Citation
U.S. Army Medical Department journal

Material Information

Title:
U.S. Army Medical Department journal
Alternate title:
United States Army Medical Department journal
Alternate Title:
AMEDD journal
Running title:
Army Medical Department journal
Abbreviated Title:
U.S. Army Med. Dep. j.
Creator:
United States -- Army Medical Department (1968- )
Place of Publication:
Fort Sam Houston, TX
Publisher:
U.S. Army Medical Department
Publication Date:
Frequency:
Quarterly[<Oct.-Dec. 2001->]
Bimonthly[ FORMER Sept.-Oct. 1994-]
quarterly
regular
Language:
English
Physical Description:
volumes : illustrations ; 28 cm

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Subjects / Keywords:
Medicine, Military -- Periodicals -- United States ( lcsh )
Military Medicine ( mesh )
Medicine ( mesh )
Medicine, Military ( fast )
United States ( mesh )
United States ( fast )
United States
Genre:
Electronic journals.
Periodicals.
Periodicals. ( fast )
Fulltext.
Government Publications, Federal.
Internet Resources.
serial ( sobekcm )
federal government publication ( marcgt )
periodical ( marcgt )
Electronic journals ( lcsh )
Periodicals ( mesh )
Periodicals ( fast )
Fulltext
Government Publications, Federal
Periodicals
Internet Resources

Notes

Dates or Sequential Designation:
Sept.-Oct. 1994-
General Note:
Title from cover.

Record Information

Source Institution:
University of Florida
Holding Location:
University of Florida
Rights Management:
This item is a work of the U.S. federal government and not subject to copyright pursuant to 17 U.S.C. §105.
Resource Identifier:
32785416 ( OCLC )
98642403 ( LCCN )
1524-0436 ( ISSN )
ocm32785416
Classification:
RC970 .U53 ( lcc )
616.9/8023/05 ( ddc )
W1 JO96 ( nlm )

Related Items

Preceded by:
Journal of the US Army Medical Department.

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Digital Military Collection

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JanuaryMarch 2016 Correlation Between Femoral Neck Shaft Angle and Surgical Management 1 in Trainees With Femoral Neck Stress Fractures CPT Robyn L. Chalupa; MAJ Jessica C. Rivera; CPT David J. Tennent; LTC (P) Anthony E. Johnson Observed Rates of Lower Extremity Stress Fractures After Implementation of the Army 6 Physical Readiness Training Program At JBSA Fort Sam Houston CPT Robyn L. Chalupa; Curtis Aberle, MSN; LTC (P) Anthony E. Johnson What Soldiers Know and Want to Know about Preventing Injuries: 10 A Needs Survey Regarding a Key Threat to Readiness Veronique Hauschild, MPH; Anna Schuh, PhD; Bruce Jones, MD, MPH Rhabdomyolysis in a Sickle Cell Trait Positive Active Duty Male 20 CPT Pulkit Saxena; CPT Christopher Chavarria; MAJ John Thurlow 24 LTC (Ret) Reva Rogers; LTC Renee Cole Muscle-related Disability Following Combat Injury Increases With Time 30 MAJ Jessica C. Rivera; Benjamin T. Corona, MD War and Rehabilitation: Occupational Therapys Power to Transform Disability into Ability 35 1 LT Catrinna Amorelli; 1 LT Lindsay Sposato Center for the Intrepid: Providing Patients POWER 39 1 LT Catrinna Amorelli; 1 LT Matthew L. Baumann; LTC Kathleen E. Yancosek; et al Implementation of a Transition of Care Coordinator at a Military Treatment Facility 47 LTC Dana Nguyen; CPT Blake Busey; LTC Mark Stackle; et al 53 During Leisure Time in Soldiers: A Prospective Surveillance Study Maj Christoph Schulze, MD, German Air Force ; Tobias Lindner, MD ; et al 60 David G. Greathouse, PT, PhD; Greg Ernst, PT, PhD; John S. Halle, PT, PhD; COL Scott W. Shaffer Q Fever 68 CPT Akira A. Shishido; LCDR Andrew G. Letizia, USN; LTC Joshua D. Hartzell Mobile Phone Health Applications for the Federal Sector 71 Capt Christin S. Burrows, USAF; MAJ Fred K. Weigel A Primary Care Telehealth Experience in a US Army Correctional Facility in Germany 76 LTC Christian Swift; Steven M. Cain, MPAS, PA-C; CPT Michael Needham Repair of a Gingival Fenestration Using an Acellular Dermal Matrix Allograft 81 COL Lawrence G. Breault; CPT Raquel C. Brentson; COL Edward B. Fowler; COL Frederick C. Bisch Reasons for Non-third Molar Extractions in a Military Population 85 MAJ Hanane Jamghili; COL William J. Greenwood; COL Peter H. Guevara; Col William J. Dunn, USAF Errata 80 J OURNAL THE UNITED STATES ARMY MEDICAL DEPARTMENT

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J OURNAL A Prof essional Publication of the AMEDD Community THE UNITED STATES ARMY MEDICAL DEPARTMENT Online issues of the AMEDD Journal are available at http://www.cs.amedd.army.mil/amedd_journal.aspx JanuaryMarch 2016 US Army Medical Department Center & School PB 8-16-1/2/3 The Army Medical Department Journal [ISSN 1524 0436 ] is published quarterly 3630 Stanley RD STE B 0204 78234 6100 The Army Medical Department Journal are listed and Journal s CORRESPONDENCE: (210) 221-6301, DSN 471-6301 DISCLAIMER: The AMEDD Journal in the AMEDD Journal AMEDD Journal CONTENT: AMEDD Journal OFFICIAL DISTRIBUTION: By Order of the Secretary of the Army: GERALD B. OKEEFE Secretary of the Army Mark A. Milley 1528705 LTG Nadja Y. West MG Steve Jones

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January March 2016 1 The most common overuse injury that leads to the dis charge of new military recruits is a stress fracture. 1 Stress fractures are associated with abrupt changes in physical activity level, such as the increase in activity some recruits are exposed to as part of military basic training. 1 Stress fractures result from repetitive, sub maximal loads on normal bone that cause bone forma tion to lag behind bone resorption, leaving bone prone to microtrauma. 2 A subset of stress fractures, subject to high tensile forces and limited vascularity, are prone to delayed healing and are at risk for complete fracture, de layed, or nonunion, and require a more aggressive treat ment approach. 3 One of the high-risk stress fractures is of the lateral femoral neck which risks osteonecrosis of the femoral head, the need for arthroplasty, and perma nent disability. 4,5 Early surgical intervention for these high risk stress fractures is recommended to prevent fracture progression. 3-5 The cost of a recruit sustaining a femoral neck stress fracture that requires surgery is estimated to exceed $100,000 per injured recruit. At performed in about 25% of cases of femoral neck stress fractures. 6 Femoral neck stress fractures make up less than 10% of all stress fractures. 4,5,7-10 These injuries are most com mon in female military recruits. 2,7 Overall, complica tions occur in 10% to 40% of all femoral neck stress fracture patients. Complication rates increase with dis placement and varus surgical reduction. 11 Both intrinsic and extrinsic factors have been associated with an increased risk of femoral neck stress fracture. Extrinsic factors may include the type of physical activ ity, prior training regimens, footwear, and environment. 7 Intrinsic factors include sex, bone density and size, mus cle size, foot shape, leg length, and hip geometry. 5,7-9,12 Hip geometry is an important intrinsic risk for stress fractures. Clinically, loads in the average loading direc tion will not cause a fracture, but loads of extreme mag nitude or extreme orientation may. 13 In cases of altered femoral neck geometry, the joint load orientation be comes more vertical with coxa valga and more horizon tal in coxa vara. 13 shaft angle of less than 120, coxa valga as an angle of greater than 140 average femoral neck shaft angle rang es from 125 to 131. 13 Femoral neck stress fractures are associated with coxa vara 14 and compression side femo ral neck stress fractures are more common. 3 The treatment of femoral neck stress fractures should trinsic factors. Treatment of most compression side fem oral neck stress fractures involves not bearing weight on the affected extremity for 6 weeks. 3 Compression Correlation Between Femoral Neck Shaft Angle and Surgical Management in Trainees With Femoral Neck Stress Fractures CPT Robyn L. Chalupa, SP, USA MAJ Jessica C. Rivera, MC, USA CPT David J. Tennent, MC, USA LTC (P) Anthony E. Johnson, MC, USA ABSTR A CT The most common overuse injury leading to medical discharge of military recruits is a stress fracture. One of the high-risk stress fractures is of the lateral femoral neck which risks osteonecrosis of the femoral head, the need for arthroplasty and permanent disability. To prevent fracture progression early surgical intervention is recommended. Surgical repairs are performed in about 25% of cases of femoral neck stress fractures at mili tary treatment facilities. Hip geometry is an important intrinsic risk for stress fractures. Loads in the average loading direction will not cause a fracture, but loads of extreme magnitude or extreme orientation may. The purpose of this study was to determine if, in the presence of femoral neck stress fracture, there is a correlation between femoral neck shaft angle, surgical treatment and outcomes. The results of this study suggest there is no correlation between return to full military duty rates, treatment, femoral neck shaft angle or fracture grade have surgery. Individuals who did not return to duty tended to have higher pain scores at initial evaluation.

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2 http://www.cs.amedd.army.mil/amedd_journal.aspx side stress fractures that show chronic changes such as cysts or intramedullary sclerosis involve more than 50% of the neck on MRI, and those that are complete may 1,2 Sariyilmaz et al used coxa vara and the resulting mechanical abnormality as an ad ditional indication for surgery. 15 Tension side femoral neck stress fractures should be treated with increased vigilance to prevent progression to complete fracture. 2,8 Nondisplaced stress fractures can be treated with can displaced fractures would require dynamic hip screw placement or arthroplasty. 15 The purpose of this study is to determine if, in the pres ence of femoral neck stress fracture, there is a correla tion between femoral neck shaft angle, surgical treat ment, and outcomes. METHODS After approval from the MTF Institutional Review Board, we performed a retrospective study. Patients that had been evaluated by orthopaedics, had imaging of the hip, and diagnosed with a femoral neck stress fracture at the MTF between June 1, 2012 and May 31, 2014 were included. We reviewed hospital and clinic records and available imaging data from surgical scheduling, elec tronic medical records, and the Picture Archive and Communication System (PACS) application. A potential subject list, shown in Table 1, was compiled using an electronic medical record search of ICD-9 codes which correspond to stress fractures of the femur, hip, and pelvis. Imagery available in PACS was reviewed to ensure the potential subjects did, in fact, have a femoral neck stress fracture and the necessary imaging studies were available for analysis. We then screened the poten tial subject list for other inclusion and exclusion criteria, shown in Table 2. Each subjects femoral neck shaft angle was measured on the anteroposterior radiograph by calculating the angle formed by the intersection of a line bisecting the midpoint of the femoral neck and the midpoint of the femoral head, and the anatomic axis of the femur, illus trated in the Figure. Each subjects MRI was then exam ined in order to grade the severity of the femoral neck stress reaction as indicated by bone edema and a frank fracture line (Table 3). Each subjects electronic medical record was examined for details on the clinical course, provider recommended activity restrictions, and ability to perform full military duty. Each subject was searched on the surgical schedule to determine whether they un derwent surgery for a femoral neck stress fracture. Comparisons among groups were then made using un paired students t test and Pearsons correlation for con tinuous data, and 2-tailed Fishers exact test for categori cal data. All analysis was performed using GraphPad Prism 6 (GraphPad Software, Inc, La Jolla, CA). CORRELATION BETWEEN FEMORAL NECK SHAFT ANGLE AND SURGICAL MANAGEMENT IN TRAINEES WITH FEMORAL NECK STRESS FRACTURES Table 1 The potential subject list of codes correspond ing to stress fractures of the femur, hip, and pelvis. ICD-9 Description 733.90 Disorder of the bone and cartilage unspecified 733.95 Stress fracture of other bone 733.96 Stress fracture of the femoral neck 733.97 Stress fracture of the shaft of the femur 733.98 Stress fracture of the pelvis 736.31 Coxa valga (acquired) 736.32 Coxa vara (acquired) 736.39 Other acquired deformities of the hip Table 2 Additional inclusion and exclusion criteria for sub ject screening. Inclusion Criteria Treated between June 1 2012 and May 31 2014 Diagnosis of a femoral neck stress fracture confirmed by MRI Age: 18 45 years Active duty Treatment by orthopaedics Available MRI and anteroposterior pelvis Exclusion Criteria Age < 18 years Age > 45 years Pathologic fracture Electronic medical record not available Imaging to evaluate stress fracture not available Illustration of the parameters used to measure the femo ral neck shaft angle determined from an anteroposterior radiograph image.

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January March 2016 3 RESULTS Search of orthopaedic encounters within the electronic medical record found 205 uses of the queried ICD-9 codes in 185 individuals. Of those, diagnosis of femoral neck stress fracture was found in 72 individuals. Nine teen individuals were excluded from the study because an MRI was not obtained as part of their workup, they had been treated at their previous duty station, had pathologic fractures, were not active duty, or had no fracture on MRI. This left 53 individuals as study par ticipants, with 10 individuals having bilateral femoral neck stress fractures (63 total stress fractures). Review of the 53 included individuals found that all of the affected individuals were initial trainees, and 12 were male (23%). The average age of the included sub jects was 22.9 years (range 18 to 39 years) and there was no difference in age between male and female subjects ( P =.3820). Thirty of the 63 affected femurs were right side (48%). All of the evaluated femoral neck stress frac tures were compression side. One male presented with a complete fracture. Women had a greater mean femoral neck shaft angle compared to men (132.20.6 versus P =.0082). Normal is consid ered 125 to 131. No correlation existed among femo ral neck shaft angles, stress fracture grades, duration of symptoms, or pain scale results per hip. Ten subjects (8 female, 2 male) had bilateral stress frac tures. All bilateral stress fractures were noted on images obtained in a single encounter. In addition, the 7 pa tients who had surgical intervention for bilateral stress ing bilateral stress fractures did not affect surgery rates ( P =.1563) or return to duty rates ( P =.4639) compared to a unilateral stress fracture. operative patients. One 19-year-old patients course was complicated by chondrolysis and went on to total joint arthroplasty. Femoral neck shaft angles were not differ ent between subjects who were not treated with surgery (131.60.8) and those who underwent percutaneous P =.8759). However, sub jects with operatively treated hips had higher stress frac ture grades on MRI (3.40.1) versus subjects who did not undergo surgery (2.90.1, P =.0059). Subjects who underwent surgery also had higher mean pain scores on presentation to orthopaedics (4.80.5) versus subjects who did not undergo surgery (3.40.5, P =.0412). Two-thirds of surgical patients did not return to full duty (16/24), and 48% of nonsurgical patients did not return to full duty (14/29, P =.2660). There was no difference between femoral neck shaft angles among subjects who were able to return to duty (132.0 1.1) and sub jects who were not able to return to duty (131.20.6, P =.5081). Stress fracture grade was also not different be tween those who returned to full military duty (3.10.1) and those who did not (3.20.1, P =.4701). There was a did not return to duty having higher mean pain scores on presentation to orthopaedics (4.60.4 not return to duty versus 3.30.6 return to duty, P =.0575). CO MM ENT The results of this study suggest there is no correlation between return to full military duty rates and treat ment, femoral neck shaft angle, or fracture grade on pain level at presentation and lower return to duty rates. fracture grade and pain than those that did not have surgery. The femoral neck shaft angle was found to be more valgus in women. Additionally, the mean angle in this cohort was more valgus than the previously cited normal range of 125 to 131. 13 Bilateral stress fractures were found in 19% of study participants. In this study, all of the patients who had stress fractures were trainees. This suggests initial training places added stress on the femoral neck that either does not continue after conditioning or results in the attrition of trainees prone to these fractures. Individual preconditioning and dietary variance would affect how the trainee reacts to the increase in physical activities unique to initial train ing. The programs that have shown to decrease training injuries, such as command awareness, provider training, and the Army Physical Readiness Training (PRT) pro gram, should be continued. 6 This study found no tension-sided femoral neck stress fractures. This is not surprising because compressionportion of surgically-treated fractures was 49%. This percentage is greater than previously presented in the Table 3 Criteria table used to grade severity of the femoral neck stress reaction based on examination of the subjects MRI imagery. Adapted from Arendt et al. 16 Grade STIR Signal Change T 2 Signal Change T 1 Signal Change Plain X-ray Film 1 Present None None Negative 2 Present Present None Negative 3 Present Present Present Periosteal reaction 4 Present Fracture line Fracture line Periosteal reaction or fracture line Short T 1 inverse recovery imaging

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4 http://www.cs.amedd.army.mil/amedd_journal.aspx literature (25%). 6 Although there was no statistically pain level, the stress fracture grade and pain level were higher for those operatively treated. While some litera ture supports treating compression side stress fractures with strict limitation of weight bearing, 3 our high opera tive rate is evidence that surgeon and facility consider ations play a role in management of this condition. For example, surgeons at this MTF must consider whether strict nonweightbearing is reasonable for individuals with training demands within the military environment. Clinically, providers should continue to have a high index of suspicion for femoral neck stress fractures in trainees presenting with hip pain. An MRI should be obtained if history warrants. When obtaining MRIs, the contralateral hip should be imaged to exclude asymp tomatic stress reaction in the contralateral hip. 3,17 Care should also include identifying and treating any intrin sic factors that put the trainee at risk for stress fracture. 3 Treatment may need to include supplementation with calcium and vitamin D, or treatment of women with low-dose estrogen. 8 However, not all intrinsic factors are amenable to intervention and focus must remain on 8 Ini prevention. 8 These could include progressive resistance training and protective exercises such as the forward lunge, isokinetic hip extension, one-legged long jump, 8,18,19 All retrospective studies have similar limitations includ ing those imposed by querying records that differ in quality. Not all data that was desired was recorded in every medical record. Many lacked record of pain scale, duration of symptoms, and duration of restricted weight bearing. This study was unable to assess for female athlete triad due to the lack of records on the patients menstrual cycle and diet. In post-hoc power analysis us ing Stata 13.1, we found we were adequately powered at 0.9519 for the comparison between return to full mili tary duty and those that did not with regard to mean femoral neck shaft angle. A follow up study to obtain a power of 0.80 would require 424 subjects, with 212 sub jects each in the surgical and nonsurgical groups, for the comparison between operatively treated hips and femo ral neck shaft angles. So while we were adequately pow ered with this sample size to examine some dependent variables, we were not adequately powered to examine all of them. A study of such size would not be possible at this single medical facility. CONCLUSION Both intrinsic and extrinsic factors contribute to stress fracture. Extrinsic factors may include the type of physi cal activity, prior training regimens, footwear and en vironment. 7 Intrinsic factors include sex, bone density and size, muscle size, foot shape, leg length, and hip ge ometry. 5,7-9,12 Those charged with training design should to prevent stress fractures. Future studies that prospec tively gather information on female athlete triad, meta sonal differences in rates would be useful. Studies that randomize surgical treatment may not be possible, but nonoperative treatment modalities involving treatment helpful in helping care providers choose the best treat ment to avoid the patients separation. Stress modeling of the exercises preformed in initial training could also fractures. Future study is also necessary to limit the REFERENCES 1. Shin AY, Gillingham BL. Fatigue fractures of the femoral neck in athletes. J Am Acad Orthop Surg 2. Boden BP, Osbahr DC, Jimenez C. Low-risk stress fractures. Am J Sports Med 3. evaluation and treatment. J Am Acad Orthop Surg 4. Pihlajamaki HK, Ruohola JP, Kiuru MJ, Vi suri TI. Displaced femoral neck fatigue frac tures in military recruits. J Bone Joint Surg Am 5. Behrens SB, Deren ME, Matson A, Fadale PD, Mon chik KO. Stress fractures of the pelvis and legs in Sports Health 6. Scott SJ, Feltwell DN, Knapik JJ, et al. A multiple intervention strategy for reducing femoral neck stress injuries and other serious overuse injuries in U.S. Army Basic Combat Training. Mil Med 7. of stress fracture risk in United States Military Academy cadets. Bone 8. Jacobs JM, Cameron KL, Bojescul JA. Lower ex tremity stress fractures in the military. Clin Sports Med 9. Kupferer KR, Bush DM, Cornell JE, et al. Femoral neck stress fracture in Air Force basic trainees. Mil Med CORRELATION BETWEEN FEMORAL NECK SHAFT ANGLE AND SURGICAL MANAGEMENT IN TRAINEES WITH FEMORAL NECK STRESS FRACTURES

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January March 2016 5 10. Malhotra R, Meena S, Digge VK. Tensile type of the process of healing in a high risk patient for im paired healing of fracture. Clin Cases Miner Bone Metab 11. Lee CH, Huang GS, Chao KH, Jean JL, Wu SS. Surgical treatment of displaced stress frac report of 42 cases. Arch Orthop Trauma Surg 12. Carey T, Key C, Oliver D, Biega T, Bojescul J. femoroacetabular impingement in military person nel with femoral neck stress fractures. J Surg Or thop Adv 13. load estimation predicts altered femoral load direc tions for coxa vara and coxa valga. J Musculoskelet Res 14. JA, Roman M. Stress fractures of the femoral neck and coxa vara. Arch Orthop Trauma Surg 15. Sariyilmaz K, Ozkunt O, Sungur M, Dikici F, Yazi cioglu O. Osteomalacia and coxa vara. An unusual co-existence for femoral neck stress fracture. Int J Surg Case Rep 16. review of experience at a single institution. Am J Sports Med 17. Moo IH, Lee YH, Lim KK, Mehta KV. Bilateral femoral neck stress fractures in military recruits with unilateral hip pain. J R Army Med Corps June 17, 2015 [epub ahead of print]. 18. Martelli S, Kersh ME, Schache AG, Pandy MG. Strain energy in the femoral neck during exercise. J Biomech 19. of femoral neck using musculoskeletal dynamics J Hum Kinet AUTHORS CPT Chalupa is a physician assistant with the Orthopae dic Surgery Service, Department of Orthopaedics and Rehabilitation, Brooke Army Medical Center, JBSA Fort Sam Houston, Texas. MAJ Rivera is with the US Army Institute of Surgical Research, Joint Base San Antonio Fort Sam Houston, Texas. CPT Tennent is with the Department of Orthopaedics and Rehabilitation, San Antonio Military Medical Cen ter, Joint Base San Antonio-Fort Sam Houston, Texas. LTC (P) Johnson is Chairman, Department of Orthopae dics and Rehabilitation, Brooke Army Medical Center, JBSA Fort Sam Houston, Texas. Articles published in the Army Medical Department Journal are indexed in MEDLINE, the National Library of Medicines (NLMs) bibliographic database of life sciences and biomedical information. Inclusion in the MEDLINE database ensures that citations to AMEDD Journal content will be

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6 http://www.cs.amedd.army.mil/amedd_journal.aspx Millions of dollars are lost each year to the US military in medical discharges from injuries sustained in the ini tial training of recruits. According to the Government $390 million annually in the recruitment and training months of service. 1 Financial losses arise from the cost of initial recruitment; transport to the training location; uniforms and equipment; accommodation and rations; wages; instruction and supervision; administration; and are medically discharged. Each recruit who fails to complete training costs the military thousands of dol lars. and specialty. mises military readiness by reducing force strength and depriving the military of critical skills. When over seas operations in Iraq and Afghanistan increased the military training became a serious and costly concern for all military services. of the total discharges of recruits. Although medical account for more lost duty days and delays in completion of training than any other diagnosis. 8 4 times more likely to be medically discharged. Sustain ing a stress fracture during initial military training is the most powerful predictor of discharge. 4 Given the association between medical discharge and can reduce injury rates are also likely to reduce rates of medical discharge during initial military training. lish a more comprehensive and standardized method of preventable injuries. Injury prevention measures includ and enforced progressive training. 9 The purpose of this Observed Rates of Lower Extremity Stress Fractures After Implementation of the Army Physical Readiness Training Program at JBSA Fort Sam Houston ABSTR A CT Millions of dollars are lost each year to the US military in medical discharges from injuries sustained in the initial stress fractures. Any strategies that can reduce injury rates are also likely to reduce rates of medical discharge. This study evaluated the Army Physical Readiness Training (PRT) program which was established to provide and metatarsals. The observed number of diagnoses in each time period were compared using the method.

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January March 2016 7 study is to evaluate the observed rates diagnosed in recruits following the implementation of the PRT. METHODS Our study was intended as a pilot study to evaluate the effect of implement fractures that could lead to discharge. Following Institutional Review Board electronic medical record (AHLTA) for ICD-9* codes corresponding to ity stress fractures. We included diagnoses of stress fractures to limited our search to recruits seen at McWethy Troop Medical Clinic (TMC) at Joint Base San Antonio The TMC is the facility where re cruits are initially evaluated for medical complaints. groups based upon the implemen tation date of the PRT program at JBSA Fort Sam Houston. Group 1 Anatomic regions were used to determine if PRT chang es affected one body region over the others. The thigh signed to Fort Sam Houston during the period of our study. The groups were compared using the method graphic data were collected by investigators. RESULTS tremity stress fractures diagnosed during our investigation. We observed month period prior to the implemen tation of the PRT program (Group 1). stress fractures were diagnosed dur implementation of the PRT program decrease in the overall occurrence of P tures of the tarsal bones decreased P neck stress fractures decreased by P in the occurrence of femoral ( P tical difference in the occurrence of tibial ( P ( P vic stress fractures were observed Figure shows the distribution of the stress fractures through the study period. Groupings based on anatomic region were also analyzed. thigh region ( P tures to the foot region ( P for the leg grouping was not achieved ( P is presented in Table 3. CO MM ENT The PRT program was introduced to reduce the num ber of preventable injuries by establishing a more com training. 9 Our study demonstrated a decline in the di PRT program. This decrease was shown not only in the stress fractures of the tarsal bones and the femoral neck. is encouraging because these are a subset of high* Table 2. Data of observed lower extremity stress fractures displayed by location and group. Negative percentage change repre sents a decline in the number of lower ex tremity stress fractures observed. Positive percentage change represents an increase in the number of lower extremity stress frac tures observed. Group 1 Group 2 Change % P Value Pelvis 0 0 0 % N/A Femoral neck 59 31 47 0 % P =. 003 Femoral shaft 10 4 60 0 % P =. 109 Tibia/Fibula 61 65 6 6 % P =. 720 Tarsals 84 53 36 9 % P =. 008 Metatarsals 20 21 5 0 % P =. 876 Total 234 174 25 2 % P =. 002 Table 1 The ICD-9 codes used as search criteria. Code 733.93 Stress fractures of the tibia and/or fibula 733.94 Stress fractures of the metatarsals 733.95 Stress fractures of other bones (tarsals) 733.96 Stress fractures of the femoral neck 733.97 Stress fractures of the femoral shaft 733.98 Stress fractures of the pelvis International Classification of Diseases, 9th Revision

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8 http://www.cs.amedd.army.mil/amedd_journal.aspx fracture and possibly requiring surgical intervention. 10 While we found a meaningful decrease in the number of months immediately prior to and after implementation of the PRT program. A larger cohort could be derived longer period around the time of implementation. limitations. The PRT program was only implemented for the Army recruits at JBSA Fort Sam Houston. As we sonnel that are also trained at JBSA Fort Sam Houston could be included despite not participating in the PRT program. Because the TMC is the entry point to the that we captured all recruits save those that presented less of subspecialty referral by the ED. All recruits are seen at this one TMC. We recognize that we could have missed stress fractures of individuals who chose not to seek treatment or delayed presentation until outside the stress fracture diagnoses made following specialty care evaluation because initial evaluation by the primary care potential seasonal variations similar to those seen in other injury patterns. CONCLUSION Our study demonstrated a decline in of the Army PRT program. This included a decrease in with worse outcomes. Continued investigation is war ranted considering the high cost of training dollars lost their military training. REFERENCES 1. Military Attrition: DOD Could Save Millions by Better Screening Enlisted Personnel dicting attrition in basic military training. Mil Med 3. Mil Med 4. associated with discharge during Marine Corps ba sic training. Mil Med Fiedler E. Prevalence and predictors of discharge in United States Air Force basic military training. Mil Med tors. Mil Med Table 3. Data of observed lower ex tremity stress fractures displayed by region and group. Negative percent age change represents a decline in the number of lower extremity stress fractures observed. Positive percent age change represents an increase in the number of lower extremity stress fractures observed. Group 1 Group 2 Change % P Value Pelvis 0 0 0 % N/A Thigh 69 35 49 3 % P <. 001 Leg 61 65 6 6 % P =. 720 Foot 104 74 28 8 % P =. 023 Total 234 174 25 2 % P =. 002 Distribution of diagnosed stress fractures by month for the study period April 2010 through March 2011. Metatarsals Tarsals Tibia/Fibula Femoral shaft Femoral neck 20 0 40 50 30 60 10 Apr 10 May 10 Jun 10 Jul 10 Aug 10 Sep 10 Oct 10 Nov 10 Dec 10 Jan 11 Feb 11 Mar 11 Before PRT After PRT

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January March 2016 9 7. Gemmell IM. Injuries among female army re J R Soc Med 8. of basic infantry training success. Mil Med 9. Darakjy S. United States Army physical readi physical training doctrine. J Strength Cond Res 10. evaluation and treatment. J Am Acad Orthop Surg AUTHORS CPT Chalupa is a physician assistant with the Orthopae

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10 http://www.cs.amedd.army.mil/amedd_journal.aspx Unintended injuries, in particular physical training-re threats to US military readiness. 1 As many of these inju ries are considered preventable, this study was undertak en to help determine what additional information might contribute to reducing these injuries in the US Army. HISTORIC A L REVIEW Common musculoskeletal and orthopedic injuries (ie, strains, sprains, joint derangements, and stress frac tures) are the leading threat to the medical readiness of our troops. 1 Almost 50% of all service members experi ence one or more injuries annually. 2 Each year, these in juries limit physical ability and cause disability among active duty service members, resulting in millions of medical encounters, lost or restricted duty days, and medical expenses. 1,3-6 These injuries, predominantly of the back, knees, and lower extremities, are most often due to repetitive overuse, not from acute trauma. 1,3-5,7-10 In fact, over half of these injuries result from unit or per sonal physical training activities like running or sports. 2 Even during wartime operations, medical air evacua tions are more often for nonbattle injuries such as those caused by sports and physical training than for injuries resulting from combat. 11 This problem has persisted for decades. 12,13 In 1992, an estimated 450,000 outpatient medical encounters re sulted in several million days of restricted duty. 13 In 2012, 2.2 million Department of Defense (DoD) mili tary medical encounters resulted from these same types of musculoskeletal injuries, resulting in an estimated 25 million limited duty days. 1 The Army accounts for about 40%the largest portionof these days of lim ited duty. 1,4 It has been estimated that a 1% reduction in incidence of lower back pain could translate to the retention of thousands of trained Soldiers, avoidance of ings through fewer disability payments and less con sumption of medical care. 13 The continued high incidence of these common inju ries is, in part, because Soldiers must routinely conduct physical training. Physical training is the cornerstone formance. Yet physical training and optimizing human physical performance includes minimizing injury. Sci to identify risk factors and evaluate the effectiveness of some tactics for reducing these injuries. 14-19 Risks and interventions associated with running mileage, training programs, stretching, footwear, various braces (such as ankle, back, knee), gender, age, and medication use have been and continue to be investigated. In some cases, cations that could reduce injuries. In other cases, scien (IP) tactics once believed to be effective are actually helpful. In reality, some may increase injury risks. 3 Un fortunately, anecdotal information often drives risk pre vention decisions. SCOPE OF THIS EFFORT Investigators at the US Army Public Health Center (Pro visional)* (USAPHC(P)) theorized that a lack of aware ness and confusion about risk factors and effective persistent injury problem. In order to guide the develop ment of IP educational materials to increase awareness and correct misinformation, a voluntary survey tool was used to assess current awareness about IP topics and Army audiences. METHODS A group of health analysts, health educators, and stat isticians experienced with survey tools developed a What Soldiers Know and Want to Know About Preventing Injuries: A Needs Survey Regarding a Key Threat to Readiness Anna Schuh, PhD Formerly the US Army Public Health Command.

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January March 2016 11 20 The survey, designed to be anonymous, focused on unintentional musculoskeletal in tions about heat and cold injuries. with the desire to limit the time bur den for respondents. Survey topics included demographics and job roles, personal injury history (past 12 months), awareness of injury effects, risk factors, interventions, leader ship perspectives (for nonsupervi sor responders), and IP interests (ie, activities, injury types, and infor mation sources and formats). Prior to disseminating the survey, docu mentation was submitted for review through the USAPHC(P) Human Protection Review Board. The collection of person established, broad categories provided in demographic The survey was delivered using the Vovici software application (Vovici is now Verint Enterprise Edition line survey was dispersed to Army audiences through several venues between July 9 and August 26, 2014 (6 weeks). Venues included postings on Army medical and nonmedical social media sites, websites, and emails. Posting of the survey link was vol untary for the proponent organizations. All responses were received in a protected data archive only accessible by selected project investigators. To assess general awareness of the problem, 4 evidence-based statements regarding most common musculoskeletal injuries within the Army and leading causes of these injuries were provided for respondents to indicate their level of agreement (on a 5point scale from Strongly Agree to Strongly Disagree). Respondents also scored the effects of vari ous risk factors and prevention measures for musculoskeletal injuries by indicating whether they believed the measures decrease risk, neither increase/decrease risk, increase risk, or whether the respondent was not sure. The correctness of statements were evalu evidence, 1,5,11 including a systematic review of physical training injury interven tion conducted by DoD experts. 3 In addition, respondents were asked to choose activities about which they were most interested in receiving IP information. Sixteen options (in cluding other) were provided with the instruction to select all that apply. Responders who were not healthcare providers/educators were asked 4 ences or beliefs regarding their lead erships support or interest in injury asking respondents about preferred format and venue for obtaining ad ditional IP information, and an open comments. free-text responses was completed by 2 investigators who separately reviewed all individual responses to de termine whether responses could be grouped with preestablished response categories or into any newly cre ated categories. Table 1 Demographics of Respondents Completing Survey (N= 685 ). Total Military Civilian Affiliation Military 527 (77%) Civilian 158 (23%) Gender Male 467 (68%) 377 90 Female 218 (32%) 150 68 Age (years) <20 10 (1%) 9 1 21-30 131 (19%) 123 8 31-40 192 (28%) 179 13 41-50 205 (30%) 165 40 >50 147 (22%) 51 96 Job Field Medical 265 (39%) 235 30 Nonmedical 420 (61%) 292 128 Figure 1 Percentage distribution of injury causes among respondents who reported injury (n=360) in response to the following question: What was the cause of your most severe injury in the past 12 months? A B C D E F G H I J 10% 20% 0% 15% 5% 25% 35% 30% A. Running F. Parachuting B. Exercise other than running G. Combat training/obstacle course C. Lift/push/pull H. Road marching D. Sports I. Motor vehicle/motorcycle E. Slip/trip/fall J. Other (variety of activities: general everyday tasks; pushing/pull/lifting items)

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12 http://www.cs.amedd.army.mil/amedd_journal.aspx RESULTS General and Demographics The survey was initiated by 926 persons and fully com pleted by 685 respondents. The average time taken to complete the survey was 14 minutes. A comparison of the respondents who completed the survey (685) differences. Table 1 summarizes key demographic characteristics. (32%) responded. Very few responders were under 20 years of age, most falling between 21-50 years of age. Of the military respondents, almost half were of medi cal areas of concentration or military occupational spe cialties. Of these, the largest portions were physician assistants (32%), followed by physical therapists (18%). logical, radiological and nuclear specialists, infantry, military intelligence, ordnance, and others. Over half (53%) of respondents reported musculoskel etal injuries in the previous 12 months that affected their physical ability to do daily tasks or exercises. Of these, 61% were described as primarily associated with overuse. The most common cause reported was running (34%), as shown in Figure 1. Knowledge and Awareness in Table 2. The responses of all medical respondents (ie, healthcare/educator providers) followed the same trends as the overall trends for all respondents, with slightly more accurate answers and slightly fewer unsure re chose strong or very strong agreement with each of the 4 evidence-based statements regarding the general magnitude and types of the injury problem. However, 23% neither agreed nor disagreed. Respondents were less likely to identify correct for responses pertaining to musculoskeletal injury risk factors and interventions than for those pertaining to heat and cold injury (data not shown). Responses for risk factors that were most incorrect included the increased risks that are associated smoking. For interventions, higher percentages of incor rect responses were found regarding the effectiveness of ankle braces and cotton socks, and the lack of IP effec tiveness that has been shown with back braces, stretch wearing of minimalist running shoes. Injury Prevention Interests Figure 2 presents the types of activities about which respondents were most interested in receiving IP infor mation. Respondents chose an average of 5 activities (mean 4.98, SD 2.84). Despite some minor variations, activity interests were very similar between medical and nonmedical responders. 20 Write-in responses for other activities not listed included yoga, biking, and soccer. Sprains/strains/torn muscles and tendonitis/bur by both those personnel not in the health community (78% and 74%, respectively) and healthcare/educators (84% and 88%, respectively). Of next greatest interest to both groups were torn ligaments (56% for those not in the health community and 59% of those from health chronic conditions such as arthritis. A common topic appearing in free-text comments con Some respondents noted that because physical train ing is integral to optimizing Army readiness, Soldiers should be treated more as athletes and coaching or pro fessional guidance about injury prevention should be guidance concerning the prevention of re-injury. One suggestion made by a few respondents was to provide to participate in activities that are likely to result in reinjury. Of the 265 healthcare/health educator respond ers, 81% indicated that they would like products to help communicate information about risk factors and IP tac tics to their patients/customers. Perceptions of Leadership and Medical Roles The experiences or beliefs those not in the health com munity (providers and/or educators) regarding their lead erships support or interest in IP are shown in Figure 3. Only a slight majority (37% to 44%, depending on the statement) described positive leadership emphasis/sup port. Approximately a third (25% to 35%) had neutral perceptions and just under a third (22% to 32%) had neg ative views regarding their leaderships emphasis on and strongly with one another ( P <.01, correlation >0.74 to mately one-third of respondents provided an additional WHAT SOLDIERS KNOW AND WANT TO KNOW ABOUT PREVENTING INJURIES: A NEEDS SURVEY REGARDING A KEY THREAT TO READINESS

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January March 2016 13 Figure 2 Percentage distribution of respondents choices of activities for which they were most interested in receiving information related to injury prevention. Note: Since each respondent was allowed to select all activities that apply, the sum of percentages displayed exceeds 100% 10% 20% 0% 60% 50% 70% 80% 40% 30% A K B L C M D N E O F P G H I J A. Running I. Motor vehicle/motorcycle accidents B. Weight training (free weights, weight machines) J. Basketball C. Agility, calisthenics, stretching K. Snow Sports (skiing, snowboarding) D. Extreme conditioning (CrossFit, P90Xm etc) L. Parachuting E. Road marching M. Football F. Heat N. Softball/baseball G. Cold O. Other H. Work related falling/tripping P. Racquet sports (racquetball, tennis) Examples of comments written by respondents in the free-text area of the injury prevention survey. Changing the mentality of injury is a must within the military. Many of my patients report injuries weeks/ months/years after the initial injury and the damage has been exacerbated from continued use. Teaching peo as a whole. Most of patients that I see are musculoskeletal due to overuse (overtraining). One of the biggest things I see is the leadership not taking care of their Joes and allowing them to modify their training according to their injury. Leaders need to be educated. They play a direct role in helping the junior Soldiers prevent and recover from injury. In many cases common sense is lacking.... with leadership. Some examples of such responses are shown below. Despite awareness of the magnitude of the musculoskeletal injury problem, free-text responses suggested that many believe that such injuries are inher ent to a Soldiers job, and are even a way to screen out Sergeants and First Sergeants. Responders indicated that this was necessary to change what was described as a suck it up and no pain is no gain attitude and to improve awareness about the negative effect of trainingguidance for reconditioning and recovery, especially af jury problem. Leaders were described as being unaware of the magnitude of the adverse impacts that uninten tional injuries have on the Army, and not recognizing what they can do to reduce these injuries. Suggestions

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14 http://www.cs.amedd.army.mil/amedd_journal.aspx Another major topic cited in free-text responses de spondents indicated that although inconsistencies and in part to individual Soldiers motivations, some respon dents suggested problems within the medical commu supported diagnoses, inconsistencies in work and physi bilitation guidance were cited as areas that could be improved. CO MM ENT The size of the response to the voluntary survey was larger than expected and thus was considered a positive Table 2. Distribution by percentage of respondents beliefs on musculoskeletal injury risks and interventions. Factors/interventions that: %N [ 685 total respondents] %n [ 268 healthcare/educators] Increase Risk Of Injury Decrease Risk Neither more nor less Increase Risk Not Sure Increased running mileage 2% 2% 15% 10% 80% 86% 3% 2% Dehydration 1% 1% 7% 8% 89% 90% 2% 2% Prior injury 1% 1% 4% 2% 94% 97% 2% 0% Cigarette smoking 1% 1% 16% 8% 75% 89% 9% 2% High flexibility 71% 59% 16% 19% 10% 20% 3% 2% Very thin body type 6% 5% 56% 53% 25% 33% 13% 9% Does Not Decrease Or May Increase Risk Decrease Risk Neither more nor less Increase Risk Not Sure Back brace/lift belt (for job or weight training) 56% 44% 23% 33% 13% 18% 8% 4% Over-the-counter anti-inflammatories before workouts 19% 16% 39% 48% 26% 26% 16% 10% Stretching before exercise 58% 41% 27% 38% 12% 19% 3% 2% Reduce Risk Decrease Risk Neither more nor less Increase Risk Not Sure Ankle brace (for basketball, parachuting) 61% 59% 22% 27% 9% 9% 8% 5% Cotton socks 22% 20% 57% 62% 8% 9% 13% 8% Does Not Either Decrease Or Increase Risk Decrease Risk Neither more nor less Increase Risk Not Sure Minimalist running shoes 5% 5% 22% 25% 58% 58% 15% 12% Effect On Risk Not Evident/Is Variable Decrease Risk Neither more nor less Increase Risk Not Sure Fatigue/lack of sleep 1% 1% 5% 3% 91% 95% 2% 1% Older age (>40 years) 1% 1% 16% 15% 80% 83% 2% 1% Male 6% 9% 63% 58% 20% 26% 11% 7% Energy or dietary supplements 3% 2% 27% 28% 56% 61% 13% 9% Older running shoes 1% 0% 6% 7% 91% 92% 2% 0% 3 Key concerns Topic for improved education given more than 10% incorrect responses WHAT SOLDIERS KNOW AND WANT TO KNOW ABOUT PREVENTING INJURIES: A NEEDS SURVEY REGARDING A KEY THREAT TO READINESS

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January March 2016 15 indication of interest in this topic. Though the respon dents included civilians, the large portion of military personnel provides an indication of the knowledge and interests of the overall active duty Soldier population. This is supported in part by the similarities in the in jury experience of the respondents to prior studies of have shown that, like the survey respondents, about one half of personnel are injured each year, and that leading causes of these injuries include running, nonrunning ex ercise, and sports. 2,17,18 While most respondents demonstrated a fairly accurate awareness regarding the general magnitude of this Army injury problem, approximately one third either disagree or are neutral to acknowledgement of the documented evidence. This suggests a majority are aware of the prob lem. In addition, respondents indicated through free-text responses that there remains a common belief that these injuries are inherently part of the job and thus cannot be prevented. They indicate that part of this problem is many unit leaders may be unaware of the adverse im pacts that training-related overuse injuries have on Army readiness or how they can help reduce these injuries. The current level of awareness is further exacerbated by confusion about certain risk factors and effective ries among both nonmedical and medical respondents. Awareness of risk factors and interventions was greater for heat and cold injuries (not addressed in this article), and cold injury prevention training and strict account ability for such injuries. 23,24 Though the overall magni tude of musculoskeletal injuries in the Army is much greater than that of heat and cold injuries, current poli nually or at any level of a Soldiers basic, advanced, spe ported educational products are needed to increase the broader Army communitys knowledge of injury causes, risk factors, and the effectiveness of interventions. cal personnel to educate patients, and be straightforward enough for their patients (Soldiers) to understand. Key Activities of Interest Injury prevention education and training needs can be or contribute to common injuries. Key activities identi causes of their own injuries (Figure 1) as well as top causes attributed to overall injuries to Army personnel 2 : My leadership be lieves injuries can be prevented and makes it a priority. 22% 44% 34% I am kept informed about the key types and risks of injuries in our unit/workforce. 32% 31% 37% I am provided information to help reduce injuries (my own and/or others). 32% 25% 43% My leadership models injury prevention efforts. 27% 35% 38% Strongly disagree/Disagree Strongly agree/Agree Neither agree nor disagree Figure 3 Percentage distribution of respondents perceptions of leadership interest in injury prevention.

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16 http://www.cs.amedd.army.mil/amedd_journal.aspx Running Consistent with prior Army studies, 8,11,17,19 run ning was the most common cause of injury cited by sur vey respondents and was the IP topic of greatest interest. information about how to run correctly, evidence does on risk factors and guidance about proper conditioning and avoidance of over-training problems can be provid ed through educational materials. Weight-training and Extreme Conditioning Respondents also desired information regarding proper form and training and extreme conditioning. While some educa tion products can be developed to advise against certain trainers are recommended to give proper individualized instruction for these activities, especially for persons who have had prior injury. Agility, Cross-training, and Stretching recognized the importance of a mixed exercise program and desired additional information about cross training desired to explain different types of stretching tech when and how to incorporate them into a training pro gram. Road Marches About half of the respondents desired ad ditional IP guidance for minimizing injuries resulting tary training activity topic 25,26 may provide information for better educational products that describe key risk factors and injury types, with suggestions to minimize risks. Risk factors and Interventions survey, the topics considered of greatest importance are those for which the majority of respondents exhibited lowest awareness as indicated by incorrect responses regarding the degree of risk associated with risk factors and interventions. While future study of effective inter ventions is still needed, increased awareness of current evidence is warranted for topics such as: Body Type and Injury Risk under the incorrect impression that a thin body type does not affect injury risk, and another 6% thought that risk of injury, 9 will also increase risk to injuries especially stress frac tures. 17-19 Products should be developed to help dispel myths that thinner means healthier. Flexibility and Stretching Though evidence has shown risk of injury), 9,18,19 71% of respondents believed that most respondents (58% total, 41% healthcare/educators) consider stretching prior to exercise to be a means of to support this. 3 Current data is rather mixed. The com plexity of variables include different types of stretch ing (eg, static versus dynamic), different body types and 3,27-29 Given the unknowns, current expert guidance is to avoid static stretching prior to exercise and instead use audiences should be made aware of the variables and unknowns Footwear Responses show confusion regarding risks re sulting from use of cotton socks, minimalist shoes, and older running shoes. For example, the use of minimalist shoes (shoes with limited sole and zero drop heel to toe support) has been a popular trend in the past few years. While marketers have purported these shoes re duce injury risk, a majority of our survey respondents (58%) indicated they believe that minimalist shoes in crease the risk of musculoskeletal injury. Evidence does not indicate they increase or decrease risk of injury compared to other shoe types. 30,31 Products that clarify existing evidence and dispel myths on these topics are needed. Braces educators) considered back braces/belts to be a means of decreasing injury risk. However, substantial evidence indicates that they do not reduce risk, and both military policy and national guidance advise against their use. 3 This is especially important since concerns suggest a potential for increased risk due to use. On the other hand, the use of ankle braces to prevent injuries in bas ketball and parachuting has been strongly supported by 3,8,33-36 Products that clarify effective duction are needed. Enhancing Unit Leadership Awareness Essential elements of IP include leadership awareness, interest, and activity. 3 Consistent with prior evaluation, 13 the respondents in this survey pointed to leadership at the WHAT SOLDIERS KNOW AND WANT TO KNOW ABOUT PREVENTING INJURIES: A NEEDS SURVEY REGARDING A KEY THREAT TO READINESS

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January March 2016 17 (especially with running) and marginalizing those who leaders, who have direct oversight of physical training, As many unit leaders may not be reached without a di rect mandate through their chain of command, respon authority to implement mandated training would help to effectively implement this recommendation. Medical Profile Improvements Based on responses from this survey and consistent with a prior study, 13 the lack of consistent documentation of reason that unit leaders ignore or marginalize those on a of consistency may also encourage misuse of the Army cannot address all Soldiers motivational differences, and inclusion of detailed rehabilitation and recondition ing procedures could improve the validity and credibil number of re-injuries and incidence of chronic injuries in what is a relatively young population. Limitations As it is not possible to determine the number of persons who were aware of the survey, response rates could not be estimated. A comparison of demographic data from this survey to that of the overall Army active duty popu lation (eg, 86.4% male, 13.6% female; source: Armed Forces Health Surveillance data, 2013) shows the lim ited sample of respondents is not a cross-sectional rep resentation of the Army. In addition, almost half of the respondents were from areas of concentration or mili tary occupational specialties related to medicine, which is a much more substantial representation than that of the overall Army. However, the medical respondents referred to problems and interests on behalf of their patients, which at least indirectly represent the broad er Army population. In addition, injury experiences of broader Army. 2,15-17 In addition, medical professionals CONCLUSION Considering the long-standing magnitude of a prob lem that has been documented for decades, awareness among Soldiers regarding physical training injuries and vey indicate that many personnel desire additional in educational materials can empower individuals to help reduce common musculoskeletal injuries in the Army. Products should address both knowledge gaps as well as topics of particular interest to the audience. To achieve a population-level reduction in injuries, improvements in leadership awareness and possibly even policy-level accountability are needed. Because lack of awareness among unit leaders may inhibit Army human perfor mance optimization, they should be a key audience for future IP educational efforts. The Army medical com munity can also become better partners with its opera tional and Soldier training counterparts. This includes mitigate the occurrence of re-injuries and ensure the most effective rehabilitation, as well as assisting with future IP awareness and education. ACKNOWLEDG M ENTS Hall of the USAPHC(P) for their assistance with survey development. REFERENCES 1. Jones BH. Strategies for optimizing military physi cal readiness and preventing musculoskeletal inju ries in the 21st century. US Army Med Dep J Octo ber-December 2013:7-23. 2. Loringer K, Bedno S, Hauret K, Jones B, Kao T, Injuries from Participation in Sports, Exercise, and Recreational Activities Among Ac tive Duty Service Members Aberdeen Proving Available at: http://www.dtic.mil/dtic/tr/fulltext/u2/ 3. Prevention of physical training-related injuries: recommendations for the military and other active populations based on expedited systematic reviews. Am J Prev Med 2010;38(suppl 1):S156-S181. 4. idence-based public health approach to injury pri orities recommendations for the US military. Am J Prev Med 2010;38(suppl 1):S1-S10. 5. Ruscio BA, Jones BH, Bullock SH, et al. A process to identify military injury prevention priorities based on injury type and limited duty days. Am J Prev Med 2010;38(suppl 1):S19-S33.

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18 http://www.cs.amedd.army.mil/amedd_journal.aspx 6. en C, Strassels SA. Diagnoses and factors associated with medical evacuation and return to duty for ser dom or Operation Enduring Freedom: a prospective cohort study. Lancet 2010;375(9711):301-309. 7. T, Jones B. Effects of personal and occupational stress on injuries in a young, physically active pop ulation: a survey of military personnel. Mil Med 2014;179(11):1311-1318. 8. Preventing US Military Injuries: The Process, Pri orities, and Epidemiologic Evidence Aberdeen http://www.dtic.mil/dtic/tr/fulltext/u2/a496266.pdf. 9. Assessing Fitness for Military Enlistment: Physical, Medical, and Men tal Health Standards Academy Press; 2006:82-84. 10. tional injuries in the United States Army: focus on gender. Am J Prev Med 2007;33(6):464-470. 11. and Enduring Freedom, U.S. Army, 2001-2006. Am J Prev Med 2010;38(suppl 1):S94-S107. 12. Atlas of injuries in the United States Armed Forces. Mil Med 1999;164 (suppl 8):1-633. 13. Walters TJ. Injury Prevention in the US Army, A Key Component of Transformation Carlisle Bar racks, PA: US Army War College; 2002. Document 20020806 403. Available at: www.dtic.mil/cgi-bin/ GetTRDoc?AD=ADA404492 ber 19, 2015. 14. Jones BH, Hauschild VD, Dada EO, Grier TL, on injury during US Army Basic Combat Training. Am J Prev Med 2015;49(1):e1-e3. 15. Bushman TT, Jones BH. Occupation and other risk factors for injury among enlisted U.S. Army Sol diers. Public Health 2015;129:531-538. 16. parachuting injuries, associated events, and in jury risk factors. Aviat Space Environ Med 2011;82(8):797-804. 17. Jones BH. Stress fracture risk factors in basic com bat training. Int J Sports Med 2012;33(11):940-946. 18. Hauret K, Patton JF, Jones BH. Risk factors for training-related injuries among men and women in basic combat training. Med Sci Sports Exerc 2001;33(6):946-954. 19. juries associated with physical training among young men in the Army. Med Sci Sports Exerc 1993;25(2):197-203. 20. Hauschild V, Schuh A. Injury Prevention Survey: Army Awareness Assessment and Needs Analysis, July 9 August 26 2014 Aberdeen Proving Ground, Public Health Report S.0023151. 21. Knapik JJ, et al. and after deployment by the 10th Mountain Divi sion to Afghanistan for Operation Enduring Free dom 22. Knapik JJ, Jones SB, Darakjy S, et al. Injuries Among Army Light-Wheel Vehicle Mechanics 2015. 23. for the 2013 Heat Season. Fort Sam Houston, TX: 24. Technical Bulletin (Medical) 508: Prevention and Management of Cold Weather Injuries Washing ton DC: US Dept of the Army; 2005. Available at: http://armypubs.army.mil/med/DR_pubs/dr_a/pdf/ 25. Knapik JJ, Harman EA, Steelman RA, Graham BS. A systematic review of the effects of physical train ing on load carriage performance. J Strength Cond Res 2012;26(2):585-597. 26. Knapik JJ. Prevention of blisters. J Spec Oper Med 2014;14(2):95-97. 27. ing to prevent or reduce muscle soreness after ex ercise. Cochrane Database Syst Rev [serial online]. 2011;6(7). 28. part of a warm-up for the prevention of exerciserelated injury. Res Sports Med 2008;16(3):213-231. 29. Thacker SB, Gilchrist J, Stroup DF, Kimsey CD Jr. The impact of stretching on sports injury risk: a systematic review of the literature. Med Sci Sports Exerc 2004;36(3):371-378. WHAT SOLDIERS KNOW AND WANT TO KNOW ABOUT PREVENTING INJURIES: A NEEDS SURVEY REGARDING A KEY THREAT TO READINESS

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January March 2016 19 30. performance among soldiers wearing minimalist running shoes compared to traditional running amedd.army.mil/PHC%20Resource%20Library/ ber 20, 2015. [Abstract: Med Sci Sports Exerc 2013;45(5):S52] 31. bate: can minimalist shoes reduce running-related injuries?. Curr Sports Med Rep 2012;11(3):160-165. 32. Luippold RS, Sulky SI, Amoroso PJ. Effectiveness of an external ankle brace in reducing parachutingrelated ankle injuries. Inj Prev 2011;17(1):58-61. 33. Knapik JJ, Spiess S, Swedler DI, Grier TL, Dara kjy SS, Jones BH. Systematic review of the para chute ankle brace: injury risk reduction and cost effectiveness. Am J Prev Med 2010;38(suppl 1): S182-S188. 34. injuries: a literature review. Occup Med (Lond) 1999;49(1):17-26. 35. study, 1993-2002. Am J Prev Med 2010;38(suppl 1):S134-S140. 36. Ankle injuries in basketball: injury rate and risk factors. Br J Sports Med 2001;35(2):103-108. AUTHORS Army Public Health Center (Provisional), Aberdeen

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20 http://www.cs.amedd.army.mil/amedd_journal.aspx In 1970, physicians at William Beaumont Army Medi cal Center in El Paso, Texas, noted a series of 4 cases of sudden death in Army cadets associated with sickle cell trait (SCT). 1 Seven years later, Koppes et al 2 noted another 4 recruits, all with known sickle cell trait, were hospitalized for exertional rhabdomyolysis (ER) leading to myoglobinuric renal failure. These reports prompted further evaluation, leading to a military study which noted that among a total of 2 million recruits at army basic combat training, there was a higher incidence (40 times) of unexplained sudden death in black recruits compared to the general military population. In addi cruits with SCT was 30 times more common than black recruits without SCT. 3 this risk factor, patients in the military and athletic set tings with SCT continue to suffer injury and even death due to this underlying condition. 4-8 We report the case of a young, active duty SCT positive African American male presenting with exertional rhab domyolysis complicated by myoglobinuric renal failure delayed despite a typical clinical presentation and avail able SCT screening results. This case highlights the importance of the recognition of SCT as a risk factor for severe rhabdomyolysis, and suggests the need for a more robust and effective SCT screening program. CA SE REPORT In May 2015, a 26-year-old active duty African Ameri can male Army Soldier stationed in El Paso, Texas, experienced sudden severe leg and back pain while performing the Army Physical Fitness Test. Symptoms onset occurred after completing the pushup and sit-up portions. Cramping occurred while undergoing the 2-mile run and quickly progressed to such intensity that he was unable to ambulate, requiring a wheelchair for transport. He subsequently presented to an acute care clinic the following day and received Ketorolac 60 mg intramuscularly for intense back spasms prior to being released to home. Four days later, he presented to the emergency room for progressive cramping, nausea, and oral intolerance. Despite clinical evidence of rhabdomyolsis with clas cells), he was given a prescription of sulfamethoxazole/ trimethoprim for suspected urinary tract infection and discharged from the emergency room. The following day, he represented to the emergency room with worsening muscle pain, oral intolerance, and the new complaint of inability to urinate or defecate. On initial physical exam, the patient was found to have sig the lower back. No signs of altered mental status, as terixis, or paresthesia were noted on physical exam, and peripheral pulses were intact throughout. He denied any recent viral illness or prodrome. Initial laboratory eval CK of 37,069 U/L, serum urea nitrogen (SUN) 113 mg/ dL, serum Cr 13.6 mg/dL, AST of 704 U/L, ALT 424 U/L, and serum potassium of 4.4 mg/dL (most recently 4.2 mg/dL 2 years prior). Urinalysis again demonstrated Rhabdomyolysis in a Sickle Cell Trait Positive Active Duty Male Soldier CPT Pulkit Saxena, MC, USA CPT Christopher Chavarria, MC, USA MAJ John Thurlow, MC, USA ABSTR A CT population over 40 years ago. Although commonly a benign condition, numerous studies and case reports sudden cardiac death. We report a recent case of an SCT positive African American active duty male Soldier who suffered exertional rhabdomyolysis following an Army Physical Fitness Test. His course was complicated by acute renal failure requiring hemodialysis, and he eventually recovered renal function. The diagnosis was highlights the importance of the recognition of SCT as a risk factor for severe rhabdomyolysis, and suggests more must be done for an effective SCT screening program for the active duty military population.

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January March 2016 21 pelvic CT-scan was performed showing mild right peri nephric stranding with no hydronephrosis or hydroure ter. The patient was subsequently admitted to the inter nal medicine service with a presumptive diagnosis of rhabdomyolysis-induced acute kidney injury. It was not until this time that the patients SCT positivity was doc umented while being evaluated for his acute complaints, despite positive screening history and family history of exertional rhabdomyolysis. initially received aggressive intravenous hydration, but uptrend in his serum urea nitrogen and creatinine levels. Hemodialysis was initiated on hospital day 2 for symp tomatic uremia manifested by asterixis and nausea. The patient underwent 5 sessions of hemodialysis with im provement of his clinical function, as well as laboratory At time of discharge, urine output was approximately 3 improvement in SUN (42 mg/dL), serum creatinine (4.6 mg/dL) and CK of (250 U/L). During admission, serum electrophoresis was ordered and would later be reported as 39.4% HgbS, 57.3% HgbA, and 3.3% HgbA2. The patient was seen in follow-up a month after his ini ment with a SUN creatinine to 18 mg/dL and 1.6 mg/ dL respectively. He is currently in the medical evalua tion board process for discharge in accordance with the provisions of Army Regulation 40-501 9 regarding exer tional rhabdomyolysis in the setting of known sickle cell trait requiring dialysis. CO MM ENT Sickle cell trait is an inherited, incompletely dominant hematologic disorder that causes red blood cell sick ling during low oxygen states. It is present in 80,000 to 100,000 Americans, with a presence in African Ameri cans at a rate of 8% to 10%. 10 The majority of individuals who are SCT positive experience no deleterious effect to their life span and often do not encounter medical com plications during exertion. Many cases have been re ported of sickle cell trait in athletes and military recruits for whom physical exertion results in severe medical morbidities such as rhabdomyolysis. 4,5,8 The incidence of SCT associated ER is unknown, the incidence of ER in military trainees is 22.2 cases per 100,000 trainees. 11 The precise mechanism of ER in SCT carriers is unclear. It has been speculated that the combination of severe hypoxemia, lactic acidosis, hyperthermia, and red cell dehydration that occur in muscles being exercised pre cipitates an environment in which red blood cells will sickle. Martin et al 12 produced evidence of this by show ing that exercise and physical exertion resulted in in creased sickling in venous blood when testing military recruits performing arm exercises. Another hypothesis is that increased sickling leads to vasooclusive crisis in the muscle that leads to muscle cell breakdown and injury. Injured muscle cells release cellular contents, including myoglobin into the blood stream. Myoglobin subsequently causes renal injury via renal vasoconstriction, formation of intratubular casts, and direct toxicity to the tubular cells of the kidney. 13 Patients serum creatinine kinase and serum creatinine trend during hospitalization. Hospital Day Serum Creatinine Kinase Level (U/L) Serum Creatinine Level (mg/dL) 4 10 0 8 6 2 16 12 14 4 5 3 6 2 7 8 9 10 11 1 20000 15000 10000 25000 5000 0 30000 35000 CK Level Serum Cr

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22 http://www.cs.amedd.army.mil/amedd_journal.aspx In a recent study on the genetic polymorphisms asso ciated with ER, Deuster et al 14 corroborated the link between SCT and ER. However, they also noted that a causal pathogenic link remains unclear. The study indicates that, in contrast to an exertional sickling hy pothesis, SCT may instead be a surrogate for some other genetically linked risk, or, alternatively, part of a 2-hit phenomenon. The uncertainty of the precise role SCT has in ER is the foundation of an ongoing debate con cerning the premise of sickle cell screening. The American Society of Hematology (ASH) guidelines oppose universal screening for SCT, stating that it does not properly address the issues at hand and places a stig matization on SCT-positive individuals. 15,16 The associa tion instead supports administering universal precau tions to reduce exercise induced injury and heat-related injury such as those implemented by the US Army. The ASH policy of universal precautions and the omission of a requirement for SCT testing has also been supported by clinicians and some professional medical organiza tions. 16 Also of note, the ASH recommends increased research into the relationship of SCT with exertioninduced illness such as rhabdomyolysis before further policies are established. 16 The opposing view supporting testing for SCT notes that universal precautions are ineffective and further inter vention and screening is needed to properly identify this patient population. In 1996, the Department of Defense dropped its regulation requiring all military divisions to screen for SCT, leaving the decision to each military branch. The Army is the only branch that does not spe cautions with its recruits in an effort to reduce morbid ity and mortality. In the past 5 years, numerous studies recruits with SCT who suffered medical complications while undergoing strenuous exercise ranging from rhab domyolysis, compartment syndrome, and even sudden cardiac death. In the civilian sector; following the death of a college football player in 2010, the National Colle giate Athletic Association adopted a policy* of manda tory testing for sickle cell trait in all athletes who seek to participate in Division I athletics 15,17 a population similar to the active duty military population. Further, a recent (2012) study of approximately 2 million athlete years showed that the risk of exertional death of Division I football players with SCT was 37 times higher than those athletes without SCT. 18 These studies all describe medical conditions for which timely diagnosis and treat ment are imperative in improving medical outcomes. Our case report illustrates that despite universal precau tions for Army Soldiers, severe negative outcomes with exertion can occur in SCT-positive individuals. In fact, guidelines written by the Uniformed Services Univer sity Consortium for Health and Military Performance calls for referral of active duty military personnel with a concomitant diagnosis of ER and SCT to the medical evaluation board for review of their military status. 19 Sickle cell trait status is an invaluable clinical deter in SCT screening programs with emphasis on rapid incidence of adverse outcomes and ultimately improve patient care. This could be aided with a policy by which SCT status is made more apparent on patient medical records and hospital electronic medical records, such as alerts in past medical history or allergies. Sickle cell trait positive patients should not be given nonsteriodal cramping until after a workup for ER, including renal function assessment. Also, SCT screening tests should be easily accessible. Finally, all clinicians, including physician extenders, must be aware of the association of SCT and ER. Prompt recognition and proper treat ment of exertional rhabdomyolysis is essential to avoid REFERENCES 1. Jones SR, Binder RA, Donowho EM Jr. Sud den death in sickle-cell trait. N Engl J Med 1970;282(6):323-325. 2. Koppes GM, Daly JJ, Coltman CA Jr, Butkus DE. Exertion-induced rhabdomyolysis with acute renal failure and disseminated intravascular coagulation in sickle cell trait. Am J Med 1977;63(2):313-317. 3. Kark JA, Posey DM, Schumacher HR, Rueh le CJ. Sickle-cell trait as a risk factor for sud den death in physical training. N Engl J Med 1987;317(13):781-787. 4. Fajardo KA, Tchandja J. Exercise-induced cardiac arrest in a sickle cell trait-positive Air Force recruit: a case report. Mil Med 2015;180(3):e372-e374. 5. Ferster K, Eichner ER. Exertional sickling deaths in Army recruits with sickle cell trait. Mil Med 2012;177(1):56-59. 6. Anzalone ML, Green VS, Buja M, Sanchez LA, Harrykissoon RI, Eichner ER. Sickle cell trait and fatal rhabdomyolysis in football training: a case study. Med Sci Sports Exerc 2010;42(1):3-7. *http://www.ncaa.org/health-and-safety/medical-conditions/sickle-cell-trait

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January March 2016 23 7. Shelmadine BD, Baltensperger A, Wilson RL, Bowden RG. Rhabdomyolysis and acute renal fail ure in a sickle cell trait athlete: a case study. Clin J Sport Med 2013;23(3):235-237. 8. Ridha A, Khan A, Al-Abayechi S, Puthenveetil V. Acute compartment syndrome secondary to rhab domyolysis in a sickle cell trait patient. Lancet 2014;384(9960):2172. 9. Army Regulation 40-51: Standards of Medical Fit ness Washington, DC: US Dept of the Army; Au gust 2011:35. Available at: http://www.apd.army. 2015. 10. Motulsky AG. Frequency of sickling disorders in U.S. blacks. N Engl J Med 1973;288(1):31-33. 11. Alpers JP, Jones LK Jr. Natural history of exer tional rhabdomyolysis: a population-based analysis. Muscle Nerve 2010;42(4):487-491. 12. Martin TW, Weisman IM, Zeballos RJ, Stephenson SR. Exercise and hypoxia increase sickling in ve nous blood from an exercising limb in individuals with sickle cell trait. Am J Med 1989;87(1):48-56. 13. Bosch X, Poch E, Grau JM. Rhabdomyoly sis and acute kidney injury. N Engl J Med 2009;361(1):62-72. 14. Deuster PA, Contreras-Sesvold CL, OConnor FG, et al. Genetic polymorphisms associated with exertional rhabdomyolysis. Eur J Appl Physiol 2013;113(8):1997-2004. 15. Thompson AA. Sickle cell trait testing and ath letic participation: a solution in search of a prob lem? Hematology Am Soc Hematol Educ Program 2013;2013:632-637. 16. American Society of Hematology. Statement on Screening for Sickle Cell Trait and Athletic Par ticipation [internet]. January 26, 2012. Available at: http://www.hematology.org/Advocacy/State ments/2650.aspx. Accessed July 16, 2015. 17. Anderson SA, Doperak J, Chimes GP. Recommen dations for routine sickle cell trait screening for NCAA division I athletes. PM R 2011;3(2):168-174. 18. Harmon KG, Drezner JA, Klossner D, Asif IM. Sickle cell trait associated with a RR of death of 37 times in National Collegiate Athletic Asso ciation football athletes: a database with 2 million athlete-years as the denominator. Br J Sports Med 2012;46(5):325-330. 19. OConnor FG, Campbell WW, Heled Y, et al. Clini cal Practice Guideline for the Management of Ex Bethesda, MD: Uniformed Services University of the Health Sciences. Available at: https://qmo.amedd.army. sis.pdf. Accessed December 31, 2015. AUTHORS CPT Saxena and CPT Chavarria are Internal Medicine Residents, Department of Medicine, William Beaumont Army Medical Center, El Paso, Texas. MAJ Thurlow is Chief, Department of Nephrology, Wil liam Beaumont Army Medical Center, El Paso, Texas. RHABDOMYOLYSIS IN A SICKLE CELL TRAIT POSITIVE ACTIVE DUTY MALE SOLDIER

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24 http://www.cs.amedd.army.mil/amedd_journal.aspx Relocation from northern to southern climates is a rou tine occurrence for US military service members. It is also common for newly relocated individuals to partici and humid environment typically requires 7 to 14 days of exposure to the new climate. 1 2 Indi viduals who commence exercise in a hypohydrated state temperature and cardiovascular strain; any hindrance tial risk for heat injuries. 3 Dehydration levels as small 6 documented incidences of heat stroke and/or heat injury 7 Service members in 7 thus hypohydration may also be an exacerbat The purpose of this study was to determine if Soldiers METHODS Hydration Status in US Military Officer Students ABSTR A CT 2 P =

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January March 2016 25 vided a completed survey to the research team prior to levels. The urine sample was then discarded. Urine spe yet valid method to determine hydration status. Spe 11-14 The survey collected secondary outcome variables in ST A TISTIC A L AN A LYSIS t test evaluated differences or RESULTS Subject Descriptive Data P P P Figure 1 US Army Public Health Command Urine Color Hydra tion Chart.

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26 http://www.cs.amedd.army.mil/amedd_journal.aspx P 2 2 P<. r P<. r P<. r P = r P = Hydration Status Thirty-one percent of Soldiers met the criteria for P = days or less were hypohydrated at the time of the P = P = a cool climate were hypohydrated compared to those from a hot cli P = no such observance was found in 36% hot climate; P = conducted to predict hydration sta Table 2 details the 2 independent rion as predictors of hydration sta P = P = 2 indicated a small relationship be tween prediction and hydration APFT Performance P = r Table 1 BOLC and CCC Student Demographic Descriptive Results. BOLC (N= 132) CCC (N= 64 ) Male (N= 106 ) Female (N= 90 ) Hydrated (N= 135 ) Hypohydrated (N= 61 ) MeanSD Age (yr) 28.3.0 34.36.2 31.06.4 29.45.6 30.06.2 30.85.7 BMI (kg/m 2 ) 24.83.0 25.63.2 26.13.1 24.02.8 24.93.1 25.53.2 Time in service (yr) 3.54.8 8.85.6 5.76.0 4.75.1 5.25.5 5.36.0 n (%N) Male 70 (53%) 36 (56%) 66 (49%) 40 (66%) Female 62 (47%) 28 (44%) 69 (51%) 21 (34%) Rank 2 LT 73 (55%) 0 (0%) 35 (33%) 38 (42%) 53 (39%) 20 (33%) 1 LT 8 (6%) 1 (2%) 5 (5%) 4 (5%) 6 (4%) 3 (5%) CPT 49 (37%) 58 (90%) 60 (56%) 47 (52%) 71 (53%) 36 (59%) MAJ 2 (2%) 4 (6%) 5 (5%) 1 (1%) 4 (3%) 2 (3%) LTC 0 (0) 1 (2%) 1 (1%) 0 (0) 1 (1%) 0 (0) Commission Source ROTC/academy 51 (39%) 28 (44%) 47 (44%) 32 (35%) 58 (43%) 21 (34%) Direct (from civilian) 44 (33%) 15 (23%) 32 (30%) 27 (30%) 37 (27%) 22 (36%) Prior enlisted 37 (28%) 21 (33%) 27 (26%) 31 (34%) 40 (30%) 18 (30%) Cool climate origin 65 (50%) 25 (41%) 51 (49%) 39 (44%) 61 (47%) 29 (48%) In Texas 9 days or more 117 (89%) 10 (16%) 66 (62%) 61 (68%) 95 (70%) 32 (53%) P <.05 Table 2 hydration. Independent Variable B (SE) Wald Sig Exp(B) Odds Ratio 95% CI for Exp(B) Lower Upper Days in Texas ( 1 ) 0.745 (0.322) 5.349 0.021 2.106 1.120 3.958 Sex ( 1 ) -0.665 (0.324) 4.210 0.04 0.514 0.272 0.971 Model 2 =10.118 Pseudo R 2 =0.071 (Nagelkerke) Goodness-of-Fit 2 =0.998 d =2 P =.607 (Hosmer-Lemeshow test) Notes: The dependent variable is hydration status, coded: 0= Well hydrated or mild hypohydrated (USG <1.02 ) 1= Significant or severe hypohydration (USG ) The independent variables used in the model: Sex, coded 1= female; 2= Male Days in Texas, coded 0=<9 days; days HYDRATION STATUS IN US MILITARY OFFICER STUDENTS

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January March 2016 27 P<. P = P = CO MM ENT a relationship between previous location and hydration status. This association may be attributed to the shorter additional time. 1 crease in urine protein metabolites. 11 amount of muscle mass needed to cause increased urine protein metabolites is unknown at this time. In this P = ference in the prevalence of hypohydration between contribute to the lower prevalence of hypohydration required to determine why differences are seen in the 16 Un tion and severity of dehydration levels in this population. or a method to collect data to understand the dissonance recommendations for inclusion in their heat-injury miti 1. may help them prepare to exercise in a hot environment. 2. or multiple bouts of physical activity in a hot environment. 3. 17 2 max intensity tensity and duration.

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28 http://www.cs.amedd.army.mil/amedd_journal.aspx 4. https://usaphcapps.amedd.army.mil a urine hydration color charts may further assist 2 porary duty. CONCLUSION ACKNOWLEDGE M ENTS for research mentorship and protocol development; and REFERENCES 1. decay of heat acclimatisation in trained athletes. Sports Med 2. and involuntary dehydration. Med Sci Sports Exerc 3. intake. J Appl Physiol (1985) 4. Sports Med ness and on exercise performance. Eur J Clin Nutr 6. Medical Aspects of Harsh Environments 7. MSMR heat illness in Soldiers. Med Sci Sports Exerc Com pr Physiol 11. markers of hydration status. Eur J Appl Physiol 12. Med Sci Sports Exerc Euhydration USG 1.016 Osmolality 522 Color 4 Hypohydration USG 1.035 Osmolality 1252 Color 7 Figure 2 Samples comparing USG and color of urine from subjects in euhydrated and hypohydrated hydra tion status respectively. HYDRATION STATUS IN US MILITARY OFFICER STUDENTS

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January March 2016 29 13. dehydration assessment markers. Am J Clin Nutr 14. Med Sci Sports Exerc 16. Army Regulation 600-9: The Army Body Compo sition Program 17. Wilderness Medicine AUTHORS

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30 http://www.cs.amedd.army.mil/amedd_journal.aspx Combat extremity injuries frequently result in last ing disability. Recent publications from our Institution have helped delineate the nature of war wound sequalea, paedic-related disability. 1,2 Among those is the irrecov erable loss of skeletal muscle, or volumetric muscle loss (VML), which clinically can result in loss of motor pow er, fatigability, and cosmetic aberrations. 3 Animal mod els of VML indicate that strength loss after small VMLs (10%-20% loss of total muscle volume) is dispropor 4,5 Furthermore, loss of overlying muscle can adversely affect fracture healing because of multifactorial contributions skeletal muscle supplies to the fracture biology. 6-9 That VML is clini of wounded service members with Type III open tibia fractures who are medically retired from the military. 10 Currently, the loss of skeletal muscle is not a clinical target due to the lack of available therapies to address the volumetric defect and due to the clinical empha sis on bone healing rather than the overlying muscle the remaining skeletal muscle and limit the ability for the muscle group to optimally rehabilitate. This sup position is supported by limited clinical observations of patients with VML that present chronic functional therapy. 3,11,12 A preclinical rodent study demonstrated that VML-injured muscle strength can increase in re sponse to physical therapy (ie, wheel running). But no was observed, raising questions regarding the main tenance of plasticity of the traumatized musculature. 13 remodeling response after VML injury that may eventu ally exhaust the regenerative potential of the remaining portion of the injured musculature and lead to a progres sive further loss of function. Preclinical animal studies have documented some evidence of this potential condi tion, such as the prolonged presence of centrally located sion. 3,4,14 All told, growing evidence suggests that VML injury may present a progressive degenerative condition. Muscle-related Disability Following Combat Injury Increases With Time MAJ Jessica C Rivera, MC, USA Benjamin T. Corona, PhD ABSTR A CT Background: Combat injuries are most often to the extremities, resulting in a majority of long term disabilities be ing of orthopaedic nature. Some injuries are expected to improve with time. The Army Physical Evaluation Board (PEB) gives consideration for conditions that may improve with further care by placing eligible patients on a tem porary retirement list. While this may be appropriate for some conditions, injuries such as those to skeletal muscle can be irrecoverable. We aimed to examine combat injured subjects with known muscle injuries who were placed in temporary retirement status to determine if their muscle conditions improved. We hypothesized that muscle-related disability would not improve despite additional time for recovery. Methods: The PEB results of 33 combat wounded service members were reviewed to determine what individuals were placed in temporary retirement status. We compared what muscle conditions were present at each PEB exami also compared if the disability rating assigned to the muscle condition changed with time. Findings: of the subjects experienced improvement in their muscle condition as measured by disability ratings. Seven subjects initial exam. Two subjects have muscle disability ratings that were unchanged. Conclusions: While temporary retirement status provided opportunities for injured service members to experience additional improvement prior to permanent retirement, not all conditions can be expected to improve. This study demonstrates that the Army PEB ratings for muscle conditions did not improve despite additional recovery time being granted to the subjects on temporary retirement status. Transforming growth factor beta 1

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January March 2016 31 Unfortunately, the natural history of an injured limbs function after VML injury is unknown. We aim to ex plore preliminary evidence on the natural history of VML injury by examining disability outcomes over time in a cohort of wounded service members with mus cle-related disability. We hypothesize that VML injuries result in deterioration of muscle function with time. METHODS This study was conducted in accordance with an Insti tutional Review Board approved protocol. We examined the Army Physical Evaluation Board (PEB) results of previously published cohorts of medically retired ser vice members to determine how disability designations for muscle injury change with time for service members who underwent more than one examination by the PEB. In brief, a 450 service member cohorts overall disability characteristics were published by Cross et al 1 and dis ability related directly to muscle conditions is described by Corona et al 10 for 36 service members (8%). Of the 36 individuals with muscle-related disability, 33 had docu mentation in their medical records describing the volu metric loss and persistent weakness, allowing us to con cause of their muscle-related disability. The disability designation itself is assigned by the PEB as any condi tion that detracts from an injured service members abil ity to perform his or her military occupational specialty signed a percentage rating which, on a spectrum from Once the PEB determines an injured service member ditions are enumerated and rated, the service member may be medically retired or separated from active duty. The PEB can also determine that the service members injury is not stabilized enough to determine to what In this case, the PEB expects that the illness or injury will improve with additional care and that the service assumption is that the condition will improve and the service member should not be separated or medically retired from active duty prematurely. In this case, the PEB places the service member on Temporary Disabil ity Retirement List (TDRL). The service member con tinues to get care for the conditions and is reevaluated periodically by the PEB to determine if the condition is is reached) or medical retirement/separation, the PEB signs each a disability rating. We examined the PEB database outcomes for the 33 cle condition to identify which subjects were placed on TDRL for any period of time prior to being medical retired. Because the assumption for TDRL placement is that the conditions in question may improve, we ex amined the changes in disability ratings for the muscle conditions between the initial PEB evaluations, iterative position at the time of each service members medical retirement. This allowed us to determine if, from the PEB evaluation standpoint, disabling muscle conditions by the assigned disability rating. The time between the evaluations was noted in an attempt to describe how VML injuries change with time in terms of increments of disability ratings. Comparisons between subjects with different PEB outcomes were made using students 2-tailed t test. Linear regression analysis was performed to determine if disability rating increased as a function of time postinjury. To perform regression analysis, pa tients who did not have a VML disability rating upon initial TDRL were given a disability of 0%. Statistical RESULTS tion. Their average age was 28.21.7 years (range 22-44 years) and median rank was E6 (range E4-O6). Combin all disability rating was 64% (range 20%-100%) and av erage individual disability rating for just the VML was 29% (range 0%-60%). The average time between their dates of injury and respective medical retirement was 681 days (range 246-995 days). Eighteen (55%) subjects were placed on TDRL during cal retirement. Their average age was 24.51.2 years (range 19-35 years) and median rank was E4 (range E4E6). Age was not different compared to service mem ation ( P =.0784) but service members placed on TDRL ( P =.0140). Their average overall disability rating com 20%-70%) and average individual disability rating for just the VML was 25% (range 10%-60%). The overall rating for service members who were medically retired

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32 http://www.cs.amedd.army.mil/amedd_journal.aspx members placed on TDRL prior to retirement was P =.0463) but the disability rating assigned to the VML alone was not differ ent ( P =.5140). The average time between their dates of injury and respective medical retirement was 1,293 days (range 630-1,986 days). Because of the additional time allowed for maximal medical ration between date of injury and date of medical retirement ( P <.0001). Of the 18 service members that were placed on TDRL, 7 subjects with an initial muscle condition rating were granted a higher (more disabling) rat 40%], P =.0313). The charts in the Figure demon strate the increase in the disability ratings for each were not assigned a muscle-related disabling con dition at their initial PEB evaluation but went on All of these service members had a pain or loss of motion rating initially which was recognized as a muscle condition at their follow up evalua tion as shown in the Table. The remaining 2 ser vice members had VML disability ratings which did not increase or decrease between their initial ment dispositions, one with a 20% VML disability rating and one with a 30% VML disability rating. CO MM ENT These results indicate that, for a portion of service members with VML related disability following combat injuries, some are medically retired at on TDRL for a period of time prior to medical retirement. Despite the intent of TDRL which is to allow for improvement until maximal medical tions for service members placed on TDRL result in worsening VML disability. Sixteen of the 18 (89%) service members placed on TDRL either had an positions or were recognized to have a VML related dis at interval evaluations. Some differences existed between the service members and those who were placed on TDRL. First evaluation retirees were of higher rank, tended to be older but more senior service member would not improve given tirement was probably due to the cumulative amount of Disability rating due to VML injury of patients on TDRL. Disability rat muscle rating upon initial TDRL review. Regression analysis indicates R 2 = 0.24 P =.0032). 18 14 10 6 17 13 9 5 2 16 12 8 4 1 15 11 7 3 2190 1825 1460 1095 730 365 0 20 0 30 40 50 60 70 10 % Disability 20 0 30 40 50 60 70 10 % Disability A B TPI (days) Subject Final (with initial rating) Initial Final (with no initial rating) Initial MUSCLE-RELATED DISABILITY FOLLOWING COMBAT INJURY INCREASES WITH TIME

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January March 2016 33 their higher overall disability rating. The contribution of VML to the overall rat ing was not different between the groups, suggesting that other injuries contributed in part to their medical retirement at their The VML disabling conditions of ser vice members placed on TDRL did not improve but rather deteriorated. This is anticipated for a number of potential rea sons. Volumetric muscle loss is not ad dressed during acute stages of care and, therefore, the remaining muscle mass is left to undergo continued degeneration and prolonged remodeling. 3,4 During this time, VML injury propagates extensive sively restricts range of motion. It is likely under this condition that the injured musculature exhib its reduced or disuse atrophy. Coupled with the clinical observations that physical rehabilitation of VML inju cle strength of the injured musculature, it is predictable that VML presents a deteriorating condition. Prospec pathophysiology of VML injured muscle. Limitations to our study include the use of the PEB dis ability designations as surrogates for true disability and our small sample size. The PEB ratings are assigned in accordance with the Veterans Affairs System for Rat ing Disabilities (VASRD), which at minimum provides a uniform guidance to how the PEB designations should be assigned. While every grading system contains some level of subjectivity, the VASRD guidance is enforced to attempt to minimize interrater differences. The PEB function or other true deterioration in clinical status. We used the PEB disability rating as a surrogate for wors ening muscle condition, however, because the ratings detracts from a service members ability to perform on active duty job. As such, we feel that the increased dis ability rating between time points for any given service member provides some measure of decreased functional status attributable to the VML. Finally, our small sam ple size may not allow us to make accurate statistical inferences. This is a limitation imparted by the avail ability of retrospective data. However, when taken in total with the overall description of the larger published cohort, this data adds to the granular detail of the longterm sequelae of extremity injury not found in a vast majority of descriptive studies on war injury. In conclusion, these data are consistent with growing body of preclinical literature demonstrating whole mus cle unit deterioration following VML injury. The natu ral history of VML in human subjects has not been de scribed. This is foundational preliminary evidence that the natural history of combat sustained VML injury is also one of deterioration. REFERENCES 1. Cross JD, Ficke JR, Hsu JR, Masini BD, Wenke JC. of long-term disabilities. J Am Acad Orthop Surg 2011;19(suppl 1):S1-S7. 2. Cross JD, Stinner DJ, Burns TC, Wenke JC, Hsu JR, Skeletal Trauma Research C. Return to duty after type III open tibia fracture J Orthop Trauma 2012;26(1):43-47. 3. frank loss of tissue. J Orthop Res 2015;33(1):40-46. 4. ters TJ, Rathbone CR. Autologous minced muscle grafts: a tissue engineering therapy for the volu metric loss of skeletal muscle. Am J Physiol Cell Physiol 2013;305(7):C761-C775. 5. ery following autograft treatment of volumetric muscle loss in the quadriceps femoris J Biomech 2014;47(9):2013-2021. 6. Pereira C, Relaix F, Miclau T, Marcucio R, Colnot C. Role of muscle stem cells during skeletal regen eration. Stem Cells 2015;33(5):1501-1511. Nine subjects were given disability rating for nonmuscle conditions at their evaluation. Subject Initial Rated Clinical Condition, Rating Final Muscle Rating of VML Site of VML 1 Limited range of motion of the ankle, 20% 20% Posterior Leg 2 Pain and decreased range of motion in the ankle, 20% 20% Posterior Leg 3 Decreased range of motion of the shoulder along with sensory deficits in the hand, 30% 10% Deltoid 4 Chronic thigh pain, 0% 10% Quadriceps 5 Shoulder pain, 20% 30% Deltoid 6 Healing tibia fracture, 30% 50% Posterior Leg 7 Hand weakness and chronic pain, 10% 10% Volar forearm 8 Chronic Pain, 0 % 10% Posterior Leg 9 Neuralgia, 10% 10% Quadriceps

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34 http://www.cs.amedd.army.mil/amedd_journal.aspx 7. fracture healing in rat tibia. J Orthop Trauma 2003;17(6):430-435. 8. Poor muscle coverage delays fracture healing in rats. Acta Orthop Scand 2002;73(4):471-474. 9. strength of union at the site of osteotomy after de vascularization of a segment of canine tibia. J Bone Joint Surg Am 1991;73(9):1323-1330. 10. bone CR. Volumetric muscle loss leads to perma nent disability following extremity trauma. J Reha bil Res Dev In press. 11. Boninger ML, Dearth CL, Ambrosio F, Badylak SF. Targeted rehabilitation after extracellular ma trix scaffold transplantation for the treatment of volumetric muscle loss. Am J Phys Med Rehabil 2014;93(11 suppl 3):S79-S87. 12. Mase VJ, Jr., Hsu JR, Wolf SE, Wenke JC, Baer plication of an acellular biologic scaffold for surgi cal repair of a large, traumatic quadriceps femoris muscle defect. Orthopedics 2010;33(7):511. 13. rehabilitation improves muscle function following volumetric muscle loss injury. BMC Sports Sci Med Rehabil 2014;6(1):41. 14. Corona BT, Wu X, Ward CL, McDaniel JS, Rath bone CR, Walters TJ. The promotion of a functional loss injury following the transplantation of muscleECM. Biomaterials 2013;34(13):3324-3335. AUTHORS MAJ Rivera and Dr Corona are with the US Army Insti tute of Surgical Research, Joint Base San Antonio Fort Sam Houston, Texas. MUSCLE-RELATED DISABILITY FOLLOWING COMBAT INJURY INCREASES WITH TIME

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January March 2016 35 The Global War on Terror has left an indelible mark on Americans, particularly on US military personnel who have served on multiple overseas deployments. The me dia has highlighted stories of Soldiers with amputations, traumatic brain injuries, and posttraumatic stress dis order. The Armys response to ensure provision of total care for wounded Soldiers following serious injuries is the Warrior Transition Unit (WTU), a comprehensive program designed to house, rehabilitate, and return Soldiers to duty or foster a transition from military to civilian life. Occupational therapists have historically been agents of social change related to disability, and occupational therapy practitioners provide care at the WTU as part of an interdisciplinary team. An exami nation of the WTU provides insight into disability, and considerations of the WTU helps inform future practice. EST A BLISH M ENT OF THE WA RRIOR TR A NSITION UNIT In response to the recognition in 2007 of the extent of substandard care for wounded military personnel, 1 the Army established 35 WTUs at major bases in the conti nental United States and overseas to ensure the availabil ity of professional services for those Wounded Warriors. 2 The mission of the WTU is to heal and prepare [the Soldier] for transition, and it aims to accomplish this by providing each Soldier with a Comprehensive Transi tion Plan (CTP). 3 While working through the CTP, the Soldier has access to a system called the Triad of Care. This Triad includes a squad leader, a nurse care manager, and a primary care manager who is either a physician or physicians assistant. 3 The Triad is supplemented by an interdisciplinary team of occupational therapists, physi cal therapists, social workers, transition coordinators, and career counselors, among others. 2 The command structure of the WTU provides oversight and accountability. While assigned to the WTU, the housing, normal pay and allowances, and healthcare ser vices. The Soldiers daily responsibilities are to attend medical appointments, engage in therapy to learn new life skills, and seek career counseling to transition out of the military or to a new military occupational specialty, as appropriate for the Soldiers future plans. Active Duty, National Guard, and Reserve Soldiers who have sustained physical and/or mental health injuries while serving and who require at least 6 months of in tensive medical care are accepted into the WTU. A fact sheet published by the Warrior Transition Command 4 states that as of February 2, 2015, the majority (84%) of the 4,001 Soldiers remaining in the WTU have been deployed at some point, but only 167 were injured in combat. Currently, the WTU success rate of returning Soldiers to duty is approximately 45%. The WTU recog nizes that work is important to the Soldiers mental and physical well-being, therefore, returning the Soldier to a purposeful worker role is emphasized within occupa tional therapy treatment. EVOLUTION A ND AD A PT A TION cupations to restore mental and physical health are foun dational tenets of occupational therapy. One fundamen tal example of this is the moral treatment movement in Europe in the 18th and 19th centuries. That move ment marked a critical paradigm shift when individuals with mental illness began to participate in work tasks, or meaningful occupations, rather than being restrained. Adolph Meyer, the psychiatrist recognized as the fa ther of occupational therapy, acknowledged the link between meaningful occupations and overall health, an idea ahead of its time. 5 Since its creation and throughout its growth, occupational therapy has long been rooted in social justice, fostering cultural change related to dis ability. Presently, occupational therapy and healthcare provision continue to evolve within the WTU. As of 2015, the WTU has downsized from 35 to 25 units in operation with 11 Community Care Units, smaller units for Soldiers with less complex care needs which allow them to heal closer to home. 2,4 Fewer service War and Rehabilitation: Occupational Therapys Power to Transform Disability Into Ability 1LT Catrinna Amorelli, SP, USA 1LT Lindsay Sposato, SP, USA

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36 http://www.cs.amedd.army.mil/amedd_journal.aspx members are deploying and returning with injuries as the militarys current presence and involvement in over ated the closure of select WTUs while ensuring no deg radation to the care and services provided to Soldiers and their families.* The WTUs at 5 regional medical commands have been designated for inactivation by Au gust 2016. Consequently, Soldiers within those WTUs will be transferred to other units.* As the WTU struc ture continues to evolve and downsize, there is an op portunity to critically evaluate it. LESSONS LE A RNED of the military unit structure which fosters unit cama raderie among Soldiers, the interdisciplinary team of healthcare providers, and the inclusion of the Soldiers family members in the plan of care. Despite the ben well. As shown in the inset, these include the potential that receiving a medical disability rating may incentiv ability may foster symptom exaggeration, and the mul tilayer administrative and clinical processes may cause extended lengths of stay, perhaps beyond the ideal time required for rehabilitation goals to be reached. The criticism that the WTU may create a climate that tive, since the language was purposefully written so the Soldiers would identify themselves as Warriors in tran sition. Regardless of intentions, Soldiers learn about the medical disability rating system and the fact that ad ditional diagnoses in their medical record can result in susceptible Soldiers to identify with their diagnoses, and even seek additional diagnoses to add to their medi cal disability claim. Occupational therapy practitioners who work closely with Soldiers vulnerable to identify ing with the sick role must be proactive. As creators of change, therapists can facilitate an incentive to recover and identify with ability rather than disability. APPE A L TO ACTION It is necessary to create a shift relating to the Soldier mindset that surrounds the disability rating system. Dis ability ratings by Veterans Affairs are assigned to Sol diers who have sustained injuries or diseases that are service-related, such as qualifying Soldiers receiving care within the WTU. 6 A disability rating is a percentage (0%-100%) assigned to a Soldier based on injury or ill ness severity. The higher the rating, the greater amount of compensation provided from the government. 6 In stead of promoting health, the system may inadvertently function. Reliance on a disability rating may provide a predictable, continuous income, but may also inadver to the system including the possibility of a lump sum disability payment (rather than a continuous payment), coupled with a release for all future disability claims, could effectively deter system misuse. After acceptance of a lump sum with a release, there may be less incentive for discharged Soldiers to revisit their disability claims and continue the cycle of dependence. As rehabilitation professionals within the WTU, occu pational therapists must hold themselves accountable for services rendered, as well as services withheld. Soldiers deserve compensation for injuries, but allowing Soldiers to advance towards a higher rating than warranted is a disservice not only to the Soldier, but to the ethical standards of the profession. The Army values and the occupational therapy code of ethics should be revisited frequently to regain focus for both Soldier and therapist. Occupational therapists can steer the rehabilitation para digm from the medical model to the social integrative model of disability. The medical model views disability as a negative occurrence, which can leave an individual dependent on supports and unmotivated to reintegrate into previous roles and responsibilities. In this model, the individual may assume the sick role and attempt to incentivize his or her disability. In contrast, the social integrative model views disability as a naturally-occur ring phenomenon. Through full participation in occupa tions and roles, the individual will become more resil ient, therefore regaining health and wellness. 7 Therapists WAR AND REHABILITATION: OCCUPATIONAL THERAPYS POWER TO TRANSFORM DISABILITY INTO ABILITY US Army Medical Command OPORD 15-31 February 2015 Internal military document not readily accessible by the general public. Interdisciplinary communication and teamwork assistance structure Considerations/Concerns

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January March 2016 37 must be cautious in labeling clients as disabled. Instead, care must be taken to assist the Soldier in creating a new identity, one that promotes ability. Finally, as with any system of multilayer administrative and clinical processes, there may be unexpected delays or breakdowns in coordination in regards to delivery of care. In-processing, out-processing, and any executive healthcare system may expose the Soldier to getting lost process of the Integrated Disability Evaluation System, which determines whether a Soldier can return to duty or separate from military service with a disability payment, is recognized as slow-moving. 8 Occupational therapists should strive to educate Soldiers on the functions of the WTU, while simultaneously keeping the Soldier motivat ed, goal-focused, and proactive towards discharge. As sisting Soldiers to take an active role in managing their own care provides accountability and a sense of purpose. Overall, lessons cultivated go far beyond the WTU, and within the civilian sector of support systems. APPLIC A TION WITHIN THE CIVILI A N SECTOR Civilian social supports provide similar opportunities to incentivize disability. With the implementation of the Affordable Care Act in 2010, Medicaid coverage was ex panded, adding millions of individuals to this system of care. 9 Supporters stated the expansion provided assis tance for individuals who, prior to the initiative, did not qualify. However, challengers of this expansion argue that it may promote dependence on the governments as sistance. Social Security Disability Insurance is a highly criticized program which cycles around an individuals impairment(s) and inability to provide for oneself, pos sibly incentivizing disability and encouraging exaggera tion of symptoms. 10 These systems of support are only a few of the civilian programs which are criticized for potential encouragement to remain in the system, ac cepting a dysfunctional disability role as part of ones personal identity. The roots of occupational therapy and history have shown that individuals need meaningful roles and en gagement in occupations to restore or maintain overall health. Occupation has been recognized as a means of treatment for mental and physical illness since the 18th century, long before the term occupational ther 5 In 1915, Hall and Buck 11 discussed the importance of engagement, or occupation in occupational therapy lingo, as a means of recuperation, stating: For the well-to-do, work with the hands may be a potent remedy against the harmful effects of idleness As a profession, occupational therapists have known for nearly a century that participation in occupations is a way to restore health. Whether in the WTU or in the ci vilian sector, occupational therapists do well to remind clients that it is in their best interest to be engaged and fully participate in occupations. Furthermore, in pursuit of health for clients, occupational therapists may simul taneously discourage unnecessary reliance on social support and subsequent idleness. CONCLUSION In any social support system, loopholes will be found and resources may be unjustly over-utilized. As this is never the purpose of these programs, health profession als should transform unhealthy mindsets and behaviors toward independence. As the past has demonstrated, occupational therapy practitioners can be instrumental in analyzing and altering the future of such services. Through war and rehabilitation, Army occupational therapists have the unique opportunity to be actively involved in a large, evolving healthcare system. The WTU is simply one example of a support system devel military or civilian sector, it is the duty of occupational therapists to motivate clients to accomplish the mission of return to function, independence, health, and partici pation in meaningful occupations. In this way the focus is empowerment, not entitlement. REFERENCES 1. Priest D, Hull A. Soldiers face neglect, frustra tion at Armys top medical facility. The Washing ton Post. February 18, 2007. Available at: http:// www.washingtonpost.com/wp-dyn/content/arti cle/2007/02/17/AR2007021701172.html. Accessed July 20, 2015. 2. Erickson MW, Secrest DS, Gray AL. Army occu pational therapy in the warrior transition. OT Prac tice. 2008;13(13):10-14. 3. US Army Warrior Transition Command. Warrior Transition Units [internet]. December 2014. Avail able at: http://www.wtc.army.mil/documents/fact sheets/WTU_FACT_SHEET.pdf. Accessed July 20, 2015. 4. US Army Warrior Transition Command. Warrior Transition Command [internet] February 2015. Available at: http://www.wtc.army.mil/documents/ factsheets/WTC_Overview_FactSheet_FINAL. pdf. Accessed July 20, 2015.

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38 http://www.cs.amedd.army.mil/amedd_journal.aspx 5. Reed K, Hocking C, Smythe L. The meaning of occupation: historical and contemporary connec tions between health and occupation. N Z J Occup Ther. 2013;60(1):38-44. Available at: https://www. questia.com/library/journal/1G1-328657463/themeaning-of-occupation-historical-and-contempo rary. Accessed October 5, 2015. 6. US Department of Veterans Affairs. Compensa tion [internet]. August 2015. Available at: http:// cessed July 20, 2015. 7. Cooper RA, Pasquina PF, Drach R eds. Warrior Transition Leader: Medical Rehabilitation Hand book Fort Sam Houston, Texas: Borden Institute; 2009. 8. US Army Warrior Transition Command. Integrat ed Disability Evaluation System (IDES) [internet]. Available at: http://www.wtc.army.mil/modules/ Soldier/s6-ides.html. Updated June 22, 2015. Ac cessed July 20, 2015. 9. Centers for Medicare and Medicaid Services. Eli gibility [internet]. Available at: http://www.med icaid.gov/medicaid-chip-program-information/bytopics/eligibility/eligibility.html. Accessed July 20, 2015. 10. Burke TF, Barnes J. Republicans want to reform disability insurance. Heres why thats hard. The Washington Post. February 17, 2015. Available at: http://www.washingtonpost.com/blogs/monkeycage/wp/2015/02/17/republicans-want-to-reformdisability-insurance-heres-why-thats-hard. Accessed July 20, 2015. 11. Hall HJ, Buck MM. The Work of Our Hands: A Study of Occupations for Invalids New York, NY: Moffat, Yard & Company; 1915. AUTHORS 1LT Amorelli and 1LT Sposato are Senior Fellows in the Army-Baylor University Doctor of Science in Occupa tional Therapy Program, Fort Sam Houston, Texas. WAR AND REHABILITATION: OCCUPATIONAL THERAPYS POWER TO TRANSFORM DISABILITY INTO ABILITY

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January March 2016 39 Never underestimate your POWER to change yourself H. Jackson Brown, Jr The Center for the Intrepid (CFI) at Fort Sam Houston, 1 The CFI staff INTREPID DYN AM IC EXOSKELET A L ORTHOSIS PERFOR MA NCEOPTI M IZ A TION WA RRIOR ENH A NCED REH A BILIT A TION Customized to the patient 4 tients referred to the CFI with any Center for the Intrepid: Providing Patients POWER

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40 http://www.cs.amedd.army.mil/amedd_journal.aspx IM PLE M ENT A TION OF THE POWER PROGR AM of each patient with respect to his or her treatment Power Program Modules Health Psychology CENTER FOR THE INTREPID: PROVIDING PATIENTS POWER Figure 1 An interdisciplinary approach provides specialized, holistic, practice-based patient care. OCCUPATIONAL THERAPY ORTHOTICS & PROSTHETICS PHYSICAL THERAPY CASE MANAGEMENT RECREATIONAL THERAPY HEALTH PSYCHOLOGY PHYSIATRY RESEARCH DIETETICS Professions Integral to the POWER Program Case Management Management of cases by coordination of all ser vices and facilities transitions surrounding patient discharge. Dietetics One on one and group sessions to promote healthy eating, dietary modifications, and illness prevention through proper nutrition. Health Psychology One on one and group therapy sessions with a focus on education of behavioral health techniques to im rove outcomes. Occupational Therapy Engages the patient in meaningful thearpeutic activi ties to return to their highest level of function and quality of life. Orthotics & Prosthetics Custom fabrication of prosthetic and orthotic devices. Physiatry Thorough and ongoing evaluation and holistic manage ment of patients. Serves as the lead provider for the rehabilitation care of each patient. Physical Therapy Evaluation and treatment of neuromusculoskeletal conditions. Provides therapeutic exercises, modali ties, and gait training. Recreational Therapy Facilitates emotional and physical health through lei sure pursuits and community reintegration. Lead ser vice for biofeedback training. Research Contributes to the objective assessment of outcomes to ensure/develop best practice.

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January March 2016 41 Figure 2 The main modules and corresponding submodules of the POWER Program. Nutrition 1 Nutritional Survey 2 Laboratory Evaluation a. CBC, iron-panel, sTfr b. Chem 7 c. Lipid panel d. 25 -OH d 3 The 5 Rs a. Rehydrate b. Repair c. Rest d. Revitalize e. Reload 4 Individual Classes a. Review Labs b. Body composition c. Review supplements d. Goal setting e. Follow-up as needed Health Psychology 1 Performance Education a. Stress management b. Sleep c. Pain I d. Pain II 2 Skill Acquisition a. Attention and self-talk b. Critical thinking and self-analysis c. Anger management d. Learned optimism Activity 1 Evaluation and Screening Tools a. History and physical exam b. Biodex c. Biofeedback d. FCE-M e. Military performance lab 2 Restoration a. Strength training b. BFR c. Motion d. AlterG e. Edema recovery f. Flowrider 3 Return to Run a. Sprinting b. Plyometrics c. Cut dynamics d. Landing mechanics e. Power development f. Acceleration/deceleration 4 Return to Duty a. FCE-M c. FATS d. WFSC Freedom Park e. CAREN f. Community outings Glossary CAREN Computer Assisted Rehabilitation ENvironment MOS military occupational specialty CBC complete blood count sTfr soluble transferrin receptor Chem 7 basic metabolic panel WFSC Warrior and Family Support Center FATS Firearms Training Simulator 25 -OH d 25 hydroxyvitamin D

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42 http://www.cs.amedd.army.mil/amedd_journal.aspx 8,9 mechanoreceptors in a pain experience, introduction to tion and stiffness. Learned optimism Nutrition CENTER FOR THE INTREPID: PROVIDING PATIENTS POWER

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January March 2016 43 Rehydration tient. Repair emphasizes to patients the importance of Rest Revitalize emphasizes the need to reload their mus 11 In addition to Activity treatment options for patient care. 14 Fur

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44 http://www.cs.amedd.army.mil/amedd_journal.aspx scenarios. 1 combat. EV A LU A TION OF THE POWER PROGR AM independence. independence. VA LUE TO THE MILIT A RY 18 CENTER FOR THE INTREPID: PROVIDING PATIENTS POWER

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January March 2016 45 19 CONCLUSION REFERENCES 1. J Hand Ther J Surg Orth Adv. J Trauma 4. Int J Athl Ther Train care. N Engl J Med J Sport Health Sci Neuro sci Biobehav Rev 8. Qual Life Res 9. J Hosp Med. Strength Cond J 11. Curr Sports Med Rep. Mil Med J Strength Cond Res 14. J Orthop Res. mance. J Bone Joint Surg AM. putation. J Neuroeng Rehabil Gait Posture. 18. US Army Med Dep J 19. .. Accessed Au ment of an individual or group. Source: MerriamWebster Medi cal Dictionary

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46 http://www.cs.amedd.army.mil/amedd_journal.aspx AUTHORS Texas. CENTER FOR THE INTREPID: PROVIDING PATIENTS POWER

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January March 2016 47 Safety, quality, and the cost of healthcare are currently at the forefront of healthcare discussions in the United States. One of the most vulnerable periods for a hospital ized patient occurs during transfer of that patients care among providers or between healthcare settings. This since these transitions of care are prone to confusion, miscommunication, and medical errors. 1,2 Within hospital systems, discharge planning services aim to ease the patient transition from the hospital. Many studies suggest that these services decrease cost and utilization rates. A 2013 Cochrane review evalu ated the value of hospital discharge planning and deter mined that individualized hospital discharge plans lead to reductions in hospital length of stay and readmission rates. 3 Additional evidence in the Cochrane review was inconsistent regarding the impact of discharge planning on cost, mortality, or other health outcomes. When compared to the availability of hospital-based discharge planning services, fewer systems exist to as sist patients after discharge from the hospital. Often, patients experience problems which arise after their hospital discharge, but prior to a follow-up appointment. During this time, hospital discharge planners are not al ways available, and the patients primary care medical problems that may arise during the transition of care from the hospital include inaccurately reconciled medi cation lists, inadequate access to appropriate social sup port or transportation to appointments, poorly coordi nated postdischarge home medical services, or lack of access to a physician for follow-up outpatient care. Each of these issues can contribute to medical errors, patient morbidity, and rehospitalization rates. 4,5 As these prob lems have become more apparent, they have become in creasingly studied in an attempt to decrease costs while improving patient safety and the quality of care deliv ered during the transition periods. One of the strongest bodies of evidence supporting a deliberate approach to facilitating care transitions is described in Boston Universitys Project RED (ReEngineered Discharge) research group (https://www. bu.edu/fammed/projectred/). Project RED researchers executed and evaluated strategies for successful patient transition from the inpatient to the outpatient care set tings. Through the development and implementation of reduced both hospital readmissions and postdischarge visits to the ED. 6 As an additional part of their project, they published a tool kit for other health teams to employ when discharging patients. 7 Other studies demonstrated Implementation of a Transition of Care Coordinator at a Military Treatment Facility LTC Dana Nguyen, MC, USA CPT Sarah Strickland, MC, USA CPT Blake Busey, MC, USA CPT Ashley Roselle, MC, USA LTC Mark Stackle, MC, USA CPT Scott Hahn, MC, USA Tammy Donoway, DO CPT Nick Bennett, MC, USA ABSTR A CT A patients transition from the inpatient to the outpatient setting is complex and prone to medical errors. This subsequently increases patient morbidity and cost to the healthcare system. Methods: Our quality improvement initiative used a licensed clinical social worker from within a Family Medi cine residency clinic to serve as a Transitions of Care Coordinator (TOCC) with the goal of decreasing patient morbidity and system cost. Results: P =.01). Pearson correlation during our postimplementation period suggested an inverse relationship between contact by a TOCC and emergency department (ED) and hospital utilization rates ( r =-0.68, P =.05 and r =0.062, P =.005, respectively). However, P P cantly increased overall between the pre-and postimplementation periods. Conclusions: increased the frequency of ED visits and readmissions to the inpatient service for patients discharged from the Family Medicine inpatient service.

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48 http://www.cs.amedd.army.mil/amedd_journal.aspx similar evidence with regard to the effect of discharge planning protocols on ED utilization and hospital read mission rates. 8-11 Studies such as these have led to campaigns throughout the United States designed to improve the quality of pa tient care delivered during this transition period. One of the largest such campaigns is the 2010 Partnership for Patients Campaign led by the Department of Health and Human Services. As part of this campaign, over 3,700 hospitals have collaborated in order to make hospitals safer, less costly, and more reliable. One of the 2 corner stone goals of the Partnership for Patients campaign is to 12 The Department of Defense and the Military Healthcare System (MHS) joined other federal agencies to support the Partnership for Patients campaign. 13 As part of its campaign, the MHS recommended adoption of the Project RED toolkit within its healthcare facilities. Based on this MHS recommendation and other local mandates to improve the quality of healthcare within our institution, the leadership of the Womack Army Medical Center established a Project RED team to fa cilitate transitions of care throughout its health system. As part of this effort, the Family Medicine residency clinic implemented the use of a licensed clinical social worker to serve as the transitions of care coordinator (TOCC) for patients enrolled in the residency clinic and cared for by the Family Medicine inpatient team. The TOCCs primary role was to enable effective and safe transitions of care from the inpatient ward to the followup outpatient appointment. With the implementation of the TOCC, our objectives were to increase the number of patients that had follow-up appointments with their primary care manager (PCM) shortly after hospital dis charge, identify and assist with patient problems post hospitalization, decrease the frequency of emergency department (ED) visits posthospitalization, decrease hospital readmissions to the Family Medicine inpatient team, and improve the overall quality of care for our high acuity patients. Overall, we aimed to study the relative quality metrics associated with implementation of a transitions of care coordinator within an academic clinic in the MHS. METHODS This study was conducted as a local quality improve ment initiative. Within our Family Medicine residency clinic at a large Army military treatment facility, we implemented a TOCC to facilitate a smoother transition to outpatient healthcare for patients recently discharged from the hospital. We chose a licensed clinical social worker to assume this role. The initial step in our transition of care protocol was for the TOCC to contact all patients discharged from the Family Medicine inpatient team within 48 hours of discharge. The TOCC used a structured interview script based on Project RED guidelines which reviewed the pa tients diagnosis, discharge medications, follow-up ap pointments, consultations, and overall plan of care. The the patients had a follow-up visit in our clinic (prefera bly with the primary care manager), answering patients questions about their hospitalization, ensuring patients received any indicated postdischarge services, bringing medication reconciliation questions to the attention of the inpatient team and the PCM, and addressing any ad ditional patient concerns. The TOCC conducted these encounters telephonically and documented the results within the electronic medical record. All adult admissions to the Family Medicine inpatient team from February 2013 through March 2014 were evaluated monthly for primary outcomes data. Chart re views were conducted with the following primary out come variables recorded: 1. Number of patients contacted by the TOCC within 48 business hours. 2. Number of patients who completed a follow-up visit within 7 days of discharge in our practice. 3. Number of patients who completed a follow-up visit within 7 days of discharge with their PCM. 4. Number of patients who completed a follow-up visit within 14 days of discharge in our practice. 5. Number of patients who completed a follow-up visit within 14 days of discharge with their PCM. 6. Number of ED visits within 30 days of admission. 7. Number of readmissions to our facility within 30 days of discharge. A run chart was constructed from this data to identify any emerging trends. At 6 months following the TOCC implementation, the data was analyzed by run charts as well as via SPSS Statistics 20.0 (IBM Corp, Armonk, New York) analysis. RESULTS Table 1 shows the demographic characteristics of the pa tient groups admitted to the Family Medicine inpatient adult medicine service during the preimplementation and the postimplementation periods. Outcome variables were assessed comparing the preimplementation and the postimplementation periods for the TOCC. During this analysis, we did not consider whether the TOCC actual ly contacted the patient during the postimplementation IMPLEMENTATION OF A TRANSITION OF CARE COORDINATOR AT A MILITARY TREATMENT FACILITY

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January March 2016 49 of cases. Table 1 also compares outcome variables for these periods regardless of TOCC contact. As expected, the number of documented patient contacts by our pri P =.01). Additionally, the percentage of ED vis P =.02) and hospital readmissions P =.01) increased during the postimple mentation period. Figure 1 shows the run chart of primary outcome mea sures after we implemented the TOCC. Over the course of 6 months, the number of patients from our practice contacted within 48 business hours after hospital dis this time period, the percentage of patients completing a follow-up appointment within 14 days of discharge also increased. This increase also included the num ber of patients that were able to see their PCM. The percentage of ED visits as well as the percentage of patients readmitted within 30 days appeared to have a declining trend after our implementation. No trends of discharge. The postimplementation data was analyzed for correla tions using Pearson product moment correlation. The Table 2. In the post implementation period, receiving a phone call within 48 hours postdischarge from our TOCC correlated inversely with 30-day readmissions, as well as ED visits following hospital discharge ( r = -0.68, P =.05 and r =0.062, P =.005, respectively). The 14-day PCM follow-up visit also correlated, though less strongly, with decreased ED visits and 30-day read missions following discharge ( r =-0.13, P =.017 and r = -0.31, P =.006, respectively). The postimplementation period was also analyzed to determine if an actual contact within 48 hours by the TOCC or within 14 days by the PCM made differences in patient outcomes among this group. Tables 3 and 4 show this data. Contact by the TOCC within 48 hours talization ED utilization or hospital readmission rates. Patient follow-up within 14 days of hospitalization with P admission rates. Finally, data from February and March of 2013 was compared to data from February and March of 2014 to identify possible seasonal variation. In 2014, there was a slight reduction in ED visits following implementation of the TOCC (Figures 2 and 3). Between 2013 and 2014, ED visits in February and March, respectively. Between 2013 and 2014, there was an absolute rate increase of 2014 for 30 day hospital readmissions, respectively. CO MM ENT As part of our study design, we theorized that the imple mentation of a TOCC would decrease health care uti and hospital readmissions within 30 days. However, Table 1 Comparison of patient outcome variables for preimplementation vs postimplementation of a TOCC. Preimple mentation Postimple mentation P value Demographics Patients (N) 160 256 Men (%N) 82 (51.2%) 125 (48.8%) Average Age (years) 57 61 Outcome Results [ n(%N) ] 48-hour Call 5 (3.1%) 103 (40.2%) .01 7-day Appt 77 (48.1%) 128 (50.0%) .71 7-day PCM Appt 47 (29.4%) 84 (32.8%) .46 14-day Appt 106 (66.3%) 171 (66.8%) .91 14-day PCM Appt 68 (42.5%) 121 (47.3%) .34 ED Visits 19 (11.9%) 53 (20.8%) .02 30-day Readmission 9 (5.6%) 35 (13.7%) .01 Figure 1 Trend lines for monthly reports of primary outcome measures following implementation of TOCC 48-hour call back. ED Visits per Admission 14-day Follow-up 30-day Readmission 48-Hour Call 14-day PCM Notes: (a) Standardized script (b) ED electronic medical record implementation (c) Direct counseling Sep 2013 (a) Oct 2013 (b) Nov 2013 (c) Dec 2013 Jan 2014 Feb 2014 Mar 2014 40% 50% 0% 30% 60% 20% 70% 10% 80% 90%

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50 http://www.cs.amedd.army.mil/amedd_journal.aspx review of the overall preimplementation and postimple mentation data suggests that our populations ED visits and readmissions actually increased after our TOCC initiative. Similarly, when considering the possible ben we theorized that higher rates of PCM visits would de crease utilization rates. This was not the case, however, as patients seeing their PCM within 14 days during our utilization and hospital readmission rates. The cause of these seemingly paradoxical results is unclear. Patients typically have increased morbidity rates in the posthospitalization period. Increased con tact by our outpatient practice may be simply identify ing problems or complications at an earlier time period. Although this may negatively affect utilization rates, it may be providing improved quality of care in regard to long-term patient outcomes. This was not evaluated in our study. Also, examining data from across our entire medical center would generate stronger statistical power to assess the increased utilization rates. In our postimplementation period, higher rates of timely contact by the TOCC was inversely correlated with the ED and hospital utilization rates, as evaluated by a Pear 2 analysis of these measures rates of utilization for those same patients. These trends still suggest promise of utilization and cost savings ben IMPLEMENTATION OF A TRANSITION OF CARE COORDINATOR AT A MILITARY TREATMENT FACILITY Table 2 ry outcome variables post-TOCC implementation. r P value 48 -hour Call 14 -day Follow-up 0.23 .016 14 -day PCM follow-up 0.63 .936 ED visits per admission -0.68 .050 30 -day Readmission -0.62 .005 14 -day PCM Follow-up 48 -hour Call 0.63 .936 ED Visits per admission -0.13 .017 30 -day Readmission -0.32 .001 Table 3 Comparison of emergency department and readmission outcomes between patients (N= 256 ) who were contacted by the TOCC vs those who were not contacted. 48-hour Call No n(%N) Yes n(%N) P value Patients 153 (59.8%) 103 (40.2%) ED Visits 30 (19.7%) 23 (22.3%) .62 30-day Readmission 22 (14.5%) 13 (12.6%) .67 Table 4 Comparison of emergency department and readmission outcomes between patients (N= 256 ) that completed a follow-up appointment within 14 14 -day Follow-Up No n(%N) Yes n(%N) P value Patients 85 (33.2%) 171 (66.8%) ED Visits 16 (19.0%) 37 (21.6%) .63 30 -day Readmission 13 (15.5%) 22 (12.9%) .57 14 -day PCM Follow-Up No n(%N) Yes n(%N) P value Patients 135 (52.7%) 121 (47.3%) ED Visits 20 (14.9%) 33 (27.3%) .02 30 -day Readmission 18 (13.4%) 17 (14.0%) .89 Figure 2 Comparison of outcome data between a preimple mentation month (February 2013 ) and a postimplementation month (February 2014 ). 48-hour Call ED Visits per Admission 30-day Readmission 40% 50% 0% 30% 60% 20% 10% Feb 2014 Feb 2013 0% 5.0% 52.9% 8.8% 15.0% 11.8% Figure 3 Comparison of outcome data between March 2013 (preimplementation) and March 2014 (postimplementation). 20.0% 10.0% 5.1% 3.3% 17.6% 71.8% 48-hour Call ED Visits per Admission 30-day Readmission 40% 50% 0% 30% 60% 20% 70% 10% 80% Mar 2014 Mar 2013

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January March 2016 51 tion of our practice patients being contacted within 48 contacted with 48 hours of discharge was not met due to transfers to other facilities, deaths, and a myriad of administrative challenges. Timely patient contact was hampered by incorrect phone numbers, patients who did not return phone calls, and the lack of an alternate TOCC when the primary TOCC was on vacation or ill. Despite these limitations, most discharge were contacted by our practice within a week. The use of a licensed clinical social worker as our TOCC is unique since most facilities use nurses for this func tion. The potential drawbacks of using a social worker in the role include unfamiliarity with the medications reviewed as part of the 48-hour telephone encounter. To cine reconciliation issue, he relayed the concern to both the discharging inpatient team as well as to the PCM. The advantages of using a social worker as a TOCC in clude an understanding of how to navigate a complex medical system, experience in the coordination of out patient specialty referrals and appointments, and an ap in this role include professional training and experience with counseling patients and clear communication and emotional support. There are several limitations to our study. We did not consider variables other than those described above. During the period that the TOCC was established, addi tional changes within our health system occurred which inpatient team standardized the written discharge sum mary and instructions given to all patients. Additionally, the ED transitioned from a paper health record to an electronic medical record. Each of these changes may have independently affected our studys outcomes or the ability to capture data accurately. The standardized dis charge summary was part of an overall quality improve ment measure for the Family Medicine inpatient team and was designed in accordance with Project RED and Medicare documentation requirements with their em phasis on improved readability. Additionally, we only studied patients within our military medical system. Our practice patients who were admitted to hospitals other than our facility were not included in the analysis. Despite the unanticipated outcomes involving ED utili zation and hospital readmission rates after our interven tion, the strategies used by our team within this quality improvement initiative subjectively enhanced commu nication and coordination of care within our practice. studys objectives, a standardized script for the TOCC, a standardized discharge summary format for the Family Medicine inpatient team, and the establishment of com mon, obtainable goals. We believe that the value we de rived from these strategies can be replicated, and should be used throughout the MHS. CONCLUSION The implementation of a TOCC within an academic tient populations frequency of ED visits and hospital re admissions after discharge. However, trends during our postimplementation period suggest possible future ben The broader medical literature still largely supports an ing transitions in care. Therefore, the MHS should in vestigate the utility of this effort on a larger scale. REFERENCES 1. Forster AJ, Murff HJ, Peterson JF, Gandhi TK, Bates DW. The incidence and severity of adverse events affecting patients after discharge from the hospital. Ann Intern Med 2003;138(3):161-167. 2. Forster AJ, Clark HD, Menard A, et al. Adverse events among medical patients after discharge from hospital. CMAJ 2004;170(3):345-349. 3. Shepperd S, Lannin NA, Clemson LM, McCluskey A, Cameron ID, Barras SL. Discharge planning from hospital to home. Cochrane Database Syst Rev [serial online]. 2013;1. 4. Davis MM, Devoe M, Kansagara D, Nicolaidis C, Englander H. Did I Do as Best as the System Would Let Me? Healthcare professional views on hospital to home care transitions. J Gen Intern Med 2012;27(12):1649-1656. 5. Balaban RB, Weissman JS, Samuel PA, et al. Re hance patient care: a randomized controlled study. J Gen Intern Med 2008;23:1228-1233. 6. Jack BW, Chetty VK, Anthony D, et al. A re-engi neered hospital discharge program to decrease re hospitalization: a randomized trial. Ann Intern Med 2009;150(3):179-197.

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52 http://www.cs.amedd.army.mil/amedd_journal.aspx 7. Jack B, Greenwald J, Forsythe S, et al. Developing the tools to administer a comprehensive hospital discharge program: the ReEngineered Discharge (RED) Program. In: Henriksen K, Battles JB, Keyes MA, et al, eds. Advances in Patient Safe ty: New Directions and Alternative Approaches (Vol 3:Performance and Tools). Rockville, MD: Agency for Healthcare Research and Quality. 2008. Available at: http://www.ncbi.nlm.nih.gov/books/ NBK43688/. Accessed December 24, 2015. 8. Coleman EA, Parry C, Chalmers S, Min SJ. The care transitions intervention: results of a ran domized controlled trial. Arch of Intern Med 2006;166:1822-1828. 9. Allen J, Hutchinson AM, Brown R, Livingston PM. Quality care outcomes following transitional care interventions for older people from hospital to home: a systematic review. BMC Health Serv Res 2014;14:346. 10. Cauwels JM, Jensen BJ, Winterton TL. Giv ing readmission numbers a BOOST. S D Med 2013;66(12):505-509. 11. Constantino ME, Frey B, Hall B, Painter P. The ing hospital readmissions in a medicare population. Popul Health Manag 2013;16(5):310-316. 12. Department of Health and Human Services. Part nership for Patients Campaign Website. Available at: http://partnershipforpatients.cms.gov/ Accessed January 10, 2015. 13. Military Health System. Implementation Guide for Readmissions. Washington, DC: US Dept of Defense; February 13, 2014. Available at: http:// www.health.mil/Reference-Center/Technical-Doc uments/2014/02/13/Implementation-Guide-for-Re admissions. Accessed January 10, 2015. AUTHORS LTC Nguyen is Clerkship Director, Department of Fam ily Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland. CPT Busey is a Staff Physician, Soldier Family Medical Clinic, Fort Bliss, Texas. LTC Stackle is Deputy Commander for Clinical Servic es, BG Crawford Sams US Army Health Clinic, Camp Zama, Japan. Dr Donoway and CPT Roselle are Staff Physicians, De partment of Family Medicine, Womack Army Medical Center, Fort Bragg, North Carolina. CPT Strickland is a Staff Physician, Reynolds Army Community Hospital, Fort Sill, Oklahoma. CPT Hahn is a Staff Physician, Darnall Army Commu nity Medical Center, Fort Hood, Texas. CPT Bennett is a Staff Physician, Farrelly Health Clinic, Fort Riley, Kansas. IMPLEMENTATION OF A TRANSITION OF CARE COORDINATOR AT A MILITARY TREATMENT FACILITY

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January March 2016 53 Individual body dimensions and derived characteristics 1 2 Data have 3 It has been 3 4 5 6 7 8 9 In ad 11 12 13 14 Influence of Individual Determinants on Physical Activity at Work and During Leisure Time in Soldiers: A Prospective Surveillance Study ABSTR A CT

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54 http://www.cs.amedd.army.mil/amedd_journal.aspx METHODS 2 15 16 ST A TISTIC A L AN A LYSIS t P 2 r CS R 2 b sr 2 f 2 f 2 f 2 f 2 17 RESULTS Influence of Individual Physical Determinants Age INFLUENCE OF INDIVIDUAL DETERMINANTS ON PHYSICAL ACTIVITY AT WORK AND DURING LEISURE TIME IN SOLDIERS: A PROSPECTIVE SURVEILLANCE STUDY

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January March 2016 55 r P r P r P r P r P Job Position at Work tended to be more active than 2 P P P P CS P CS P CS P Gender F P F P F P CS P CS P BMI F 2 P P P Waist Circumference Table 1 P -values of the comparison of activity levels in relation to age groups for whole day, lei sure time period, and on duty period as shown in Figure 1 Whole Day Age Group (y) 25-30 31-40 41-50 >50 <25 .001 .07 .014 .0648 25-30 .0331 .0783 .0292 31-40 .0333 .063 41-50 .0268 Leisure Time Age Group (y) 25-30 31-40 41-50 >50 <25 .015 .0453 .051 .0739 25-30 .024 .0694 .0167 31-40 .022 .0493 41-50 .0141 On Duty Age Group (y) 25-30 31-40 41-50 >50 <25 .009 .009 .023 .0239 25-30 .0676 .0547 .0992 31-40 .0798 .0826 41-50 .0706 Note: Whole day: F=3.901; e 2 =397645.31; P =.005 Leisure time: F=2.212; e 2 =334402989; P =.07 On duty: F=3.346; e 2 =762120.334; P =.012 0 100 200 300 400 500 600 700 800 900 1000 <25 (n=81) 25-30 (n=43) 31-40 (n=26) 41-50 (n=13) >50 (n=6) Steps/h Leisure Time Steps/h on Duty Steps/h Whole Day Age (years) Steps per Hour Figure 1 steps per hour (steps/h) is the mean (SE) of the detected steps of participants by age group over each daily measuring period category. Note: N= 169 total participants.

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56 http://www.cs.amedd.army.mil/amedd_journal.aspx CS P CS P CS P CS P CS P CS P CS P r P r P r P State of Health F P P F P CS P CS P CS P CS = P CS P Correlation and Regression Analysis of the Determinants-Predictors of Activity Step Count Per Hour (Mean) F P = R R 2 R 2 f 2 P = r sr 2 INFLUENCE OF INDIVIDUAL DETERMINANTS ON PHYSICAL ACTIVITY AT WORK AND DURING LEISURE TIME IN SOLDIERS: A PROSPECTIVE SURVEILLANCE STUDY Table 2. Mean (SE) step counts per hour of participants by military rank status over each daily measuring period category, with P -values of comparison among rank groups. Military Rank Status Steps per Hour P -values of Comparison With NCO Count P -values of Comparison With On Duty Leisure Time On Duty Leisure Time On Duty Leisure Time Junior Enlisted 725 (245) 411 (130) <.001 .057 <.001 .009 NCO 579 (202) 434 (208) <.001 .008 Officer 541 (219) 537 (247) <.001 .008 Figure 2 steps per hour (steps/h) is the mean (SE) of the detected steps of participants by gender over each daily measuring period cat egory. Note: N= 169 total participants. Steps/h Leisure Time Steps/h on Duty Steps/h Whole Day Steps per Hour 0 100 200 300 400 500 600 700 800 900 1000 Male (n=142) Female (n=27)

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January March 2016 57 Step Count per Hour (During Duty Hours) F P = R R 2 R 2 f 2 P = r Step Count per Hour (During Leisure Time) F P = R R 2 R 2 f 2 P = r sr 2 Step Count per Day (Mean) F P = R R 2 R 2 f 2 P = r sr 2 P = r sr 2 Step Count per Day (During Leisure Time) F P<. R R 2 R 2 f 2 P = r = sr 2 P = r sr 2 P = r sr 2 CO MM ENT 5 Waist Circumference in Centimeters Steps per Hour 91-100 (n=35) 71-80 (n=34) 101-110 (n=24) 81-90 (n=55) >110 (n=11) <70 (n=10) Steps/h Leisure Time Steps/h on Duty 0 200 400 600 800 1000 1200 Figure 4 levels. Plotted steps per hour (steps/h) is the mean (SE) of the detected steps of participants by BMI score grouping over each daily measuring period category. Note: N= 169 total participants. Figure 3 steps per hour (steps/h) is the mean (SE) of the detected steps of participants by BMI score grouping over each daily measuring period category. Note: N= 169 total participants. BMI in kg/m 2 Steps per Hour 0 100 200 300 400 500 600 700 800 25-29 (n=63) <25 (n=83) 30-34 (n=17) 5 (n=6)

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58 http://www.cs.amedd.army.mil/amedd_journal.aspx 18 in that 11 21 11 22 23 REFERENCES Eur J Clin Nutr US Army Med Dep J Sports Med Auckl NZ INFLUENCE OF INDIVIDUAL DETERMINANTS ON PHYSICAL ACTIVITY AT WORK AND DURING LEISURE TIME IN SOLDIERS: A PROSPECTIVE SURVEILLANCE STUDY Table 3 P -values of the comparison of activity levels in relation to waist circumference for leisure time period and on duty period. Leisure Time Waist Circumference 71-80 cm 81-90 cm 91-100 cm 101-110 cm >110 cm <70 cm .0023 <.0001 <.0001 <.0001 <.0001 71-80 cm .0018 .002 .0052 .001 81-90 cm .0836 .0994 .0246 91-100 cm .0871 .0328 101-110 cm .0295 On Duty Waist Circumference 71-80 cm 81-90 cm 91-100 cm 101-110 cm >110 cm <70 cm .0195 .0579 .0878 .094 .065 71-80 cm .0189 .0076 .0088 .0048 81-90 cm .051 .0487 .0223 91-100 cm .0916 .045 101-110 cm .0521 Note: Leisure time: F=3.604; e 2 =650258.13; P =.004 On duty: F=1.24; e 2 =370349.64; P =.293

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January March 2016 59 Am J Prev Med J Am Diet Assoc Prev Med Med Sci Sports Exerc J Sci Med Sport Prev Med Int J Adolesc Med Health Mil Med Int J Sports Med US Army Med Dep J US Army Med Dep J J Phys Act Health Gait Posture Statistical Power Analysis for the Behav ioral Sciences PLoS One Surg Obes Relat Dis Scand J Public Health Int J Behav Nutr Phys Act BMC Public Health AUTHORS

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60 http://www.cs.amedd.army.mil/amedd_journal.aspx Median mononeuropathy at or distal to the wrist, or car pal tunnel syndrome, is the most common peripheral nerve compression disorder in the upper extremity. 1-4 Carpal tunnel syndrome (CTS) is one of a number of muscle, tendon, and nerve-related disorders that affect people performing intensive work with their hands. 5-7 compression neuropathy of the median nerve at the level of the wrist, characterized physiologically by evidence of increased pressure within the carpal tunnel and de creased function of the nerve at that level. 8 sidered essential screening tools for detecting signs and symptoms of peripheral neuropathy. 9-12 Nerve conduction measurement is often performed on the median nerve to determine whether certain entrapment neuropathies are present, and nerve conduction studies are considered the gold standard or has criterion-related validation when assessing the electrophysiological status of the periph eral nerve. 3,9-15 The electrophysiological examination including both nerve conduction and electromyography cation in the nerve pathway, involvement of sensory and/ or motor axons, and the presence of myelinopathy and/ or axonopathy neuropathic process. 10-12 NEUROPHYSIOLOGIC A L CL A SSIFIC A TION SYSTE M S FOR PA TIENTS WITH CTS Different ways of expressing the severity of carpal tun nel syndrome are found in the existing literature and in clinical records. In 2000, Bland 16 documented the distri bution of patients with CTS on a scale based upon nerve GEHS Neurophysiological Classification System for Patients with Carpal Tunnel Syndrome David G. Greathouse, PT, PhD Greg Ernst, PT, PhD John S. Halle, PT, PhD ABSTR A CT Background: Median neuropathy at or distal to the wrist or carpal tunnel syndrome (CTS) is one of a number of muscle, tendon, and nerve-related disorders that affect people performing intensive work with their hands. Following a thorough history and physical examination, electrophysiological examination including both nerve conduction studies (NCS) and electromyography (EMG) testing may be performed and currently serve as the reference standard nerve pathway, involvement of sensory and/or motor axons, and the presence of myelinopathy and/or axonopathy neuropathic process. Clinical electrophysiologists now have 2 for patients with CTS are discussed. into the presentation and discussion of these case studies. CTS. The Bland system documents the distribution of patients with CTS on a scale based upon nerve conduction study

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January March 2016 61 normal values used in any given electrodiagnostic neurophysiological grading and a numerical score derived from the clinical history. 16,17 Blands neuro physiological grading scale for patients with CTS is shown in Table 1. Nerve conduction studies (NCS) and electromyog raphy (EMG) testing will provide electrophysiolog ical evidence of pathological conditions of the me dian nerve to include demyelination (myelinopathy) and axon loss (axonopathy). 9-12 cation system for patients with carpal tunnel syn does not include any reference to the EMG portion of the electrophysiological evaluation. 16 patients with CTS was introduced in 2012. 18 The GEHS (Greathouse, Ernst, Halle, and Shaffer) neu EMG components of the electrophysiological ex vides electrophysiological evidence of myelinopa thy and/or axonopathy for patients with CTS. The patients with CTS is shown in Table 2. for patients with CTS is comprised of data from both the NCS and EMG components of the electro physiological examination. 18 Furthermore, this new myelinopathy and/or axonopathy. The GEHS neu with CTS is presently being used by clinical elec trophysiologists and has been cited in numerous re search manuscripts. 19-23 The purpose of developing and implementing the patients with CTS is to provide health care providers an enhanced system of electrophysiological evaluation and grading scale so that they may evaluate and treat their patients with CTS with the most complete elec trophysiological data that includes both NCS and EMG testing. This article describes the GEHS neurophysi presents 2 case studies of patients with electrophysi ological evidence of CTS. The Bland and GEHS neuro is incorporated into the presentation and discussion of these case studies. Case 1 by an orthopaedic surgeon for electrophysiological eval uation of suspected bilateral CTS. She is employed as a unit coordinator at a local school district. In January 2013, the patient noted numbness and tingling (N/T) in the palmar surface of both hands. She has no past medi cal history of bilateral upper extremity problems and Table 1 Blands Neurophysiological Grading Scale for Patients with carpal tunnel syndrome. 17 Grade Nerve Conduction Findings 0 Normal Normal motor and sensory conduction studies 1 Very mild CTS demonstrable only with most sensitive tests 2 Mild Sensory nerve conduction velocity slow on finger/wrist measurement Normal terminal motor latency 3 Moderate Sensory potential preserved Motor slowing; DML to ABP <6.5 ms 4 Severe Sensory potentials absent Motor potential preserved; DML to APB <6.5 ms 5 Very Severe Sensory potentials absent DML to APB >6.5 ms 6 Ext Severe Sensory and motor potentials effectively unrecordable Surface motor potential from ABP <0.2 mV amplitude DSL indicates distal sensory latency; DML, distal motor latency; APB, abductor pollicis brevis; and Ext, extremely. Table 2 with carpal tunnel syndrome. 19 Grade Nerve Conduction and EMG Findings Very Mild Abnormal comparison study; eg, prolonged compari son study between D 4 median/ulnar DSLs Normal EMG of the APB Mild (sensory only) Prolonged palmar and/or D 2 DSLs Normal DML to APB Normal EMG of the APB Mild (sensory and motor) Prolonged palmar and/or D 2 DSLs Prolonged DML to APB < 5 0 ms Normal EMG of the APB Moderate Prolonged or absent DSLs Prolonged DML to APB < 6 0 ms Normal EMG of the APB Moderate/Severe Prolonged or absent DSLs Prolonged DML to APB > 6 0 ms EMG presence of abnormal spontaneous electri cal activity in the APB; no decrease in interference pattern or abnormal MUP duration and amplitude of the APB Severe Prolonged or absent DSLs Prolonged DML to APB > 7 0 ms EMG presence of abnormal spontaneous electrical activity in the APB; decreased interference pattern of APB, may have abnormal duration and amplitude of motor unit potentials in the APB DSL indicates distal sensory latency; DML, distal motor latency; EMG, electromyography APB, abductor pollicis brevis; APB, abductor pollicis brevis; and D 2 digit 2 (index finger).

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62 http://www.cs.amedd.army.mil/amedd_journal.aspx denies recent trauma to the neck or both upper extremi N/T in the palmar surfaces of all digits (D1-D5), but but less severe in the left hand. No proximal N/T, pain, history of headaches, or visual or cranial nerve problems. She was evaluated and treated by a chiropractic provider without relief of symptoms. She wears bilateral wrist splints with some relief of symptoms from this interven tion. The patient is being treated for anxiety but other wise, the review of systems is noncontributory for car diovascular, pulmonary, gastrointestinal, genitourinary, or endocrine problems. She denies diabetes, heavy metal exposure, thyroid disease, renal disease, or alcohol abuse, and has no family history of neuromuscular disease. amination, the patient displayed mild decreased motion of active cervical mobility in all planes with mild neck pain or right side bend and rotation. The Spurlings test to the right produced neck pain, but no neck pain was produced on the left maneuver. Neither the left nor right had normal active mobility of bilateral shoulder, elbow, forearm, wrist, and hand motions. There was normal (5/5) motor strength testing of bilateral shoulder, elbow, forearm, wrist, and hand motions and there was no at hands. There was a decreased sensation to light touch and pain (pin prick) in the palmar surfaces of the right ing all peripheral nerves and dermatomes (C4-T1). The Tinels and Phalens tests were negative for bilateral me dian nerve involvement at the wrists. There were normal radial pulses bilaterally for thoracic outlet syndrome in the scalene, costoclavicular, and pectoralis minor/clavi pectoral fasica humeral maneuvers. studies are provided in Tables 3 and 4, respectively. Clin by the shaded cells in Table 3. Electromyography of se cervical paravertebral muscles were normal (Table 4). In conclusion of case study 1: this was an abnormal NCS bilateral low cervical paravertebral muscles. There was electrophysiologic evidence on this exam of a mild, bi lateral (right = left) median mononeuropathy at or distal to the wrist; demyelinating neuropathic process; affect was no electrophysiologic evidence on this exam of (1) bilateral median mononeuropathy in the forearms; (2) eral cervical paravertebral muscles. Based on the case study 1 results, the GEHS neuro right median nerves) CTS with prolonged palmar and erate CTS with sensory potential preserved and motor Bland system does not include EMG evaluation of the lateral median motor and sensory involvement with a demyelinating neuropathic process, but only the GEHS Case 2 by her primary care provider for electrophysiologi cal evaluation of suspected CTS. The patient is a bus driver. In 2000, the patient was evaluated with NCS and diagnosed with CTS, resulting with treatment of bilateral wrist splints. She had decreased pain and N/T in both hands after using the wrist splints. In the sum mer of 2014, she noted increased pain and N/T in both her wrist splints, but the splints only exacerbated her symptoms. The hand pain and N/T increased with driv ing and at night. She reported right shoulder pain but wrist. She had N/T in the palmar surfaces of both hands D1-D5, right more than left. She denied neck pain or ra patient is being treated for congestive heart failure and of systems was noncontributory for cardiovascular, pul monary, gastrointestinal, genitourinary, or endocrine GEHS NEUROPHYSIOLOGICAL CLASSIFICATION SYSTEM FOR PATIENTS WITH CARPAL TUNNEL SYNDROME

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January March 2016 63 problems. She denied diabetes, heavy metal exposure, thyroid disease, renal disease, or alcohol abuse. Her ma ternal aunt has multiple sclerosis, but otherwise there is no family history of neuromuscular disease. examination, the patient had normal active cervical left and right Spurling maneuvers were normal without ity of bilateral shoulder, elbow, forearm, wrist, and hand motions. There was 3+/5 motor strength of the bilateral normal (5/5) motor strength testing of bilateral shoulder, Table 3 Case 1 : Nerve Conduction Study Results. Note: clinically noteworthy values are indicated by shaded cells. Anti Sensory Summary Site NR Peak (ms) Normal Peak (ms) P-T Amplitude ( V) Normal P-T Amplitude ( V) Site 1 Site 2 P (ms) Distance (cm) Velocity (m/s) Normal Velocity (m/s) Left Superficial Radial Anti Sensory (Base 1 st Digit) D1 2.3 <2.7 21.4 D1 Base 1st Digit 2.3 10.0 43 Right Superficial Radial Anti Sensory (Base 1 st Digit) D1 2.5 <2.7 28.4 D1 Base 1st Digit 2.5 10.0 40 Ortho Sensory Summary Site NR Peak (ms) Normal Peak (ms) P-T Amplitude ( V) Normal P-T Amplitude ( V) Site 1 Site 2 P (ms) Distance (cm) Velocity (m/s) Normal Velocity (m/s) Left Median Ortho Sensory (Wrist) Palm 2.8 <2.2 46.3 >15 Palm Wrist 2.8 8.0 29 D2 4.0 <3.6 21.9 >15 D2 Wrist 4.0 14.0 35 Right Median Ortho Sensory (Wrist) Palm 2.8 <2.2 26.8 >15 Palm Wrist 2.8 8.0 29 D2 4.3 <3.6 13.8 >15 D2 Wrist 4.3 14.0 33 Left Ulnar Ortho Sensory (Wrist) Palm 1.7 <2.2 60.8 >10 Palm Wrist 1.7 8.0 47 D5 2.9 <3.5 23.8 >10 D5 Wrist 2.9 14.0 48 Right Ulnar Ortho Sensory (Wrist) Palm 1.8 <2.2 48.2 >10 Palm Wrist 1.8 8.0 44 D5 2.9 <3.5 27.0 >10 D5 Wrist 2.9 14.0 48 Motor Summary Site NR Onset (ms) Normal Onset (ms) O-P Amplitude (mV) Normal O-P Amplitude (mV) Site 1 Site 2 O (ms) Distance (cm) Velocity (m/s) Normal Velocity (m/s) Left Median Motor (Abd Poll Brev) Wrist 4.8 <4.2 4.8 >5 Elbow Wrist 3.6 23.0 64 >50 Elbow 8.4 6.7 Right Median Motor (Abd Poll Brev) Wrist 4.9 <4.2 3.1 >5 Elbow Wrist 4.4 25.0 57 >50 Elbow 9.3 3.3 Left Ulnar Motor (Abd Dig Minimi) Wrist 2.9 <3.6 7.2 >5 B Elbow Wrist 3.2 20.0 63 >50 B Elbow 6.1 5.1 A Elbow B Elbow 1.6 12.0 75 >50 A Elbow 7.7 5.5 Right Ulnar Motor (Abd Dig Minimi) Wrist 2.8 <3.6 8.6 >5 B Elbow Wrist 3.3 21.0 64 >50 B Elbow 6.1 8.5 A Elbow B Elbow 1.6 12.0 75 >50 A Elbow 7.7 8.2 NR indicates no response; P-T, peak to trough; and O-P, onset to peak.

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64 http://www.cs.amedd.army.mil/amedd_journal.aspx elbow, forearm, wrist, and hand motions, and there was in both hands. There was a decreased sensation to light the right thenar eminence and right D1, and increased tomes (C4-T1). The Tinels and Phalens tests were nega tive for bilateral median nerve involvement at the wrists. There were normal radial pulses bilaterally for thoracic outlet syndrome in the scalene, costoclavicular, and pec toralis minor/clavipectoral fasica humeral maneuvers. (C5-T1 innervation) is presented in Table 6. Clinically cated by the shaded cells in Tables 5 and 6. There was abnormal spontaneous electrical activity including in tion potentials and positive waves in both the right and interference pattern on maximum voluntary contraction In conclusion of case study 2: this was an abnormal NCS evidence on this exam of a severe, bilateral (right more than left) median mononeuropathy at or distal to the wrist; demyelinating and axonal loss neuropathic pro There was no electrophysiological evidence on this exam of: (1) bilateral median mononeuropathy in the neuropathy; (3) bilateral brachial plexopathy; or (4) bi Based on the case study 2 results, the GEHS neurophysi ological evidence of chronic denervation in both the left lateral, very severe CTS with sensory potentials absent seconds. The Bland system does not include EMG eval involvement with a demyelinating neuropathic process, Table 4 Case 1 : Electromyography Results. Side Muscle Nerve Root Ins Act Fibs Psw Amp Dur Poly Recrt Int Pat Comment Right 1 stDorInt Ulnar C8-T1 Nml Nml Nml Nml Nml 0 Nml Nml Right Abd Poll Brev Median C8-T1 Nml Nml Nml Nml Nml 0 Nml Nml Right PronatorTeres Median C6-7 Nml Nml Nml Nml Nml 0 Nml Nml Right ExtCarRadLong Radial C6-7 Nml Nml Nml Nml Nml 0 Nml Nml Right Biceps Musculocut C5-6 Nml Nml Nml Nml Nml 0 Nml Nml Right Triceps Radial C6-7-8 Nml Nml Nml Nml Nml 0 Nml Nml Right Deltoid Axillary C5-6 Nml Nml Nml Nml Nml 0 Nml Nml Right Cervical Parasp Low Rami C7-8 Nml Nml Nml Left 1 stDorInt Ulnar C8-T1 Nml Nml Nml Nml Nml 0 Nml Nml Left Abd Poll Brev Median C8-T1 Nml Nml Nml Nml Nml 0 Nml Nml Left PronatorTeres Median C6-7 Nml Nml Nml Nml Nml 0 Nml Nml Left ExtCarRadLong Radial C6-7 Nml Nml Nml Nml Nml 0 Nml Nml Left Biceps Musculocut C5-6 Nml Nml Nml Nml Nml 0 Nml Nml Left Triceps Radial C6-7-8 Nml Nml Nml Nml Nml 0 Nml Nml Left Deltoid Axillary C5-6 Nml Nml Nml Nml Nml 0 Nml Nml Left Cervical Parasp Low Rami C7-8 Nml Nml Nml Abbreviations Nml: normal Psw: positive sharp waves Poly: polyphasic Ins Act: insertional activity Amp: amplitude Recrt: recruitment Fibs: fibrillation potentials Dur: duration Int Pat: interference pattern GEHS NEUROPHYSIOLOGICAL CLASSIFICATION SYSTEM FOR PATIENTS WITH CARPAL TUNNEL SYNDROME

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January March 2016 65 CO MM ENT The advantage of having this additional information regarding EMG changes (axonopathy) for patients with CTS, is that it provides the health care team and the patient with information that may be useful in determin ing next treatment steps as well as long-term prognosis. In the case of a patient with EMG changes, the combined effects of compression and ischemia are evident with the loss of a subset of axons and the denervation of a segment Table 5 Case 2 : Nerve Conduction Study Results. Note: clinically noteworthy values are indicated by shaded cells. Anti Sensory Summary Site NR Peak (ms) Normal Peak (ms) P-T Amplitude ( V) Normal P-T Amplitude ( V) Site 1 Site 2 P (ms) Distance (cm) Velocity (m/s) Normal Velocity (m/s) Left Superficial Radial Anti Sensory (Base 1 st Digit) D1 2.3 <2.7 38.8 D1 Base 1st Digit 2.3 10.0 43 Right Superficial Radial Anti Sensory (Base 1 st Digit) D1 2.3 <2.7 33.1 D1 Base 1st Digit 2.5 10.0 43 Ortho Sensory Summary Site NR Peak (ms) Normal Peak (ms) P-T Amplitude ( V) Normal P-T Amplitude ( V) Site 1 Site 2 P (ms) Distance (cm) Velocity (m/s) Normal Velocity (m/s) Left Median Ortho Sensory (Wrist) Palm 4.2 <2.2 15.7 >15 Palm Wrist 4.2 8.0 19 D2 5.1 <3.6 16.3 >15 D2 Wrist 5.1 14.0 27 Right Median Ortho Sensory (Wrist) Palm NR <2.2 >15 Palm Wrist 8.0 D2 NR <3.6 >15 D2 Wrist 14.0 Left Ulnar Ortho Sensory (Wrist) Palm 1.9 <2.2 36.6 >10 Palm Wrist 1.9 8.0 42 D5 3.3 <3.5 15.5 >10 D5 Wrist 3.3 14.0 42 Right Ulnar Ortho Sensory (Wrist) Palm 1.9 <2.2 30.1 >10 Palm Wrist 1.9 8.0 42 D5 3.3 <3.5 17.3 >10 D5 Wrist 3.3 14.0 42 Motor Summary Site NR Onset (ms) Normal Onset (ms) O-P Amplitude (mV) Normal O-P Amplitude (mV) Site 1 Site 2 O (ms) Distance (cm) Velocity (m/s) Normal Velocity (m/s) Left Median Motor (Abd Poll Brev) Wrist 9.1 <4.2 4.6 >5 Elbow Wrist 4.8 25.0 52 >50 Elbow 13.9 4.8 Right Median Motor (Abd Poll Brev) Wrist 8.9 <4.2 2.0 >5 Elbow Wrist 4.8 26.0 54 >50 Elbow 13.7 1.5 Left Ulnar Motor (Abd Dig Minimi) Wrist 3.4 <3.6 5.7 >5 B Elbow Wrist 3.6 22.0 61 >50 B Elbow 7.0 7.4 A Elbow B Elbow 1.6 11.0 69 >50 A Elbow 8.6 6.6 Right Ulnar Motor (Abd Dig Minimi) Wrist 3.2 <3.6 10.9 >5 B Elbow Wrist 3.6 20.0 56 >50 B Elbow 6.8 9.8 A Elbow B Elbow 1.6 11.0 69 >50 A Elbow 8.4 7.6 NR indicates no response; P-T, peak to trough; and O-P, onset to peak.

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66 http://www.cs.amedd.army.mil/amedd_journal.aspx insertional activity and abnormal resting potentials (eg, ally, EMG examination provides the healthcare team with information regarding the presence, morphology, and recruitment pattern of motor units that is critical for if reinnervation (polyphasic or large motor potentials) is truly occurring. Collectively, the EMG examination af that allows the healthcare team, in concert with the pa tient, to carefully consider interventions. 9-12,24,26 provide a framework for reporting and categorizing carpal tunnel syndrome based on neurophysiologic ed. Currently research is limited to previous work by Bland et al who surveyed 1,268 patients who had un dergone carpal tunnel decompression. Multiregression greater age, lower symptom scores, longer disease du P <.05) predic tors of poor surgical outcome. Nerve conduction studies had the strongest effect of predictors, with patients with middle-grade nerve conduction abnormalities having better results than those with normal results or severe abnormalities. 17 ditional longitudinal studies examining the predictive tion schemes regarding various interventions (duty limi tations, splinting, mobilization, injection, and surgical release) are recommended. Future trials should also go beyond subjective reporting and include various out mance testing, and healthcare utilization) and rigorous statistical analysis to determine the prognostic utility SU MMA RY A ND CLINIC A L RELEV A NCE Clinical electrophysiologists now have 2 neurophysi from which to choose when preparing their electrophys tem was formulated based on nerve conduction study exact normal values used in any given electrodiagnostic the grading scale. The GEHS neurophysiological clas and EMG components of the electrophysiological ex tion system provides electrophysiological evidence of myelinopathy and/or axonopathy for patients with CTS. Future research comparing the psychometric properties and prognostic utility of the Bland and GEHS neuro REFERENCES 1. Bickel K. Carpal tunnel syndrome. J Hand Surg Am 2010;35:147-152. 2. lems. In: Cooper C, ed. Fundamentals of Hand Therapy: Clinical Reasoning and Treatment Guide lines for Common Diagnoses of the Upper Extrem ity 3. MacDermid JC, Doherty T. Clinical and elec trodiagnostic testing of carpal tunnel syndrome: a narrative review. J Orthop Sports Phys Ther 2004;34:565-588. Table 6 Case 2 : Electromyography Results. Note: clinically noteworthy values are indicated by shaded cells. Side Muscle Nerve Root Ins Act Fibs Psw Amp Dur Poly Recrt Int Pat Comment Right 1 stDorInt Ulnar C8-T1 Nml Nml Nml Nml Nml 0 Nml Nml Right PronatorTeres Median C6-7 Nml Nml Nml Nml Nml 0 Nml Nml Right Abd Poll Brev Radial C8-T1 Incr 3+ 3+ Nml Nml 0 Reduced 50% fib amp< 100 Right Biceps Musculocut C5-6 Nml Nml Nml Nml Nml 0 Nml Nml Right Triceps Radial C6-7-8 Nml Nml Nml Nml Nml 0 Nml Nml Right Deltoid Axillary C5-6 Nml Nml Nml Nml Nml 0 Nml Nml Left 1 stDorInt Ulnar C8-T1 Nml Nml Nml Nml Nml 0 Nml Nml Left Abd Poll Brev Median C8-T1 Incr 2+ 2+ Nml Nml 0 Nml Nml fib amp< 100 Left PronatorTeres Median C6-7 Nml Nml Nml Nml Nml 0 Nml Nml Left Biceps Musculocut C5-6 Nml Nml Nml Nml Nml 0 Nml Nml Left Triceps Radial C6-7-8 Nml Nml Nml Nml Nml 0 Nml Nml Left Deltoid Axillary C5-6 Nml Nml Nml Nml Nml 0 Nml Nml Abbreviations Nml: normal Psw: positive sharp waves Poly: polyphasic Incr: increased Ins Act: insertional activity Amp: amplitude Recrt: recruitment fib amp: fibrillation potential amplitude Fibs: fibrillation potentials Dur: duration Int Pat: interference pattern GEHS NEUROPHYSIOLOGICAL CLASSIFICATION SYSTEM FOR PATIENTS WITH CARPAL TUNNEL SYNDROME

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January March 2016 67 4. cine: Practice parameter for electrodiagnostic stud ies in carpal tunnel syndrome: Summary statement. Muscle Nerve 1993;16:1390-1391. 5. Franklin GM, Haug J, Heyer N, Checkoway H, Am J Public Health 1991;81(6):741-746. 6. occupational carpal tunnel syndrome. Wis Med J 1991;90(2):80, 82-83. 7. Prevalence of upper extremity neuropathy in a clin ical dentist population. JADA 1993;124(8):67-72. 8. Clinical Guidelines on Diagnosis of Carpal Tun nel Syndrome www. aaos.org/research/guidelines/CTS_ guideline.pdf. 9. cine: Practice parameter for electrodiagnostic stud ies in carpal tunnel syndrome: summary statement. Muscle Nerve 1993;16:1390-1391. 10. Electrodiagno stic Medicine 2nd ed Belfus: 2002. 11. Kimura J. Electrodiagnosis in Diseases of Nerve and Muscle: Principles and Practice 3rd ed New 12. Clinical Electromyography in Nerve Con duction Studies. 13. van Dijk JG. Multiple tests and diagnostic validity. Muscle Nerve 1995;18:353-355. 14. Graham B. The value added by electrodiagnostic testing in the diagnosis of carpal tunnel syndrome. J Bone Joint Surg Am 2008;90:2587-2593. 15. review of the usefulness of nerve conduction stud ies and electromyography for the evaluation of pa tients with carpal tunnel syndrome. Muscle Nerve 1993;16:1392-1414. 16. for carpal tunnel syndrome. Muscle Nerve 2000; 23(8):1280-1283. 17. Bland JD. Do nerve conduction studies predict the outcome of carpal tunnel decompression?. Muscle Nerve 2001;24(7):935-940. 18. Greathouse DG. tients with carpal tunnel syndrome. Electroneuro myographic Symposium Proceedings September 14, 2012:22-24. 19. cal and electrodiagnostic abnormalities of the me dian nerve in dental assistants. J Orthop Sports Phys Ther 2009;39(9):693-701. 20. Greathouse DG. Clinical and electrodiagnostic ab tal assistants at the onset of training. US Army Med Dep J July-September 2012:72-81. 21. Moore JH, Greathouse DG. Median and ul mand band members. Med Probl Perform Art 2013;28(4):188-194. 22. at Fort Sam Houston, Texas. US Army Med Dep J 23. Galloway K, Greathouse DG. Carpal tunnel syn drome in an obese adolescent: a case report. Pedi atr Phys Ther In press. 24. tunnel syndrome. Neurol Clin 2012;30(2):457-4 77. AUTHORS Dr Greathouse is Director, Clinical Electrophysiol ogy Services, Texas Physical Therapy Specialists, New Sam Houston, TX. TX, and Clinical electrophysiologist, Hand Center of San Dr Halle is a Professor, School of Physical Therapy, gram in Physical Therapy, Fort Sam Houston, TX, Chief, Medical Specialist Corps, Fort Sam Houston, TX.

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68 http://www.cs.amedd.army.mil/amedd_journal.aspx Q fever is a zoonotic infection caused by the obligate in tracellular gram negative bacteria Coxiella burnetti 1 First illness that occasionally causes more severe disease or a in Iraq and Iran. 1-4 Estimates from recent studies in the 2-6 C burnetti infects 1-7 Human infection usually occurs through inhalation of dust or aerosols CLINIC A L PRESENT A TION Severe infection The mortality rate varies but is generally estimated to be about 2%. 1-7 C burnetti Pregnant The most common ter initial infection. DI A GNOSIS 7 4-6 ratory variation. Commercial laboratories should be avoided as results C bur netii PCR test is available at some DoD laboratories and may Q Fever ABSTR A CT

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October December 2015 69 tion. This is best done under the guidance of an infec Consid further instruction and guidance on the diagnosis and management of Q fever. TRE A T M ENT til delivery. 7 Treatment for not available in the United States and requires serologic 7 Prevention IM PORT A NCE IN A DEPLOYED SETTING C burnetii currently category B. 1 2 REFERENCES 1. Front Mi crobiol 2. Petruccelli B. Q Fever and the US military. Emerg Infect Dis ciety. Mil Med 4. Am J Trop Med Hyg Am J Trop Med Hyg 6. Am J Trop Med Hyg Q fever management algorithm. Adapted from Armed Forces Infectious Diseases Society guidelines. 3 Serology should be performed at the same reference lab to minimize interlaboratory variability. Acute Q fever suspected Positive Negative Infectious diseases consultation No further testing or treatment Repeat clinical assess ment and serology at 6, 12, 18, and 24 months. Empirically treat with doxycy cline 100 mg po bid for 14 days while serologic workup or PCR is pending. Obtain acute serology at ini tial presentation and convales cent serology at 2-6 weeks.

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70 http://www.cs.amedd.army.mil/amedd_journal.aspx 7. MMWR Recomm Rep AUTHORS

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January March 2016 71 Although 90% of American adults now own a mobile phone and 64% own some form of smartphone, 1,2 the opportunities for using them in healthcare delivery have remained largely unexplored. Mobile phones are porta ble, accessible, and ideal for transmitting individualized information; thus, they have the potential to provide means to streamline healthcare at relatively small cost outlays. 3 For now, however, applying mobile phone use to that found in academic studies; despite the evidence indicating the prospective value of employing mobile technology in healthcare, we found no indication that federal healthcare leaders have exercised the capacity on a scale of any magnitude. We recognize the substantial potential for using mobile phones in the areas of primary, preventive, and population health, and a need for federal healthcare to improve its use of this technology to stay competitive in the areas of access, costs, and satisfaction. To seize that potential and answer that need, we propose a 5-year federal implementation plan to integrate mobile phone capabilities into federal healthcare delivery. METHODS We began our analysis with a comprehensive review of the literature. Using Google Scholar, the Association for Computing Machinery Database, and PubMed, we queried the extant recent literature (2009 to the present) using the following criteria: mobile phone health appli cations and cell phone text message health From the result of our query, we included articles and studies spe healthcare. We excluded those articles that did not have a focus on the use of mobile phones toward improving healthcare such as articles concerning the medical side effects of prolonged cell phone use. From our review and analysis of the initial set of articles, in mobile application use in healthcare: primary, preven tive, and population health applications. These themes include search query terms such as mobile phones pri mary care and cell phone preventive health Synthesiz articles for subsequent analysis. Our review of the stud ies formed our recommendation. FINDINGS Primary Care for the patient. 4 Mobile Phone Health Applications for the Federal Sector Capt Christin S. Burrows, MS, USAF MAJ Fred K. Weigel, MS, USA ABSTR A CT Purpose: role in the future of healthcare delivery. Today, 90% of American adults own a mobile phone and 64% own a smartphone, yet many healthcare organizations are only beginning to explore the opportunities in which mo bile phones can improve and streamline care. Method: After searching Google Scholar, the Association for Computing Machinery Database, and PubMed for articles related to mobile phone health applications and cell phone text message health, we selected articles review and analysis. Findings: healthcare: primary, preventive, and population health. We recommend federal health leaders pursue the value and potential in these areas; not only because 90% of Americans already own mobile phones, but also because mobile phone integration can provide substantial access and potential cost savings. Conclusion: propose a 5-year federal implementation plan to integrate mobile phone capabilities into federal healthcare delivery. Our proposal has the potential to improve access, reduce costs, and increase patient satisfaction, there fore changing the way the federal sector delivers healthcare by 2021.

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72 http://www.cs.amedd.army.mil/amedd_journal.aspx mobile phone technology in healthcare delivery is found in primary care. Both the civilian and federal sectors face a primary care shortage, and the lack of access cre ates overcrowded emergency rooms and rising costs. 4 In the United States, primary care access is one of health cares biggest challenges, 5 and recent studies show that various mobile phone applications can help to improve that access. First, messaging capabilities between primary care managers and patients can reduce the number of routine visits that do not require face-to-face interaction, such as for prescription renewals. Military treatment facility administrators have started to explore secure messaging in primary care delivery. Secure messaging provides a method to communicate health information electroni cally while protecting the health information from un authorized viewing. Available on mobile phones, a goal of secure messaging is to ease communication between primary care managers and patients, allowing patients to ask routine questions without an appointment. Imple mented correctly, the secure messaging system can im prove access for those who need a physical visit, recap turing care that the military might otherwise send to the civilian sector. Second, studies show that using text messaging for ap pointments, resulting in up to 40% improved attendance rates. 6,7 These attendance rates receive great attention and are highly visible in the federal system, because of the negative effect that missed appointments have on ac cess and costs. Most efforts to improve missed appoint ment rates in the military are based on enforcing pu nitive measures, but these recent studies suggest that a proactive text messaging approach can be very effective and a viable alternative. 6,7 Although the US Army has started to use text messages as appointment reminders, the method has been employed only on a limited scale. 8 Finally, mobile phones have the potential to improve ac cess by enabling providers and disease managers to ef fectively monitor chronic conditions. Most relevant stud ies focus on diabetes, hypertension, and asthma man agement. 9 Many studies show that text messaging and proving blood sugar measures in diabetes patients who received continual text messages to monitor and con trol their levels. 9 These encouraging text messages spur patients to be involved with their own care, which can help keep them from further complications. Therefore, effective disease management via mobile phones pro vides a viable option to preserve valuable primary care appointment availability through inspiring a high level of patient engagement in personal health maintenance. Preventive Health and immunization reminders, among others. Research ers often focus on smoking cessation, in part because smoking is so prevalentit is the leading cause of pre mature deaths in the United States and responsible for 1 in 5 deaths nationwide 10 and because mobile phone intervention results are so dramatic, increasing cessa tion rates by up to 70%. 11 Most experiments include interactive text messages that send smokers positive to messages when the smokers need extra encourage ment. These studies have been among those indicating the most effective mobile phone use interventions; the tion rates both in the shortand long-term. 11,12 However, there is limited published literature about mobile phone use as a smoking cessation tool, and that lack of litera ture may be a contributing factor to Whittaker and col providing a long-term effect on smoking cessation. 11 Another potential preventive health application is the use time interventions. 13 People could program their phone workplace smoking area and favorite fast food restaurant A visit to these loca tions would generate a reminder to avoid unhealthy be haviors, intervening in moments of weakened willpower. The main goal for any preventive health intervention is to change poor behaviors while encouraging good be haviors, so incentives have a large role in mobile phone integration with preventive care. Most mobile phone prevention studies to date focus on intrinsic rewards ward a goal. 14,15 However, there may be an opportunity to study prevention with other reward systems, especial ly in the social networking setting. Ultimately, preven tion, with or without mobile phones, is about positively responsibility for healthcare. Population Health Mobile phones have several applications in popula tion health. Healthcare leaders could adopt the model of other data-gathering industries and collect individ ual health information via mobile phones, analyzing MOBILE PHONE HEALTH APPLICATIONS FOR THE FEDERAL SECTOR

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January March 2016 73 the data to determine current and localized trends in population health. There are already applications test amounts of user-input data to determine where out breaks happen. 16 For example, Chunara and colleagues 16 outline their own Outbreaks Near Me, an application for Android and iPhone smartphones, with which users can provide real-time disease outbreak reports. They further describe other applications for disease and disaster re porting as well as the ability to integrate the reporting with internet-based outbreak monitoring systems, such as HealthMap.org (http://www.healthmap.org/en/). These types of applications are especially helpful with primary care managers when they have a virus that only requires symptom management, so the primary care facility may not have an accurate picture of the virus prevalence without self-reporting. Once trends materi alize, mobile phones can be used to disseminate popu lation health messages back to the people. Patients can their area and provide helpful reminders such as to wash their hands or get vaccinated. This infrastructure would be particularly helpful for population protection; if pub messaging could disseminate that information to many people simultaneously. Although the Army has started to explore mobile phone 8 many federal administrators have not been quick to adopt mobile phone technology, perhaps due to the asso ciated challenges. We propose the implementation of a 5-year plan that depends on the federal sectors ability to Integrated into our proposal, federal health leaders will have to implement security measures to protect patient information as well as decide how to best capture vir tual workload and collect reimbursement from insurers. Without good reimbursement methods, detailed costsavings of mobile phone use is almost impossible. We provide greater detail of our proposal in the next section. CO MM ENT After researching effective methods for incorporat ing mobile phones into health delivery, we propose a 3-phase, 5-year plan for the federal sector to improve access, costs, and patient satisfaction by 2021, allowing federal health to compete in todays health environment. perfecting the new secure messaging systems in mili tary health. For example, the Air Force is currently introducing its secure messaging system, MiCare, which advertises a 72-hour response time from a primary care managers. 17 It is critical that Air Force leadership focuses cordingly; if this response window is broken early and often in MiCares debut, patients will view secure mes saging as a burden instead of an improvement to their health delivery, making them very hesitant to participate in future efforts. Secure messaging is a pilot program for the federal sector, and military treatment facility leaders should take great care to ensure a smooth implementation. The second phase in our proposal, lasting approximately 2 years, includes implementing high-visibility programs of interactive appointment and smoking cessation re minders. First, federal health will focus on interactive appointment messages, giving patients the option to reply and immediately reschedule. This is a relatively simple way to improve access and gain patient support for future mobile phone integration. Second, the federal sector will implement an interactive messaging system to assist with smoking cessation in its health and well ness centers. Encouraging smokers to quit is important for both individual health and rising healthcare costs, and this effort will again garner further support for fu ture mobile health applications. Gaining the patients for the third phase. mobile phones into the federal health sectors disease management and population health programs. This phase depends on the success of patient engagement mobile phones receives the appropriate public support response, federal health providers can next start col lecting information from the patients. Patients can input disease management measures into applications or text messages, which can give the provider better oversight and identify complications before they become severe. Potentially, the disease management information could be integrated into currently available internet-based out break monitoring platforms. Similarly, public health of to analyze localized illness trends. LI M IT A TIONS A ND ADDITION A L RESE A RCH As with other approaches that focus on the archival anal ysis, the sampling procedure is a limitation. 18 Despite search criteria for this study, the potential search criteria options are vast. It is possible, perhaps likely, that had we included additional search terms, our search would

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74 http://www.cs.amedd.army.mil/amedd_journal.aspx have revealed additional articles that would inform this study. Likewise, had we searched in additional databas es, we may have unearthed other literature. Future re scope and database selections. Through this research, we exposed several areas for fur ther inquiry. Although there are numerous studies on appointment reminders, most that we found are limited to one-way messaging: caregivers to patients. Future studies should consider investigating interactive mes saging with rescheduling capability, as well as its effect on access. We found that the literature on cost-savings for mobile phones in healthcare is also lacking. Explor ing reimbursement models for provider messaging and the effect on costs would contribute insights into reduc ing costs in healthcare mobile phone use that would be of interest to both researchers and practitioners. An additional limitation for this study is the sheer pace of innovation; because technology changes at a rapid pace, arguably, some of our suggested applications for mobile phone use may be obsolete and supplanted by newer technology by 2021. Future researchers should note that because of the pace of technology innovation and development, the 5-year plan we propose is suitable for longitudinal study. CONCLUSION The federal health system should employ the 5-year inte gration plan now to fully use mobile phones in the areas of primary, preventive, and population health. Employ ing these programs quickly and accurately can help the federal healthcare sector stay competitive in todays en vironment by improving access, controlling purchasedcare costs, and increasing patient satisfaction, all of which will change the way that federal administrators deliver healthcare as we head into the 2020s. REFERENCES 1. fact sheet. 2014. Available at: http://www.pewinter net.org/fact-sheets/mobile-technology-fact-sheet/. Accessed August 10, 2015. 2. Smith A. US Smartphone Use in 2015 [internet]. Pew Research Center. 2015. Available at: http:// www.pewinternet.org/2015/04/01/us-smartphoneuse-in-2015/. Accessed December 21, 2015. 3. ping the space of mobile-phone health interven tions. J Biomed Inform 2012;45(1):184-198. 4. Shi L, Singh DA. Delivering Healthcare In Amer ica: A Systems Approach 6th ed. Burlington, MA: Jones and Bartlett Learning; 2014. 5. Bodenheimer T, Pham HH. Primary care: cur rent problems and proposed solutions. Health Aff 2010;29(5):799-805. 6. Hocking GR, Wand J, Stott S, Ali H, Kaldor J. How effective are short message service re minders at increasing clinic attendance? A metaanalysis and systematic review. Health Serv Res 2012;47(2):614-632. 7. Perron NJ, Dao MD, Kossovsky MP, et al. Reduc tion of missed appointments at an urban primary care clinic: a randomized control study. BMC Fam Pract 2010;11(1):79. 8. Poropatich R, Pavliscsak HH, Rasche J, Barrigan C, Vigersky RA, Fonda SJ, Bell A. Mobile health care in the US Army. Proc Wirel Health 2010 2010:184-187. Available at: http://dl.acm.org/cita tion.cfm?id=1921103. Accessed December 21, 2015. 9. change interventions delivered by mobile tele phone short-message service. Am J Prev Med 2009;36(2):165-173. 10. American Lung Association, Research and Pro gram Services, Epidemiology and Statistics Unit. Trends in Tobacco Use [internet]. July 2011. Avail research/trend-reports/Tobacco-Trend-Report.pdf. Accessed January 2014. 11. Whittaker R, McRobbie H, Bullen C, Borland R, tions for smoking cessation. Cochrane Database Syst Rev [serial online]. 2012;(11). 12. Free C, Knight R, Robertson S, et al. Smoking ces sation support delivered via mobile phone text mes saging (txt2stop): a single-blind, randomised trial. Lancet 2011;378(9785):49-55. 13. Patrick K, Griswold WG, Raab F, Intille SS. Health and the mobile phone. Am J Prev Med 2008;35(2):177-181. 14. Riley WT, Rivera DE, Atienza AA, Nilsen W, Al lison SM, Mermelstein R. Health behavior models in the age of mobile interventions: are our theories up to the task?. Transl Behav Med 2011;1(1):53-71. 15. ing theory of behavioral change. Psychol Rev 1977;84(2):191-215. 16. Chunara R, Mekaru SR, Chan EH, Kass-Hout T, Iacucci AA, Brownstein JS. Participatory epidemi ology: use of mobile phones for community-based health reporting. PLoS Med 2010;7(12). 17. Davis K. Sign on to MiCare to connect with your doctor online. Air Force Times April 6, 2014. Available at: http://archive.airforcetimes.com/ar ticle/20140406/BENEFITS06/304060021/SignMiCare-connect-your-doctor-online. Accessed De cember 21, 2015. MOBILE PHONE HEALTH APPLICATIONS FOR THE FEDERAL SECTOR

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January March 2016 75 18. Weigel FK, Rainer Jr RK, Hazen BT, Cegielski CG, Ford FN. Uncovering research opportunities in the medical in Comm Assoc Inform Syst 2013;33(1):15-32. Available at: http://aisel. aisnet.org/cais/vol33/iss1/2/. Accessed December 21, 2015. AUTHORS Capt Burrows is a Resident at Massachusetts General Hospital, Boston Massachusetts, as part of the Masters of Health Administration/Masters of Business Administration Joint Degree Program, Army-Baylor University Graduate Program in Health and Business Administration, AMEDDC&S/Health Readiness Center of Excellence, Joint Base San AntonioFort Sam Houston, Texas. MAJ Weigel is the Chair, Research & Faculty Development Committee, and Associate Professor, Army-Baylor Univer sity Graduate Program in Health and Business Administration, AMEDDC&S/Health Readiness Center of Excellence, Joint Base San Antonio-Fort Sam Houston, Texas.

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76 http://www.cs.amedd.army.mil/amedd_journal.aspx Care of prisoners or inmates of correctional facilities poses unique challenges. These include considerations of security threats, challenge of transportation under secure conditions, a varying and highly transient popu lation, and often the remote locations of correctional fa cilities must all be taken into account when developing a strategy for medical care of this population. In Europe, the US Army Correctional Facility (COR FAC) was previously located at Mannheim, Germany, 45 geographical miles from the nearest military medi cal treatment facility (MTF). It moved in 2015 and is now located in Sembach, Germany. The location is 30 to 60 minutes from provider locations at various clin ics. The CORFAC census generally ranges from 13-15 inmates who are young (aged 18-40 years) and generally to a stateside correctional facility. This mission requires cient use of a full time privileged medical provider. Ad ditionally, the requirement for a provider to commute to and from the CORFAC daily put an unacceptable burden on the productivity of that providers assigned clinic. Therefore, a solution was proposed in the form of establishing a telehealth protocol. Telehealth, the practice of interviewing and examining a patient from a remote location using the assistance of trained technicians and high quality video and sound equipment, has been studied for many years in various settings, including prison facilities. 1-5 While TH has have been inconsistent. 6 One concept that seems to be clear is that despite initial resistance from providers and patients, the effectiveness, and satisfaction (for both pro viders and patients) tends to increase with time and ex posure to TH medicine. 1,7,8 The Department of Defense and Landstuhl Regional Medical Center (LRMC) have invested in the expansion and development of a TH program which has potential in communities that are not large enough to justify a dedicated provider. A Primary Care Telehealth Experience in a US Army Correctional Facility in Germany LTC Christian Swift, AN, USA Steven M. Cain, MPAS, PA-C CPT Michael Needham, MC, USA ABSTR A CT Objective: To assess the feasibility of using telehealth (TH) equipment and infrastructure within the US Armys European Theater to evaluate and treat inmates with general medical complaints, and perform physicals and medical safety checks in a US Army Correctional Facility (CORFAC). Methods and Materials: Synchronous TH encounters were performed using Polycom RealPresence software Practitioner Cart along with AMD Global Telemedicine devices at the originating site within the CORFAC. These devices included an AMD-2500 General Exam Camera, AMD Fiber optic Otoscope, and AMD Telephonic Stethoscope. Patient consent for TH was obtained, and they were seen in the Medical Dispensary with Army Medics presenting the patients to the providers via TH. Results: From May 22, 2014, to January 12, 2015, a physician assistant, nurse practitioner, and 4 physicians completed 177 synchronous TH encounters primarily at a CORFAC in Mannheim, Germany. Of these 177 encounters, 114 were Special Housing Unit (SHU) safety checks and 63 encounters were for physicals, medication management, and a variety of medical complaints including acute infections, abdominal pain, and musculoskeletal and dermatological complaints. Conclusion: Synchronous TH was an effective option for the delivery of high quality routine medical care for minor illnesses, injuries, and other nonurgent conditions, as well as for general physicals and SHU checks in a correctional facility. Acceptance by providers and clinic staff was found to be high. Inmates were generally highlighting one of the challenges with acceptance of telehealth programs.

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January March 2016 77 This article reviews the implementation ropean CORFAC. The support of this type of unit can be accomplished by any TH trained provider from any location where video conferencing equipment was available. Any provider connected to the Europe Regional Medical Com mand (ERMC) intranet can perform medical video teleconferencing from was to assess the feasibility of medical visits via TH while meeting the medi cal mission needs of the CORFAC. The result envisioned was high quality care while decreasing the time and costs spent in provider transportation to and from his/her assigned location. MA TERI A LS A ND METHODS Program Organization Implementation of this TH effort re quired a rethinking of the delivery of medical care at the CORFAC by the dispensary technician staff, the pri mary care providers, and ultimately the patients themselves. Initially, potential sistance from medical personnel, lack culties coordinating services. In March (THPO) and the CORFAC Dispensary Team began meeting to work through barriers and technical and clinical is sues. A standard operating procedure was written with guidelines outlining tasks and roles. Inquiries were made to the American Correctional Association regarding the feasibility and legality of TH in prison systems. Many institutions in the United States were using some form of TH, even if only simple telephonic connections. A 2004 survey of institutions in all 50 states revealed that slightly over eral institutions use some type of TH or telemedicine applications. 1 Armed with some existing experience de livering specialty care via synchronous TH in Europe, THPO began training providers and dispensary medical technicians in the use of TH equipment. Per Army Tele health Policy Memo 08-053,* written informed consent is required prior to participating in synchronous TH. This is obtained from inmates during CORFAC initial processing. Only one inmate chose not to consent to being seen for his medi cal issues via TH. Telehealth Clinic was performed Monday through Friday, ex cept Wednesdays when a provider was present at the CORFAC. Inmates would register for sick call the night prior and at an agreed upon time the next morn ing, the TH Clinic would commence in which both patient and the provider would meet in the Virtual Exam Room. The medics assisted providers with physical exam elements during the TH encounter. Special Housing Unit checks were also performed via TH during weekdays. The Special Housing Unit (SHU) is a location within the correctional facil ity where inmates are in cells in what Special Housing Unit checks are a daily medical safety check which must be performed by a credentialed medical provider assessing both the inmates cell condition and the general health of the inmate. Special Housing Unit checks consist of a brief presentation by the guard staff as to the condition of the cell and a brief interview with the inmate regarding any overnight health issues or concerns. A review of Ameri can Correctional Association Guide checks via TH met the duty of the facil ity to provide face-to-face credentialed provider daily medical safety checks. 2 A small group of internists at LRMC were trained to perform these checks via TH on weekends. Sick call presenting complaints were mostly minor in volving medication issues, acute illnesses, and injuries as shown in the Table. Physical exams were performed via TH using mostly the TH general exam camera, stethoscope, and otoscope. Emergency procedures were in place for the occasion that an inmate presents to the TH sick call with a problem requiring evaluation at the Emergency Department. Telehealth Equipment at CORFAC Originating Site com, Inc, San Jose, CA) along with telehealth devices such as the AMD-2500 General Exam Camera, AMD Internal military document not readily accessible by the general public. Correctional Facility Telehealth Pa tient Encounters. Reason For Encounter Number of Encounters Confinement physical 8 Periodic Health Assessment 8 Medication visit 8 Abdominal pain 6 Transfer physical 5 Musculoskeletal pain/ injury (other) 5 Intake medical screening 3 Back pain 2 Rash 2 Onychomycosis 2 URI (cold symptoms) 2 Knee pain 1 Lower extremity contusion 1 Toe pain 1 Ankle injury 1 Wrist injury 1 Dry scalp 1 Pharyngitis 1 Chest pain 1 Difficulty sleeping 1 ER F/U syncope 1 Generalized weakness 1 Diarrhea 1 Total sick call encounters 63 Special Housing Unit checks 114 Total TH encounters 177 One abdominal pain patient transferred to emergency department for evaluation.

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78 http://www.cs.amedd.army.mil/amedd_journal.aspx Fiberoptic Otoscope, and AMD Telephonic Stethoscope (AMD Global Telemedicine, Chelmsford MA) (Figures 1, 2). By 2010, nearly all Army clinics in Europe had ro bust TH capabilities. Although not originally slated for the equipment, these items were installed at the COR FAC from a clinic in Germany which was not using them were installed in all behavioral health clinics including tioner Cart and the telehealth general exam camera, oto to perform comprehensive assessments of patients at the CORFAC for most primary care/sick call complaints presented by this patient group. Telehealth Equipment at Distant Site Technicians from the LRMC Video Network Center (VNC) installed PolyCom RealPresence software on providers laptops at Kleber Army Health Clinic and installed on monitors on the provider desks or in a video teleconference (VTC) room. LRMC Video Network Center The LRMC VNC manages the VTC servers for both nonmedical and medical conferencing using PolyCom CMA Gatekeeper. At the initiation of every medical VTC encounter, the VNC technicians would assign the connection for patient privacy. The VNC also checked the audio and video quality of each encounter and were available anytime there were connection problems. Rarely were there any audio/video issues and there were no technical issues that prompted cessation of TH ser vices. Bandwidth within the ERMC Network was suf near negligible network delay. Electronic Medical Record Data and Peer Review Encounters and provider notes were documented in the patients outpatient military electronic medical record (AHLTA). Physician peer review was performed and no Data Patient encounter data for physicals and sick call visits were culled from a variety of sources, including a pass word-protected ERMC TH cart reservation calendar for which all TH Encounters in ERMC are documented, and daily printed AHLTA clinic lists from the CORE FAC dispensary. Special Housing Unit checks were all documented on a CORFAC blotter report and each in an electronic Standard Form 600 signed by the provider assigned that day. RESULTS Providers participating in the care of inmates via TH consisted of a physician assistant, nurse practitioner, family practitioner, and a group of 3 internists who saw inmates on the weekend for SHU checks. These Figure 1 (A) PolyCom HDX 9000 Practitioner Cart at originat ing/patient location; (B) provider laptop with PolyCom Real Presence software at healthcare provider location. B A Figure 2 AMD Global Telemedicine instruments which are on the Practitioner Cart for use in assessing the patient. Stethoscope Fiberoptic Cable General Exam Camera Otoscope Illumination System A PRIMARY CARE TELEHEALTH EXPERIENCE IN A US ARMY CORRECTIONAL FACILITY IN GERMANY

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January March 2016 79 providers completed 177 synchronous TH encounters, primarily at the Mannheim and Sembach CORFACs. Patients were seen weekly from May 22, 2014, to Janu ary 12, 2015. Of these 177 TH encounters, 114 were SHU safety checks and 63 were for physicals, medication vis its, and a variety of other typical acute care complaints. During this time, only one patient required transfer to a higher level of care during a TH encounter. The inmate complained of severe epigastric pain which necessitated transfer to the LRMC Emergency Department for evalu ation due to the limitation of ancillary services of lab and x-ray at the US Army Correctional Facility-Europe. Primary Care Encounters The routine physical and sick call types of encounters comprised 63 of the encounters as shown in the Table. About one-third (24) of those encounters were for physi cals and medication visits. All newly incarcerated in mates require an initial medical screening to assess any 48 hours of arrival. Intake medical screenings and phys icals were accomplished using synchronous TH equip ment. The remainder of the encounters addressed a vari ety of complaints which were easily assessed using TH. Special Housing Unit Checks The SHU encounters consisted of a brief presentation by the CORFAC medic or guard staff relaying the ap pearance and condition of the inmates cell and any overnight events affecting the inmates health. The en counters were brief and did not require use of telehealth examination devices. The encounters were very easily accomplished via TH. A SHU check could turn into a medical encounter if the inmate had a medical com plaint, but this did not occur during the pilot study. Provider, Staff and Inmate Satisfaction Although not formally surveyed, there was a generally good acceptance by the providers involved in the pro gram and appreciation for the high quality of the net work connections and TH medical devices used. The clear advantage for providers was being able to man age minor sick-call type complaints and physicals via driving. There was general acceptance of the idea of stered knowing that every Wednesday a provider would be in-house to see inmates and perform follow-ups. There was also recognition that contingency plans and access to local emergency service was also available if required. Providers noted satisfaction with the capabili ties of the TH equipment to include general exam cam with the telephonic stethoscope. It seemed to perform well for heart sounds when the distant provider wore headphones. For breath sounds however, it seemed less useful, possibly due to cord or connection interference noise. The idea of seeing patients from a distance via TH is new to many medical care providers and although acceptance is not immediate, providers recognize that high quality encounters can be achieved and acceptance improves over time. ence. Many inmates did express a preference to see a many of the initial intake medical screenings of the in mates are performed while the patients are handcuffed. Despite some reported dissatisfaction, nearly all inmates freely consented to the encounters and many came back multiple times for TH services, even though they could have waited to be seen in person on Wednesdays. Gen erally, medical visits via TH seemed to meet inmate ex pectations for high quality health care. CO MM ENT The Landstuhl THPO and CORFAC partnership started in March 2014 and has developed into an enduring line of service which continues to assist in the performance checks using synchronous TH. There is somewhat of a learning curve in both performing TH encounters as a provider and receiving care via TH as a patient. It is the view of the authors that not all types of care can be suc cessfully accomplished via TH. This particular group of inmates in this smaller correctional facility represented for short periods. However, in a larger institution with a more diverse inmate population, carefully consid ered screening criteria should be incorporated into de veloping TH programs. That is particularly important for screening to determine which patients may require a carefully nuanced or specialized physical exam or may have more urgent or emergent conditions that re quire treatment. Telehealth encounters may be used as a screening tool; an information-gathering encounter to assess whether a patient may need a face-to-face en counter or higher level of care facility. Telehealth may also be used for medical education classes such as dia betes education. CONCLUSIONS Synchronous TH was shown to be a feasible and ef fective option for the delivery of high quality, routine medical care for minor illnesses, injuries, and other nonurgent and nonemergent conditions, as well as for general physicals and checks in a population aged 18 to 30 years. Synchronous TH provided a platform for

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80 http://www.cs.amedd.army.mil/amedd_journal.aspx safe and effective health care delivery to this popula tion over a 7month period. Overall, the TH encounters appeared to be accepted by providers and clinic staff. A conservative estimate is that 660 hours of unproduc tive provider time traveling to and from the facility was encounters. Some inmates did report a preference to see providers in person. This highlights one of the challeng es with TH programs and their acceptance by both pro viders and patients. The authors believe that acceptance should improve over time as with most new technologi cal advances. ACKNOWLEDG M ENTS Special thanks to LRMC Commander COL Judith Lee for her critical advocacy and support of LRMC telehealth initiatives. Thanks as well to the physician staff who participated by seeing TH patient encounters, includ ing MAJ Daniel Hatcher, CPT Stephanie Ng, CPT Erica Murray, and CPT Michael Needham. A special thanks to all of the dedicated CORFAC Army Medic staff and the LRMC THPO staff whose support and hard work made this cooperative effort possible: SGT Matthew Be lot, SGT Brianna Lambert, SGT Brian Curtis, SFC Todd Hall, and Mr Anthonia Clark. REFERENCES 1. Magaletta, PR, Fagan, TJ, Peyrot, MF. Telehealth in the Federal Bureau of Prisons: inmates per ceptions. Prof Psychol Res Pr 502. Available at: http://dx.doi.org/10.1037/07352. Anogianakis G, Ilonidis G, Milliaras S, Anogei anaki A, Vlachakis-Milliaras E. Developing pris on telemedicine systems: the Greek experience. J Telemed Telecare 3. Ajami S, Arzani-Birgani A. The use of telemedi cine to treat prisoners. J Inform Tech Soft Eng 2013;S7. 4. Darkins A, Ryan P, Kobb R, et al. Care coordina tion/home telehealth: The systematic implementa tion of health informatics, home telehealth, and dis ease management to support the care of veteran pa tients with chronic conditions. Telemed J E Health 2008;14(10):1118-1126. 5. Ellis DG, Mayrose J, Jehle DJ, Moscat RM, Pier luisi GJ. A telemedicine model for emergency care in a short-term correctional facility. Telemed J E Health 6. LeRouge C, Tulu B, Forducey P. The business of telemedicine: strategy primer. Telemed J E Health 7. Weinstein RS, Lopez AM, Krupinski EA. Tele medicine: news from the front lines. Am J Med 2014;127(3):172-173. 8. Glaser M, Winchell T, Plant P, et al. Provider sat isfaction and patient outcomes associated with a statewide prison telemedicine program in Louisi ana. Telemed J E Health Larsen D, Stamm BH, Davis K, Magaletta PR Pris on telemedicine and telehealth utilization in the United States: state and federal perceptions of ben Telemed J E Health 2004;10(sup 10. American Correctional Association. Performance Core Jail Stan dards Alexandria, VA: American Correctional Association; 2010. AUTHORS Clinic, Kaiserslautern, Germany. Mr Cain is a surgical physician assistant and Landstuhl Telehealth Program clinical advisor, Landstuhl Regional Medical Center, Landstuhl Germany. CPT Needham is a family practice physician at the Kle ber Army Health Clinic, Kaiserslautern, Germany. Erratum In the book review article A New Monograph From the Borden Institute on pages 99-100 of the October-December 2015 issue of the AMEDD Journal the title of the book reviewed was incorrectly stated as: Long-Term Health Consequences of Exposures to Burn Pits in Iraq and Afghanistan The correct title is: Airborne Hazards Related to Deployment A PRIMARY CARE TELEHEALTH EXPERIENCE IN A US ARMY CORRECTIONAL FACILITY IN GERMANY

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January March 2016 81 Repair of a Gingival Fenestration Using an Acellular Dermal Matrix Allograft COL Lawrence G. Breault, DC, USA CPT Raquel C. Brentson, DC, USA COL Edward B. Fowler, DC, USA COL Frederick C. Bisch, DC, USA ABSTR A CT A case report illustrating the successful treatment of a gingival fenestration with an acellular dermal matrix (ADM) allograft. After 2 months of healing, the ADM was completely integrated into the soft tissues of the mandibular anterior gingiva with complete resolution of the gingival fenestration, resulting in excellent gingi val esthetics. Marginal tissue recession is of 2 types; one due to peri odontitis and the other primarily related to mechanical factors like tooth brushing. Recession from periodonti tis can involve all tooth surfaces, while recession from mechanical factors typically involves only one surface. Periodontitis is associated with plaque and calculus whereas facial recession is associated with high levels of personal oral hygiene and professional care. Predis posing factors to gingival recession include frenal pull, underlying bone dehiscence, subgingival restorations, tooth malposition, orthodontic appliances, and thin gin gival biotype. 1-5 While a wide array of various gingival defects may be diagnosed in patients, only those anomalies that also present with associated symptoms, esthetic concerns, or the potential for exacerbated sequelae may require treatment. Two commonly discussed localized gingival defects include the gingival dehiscence and fenestration. The more common of the two, the gingival dehiscence, is de scribed as an isolated area in which the root is denuded of bone. 6 The defect combines 3 characteristic qualities including gingival recession, bone loss through the mar gin of the bone, and root exposure (Figure 1). 7 In contrast, the gingival fenestration is a rarer phenom enon. 1,7,8 The word fenestration is derived from the Latin word fenestra, meaning window, which describes how the defect clinically presents. 7 A fenestration may be distinguished by the loss of overlying alveolar bone and gingiva, which results in an exposed root surface, but the marginal bone and gingiva remain intact (Figure 2). 7 Gingival fenestration defects are of uncertain etiolo gy. 1,2,7 Some authors have suggested the etiology of gin gival fenestration as subgingival calculus and the use of Gutka (a mixture of powdered tobacco, areca nut [fruit of Arecacatechu ] and slaked lime [aqueous calcium hy droxide]). 1 Other reports of gingival fenestrations have listed etiologies as extreme buccal inclination of root tips with thin or nonexistent cortical plates combined 9,10 Additionally, two of the authors (LGB and EBF) have clinically attrib uted gingival fenestrations to possible trauma leading to Figure 1 Gingival dehiscence. Figure 2 Gingival fenestration.

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82 http://www.cs.amedd.army.mil/amedd_journal.aspx bony sequestration (Figure 2) and to past use of smoke less tobacco with subsequent healing over previously exposed root calculus. Localized gingival defects are routinely corrected with autogenous grafts from either the palatal mucosa or buc cal gingiva. However, many patients may not desire a palatal graft due to the additional morbidity of the pro bleeding from the palatal donor site. 4,11 The surgical correction of gingival defects have evolved from the early use of pedicle grafts originally described by Grupe and Warren in 1956. 12 Presently, with the ad vent of the autogenous subepithelial connective tissue graft (SCTG), as described by Langer and Langer with creased to more than 90%. 13-17 An alternative to the autogenous graft is the acellular dermal matrix (ADM ) allograft. The material is human dermis which has been decellularized and treated to prevent disease transmission, leaving only a scaffold of Type I collagen. 18 of the morbidity associated with graft removal from an oral site. Several authors have reported on the success of ADM allograft 4,18-21 Repair of gingival fenestrations has been reported in the literature. 1,22-25 Previous case reports all used the SCTG for repair of the defects. This article reports a case of repair of a gingival fenestration using an ADM allograft. CA SE REPORT A male, 28-year-old Soldier was referred to the Depart ment of Periodontics for evaluation of his mandibular anterior gingiva associated with tooth #24, a mandibular central incisor (Figure 3). The patient reported a history of daily smokeless tobacco use in the area of the man dibular anterior but reported complete cessation of this product approximately 2 years prior. Subsequent to the cessation of smokeless tobacco use, the patient noticed an irregularity of his gingiva, which upon clinical examination was determined to be a gin gival fenestration (Figure 3). A review of the medical history revealed that the patient was taking no medications and no contraindications to treatment were noted. All surgical options were pre sented and discussed. The patient selected ADM as the material for the procedure. Following a presurgical rinse with 0.12% chlorhexidine and administration of local anesthesia (2% lidocaine with 1:100,000 epinephrine), the gingival fenestration was excised to expose new connective tissue margins REPAIR OF A GINGIVAL FENESTRATION USING AN ACELLULAR DERMAL MATRIX ALLOGRAFT Perio Derm: Dentsply International, Inc; York, PA. Figure 5 Hydrated ADM allograft. Figure 4 Site preparation. Figure 3 Presurgery: gingival fenestration, tooth # 24

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January March 2016 83 (Figure 4). The labial tissue was elevated to create a pouch. The tissue preparation was intentionally de signed to avoid the marginal gingiva, thereby decreas ing the chance of postsurgical recession. Following the removal of calculus with ultrasonic instrumentation, root planing was completed with hand instruments. The ADM was hydrated according to the manufacturers instructions (Figure 5), and placed under the elevated labial tissue as shown in Figure 6. The allograft was se cured with 5.0 Chromic Sutures* (Figure 7). The labial tissue was then closed over the ADM using 5.0 Vicryl Sutures* (Figure 8). Hemostasis was obtained with di rect pressure for 2 minutes. Home instruction included daily chlorhexidine oral rinsing every 12 hours as well as the administration of pain medications: acetamino phen (500 mg) with codeine (30 mg) (1 to 2 tabs every 4 to 6 hours as needed for severe pain and naproxen (500 mg) (1 tab every 12 hours as needed for moderate pain). The patient was followed at one, 2, 4, and 10 weeks (2 the soft tissues with complete integration of the ADM allograft (Figure 9). CO MM ENT Although gingival fenestration is a relatively rare occur rence, as this case report demonstrates, one of the etiolo gies of this condition can be resolution of a smokeless tobacco lesion over previously exposed calculus. The predictable repair of this clinical entity has been earlier demonstrated with the autogenous subgingival connec tive tissue graft. 1,22-25 This report demonstrates the success of surgical treat ment utilizing ADM. The advantage of this technique is the elimination of the need for autogenous donor tis sue. Additionally, the surgical design in this case did not incorporate the free gingival margin, thus reducing the risk of postsurgical recession or dehiscence formation. SU MMA RY This case illustrates the successful treatment of a gin gival fenestration with an ADM allograft. After 2 months of healing, the allograft was completely inte grated into the soft tissues of the mandibular anterior Ethicon US, LLC; Neenah, WI. Figure 6 Initial ADM placement. Figure 7 ADM secured with Chromic Sutures. Figure 8 Labial tissue sutured with Vicryl Suture Figure 9 Photo taken at 2 month postsurgical visit (complete correction of fenestration)

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84 http://www.cs.amedd.army.mil/amedd_journal.aspx gingiva with complete resolution of the gingival fenes tration. ADM allograft is easy to use and resulted in ex cellent gingival esthetics. REFERENCES 1. Pendor S, Baliga V, Muthukumaraswarmy A, Dhadse PV, Ganji KK, Thakare K. Coverage of tunnel technique: a novel approach. Case Rep Dent 2013: 902585. Epub Jul 7. 2. Maynard JG, Ochesenbein C. Mucogingival prob lems, prevalence and therapy in children. J Peri odontol 1975;46(9):543-552. 3. Bohannan HM. Studies in the alteration of ves tibular depth III. Vestibular incision. J Periodontol 1963;34(3):209-215. 4. Fowler EB, Breault LG. Root coverage with an acellular dermal allograft: a three-month case re port. J Contemp Dent Pract 2000;1(3):47-59. 5. Greenwell H, Fiorellini J, Giannobile W, et al. Oral reconstructive and corrective consid erations in periodontal therapy. J Periodontol 2005;76(9):1588-1600. 6. Singh S, Panwar M, Amora V. Management of mu cosal fenestration by multidisciplinary approach: a rare case report. Med J Armed Forces India 2013;69(1):86-89. 7. Lane J. Gingival fenestration. J Periodontol 1977;48(4):225-227. 8. Patel PV, Kumar N, Durrani F. Microsurgical aes thetic treatment of gingival fenestration by a coro nally repositioned partial thickness graft: a case report. J Clin Diagn Res 2013;7(11):2649-2650. 9. Ju Y, Tsai AH, Wu Y, et al. Surgical intervention of mucosal fenestration in the maxillary premolar: a case report. Quintessence Int 2004;35(2):125-128. 10. Chen G, Fang CT, Tong C. The management of mu cosal fenestration: a case report of two cases. Int Endo J 2009;42(2):156-164. 11. Druckman, RF, Fowler EB, Breault LG. Post-surgi cal hemorrhage: formation of a liver clot second ary to periodontal plastic surgery. J Contemp Dent Pract 2001;2(2):62-71. 12. Grupe HE, Warren RF. Repair of the gingival J Periodontol 1956;27(2):92-95. 13. 12.Nelson SW. The subpedicle connective tissue graft. A bilaminar reconstructive procedure for the coverage of denuded root surfaces. J Periodontol 1987; 58(2):95-102. 14. Cordioli G, Mortarino C, Chierico A, et al. Com parison of 2 techniques of subepithelial connective tissue graft in the treatment of gingival recessions. J Periodontol 2001;72(11):1470-1476. 15. Hirsch A, Attsal U, Chai E, et al. Root coverage and pocket reduction as combined surgical proce dures. J Periodontol 2001;72(11):1572-1579. 16. Harris RJ. Connective tissue grafts combined with either double pedicle grafts or coronally positioned pedicle grafts: results of 266 consecutively treated defects in 200 patients. Int J Peridodontics Restor ative Dent 2002;22(5):463-471. 17. Tozum TF, Dini FM. Treatment of adjacent gingi val recessions with subepithelial connective tissue Quintes sence Int 2003;34(10):7-13. 18. Sedon CL, Breault LG, Covington LL, Bishop BG. The subepithelial connective tissue graft: part 1. patient selection and surgical techniques. J Con temp Dent Pract 2005;6(1):146-162. 19. Harris RJ. A comparison of two techniques for obtaining a connective tissue graft from the palate. Int J Peridodontics Restorative Dent 1997;17(3):260-271. 20. Aichelmann-Reidy ME, Yukna RA, Evans GH, Nasr HF, Mayer ET. Clinical evaluation of acellular allograft dermis for the treatment of human gingi val recession. J Periodontol 2001;72(8):998-1005. 21. Henderson RD, Greenwell H, Drisco C, et al. Predictable multiple site root coverage using an acellular dermal matrix allograft. J Periodontol 2001;72:571-582. 22. Yang ZP. Treatment of labial fenestration of max illary central incisor. Endod Dent Traumatol 1996;12(2):104-108. 23. Sawes WL, Barnes IE. The surgical treatment of fenestrated buccal roots of an upper molara case report. Int Endod J 1983;16(2):82-86. 24. Rawlinson A. Treatment of a labial fenestra tion of a lower incisor tooth apex. Br Dent J 1984;156(12):448-449. 25. Peacock ME, Mott DA, Cuenin MF, Hokett SD, Fowler EB. Periodental plastic surgical tech nique for gingival fenestration closure. Gen Dent 2001;49(4):393-395. AUTHORS COL Breault is a Periodontal Mentor, Advanced Educa tion in General Dentistry 1 Year Training Program, US Army Dental Activity, Fort Carson, CO. CPT Brentson is a former Advanced Education in Gen eral Dentistry 1 Year Resident, US Army Dental Activity, COL Fowler is Chief of Periodontics, US Army Dental Activity, Fort Bliss, TX. COL Bisch is Chief of Periodontics, Birmingham Vet erans Administration Medical Center, Birmingham, AL, and past Director of the US Army Periodontic Training Program, US Army Dental Activity, Fort Gordon, GA. REPAIR OF A GINGIVAL FENESTRATION USING AN ACELLULAR DERMAL MATRIX ALLOGRAFT

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January March 2016 85 The mission of the US Army Dental Command is to provide responsive and reliable oral health services and 1 Based on the fact that dental care is an essential and re The reasons for and pattern of tooth loss in nonmilitary 2-18 The main reasons tal disease is the primary factor for tooth loss in older METHODS Reasons for Non-third Molar Extractions in a Military Population

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86 http://www.cs.amedd.army.mil/amedd_journal.aspx RESULTS P The second most common reason for non-third molar REASONS FOR NON-THIRD MOLAR EXTRACTIONS IN A MILITARY POPULATION The High Caries Risk Program is designed to improve overall oral health by customizing dental treatment for the individual Soldier to meet his or her needs. It seeks to create a partnership between the Soldier and the dental professional and help break the decayrepair-decay cycle. The program helps the Soldier identify risk fac tors and receive nutritional counseling, oral hygiene instructions, intensive treatment to help prevent future decay, and treatment for any cavities. The program follows Soldiers as they are assigned to various locations throughout their Army careers. Table 3 for High Caries Risk (HCR) category (yes or no). Percent ages may sum to greater than 100% because an extract ed tooth may match more than one category. Note: study sample= 320 Reason for Extraction Category P value HCR No N=143 [45% sample] n (%N) HCR Yes N=177 [55% sample] n (%N) Caries 62 (43%) 171 (97%) <.001 Failed Endo 45 (31%) 21 (12%) Preprosthetic 33 (23%) 11 (6%) Trauma 37 (26%) 8 (5%) Periodontal 25 (17%) 6 (3%) Orthodontics 11 (8%) 0 (0%) Hyperocclusion 7 (5%) 0 (0%) .003 Table 2 Reasons for extraction by age group. Percentages may sum to greater than 100% because an extracted tooth may match more than one category. Note: study sample= 320 Reason for Extraction Age Group P value 19-29 Years N=128 [45% sample] n (%N) 30-39 Years N=131 [41% sample] n (%N) 40-60 Years N=61 [19% sample] n (%N) Caries 103 (80%) 96 (73%) 34 (57%) .003 Failed Endo 25 (20%) 30 (23%) 10 (17%) .583 Preprosthetic 17 (13%) 19 (15%) 7 (12%) .865 Trauma 15 (12%) 17 (13%) 12 (20%) .289 Periodontal 5 (4%) 11 (8%) 15 (25%) <.001 Orthodontics 3 (2%) 6 (5%) 2 (3%) .614 Hyperocclusion 4 (3%) 2 (2%) 1 (2%) .648 Table 1 Reasons for extraction by gender. Percentages may sum to greater than 100% because an extracted tooth may match more than one category. Note: study sample= 320 Reason for Extraction Total (% sample) Gender P value Male N=268 [84% sample] n (%N) Female N=52 [16% sample] n (%N) Caries 233 (73%) 197 (74%) 36 (69%) .610 Failed Endo 66 (21%) 54 (20%) 12 (23%) .708 Preprosthetic 14 (14%) 34 (13%) 10 (19%) .269 Trauma 45 (14%) 37 (14%) 8 (15%) .827 Periodontal 31 (10%) 24 (9%) 7 (13%) .310 Orthodontics 11 (3%) 10 (4%) 1 (2%) 1.000 Hyperocclusion 7 (2%) 6 (2%) 1 (2%) 1.000 No Diagnosis 80 (20%)

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January March 2016 87 Table 4 Reasons for extraction by tooth location. Percent ages may sum to greater than 100% because an extracted tooth may match more than one category. Note: study sam ple= 320 Reason for Extraction Tooth Location P value Anterior N=23 [7% sample] n (%N) Posterior N=297 [93% sample] n (%N) Caries 2 (26%) 227 (76%) <.001 Failed Endo 5 (22%) 61 (21%) .796 Preprosthetic 2 (9%) 42 (14%) .753 Trauma 11 (48%) 34 (11%) <.001 Periodontal 3 (13%) 28 (9%) .477 Orthodontics 2 (19%) 9 (3%) .183 Hyperocclusion 0 (0%) 7 (2%) 1.000 P P P P Caries Risk Criteria Low Risk Criteria No incipient or cavitated primary or secondary carious lesions during current exam and no factors that may increase caries risk. Moderate Risk Criteria (any of the following) One or two incipient or cavitated primary or secondary carious lesions during current exam. No incipient or cavitated primary or secondary carious lesions during current exam but presence of at least one factor that may increase caries risk. High Risk Criteria (any of the following) Three or more incipient or cavitated primary or secondary carious lesions diagnosed during current exam. Presence of multiple factors that may increase caries risk. Xerostomia (medication, radiation, or disease induced). Suboptimal fluoride exposure (inadequate/no systemic fluoride, inadequate topical fluoride exposure). Poor oral hygiene. Irregular dental visits. Incipient lesions are noncavitated localized or generalized white spots and/or interproximal radiolu cencies. Risk Factors: factors that increase the risk of developing caries include, but are not limited to: Deep pits and fissures. Many multisurface restorations. Exposed root surfaces. Eating disorders. Frequent sugar intake (>5 times per day). Restoration overhangs and open margins. Active orthodontic treatment. Chemotherapy or radiation therapy. Developmental or acquired enamel defects. Physical disability that impedes oral hygiene. Inadequate salivary flow, as determined from PMH or unstimulated salivary flow testing (<0.2 mL/min). Source: American Dental Association

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88 http://www.cs.amedd.army.mil/amedd_journal.aspx CO MM ENT Richards et al P these Soldiers had not received dental treatment prior to ams and have most likely eliminated the active compo DoD Instruction 6025.19 Dental Class 2 (DRC 2) service members have a The second most common reason for non-third molar It is REASONS FOR NON-THIRD MOLAR EXTRACTIONS IN A MILITARY POPULATION

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January March 2016 89 Sorensen and Martinoff 27 28 ( P of most endodontically treated posterior teeth is not an P P Albandar et al con the P

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90 http://www.cs.amedd.army.mil/amedd_journal.aspx Many CONCLUSIONS REFERENCES Acta Odontol Scand Br Dent J J Dent Res Community Dent Oral Epide miol J Dent J Den Community Dent Oral Epidemiol Com munity Dent Oral Epidemiol Community Dent Oral Epidemiol Community Dent Oral Epidemiol Community Dent Oral Epidemiol Caries Res Br Dent J REASONS FOR NON-THIRD MOLAR EXTRACTIONS IN A MILITARY POPULATION

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January March 2016 91 in recipients of free dental treatment at the Univer J Oral Rehabil Int Dent J J Epidemiol The reasons for tooth J Dent J Clin Periodontol J Can Dent Assoc Scan J Dent Res Mil Med Mil Med Department of Defense Instruction 6025.19. In dividual Medical Readiness (IMR) Oral Surg Oral Med Oral Pathol Oral Radiol Endod J Prosthet Dent Oral Surg Oral Med Oral Pathol Oral Radiol Endod J Endod Evid Based Dent J Clin Periodontol Gerodontology J Periodontol J Peri odontol Community Dent Oral Epide miol Community Dent Oral Epidemiol Int Dent J Com munity Dent Health AUTHORS

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92 http://www.cs.amedd.army.mil/amedd_journal.aspx

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