidance Beliefs Questionnaire (with two subscales, physical activity and work), the Pain Catastrophizing Scale, and the Hospital Anxiety and Depression Scale. Clinically relevant cut-off scores were used to indicate risk factors of delayed recovery. Pink flags were assessed with the Pain Self-Efficacy Questionnaire and a measure of positive outcome expectations for recovery. RESULTS Two hundred and ninety participants responded to some or all of the questionnaires. Of these, 82% exceeded the cut-off scores on the physical activity subscale of the Fear Avoidance Beliefs Questionnaire, and 39% did so on the work subscale. Pain catastrophizing exceeded the cut-off in only 4.9% of the sample. Forty-three percent of these exceeded the cut-off for the anxiety subscale of the Hospital Anxiety and Depression Scale; 27% exceeded the cut-off on the depression subscale of the Hospital Anxiety and Depression Scale. Additionally, 54% endorsed scores greater than 40 on the Pain Self-Efficacy Questionnaire, and 53% endorsed a high score on the positive outcome expectations. CONCLUSIONS A substantial portion of the sample endorsed elevated scores on one or more indicators of delayed recovery from MSI. Most participants showed a fear of physical activity, and approximately half reported pain-related distress (anxiety and depression). In addition, feelings of self-efficacy and positive outcome expectations of treatment were endorsed by only about half of the participants, indicating that the remaining half did not report adaptive responses to MSI. Early identification of these risk factors will allow for targeted treatment approaches that incorporate these yellow flags into treatment and support a psychologically informed approach to physical therapy. This approach is likely to reduce delayed recovery and improve deployment readiness.
Collapse
Affiliation(s)
- Hope C Mowery
- Department of Orthopedics, New York University Langone Orthopedic Hospital, New York, NY 10014, USA
| | - Marco Campello
- Department of Orthopedics, New York University Grossman School of Medicine, New York, NY 10016, USA
| | - Gregg Ziemke
- Henry Jackson Foundation, Bethesda, MD 20817, USA
| | - Cheongeun Oh
- Department of Orthopedics, New York University Grossman School of Medicine, New York, NY 10016, USA
- Department of Population Health, New York University Grossman School of Medicine, New York, NY 10016, USA
| | - Timothy Hope
- Henry Jackson Foundation, Bethesda, MD 20817, USA
| | - Brittany Jansen
- Physical Medicine and Rehabilitation, Naval Medical Center Portsmouth, Portsmouth, VA 23708, USA
| | - Sherri Weiser
- Department of Orthopedics, New York University Grossman School of Medicine, New York, NY 10016, USA
| |
Collapse
|
2
|
McWhorter S, Simon-Arndt C, Carlson L. Overview of Navy Medicine's Limited Duty Patient Population. Mil Med 2024; 189:820-827. [PMID: 36416341 DOI: 10.1093/milmed/usac348] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 10/17/2022] [Accepted: 10/27/2022] [Indexed: 02/17/2024] Open
Abstract
INTRODUCTION U.S. Navy Medicine's temporary limited duty (LIMDU) program is the primary vehicle for managing the medical care and subsequent career outcomes of the ill and injured active component (AC) Sailors and Marines to ensure a medically ready force. Before the LIMDU Sailor and Marine Readiness Tracker System (SMART) came online, it was very difficult to examine LIMDU program administration metrics, patients' experiences during LIMDU, and their subsequent health and career outcomes. This study examined the LIMDU patient population's demographic, military career, and LIMDU-specific characteristics; identified characteristics that differed significantly by military service; and evaluated potentially modifiable factors associated with patient outcomes. MATERIALS AND METHODS A comprehensive SMART extract was used to identify all AC Sailors and Marines in active LIMDU status between October 1, 2016, and September 30, 2019. The SMART extract was merged with comprehensive administrative military personnel data by patient identifiers to create a longitudinal dataset and to conduct descriptive statistics, bivariate, and multivariate logistic regression analyses for this study. The sample included 26,591 AC Sailors and Marines with complete SMART and military personnel records who ended LIMDU on or before September 30, 2019. RESULTS During the study's 3-year period, Navy Medicine's rate of initial LIMDU entry by AC personnel increased each year from 2,041 in FY2017 to 2,424 in FY2019 per 100,000 personnel. At the time of initial entry, most LIMDU patients were male (76%), E4-E6 paygrades (54%), and had a single diagnosis recorded in their SMART records (66%). Pain patients (23%) constituted the largest diagnostic group, followed closely by musculoskeletal patients (23%), and then mental and behavioral health patients (20%). Variables that might reflect administration practices of the program did not differ significantly by service, suggesting good internal standardization of LIMDU administration across Navy Medicine. However, bivariate and multivariate analyses identified significant differences by service for almost all personal demographic, LIMDU-specific, and post-LIMDU military career sample characteristics measured at the last LIMDU close date or later. Study results suggested that the Navy and Marine Corps referred Sailors and Marines to start LIMDU for different medical reasons; to receive care from different military treatment facilities; to close LIMDU with different final actions; and to experience different post-LIMDU career outcomes. CONCLUSION Navy Medicine's SMART data is an important new resource for LIMDU program evaluation and population-level patient research, despite the data limitations and concerns identified and addressed by this study. The study results provide a baseline empirical understanding about the LIMDU patient population. Further research is necessary to interrogate the validity of these results over a longer period and to initiate other lines of inquiry. While the construction of the larger project's LIMDU patient population longitudinal dataset required a significant initial investment, future dividends from ongoing work are anticipated. Results derived from verified SMART data will benefit Navy Medicine, operational commands, and LIMDU patients alike by informing continuing efforts to improve patient health and career outcomes, identify and implement best clinical and administrative practices, and optimize force readiness.
Collapse
Affiliation(s)
| | - Cynthia Simon-Arndt
- Naval Health Research Center, San Diego, CA 92106, USA
- Leidos Inc., San Diego, CA 92121, USA
| | - Lori Carlson
- Case Management Department, Naval Medical Center, San Diego, CA 92134, USA
| |
Collapse
|
3
|
Campello M, Ziemke G, Hair LC, Oh C, Mowery H, Hope T, Weiser S. Protocol for the Implementation of Psychologically Informed Physical Therapy to Prevent Chronification in Service Members With Musculoskeletal Disorders. Mil Med 2023; 188:503-510. [PMID: 37948222 DOI: 10.1093/milmed/usad219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 03/17/2023] [Accepted: 06/07/2023] [Indexed: 11/12/2023] Open
Abstract
INTRODUCTION Musculoskeletal disorders (MSDs) are a primary cause of separation and long-term disability in active duty service members (ADSMs). Psychologically informed physical therapy (PiPT) is designed to identify and address modifiable psychological risk factors early in an MSD episode and has been proven effective in preventing chronicity in civilian populations. We developed a course to train military physical therapy (PT) personnel in PiPT for treating ADSM with MSD. This study tests the feasibility and effectiveness of our training. OBJECTIVE Establish the feasibility of implementing PiPT and its effectiveness in the U.S. military. SPECIFIC AIMS MATERIALS AND METHODS An observational, prospective, comparative cohort study will test implementation and effectiveness. First, we will observe clinical outcomes in a cohort of ADSM with MSD receiving usual PT care at a military outpatient PT clinic. Next, we will train all PT staff in PiPT. Finally, PiPT will be implemented in a second cohort of ADSM. Data will be collected from each cohort at pre-treatment, fourth PT visit, 6 months post enrollment, and 12 months post enrollment. The primary outcomes are pain interference and psychological risk for chronicity. RESULTS AND CONCLUSIONS Data collection is ongoing. Findings will identify the factors associated with PiPT outcomes in ADSM, inform the implementation of PiPT across health care settings, and allow us to document the prevalence of risk factors for chronicity in ADSM. Findings can help to prevent chronification from MSD, thereby reducing lost man-hours and enhancing military readiness, contribute to the development of a highly skilled workforce for the provision of health services to ADSM, and enhance the efficiency of health care delivery through optimal allocation of PT resources, resulting in significant cost savings for the military.
Collapse
Affiliation(s)
- Marco Campello
- New York University Grossman School of Medicine, New York, NY 10016, USA
| | - Gregg Ziemke
- Henry Jackson Foundation, Bethesda, MD 20817, USA
| | - Leslie C Hair
- Naval Medical Center Portsmouth, Portsmouth, VA 23708, USA
| | - Cheongeun Oh
- New York University Grossman School of Medicine, New York, NY 10016, USA
| | - Hope Mowery
- New York University Langone Health, New York, NY 10010, USA
| | - Timothy Hope
- Henry Jackson Foundation, Bethesda, MD 20817, USA
| | - Sherri Weiser
- New York University Grossman School of Medicine, New York, NY 10016, USA
| |
Collapse
|
4
|
Karhade AV, Bono CM, Makhni MC, Schwab JH, Sethi RK, Simpson AK, Feeley TW, Porter ME. Value-based health care in spine: where do we go from here? Spine J 2021; 21:1409-1413. [PMID: 33857667 DOI: 10.1016/j.spinee.2021.04.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 03/30/2021] [Accepted: 04/06/2021] [Indexed: 02/03/2023]
Affiliation(s)
- Aditya V Karhade
- Institute for Strategy and Competitiveness, Harvard Business School, Boston, MA, USA; Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Department of Orthopedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
| | - Christopher M Bono
- Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Melvin C Makhni
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Joseph H Schwab
- Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Rajiv K Sethi
- Neuroscience Institute, Virginia Mason Medical Center, Seattle, WA, USA; Department of Neurosurgery, Virginia Mason Medical Center, Seattle, WA, USA
| | - Andrew K Simpson
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Thomas W Feeley
- Institute for Strategy and Competitiveness, Harvard Business School, Boston, MA, USA
| | - Michael E Porter
- Institute for Strategy and Competitiveness, Harvard Business School, Boston, MA, USA
| |
Collapse
|
5
|
Johnson SM, Hutchins T, Peckham M, Anzai Y, Ryals E, Davidson HC, Shah L. Effects of implementing evidence-based appropriateness guidelines for epidural steroid injection in chronic low back pain: the EAGER (Esi Appropriateness GuidElines pRotocol) study. BMJ Open Qual 2020; 8:e000772. [PMID: 31909212 PMCID: PMC6937044 DOI: 10.1136/bmjoq-2019-000772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 11/19/2019] [Accepted: 11/28/2019] [Indexed: 11/18/2022] Open
Abstract
Objective Chronic low back pain is very common and often treated with epidural steroid injections (ESIs). As ESI referrals had been rapidly increasing at our Veterans’ Administration hospital, we were concerned that they were supplanting more comprehensive care. The objective was to determine how referral patterns and multidisciplinary care might change with the implementation of evidence-based guidelines. Methods In this retrospective observational study, multidisciplinary evidence-based guidelines were implemented in 2014 (EAGER: Esi Appropriateness GuidElines pRotocol) as part of the ordering process for an ESI. Time series analysis was performed to assess the primary outcome of subspecialty referral pattern, that is, the number of patients receiving referrals to ancillary services which might serve to provide a more comprehensive approach to their back pain. Secondary outcomes included patient-level changes (ie, body mass index, number of injections, opioid use), which were compared before and after protocol implementation. Results Comparing preimplementation and postimplementation protocol periods, referrals to physical medicine/rehabilitation increased 11.7% (p=0.003) per year and integrative health increased 2.1% (p<0.001) per year among the 2294 individual patients who received ESI through the neurointerventional radiology service. Of 100 randomly selected patients for patient-level analysis, the median body mass index decreased from 31.57 to 30.22 (p=<0.001) and the mean number of injections decreased from 1.76 to 0.73 (p<0.001). The percentage of patients using oral opioid analgesics decreased from 72% to 49% (p=<0.001). Conclusion Implementation of evidence-based guidelines for ESI referral helps guide patients into a more comprehensive care pathway for chronic low back pain and is correlated with patient-level changes such as decreased body mass index and decreased opioid usage.
Collapse
Affiliation(s)
- Scott M Johnson
- Radiology, University of Utah Health Sciences Center, Salt Lake City, Utah, USA
| | - Troy Hutchins
- Radiology, University of Utah Health Sciences Center, Salt Lake City, Utah, USA
| | - Miriam Peckham
- Radiology, University of Utah Health Sciences Center, Salt Lake City, Utah, USA
| | - Yoshimi Anzai
- Radiology, University of Utah Health Sciences Center, Salt Lake City, Utah, USA
| | - Elizabeth Ryals
- Radiology, University of Utah Health Sciences Center, Salt Lake City, Utah, USA
| | - H Christian Davidson
- Radiology, University of Utah Health Sciences Center, Salt Lake City, Utah, USA.,Radiology, George E Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, Utah, USA
| | - Lubdha Shah
- Radiology, University of Utah Health Sciences Center, Salt Lake City, Utah, USA
| |
Collapse
|
6
|
Cancelliere C, Sutton D, Côté P, French SD, Taylor-Vaisey A, Mior SA. Implementation interventions for musculoskeletal programs of care in the active military and barriers, facilitators, and outcomes of implementation: a scoping review. Implement Sci 2019; 14:82. [PMID: 31419992 PMCID: PMC6698020 DOI: 10.1186/s13012-019-0931-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Accepted: 07/31/2019] [Indexed: 11/29/2022] Open
Abstract
Background Musculoskeletal disorders are common in the active military and are associated with significant lost duty days and disability. Implementing programs of care to manage musculoskeletal disorders can be challenging in complex healthcare systems such as in the military. Understanding how programs of care for musculoskeletal disorders have been implemented in the military and how they impact outcomes may help to inform future implementation interventions in this population. Methods We conducted a scoping review using the modified Arksey and O’Malley framework to identify literature on (1) implementation interventions of musculoskeletal programs of care in the active military, (2) barriers and facilitators of implementation, and (3) implementation outcomes. We identified studies published in English by searching MEDLINE, CINAHL, Embase, and CENTRAL (Cochrane) from inception to 1 June 2018 and hand searched reference lists of relevant studies. We included empirical studies. We synthesized study results according to three taxonomies: the Effective Practice and Organization of Care (EPOC) taxonomy to classify the implementation interventions; the capability, opportunity, motivation-behavior (COM-B) system to classify barriers and facilitators of implementation; and Proctor et al.’s taxonomy (Adm Policy Ment Health 38:65–76, 2011) to classify outcomes in implementation research. Results We identified 1785 studies and 16 were relevant. All but two of the relevant studies were conducted in the USA. Implementation interventions were primarily associated with delivery arrangements (e.g., multidisciplinary care). Most barriers or facilitators of implementation were environmental (physical or social). Service and client outcomes indicated improved efficiency of clinical care and improved function and symptomology. Studies reporting implementation outcomes indicated the programs were acceptable, appropriate, feasible, or sustainable. Conclusion Identification of evidence-based approaches for the management of musculoskeletal disorders is a priority for active-duty military. Our findings can be used by military health services to inform implementation strategies for musculoskeletal programs of care. Further research is needed to better understand (1) the components of implementation interventions, (2) how to overcome barriers to implementation, and (3) how to measure implementation outcomes to improve quality of care and recovery from musculoskeletal disorders.
Collapse
Affiliation(s)
- Carol Cancelliere
- Faculty of Health Sciences, University of Ontario Institute of Technology, 2000 Simcoe Street North, Science building, Room 3000, Oshawa, Ontario, L1H 7K4, Canada. .,UOIT-CMCC Centre for Disability Prevention and Rehabilitation, Faculty of Health Sciences, University of Ontario Institute of Technology (UOIT), 2000 Simcoe Street North, Science building, Room 3000, Oshawa, Ontario, L1H 7K4, Canada. .,UOIT-CMCC Centre for Disability Prevention and Rehabilitation, Canadian Memorial Chiropractic College (CMCC), 6100 Leslie Street, Toronto, Ontario, M2H 3J1, Canada.
| | - Deborah Sutton
- UOIT-CMCC Centre for Disability Prevention and Rehabilitation, Faculty of Health Sciences, University of Ontario Institute of Technology (UOIT), 2000 Simcoe Street North, Science building, Room 3000, Oshawa, Ontario, L1H 7K4, Canada.,UOIT-CMCC Centre for Disability Prevention and Rehabilitation, Canadian Memorial Chiropractic College (CMCC), 6100 Leslie Street, Toronto, Ontario, M2H 3J1, Canada.,Division of Research and Innovation, Canadian Memorial Chiropractic College, 6100 Leslie Street, Toronto, Ontario, M2H 3J1, Canada
| | - Pierre Côté
- Faculty of Health Sciences, University of Ontario Institute of Technology, 2000 Simcoe Street North, Science building, Room 3000, Oshawa, Ontario, L1H 7K4, Canada.,UOIT-CMCC Centre for Disability Prevention and Rehabilitation, Faculty of Health Sciences, University of Ontario Institute of Technology (UOIT), 2000 Simcoe Street North, Science building, Room 3000, Oshawa, Ontario, L1H 7K4, Canada.,UOIT-CMCC Centre for Disability Prevention and Rehabilitation, Canadian Memorial Chiropractic College (CMCC), 6100 Leslie Street, Toronto, Ontario, M2H 3J1, Canada.,Division of Research and Innovation, Canadian Memorial Chiropractic College, 6100 Leslie Street, Toronto, Ontario, M2H 3J1, Canada.,Canada Research Chair in Disability Prevention and Rehabilitation, Faculty of Health Sciences, University of Ontario Institute of Technology (UOIT), 2000 Simcoe Street North, Science building, Room 3000, Oshawa, Ontario, L1H 7K4, Canada
| | - Simon D French
- School of Rehabilitation Therapy, Faculty of Health Sciences, Queen's University, Louise D. Acton Building, 31 George Street, Kingston, Ontario, K7L 3N6, Canada.,Department of Chiropractic, Faculty of Science and Engineering, Macquarie University, Macquarie Park, NSW, 2109, Australia
| | - Anne Taylor-Vaisey
- UOIT-CMCC Centre for Disability Prevention and Rehabilitation, Faculty of Health Sciences, University of Ontario Institute of Technology (UOIT), 2000 Simcoe Street North, Science building, Room 3000, Oshawa, Ontario, L1H 7K4, Canada.,UOIT-CMCC Centre for Disability Prevention and Rehabilitation, Canadian Memorial Chiropractic College (CMCC), 6100 Leslie Street, Toronto, Ontario, M2H 3J1, Canada
| | - Silvano A Mior
- Faculty of Health Sciences, University of Ontario Institute of Technology, 2000 Simcoe Street North, Science building, Room 3000, Oshawa, Ontario, L1H 7K4, Canada.,UOIT-CMCC Centre for Disability Prevention and Rehabilitation, Faculty of Health Sciences, University of Ontario Institute of Technology (UOIT), 2000 Simcoe Street North, Science building, Room 3000, Oshawa, Ontario, L1H 7K4, Canada.,UOIT-CMCC Centre for Disability Prevention and Rehabilitation, Canadian Memorial Chiropractic College (CMCC), 6100 Leslie Street, Toronto, Ontario, M2H 3J1, Canada.,Division of Research and Innovation, Canadian Memorial Chiropractic College, 6100 Leslie Street, Toronto, Ontario, M2H 3J1, Canada
| |
Collapse
|