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

Subjects

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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J OURNAL THE UNITED STATES ARMY MEDICAL DEPARTMENT OctoberDecember 2017

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J OURNALA Prof essional Publication of the AMEDD CommunityTHE UNITED STATES ARMY MEDICAL DEPARTMENTOnline issues of the AMEDD Journal are available at http://www.cs.amedd.army.mil/amedd_journal.aspxOctoberDecember 2017 US Army Health Readiness Center of Excellence PB 8-17-10/11/12 The Army Medical Department Journal [ISSN 1524-0436] is published quarterly 3630 Stanley RD STE B020478234-6100. The Army Medical Department Journal are listed and Journals CORRESPONDENCE: (210) 221-6301, DSN 471-6301DISCLAIMER: 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 1726903LTG Nadja Y. West MG Brian C. Lein Edward A. Lindeke Richard Burton

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October December 2017 iAntibiotics in the Treatment of Patients With Lower Back Pain Associated With Modic Changes: A Case Series . . . . . . . . . . . . . . . . . . . . . . . 1Gaurav Gupta, MD, FRCPC; Peter Jarzem, MD, FRCSC; Major Sean Meredith, Pharm D; et alLow Rate of Early Disabling Back Pain Following Traumatic or Posttraumatic Major Extremity Amputation . . . . . . . . . . . . . . . . . . . 10CPT James N. Foster; CPT Richard K. Hurley, Jr; MAJ Chad A. KruegerUse of Ankle Magnetic Resonance Imaging in the Active Duty Military Population: The Results of a Process Improvement Project. . . . . . . . . . . . . . . .15Maj Harold J. Goldstein; CPT Richard K. Hurley, Jr; Maj Andrew J. Sheean; et alA Randomized Controlled Trial Evaluating Methylsulfonylmethane Versus Placebo to Prevent Knee Pain in Military Initial Entry Trainees . . . . . . . . . . . . . . . . 21CPT David J. Tennent; CPT Christina M. Hylden; MAJ Benjamin K. Kocher; et alGEHS Neurophysiological Classification System for Patients with Neuropathy of the Ulnar Nerve at the Elbow . . . . . . . . . . . . . . . . . . 26David G. Greathouse, PT, PhD; Greg Ernst, PT, PhD; John S. Halle, PT, PhD; COL Scott W. ShafferThe Influence of Smoking on Recovery from Subacromial Pain Syndrome: A Cohort from the Military Health System . . . . . . . . . . . . . . . . 36MAJ Daniel I. Rhon; John S. Magel, PT, DSc, PhDReal Time Interrater Reliability of a Novel Musculoskeletal Readiness Screening Tool . . . . . 43LTC (Ret) Mark D. Thelen; LTC (Ret) Shane L. Koppenhaver; CPT Shanee E. Allen; et alCognitive Behavioral Therapy for Insomnia Treatment in a Military Deployed Operational Setting Utilizing Enlisted Combat Medics: A Quality and Process Improvement Project . . . . . . 52MAJ Rohul Amin; CPT Brooke E. WirtzSandfly Fever in AfghanistanA Sometimes Overlooked Disease of Military Importance: A Case Series and Review of the Literature . . . . . . . . . . . . . . . 60LTC John W. Downs; Capt Daniel T. Flood; MAJ Nicholas H. Orr; et alSmoking and Periodontal Disease . . . . . . . . . . . . . . . . . . 67LTC Thomas M. JohnsonCore Temperature Responses of Military Working Dogs During Training Activities and Exercise Walks . . . . . . . . . . . . . . . . . . . . . .71Catherine OBrien, MS; Anthony J. Karis, BS; William J. Tharion, MS, MBA; et alEffects of Technique-Focused Training in Conjunction with Physical Readiness Training on Army Physical Fitness Test Performance . . . . . . . . . . . . . . . 79LTC (Ret) Mark D. Thelen; LTC (Ret) Shane L. Koppenhaver; COL Noman W. Gill: COL Scott W. ShafferEvidence-based Practice and Single-case Designs in Psychotherapy . . . . . . . . .84James M. Georgoulakis, PhD, JD; CPT Johanna G. Zollmann; Christopher L. Pate, PhD; Amy J. HallettA Descriptive Analysis of Data from the Department of Defense Joint Trauma System Prehospital Trauma Registry . . . . . . . . . . . . . . . . . . . 92MAJ Steven G. Schauer; MAJ Michael D. April; MAJ Jason F. Naylor; CPT Joshua J. Oliver; et alA 12-Month Descriptive Analysis of Emergency Intubations at Brooke Army Medical Center: A National Emergency Airway Registry Study . . . . . . . . . . . . . . . 98MAJ Michael D. April; MAJ Steven G. Schauer; Calvin A. Brown III, MD; Capt Patrick C. Ng; et alEvaluation of the Significance of Individual Endogenous Risk Factors and Medical and Orthopaedic Conditions on Physical Fitness in Military Executives . . . . . . . . 105Maj Christoph Schulze, MD, German Air Force; Maj Michael Becker, MD, German Army; et al US ARMY MEDIC A L DEP A RTMENT JO U RN A L OctoberDecember 2017

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ii http://www .cs.amedd.army .mil/amedd_journal.aspx The US Army Health Readiness Center of Excellence The Army Medical Department Center and School ENVISION, DE SIGN, TRAIN, ED UCA TE, INSPIR E Joint Base San Antonio-Fort Sam Houston, Texas

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October December 2017 1With a worldwide point prevalence of 12%, low back pain lost productivity.1,2 has been complicated by poorly validated clinical tools 3,4 Thus, the treatment with various modalities used. This includes, but is not limited to lifestyle, rehabilitation, medications, injec tions, and surgical treatments.5-9Until recently, the prevailing theoretical framework was complicated by genetic, biopsychosocial, and envi ronmental factors. Similar to previous conceptualiza tions regarding disease,10 this notion was challenged by a landmark randomized placebo controlled study by Albert et al11 that investigated the use of antibiotic treatment for patients with type 1 Modic changes and disc herniation on MRI. Type 1 Modic changes refers scans of the spine that are hyperintense on T2 and hy tion and edema.12 Using the study protocol of Albert et al, patients with low back and/or lower limb pain had medical resource related measures one year after initiat ing treatment with 100 days of amoxicillin/clavulanate.11The background leading to the investigation of antibiotic treatment for LBP was well described by Albert et al.11 While it is known that the prevalence of Modic changes are higher in patients with LBP,13 numerous pathobiol ogy studies14-17 showed that intervertebral disc hernia tions had colonization rates of 19% to 71% with bacteria such as proprionibacterium acnes staphylococcus and corynebacterium propinquum Furthermore, a much greater percentage of patients with disc herniation colo nized with bacteria went on to develop Modic changes long-term.14 However, the true culture rate may be sig technical issues with sampling and bacterial preserva tion techniques, or lower given the potential risk of con tamination.17 The authors themselves had also previously carried out a nonrandomized pilot study on the effects of antibiotics in patients with chronic LBP post disc herni ation, which also showed improved clinical outcomes.19Antibiotics in the Treatment of Patients With Lower Back Pain Associated With Modic Changes: A Case SeriesGaurav Gupta, MD, FRCPC LCol Markus Besemann, MD, FRCPC Peter Jarzem, MD, FRCSC Maria Francisca Elgueta, MD Major Sean Meredith, Pharm D Roshanak Charghi, MD, FRCPC Mohan Radhakrishna, MD, FRCPC Jeffrey Chankowsky, MD, FRCPC ABSTR A CT Purpose: To determine the clinical effect of antibiotic treatment for patients with low back pain and Modic 1 changes. Methods: This is a retrospective case series of patients treated at the Canadian Forces Health Services Centre in Ottawa and the McGill University Health Centre. Where available, pain, functional, and imaging outcomes in 11 patients treated between 2013 and 2015 were analyzed to determine effect of antibiotic treatment for patients with low back pain and associated Modic 1 changes on magnetic resonance imaging. Results: Conservatively, only 3 of 11 patients met the criteria for improvement for pain and/or function. While a larger proportion improved in the long term, outcomes were not thought to be temporally attributable to an tibiotic treatment, as in most cases, ongoing therapy, medications, and/or injections were required. There did not appear to be a correlation between clinical improvement and associated end plate volume involvement for Modic changes. Conclusion: Antibiotics for the treatment of low back pain in the context of Modic changes on MRI did not excitement regarding this treatment, further research is required.

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2 http://www .cs.amedd.army .mil/amedd_journal.aspxProprionibacterium acnes is a part of the normal human ated with protecting the host against certain cancers.20 It can be pathological at sites of injury or indwelling medi in adjacent bone through the release of cytokines and propionic acid.21,22 As an anaerobe, it thrives in the disc environment, which is low in vascularity, oxygen ten sion, and pH. Colonization of a degenerated disc can oc cur via hematogenous spread, local infection, or a trans venous retrograde pathway from the pelvis.23 by Albert et al.11 history.24 Amoxicillin/clavulanate was the selected an tration,24 by regional variations in colonizing organisms.24 Fur thermore, the authors explained the rationale for the antibiotic doses used in the trial, reasons for selecting the treatment length,25 issues regarding study design, 26 the reasons behind the creation of MAST (Modic Antibiotic Spine Therapy) Medical (http://www.mastmedical.com) and 27 and why disc biopsy and culture should not be undertaken prior to treatment.28Based on the results of Albert et al,11 we sought to monitor the long-term outcomes in patients presenting with LBP and Modic 1 changes, after treatment with antibiotics. METHODS Patients were recruited across 3 clinics, including the Canadian Forces Health Services Center Ottawa, the Montreal General Hospital Spine Clinic, and the Alan Edwards Pain Management Unit. We obtained research ethics board approval for this study from both the Mc Gill University Health Centre and the Defence Research and Development Canada. Inclusion criteria were patients ranging in age from 18 to 70 years with low back and/or lower limb pain for at least 6 months, leading to at least mild to moderate effect on function, coupled with the presence of Modic 1 changes and related disc herniation at least one level. The subject had to have had MRI imaging within the previous year and inadequate response to standard phys 3 months. Patients were included in the case series with mixed Modic changes or if multiple levels were affected and Modic 1 changes predominated. The study protocol permitted the subjects to exercise during the treatment as prescribed by their treating physician. Patients were excluded if psychiatric comorbidities were low up could not be maintained for at least one year fol lowing treatment initiation, if there was an allergy/sen sitivity to the medication, kidney disease (ie, estimated 2), pregnancy, or breastfeeding. Patients provided informed consent for the treatment protocol after discussion of potential risks including infection and death. The data sup porting the protocol was discussed at length with each patient prior to initiation of treatment. All patients were treated with at least 90 days of amoxicillin/clavulanate 500/125 mg po 3 times per day (TID). One patient devel oped hepatitis with treatment, and was then placed on 100 days of doxycycline 100 mg twice daily (BID) after consultation with an infectious disease specialist. As per our protocol for standard clinical evaluations, baseline pain and functional measures were established. This was reevaluated at least one year after completion. Follow up imagery was also obtained for comparison to baseline with respect to volume of the end plate involved. All patients provided written consent to publish the positive outcome was determined a priori to be at least at a 30% reduction in numeric rating scale (NRS) and/or a 20% improvement in Oswestry Disability Index (ODI), which is commonly used as the minimally important clinical difference for patients with LBP. RESULTS A total of 11 patients were followed for at least one year following initiation of antibiotic treatment for LBP in the setting of Modic 1 changes. Eight patients were ac tively serving in the Canadian Armed Forces, while 3 others were followed through clinicians at the McGill University Health Centre. Mild Modic changes were de between 30% and 60%, and severe greater than 60% of volume.12 Figures 1 and 2 show preand postantibiotic Age at initiation of treatment ranged from 37 to 49 years, and there were 2 female patients in the series. All pa tients had LBP for at least 2 years. Prior to treatment with antibiotics, all patients had considerable therapy including medications, physical therapy, injection treat ments, and spinal manipulation. Two patients (Patients 2 and 4), had Modic 1 changes at multiple levels; one with ANTIBIOTICS IN THE TREATMENT OF PATIENTS WITH LOWER BACK PAIN ASSOCIATED WITH MODIC CHANGES: A CASE SERIES

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October December 2017 3 changes at the cervical level and lumbar spine (Patient 6), and one patient with Modic changes at the thoracic level (Patient 2). Modic 2 only changes were present in one patient at one level (Patient 2) and mixed Modic 1 (ie, with minor Modic 2) changes were present in 5 patients (Pa tients 6, 7, 8, 10, 11). Patient 1 had mixed Modic 1 and 3 changes. Optimistically, 9 patients (82%) reported im provement at follow up (Patients 1, 2, 3, 4, 7, 8, 9, 10, 11). However the time period of improve ment made it improbable that the improvement was secondary to the antibiotic regimen for most of these cases. Three (27%) patients (Patients 3, 4, 7) met the criteria for successful treatment for pain and/or functional improvement that could conceivably be related to the antibiotics themselves. Patient 3 had almost full resolution of symptoms and dis ability at 4 months, but was lost to follow up. Pa tient 4 had greater than 50% resolution for pain and a large improvement in function. The im provement may have been the result of physical therapy directed at sacroiliac joint mobilization and stabilization that were started one year af ter antibiotic treatment initiation. Patient 7 had good improvement in pain, and minor improve ment in function at one year, but wished to try other treatments that included injections. Patient 1 improved with medication and spinal manipulation initiated one year after antibiot ics. Patient 2 reported a 50% improvement in global perception, but objective pain and func tional scores remained unchanged, and ongoing medication treatment was required. Patient 5 required medication treatment (started one year after initial antibiotic treatment) and ongoing injection treatment. Patient 9 had a resolution in pain after an injection, done after the one year initiation of antibiotics. Patient 10 had an im replacement done more than one year after the initiation of antibiotic treatment. Patient 11 re ported an improvement in pain of about 50%, but not function, and he attributed his well-be ing as tied to consistent meditation and exercise (cycling). Main side effects reported were mild gastrointestinal symptoms in 3 patients, which did not preclude treat ment. There was one case of Hepatitis that required cessation of standard treatment, and normalization of liver function tests thereafter. Consistent with the earlier 11 most adverse effects were low grade gastrointestinal complaints such as loose bowel Figure 1. Saggital T1 (image A) and T2 (image B) MRI for Patient 5 pre antibiotic use, demonstrating moderate volume Modic 1 changes at the L5/S1 endplates. A B A B Figure 2. Saggital T1 (image A) and T2 (image B) MRI for Patient 5 post antibiotic use, showing progressive loss of disk height and substance as well as increasing T1 signal abnormality, mixed Modic changes, and endplate irregularity.

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4 http://www .cs.amedd.army .mil/amedd_journal.aspx3% of patients discontinuing therapy because of drugrelated adverse reactions. Follow up imaging at least one year post treatment was available in 8 of 11 cases. All patients had at least a small disc herniation/protrusion associated with Mod ic changes at the same level. There did not appear to be a correlation between improvement in symptoms and change in endplate volume involvement within the available sample. CO MM ENT Recent work11 has created a paradigm shift in the treat ment of chronic LBP when it was determined that a proportion of patients suffering from low back/lower limb pain had indolent infections remediable with a protracted course of antibiotics. The results of antibiotic treatment in the setting of disc herniation with Modic 1 changes was interesting for many reasons: ( a ) The re gions affected by Modic 1 changes reduced on MRI at one year follow-up in only the antibiotic treated group. ( b relief in the higher dose group. ( c ) Leg pain fell from 5.3 to 1.7 in the antibiotic group, but rose from 4 to 4.3 in the placebo group. ( d ) The number of sick days off work during the year was 19 days in the antibiotic group and 45 days in the placebo group. ( e ) The number of times a patient visited a doctor was nearly double in the placebo ANTIBIOTICS IN THE TREATMENT OF PATIENTS WITH LOWER BACK PAIN ASSOCIATED WITH MODIC CHANGES: A CASE SERIES Table 1. Patient Clinical Data and Outcomes Preand Postantibiotic Use (1 of 3, continued).Patient 1Patient 2Patient 3Patient 4Demographics (sex, age) & Pain Region -TreatmentMale, 45 y; LBP100 days of Doxycycline. Had Hepatitis with Amox/ClavMale, 49 y; LBPAmox/Clav, 90 daysMale, 44 y; LBP-Amox/Clav, 90 daysFemale, 37 y; LBPAmox/Clav, 90 days Past Medical History Knee pain NYD, left post hernia repair pan syndrome, depression Gout, knee OA, right radial nerve injury, right shoulder pain, left wrist pain, obesity Right inguinal hernia repair Cholelithiasis, whiplash associated disorder, iron deficiency, urinary stress incontinence Treatment prior to antibiotics Physiotherapy and NSAIDS Physiotherapy, acetaminophen, ibuprofen Physiotherapy and NSAIDs prn Hydromorphone, Oxycocet, yoga, pro lotherapy, Amitryptiline, Nortripty line, Gabapentin, inversion table How Long Pain Present2 years27 years (worse 3 years ago) Worse in last 2 years7 years Location & Type of Modic Changes L4-5 Modic 1 & 3 changes Modic 1 at T12/ L1, L3/L4.Modic 2 L5 & S1 .Disc protrusion L3/L4 and L4/L5L5/S1 Modic 1 with small disk herniation L4/5 & L5/S1 Modic 1 Disc protrusion L4-L5Pain and Function Score at Treatment Day 0NRS 2/10ODI 34% NRS 3-8/10ODI 50% NRS not documented ODI 34% NRS 7/10ODI 42% Pain and Function Score after Treatment At 6 months; NRS no change ODI 26% At 4 months; im proved night pain/ sleep, ODI 56% At 6 months; NRS decreased 25% but also taking Gabapentin At 4 months; ODI 0% At 4 months; NRS >50% relief with hydromorphone and activity restric tions post gynecologic surgery, ODI 26% At 11 months; severe increased pain and limited function associated with psychosocial stressors. Pain Function 1 year After Treatment NRS no change ODI 22% Global Perception is 50% improved but ODI 52%, NRS unchanged Lost to follow up16 months NRS >3/10, ODI 6% MRI Findings at One year Unchanged from previous Mild worsening of Modic 1 L3/4 and Modic 2 L5/S1Modic 1 unchanged at L5/S1, mild progression at L4/5Other Treatments/ Considerations, Postantibiotics Currently has 50% reduction in pain with spinal manipulation therapy and Pregabalin. Gabapentin; dosing was increased at one year follow-up. Flare of pain 6 weeks after treatment initiation. Treatment included activ ity modification, spinal manipulation therapy. Report of low back pain would have precluded promotion/posting. Tridural, long acting morphine, mental health support. Numerous psychosocial issues treated with counseling citalopram, venlafaxine quetiapine, trazadone. Found pain improved with improved mental health and physiotherapy focused on SI joint mobilization.LBP indicates low back pain; NYD, not yet diagnosed; NRS, Numerical Pain Rating Index; ODI, Oswestry Disability Index; NSAIDS, nonsteroidal antinflammatories; OA, osteoarthritis; SI, sacroiliac.

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October December 2017 5 group compared to the antibiotic group. ( f ) Quality of group, but remained stable in the placebo group. ( g ) Blood CBC, LDH, and alk phos remained normal in most cases throughout the trial.11In our case series, however, only 3 of 11 patients conser vatively met the criteria for a successful outcome from a pain and/or functional standpoint at long-term follow up. One of these required ongoing yoga exercise to man age symptoms and another wished to move forward with medications and injections. There also did not appear to be a correlation with improvement in symptoms, and the ings of the 2 previous studies using antibiotics to treat low back pain in the setting of Modic 1 changes and disc herniation.11,18Factors associated with Modic changes continue to be developed. While it is possible that Modic 1 and 2 changes are different stages of the same process,11 fat distribution and metabolic processes may also play roles.29 Other authors have theorized that mechanical forces across the disc can result in Modic changes.30From a treatment perspective, in the setting of Modic changes and LBP, exercise has not been shown to be advantageous when compared to rest.31 Intradiscal ste roid injections have been shown to be effective for pain relief and functional improvements at 6 months in pa tients with LBP and Modic 1 and 2 changes when com pared to placebo.32 While one could argue that steroids production of proprionic acid,11 it is surprising that the long-term outcomes are not poorer33 given that the po tential anti-immune effects of steroids34 could limit the remediation of the infecting organisms. Alternately, in a case-controlled series of patients undergoing microd iscecotmy associated with low back, radicular pain and degenerative disc disease, those with Modic 1 and 2 changes had a trend to less overall improvement in pain and function than those without end plate changes.35 Table 1. Patient Clinical Data and Outcomes Preand Postantibiotic Use (2 of 3, continued).Patient 5Patient 6Patient 7Demographics (sex, age) & Pain Region -TreatmentMale, 38 y; LBPAmox/Clav, 100 daysMale, 46 y; Cervicalgia and LBP Amox/Clav 90 daysMale, 39 y; LBPAmox/Clav 90 days Past Medical History Depression, Right knee arthrosco py x 3, bilateral knee osteotomies, right hand tendon repairs, steroid induced central serous choroid retinopathy Left ankle fracture, NRSectomy, septorhinoplasty Psoriasis, GERD,left knee arthroscopy, inguinal hernia repairs bilaterally, NRSectomy Treatment prior to antibiotics Increased Paroxetine, lumbar facet radiofrequency denerva tion, NSAIDS, Capsaicin cream, acetaminophen, bilateral SI joint prolotherapy, physiotherapy Acetominophen, codeine, NSAIDS NSAIDS, Chiropractics, physiotherapy, massage therapy, mental health support How Long Pain Present3 years7 years9 years Location & Type of Modic Changes L5/S1 Modic 1 changes Disc herniation L5/S1C5/6 Modic 1 changes. L5-S1; Modic 1&2. Disc protrusion L5/S L4/5 Modic 1/2 changes Disc herniation L4/5Pain and Function Score at Treatment Day 0NRS 3-5/10ODI not available NRS 3-8/10, ODI-? squats, bicep curls, shoveling, mowing the lawn, lifting groceries. NRS 5-7/10ODI 48% Pain and Function Score after Treatment At 6 months; NRS no change ODI 36% NRS no change ODI 28% At 7 months; NRS decreased 20% ODI 36% Pain Function 1 year After Treatment At 1 year; NRS unchanged ODI 44% NRS no change ODI 35 % NRS decreased 50% Minimal leg pain ODI 32% MRI Findings at One year Increased Modic L5/S1No follow-up available Improved Modic 1 L4/5Other Treatments/ Considerations, Postantibiotics Spinal manipulation therapy, gaba pentinhad significant improve ment when taking pregabalin (7 months postantibiotic treatment). Continued with radiofrequency denervation of lumbar facet joints. Most recently treated for thyroid cancer. limb, pain, less severe constant pain, ongoing limitations for sitting and standing. Stopped steroid injection.LBP indicates low back pain; NRS, Numerical Pain Rating Index; ODI, Oswestry Disability Index; NSAIDS, nonsteroidal antinflammatories; SI, sacroiliac; GERD, gastroesophageal reflux disease.

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6 http://www .cs.amedd.army .mil/amedd_journal.aspxA recent systematic review concluded that in the setting of disc herniation, there was moderate evidence for low virulent bacteria being associated with back pain related sation, it was felt the criteria for temporal relationship, consistency, dose response relationship, and analogy was not met in the existing literature. Given that Mod ic 1 changes can occur in other disc pathologies, lower quality trials did not show an association with Modic changes, bacterial infection, and LBP. Therefore, at best, there may only be a small subset of patients with LBP who would be candidates for antibiotic treatment.29Numerous questions regarding the role of antibiot ic treatment in LBP remain to be answered. It is still unclear how long treatment is required, and whether resolution of the Modic changes relates to the allevia tion of pain given the potential lag in resolution on MRI. It also remains to be determined whether serologybased tests can be developed to help monitor treatment response. Clinicians may need to consider the patients environmental exposures (ie, military postings, region of residence at onset of pain) when considering which antibiotics to use as well as have other antibiotic choices and routes available for patients that fail or cannot tol quired. Finally, the most important issue is how to man age patients with pain while they are undergoing treat ment, waiting for clinical response, or have a suboptimal result from antibiotic treatment.36ANTIBIOTICS IN THE TREATMENT OF PATIENTS WITH LOWER BACK PAIN ASSOCIATED WITH MODIC CHANGES: A CASE SERIES Table 1. Patient Clinical Data and Outcomes Preand Postantibiotic Use (3 of 3).Patient 8Patient 9Patient 10Patient 11Demographics (sex, age) & Pain Region -TreatmentMale, 41 y; LBPAmox/Clav 90 daysFemale, 39 y; LBPAmox/ Clav 90 daysMale, 39 y; Amox/Clav 100 daysMale, 38 y; Amox/Clav 90 days Past Medical History Left sided hemorrhagic stroke 2001, left elbow bursitis, tonsillectomy No PMHx Undergoing fertility treatments No PMH No PMHx Treatment prior to antibiotics Physical therapy, lumbar prolotherapy, lumbar radiofrequecy, NSAIDS, Tylenol 3Has tried physio, meds (NSAIDS, acetominophen), injections no help. Has tried physio, ergotherapy, acupunture, injections, medications Physio, core strengthening How Long Pain Present15 years. Worse in past 5 year3 years. Worse in past 2 years. Patient not at work at time of treatment11 years. Worse in past 2 years.4 years Location & Type of Modic Changes L5/S1 Modic 1/2 changes. Mild disc protrusion L5/S1Modic 1 changes Disc herniation level of L4-L5L5-S1 discopathy. Moderate Modic 1 changes mostly in inferior endplate of L5Moderate to severe mix Modic 1-2 at inferior endplate of L4. Minimal Modic 1 at superior endplate of L5Pain and Function Score at Treatment Day 0NRS6/10ODI not done NRS 9/10ODI 38% NRS 6-7/10ODI 48NRS 7/10OSW 30% Pain and Function Score after Treatment Done at 10 months. No change in NRS. Reports no change in function. ODI 26% NRS 9/10ODI 48% NRS 6-7/10ODI 48At 6 months post completion: OSW 26% NRS 2-3/10. NRS improvement not attributed to ABX, better due to exercises. Pain Function 1 year After Treatment No change in NRS ODI 22% NRS 0/10ODI not available One year after antibiotic; no pain due to cortisone injection15 months post abx; NRS 6-7/10, ODI 48%.2 years post ATB and 1 year post surgery; NRS 1-2/10, ODI 32%14 month post Abx; NRS 3-4 ODI 24% MRI Findings at One year Slightly improved Modic 1No follow-up available No changes from previous images L4-L5 mix Modic 1-2, increase changes at L5 superior endplate Modic 1Other Treatments/ Considerations, Postantibiotics Ongoing pain and exercise limitations. Not pursuing other treatment at this time. Patient feels better with yoga, epidural steroid injection. replacement, L5/S1Pain better controlled but with regular cycling and meditation.LBP indicates low back pain; NRS, Numerical Pain Rating Index; ODI, Oswestry Disability Index; NSAIDS, nonsteroidal antinflammatories; SI, sacroiliac; PMHx, past medical history; Abx, antibiotic.

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October December 2017 7 There are numerous limitations to our study. This was a small, retrospective analysis that analyzed incomplete data and did not have a comparator group. Our outcomes also did not include effect on the patients work produc tivity and health care utilization. We also used the lower dose of the antibiotic (ie, 500/125 one pill 3 times daily) compared to the higher dose, which may have a clinical advantage given the difference shown in the Albert et al trial.11 We also included patients with Modic changes at multiple levels, as we theorized the bacterial infection could be present at multiple levels and mixed Modic 1 and 2/3 changes, where Modic 1 changes predominated. Finally, this was a retrospective effectiveness analy sis since our patients were a true representation of our clinical setting, which included patients with coexisting mental health issues and were not restricted in exercise during treatment. Our experience is that these trials still make an important contribution to the literature, as similar studies have questioned the results of other land mark randomized controlled trials when applied in other clinical settings.37Therefore, while we understand the limitations of the data presented here, we have stopped the use of antibiotics in the treatment of patients with LBP and Modic changes until other centers have reported on their outcomes. CONCLUSION The use of amoxicillin/clavulanate for 3 months in pa tients with Modic changes and LBP had limited effect on reducing long-term pain and clinical outcomes in a small case series of patients. REFERENCES 1. GBD 2013 Risk Factors Collaborators. Global, regional, and national comparative risk assessment of 79 behavioural, environmental and occupation al, and metabolic risks or clusters of risks in 188 countries, 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet 2015;386(10010):2287-2323. 2. Hoy D, March L, Brooks P, et al. Measuring the global burden of low back pain. Best Pract Res Clin Rheumatol 2010;24(2):155-165. 3. Nijs J, Apeldoorn A, Hallegraeff H, et al. Low tion of predominant neuropathic, nociceptive, or central sensitization pain. Pain Physician 2015;18(3):E333-E346. 4. Corniola MV, Stienen MN, Joswig H, et al. Cor relation of pain, functional impairment, and health-related quality of life with radiological grading scales of lumbar degenerative disc disease. Acta Neurochir (Wien) 2016;158(3):499-505. doi: 10.1007/s00701-015-2700-5. 5. OKeeffe M, Purtill H, Kennedy N, et al. Compara tive effectiveness of conservative interventions havioural/psychologically informed or combined? A systematic review and meta-analysis. J Pain 2016;17(7):755-774. doi: 10.1016/j.jpain.2016.01.473. Table 2. MRI Findings Preand Postantibiotic for Available Patients.Patient Pre-MRI Post-MRI Patient 1 Mild Modic 1 changes at L4 and L5Small disk protrusion (improved from 2014) Moderate Modic 3 changes at L4 endplates Unchanged posttreatment Patient 2Mild Modic 1 at T12 and L1Mild Modic 1 at L3 and L4Moderate Modic 2 L5 & S1Small disc protrusion L3/L4 and L4/L5T12-L1 no change L3/4 worsening Modic 1 volume (still mild range) L5/S1worsening Modic 2 (still moderate range) Patient 4Moderate Modic 1 at L4Minor Modic 1 at L5Small protrusion L4/5Minor Modic 1 L5-S1 Unchanged at L5S1Mild progression at L4/5 (no change to volume classification) Minor improvement in L4-5 protrusion Patient 5Mild Modic 1 changes L5/S1 Small disk herniation L5/S1Moderate Modic 1 changes L5/S1, (increased endplate involvement) Stable disk herniation Patient 7Predominantly Modic 1 moderate volume L4 and L5 Minor Modic 2 at L4/5Small disk herniation L4/5Improved Modic 1 (less endplate involved but still in moderate range) Slight progression Modic 2 still in minor range Patient 8Predominantly mild L5/S1 Modic 1 with Modic 2 Small disk protrusion L5/S1Slightly improved Modic 1 no change in endplate volume No change in disk protrusion Patient 10 L5-S1 discopathy Moderate Modic 1 changes mostly in inferior endplate of L5No changes from previous images Patient 11Moderate to severe mixed Modic 1-2 at inferior endplate of L4. Minimal Modic 1 at superior endplate of L5Increased Modic 1 changes at L4 superior endplate L4/5 with small disk herniation

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8 http://www .cs.amedd.army .mil/amedd_journal.aspx6. Kizhakkeveettil A, Rose K, Kadar GE. Integrative therapies for low back pain that include comple mentary and alternative medicine care: a system atic review. Glob Adv Health Med 2014;3(5):49-64. doi: 10.7453/gahmj.2014.043. 7. Maas ET, Ostelo RW, Niemisto L, Jousimaa J, Hur ri H, Malmivaara A, van Tulder MW. Radiofre quency denervation for chronic low back pain. Co chrane Database Syst Rev 2015;23(10):CD008572. doi: 10.1002/14651858.CD008572.pub2. 8. Froud R, Bjrkli T, Bright P, et al. The effect of reporting funding sources, on standardized ef fect sizes in back pain trials: a systematic review and meta-regression. BMC Musculoskelet Disord 2015;30(16):370. doi: 10.1186/s12891-015-0825-6. 9. Bydon M, De la Garza-Ramos R, Macki M, Baker A, Gokaslan AK, Bydon A. Lumbar fusion versus nonoperative management for treatment of disco genic low back pain: a systematic review and metaanalysis of randomized controlled trials. J Spinal Disord Tech 2014;27(5):297-304. doi: 10.1097/ BSD.0000000000000072. 10. tive study by Forman et al. (1991) on Helicobacter pylori and stomach cancer risk. Cancer Epidemiol 2016;41:159-164. 11. Albert HB, Sorensen JS, Christensen BS, Man niche C. Antibiotic treatment in patients with chronic low back pain and vertebral bone edema (Modic type 1 changes): A double-blind random Eur Spine J 2013;22(4):697-707. 12. Modic MT, Steinberg PM, Ross JS, et al. Degen erative disk disease: assessment of changes in ver tebral body marrow with MR imaging. Radiology 1988;166(1 Pt 1):193-199. 13. Jensen TS, Karppinen J, Sorensen JS, Niinimaki J, Leboeuf-YdeC. Vertebral endplate signal changes (Modic change): a systematic literature review of lower back pain. Eur Spine J 2008;17(11):1407-1422. 14. bert PA, Elliott TS. Association between sci atica and Propionibacterium acnes. Lancet 2001;357(9273):2024-2025. 15. Stirling AJ, Jiggins M. Association between Sci atica and Skin Commensals Cleveland, OH: Inter national Society for the Study of the Lumbar Spine; 2002. 16. Corsia MF, Wack M, Denys G. Low virulence bacterial infections of intervertebral discs and the resultant spinal disease processes. Abstract pre sented at: 38th Annual Meeting of the Scoliosis Research Society; September 10-13, 2003; Quebec City, Canada. 17. Agarwal VJ, Golish R, Kondrashov D, Alamin TF. Results of bacterial culture from surgically excised intervertebral disc in 52 patients undergoing pri mary lumbar disc microdiscectomy at a single level. Spine J 2010;10:S45-S46. 18. Albert HB, Lambert P, Rollason J, et al. Does nu clear tissue infected with bacteria following disc herniations lead to Modic changes in the adjacent vertebrae?. Eur Spine J 2013;22(4):690-696. doi: 10.1007/s00586-013-2674-z. 19. Albert HB, Manniche C, Sorensen J, Dleuran BW. Antibiotic treatment in patients with lowback pain associated with Modic changes Type 1 (bone oedema): a pilot study. Br J Sports Med 2008;42(12):969-973. 20. Talib WH, Saleh S. Propionibacterium acnes Aug ments Antitumor, Anti-Angiogenesis and Immuno modulatory Effects of Melatonin on Breast Cancer Implanted in Mice. PLoS One 2015;10(4):e0124384. Available at: https://doi.org/10.1371/journal.pone. 0124384. Accessed August 14, 2017. 21. McDowell A, Patrick S, Eishi Y, Lambert P, Eady A. Propionibacterium acnes in human health and disease. Biomed Res Int 2013;2013:493564. doi: 10.1155/2013/493564. Epub December 24, 2013. 22. Fritzell P, Bergstrm T, Welinder-Olsson C. Detec tion of bacterial DNA in painful degenerated spinal discs in patients without signs of clinical infection. Eur Spine J 2004;13(8):702-706. 23. Arndt J, Charles YP, Koebel C, Bogorin I, Steib JP. Bacteriology of degenerated lumbar intervertebral disks. J Spinal Disord Tech 2012;25(7):E211-E216. 24. Albert HB. Answer to the Letter to the Editor of Benjamin John Floyd Dean entitled Do these concerning Antibiotic treatment in patients with chronic low back pain and vertebral bone edema (Modic type 1 changes): a double-blind random Eur Spine J (2013) 22:697-707. Eur Spine J 2013 Aug;22(8):1703. doi: 10.1007/s00586-013-2907-1. Available at: https://link.springer.com/article/10.1 007%2Fs00586-013-2907-1. Accessed August 14, 2017. 25. Albert HB. Answer to the letter to the editor of A. Sotto et al. concerning Antibiotic treatment in patients with chronic LOW BACK PAINand ver tebral bone edema (Modic type 1 changes): a dou by Albert HB et al., Eur Spine J (2013) 22:697-707. Eur Spine J 2013;22(8):1706. doi: 10.1007/s00586013-2905-3. Available at: https://link.springer.com/ article/10.1007%2Fs00586-013-2905-3. Accessed August 14, 2017.ANTIBIOTICS IN THE TREATMENT OF PATIENTS WITH LOWER BACK PAIN ASSOCIATED WITH MODIC CHANGES: A CASE SERIES

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October December 2017 9 26. Albert HB, Manniche C. Answer to the letter to the editor of Svend Lings entitled antibiotics for in patients with chronic low back pain and verte bral bone edema (Modic type 1 changes): a doubleAlbert HB et al., Eur Spine J (2013) 22:697-707. Eur Spine J 2014;23(2):473-476. doi: 10.1007/s00586013-2985-0. Available at: https://link.springer.com/ article/10.1007%2Fs00586-013-2985-0. Accessed August 14, 2017. 27. Albert HB. Answer to the Letter to the Editor of Benjamin John Floyd Dean et al. entitled No con inpatients with chronic low back pain and verte bral bone edema (Modic type 1 changes): a doubleAlbert HB et al., Eur Spine J (2013) 22:697-707. Eur Spine J 2013;22(8):1701. doi: 10.1007/s00586013-2906-2. Available at: https://link.springer.com/ article/10.1007%2Fs00586-013-2906-2. Accessed August 14, 2017. 28. Albert HB. Answer to the Editorial of J. ODowd and A. Casey. Eur Spine J 2013;22(8):16981699. doi: 10.1007/s00586-013-2914-2. Available at: https://link.springer.com/article/10.1007%2 Fs00586-013-2914-2. Accessed August 14, 2017. 29. Teichtahl AJ, Urquhart DM, Wang Y, Wluka AE, OSullivan R, Jones G, Cicuttini FM. Modic changes in the lumbar spine and their association with body composition, fat distribution and inter vertebral disc height a 3.0 T-MRI study. BMC Musculoskelet Disord 2016;17:92. doi: 10.1186/ s12891-016-0934-x. 30. Urquhart DM, Zheng Y, Cheng AC, Rosenfeld JV, Chan P, Liew S, Hussain SM, Cicuttini FM. Could low grade bacterial infection contribute to low back pain? A systematic review. BMC Med. 2015;13:13. doi: 10.1186/s12916-015-0267-x. 31. Jensen RK, Leboeuf-Yde C, Wedderkopp N, So rensen JS, Manniche C. Rest versus exercise as treatment for patients with low back pain and Mod ic changes. A randomized controlled clinical trial. BMC Med. 2012;10:22. doi: 10.1186/1741-7015-10-22. 32. Cao P, Jiang L, Zhuang C, Yang Y, Zhang Z, Chen W, Zheng T. Intradiscal injection therapy for de generative chronic discogenic low back pain with end plate Modic changes. Spine J 2011;11(2):100106. doi: 10.1016/j.spinee.2010.07.001. 33. Buttermann GR The effect of spinal steroid in jections for degenerative disc disease. Spine J 2004;4(5):495-505. 34. Coutinho AE, Karen E. Chapman. The anti-in cocorticoids, recent developments and mechanistic insights. Mol Cell Endocrinol 2011;335(1):2-13. doi: 10.1016/j.mce.2010.04.005. 35. Chin KR, Tomlinson DT, Auerbach JD, Shatsky JB, Deirmengian CA. Success of lumbar micro discectomy in patients with modic changes and low-back pain: a prospective pilot study. J Spinal Disord Tech 2008;21(2):139-144. doi: 10.1097/ BSD.0b013e318093e5dc. 36. ODowd J, Casey A Antibiotics a cure for back pain, a false dawn or a new era? Eur Spine J 2013;22(8):1694-1697. doi: 10.1007/s00586-013-28 93-3. 37. Gupta G, Radhakrishna M, Chankowsky J, Asenjo JF. Methylene blue in the treatment of discogenic low back pain. Pain Physician 2012;15(4):333-338. AUTHORS Dr Gupta, a physiatrist, works with the Canadian Forces Health Services Centre-Ottawa and the Alan Edwards Pain Management Unit of the Department of Anesthesia, Montreal General Hospital. He is also an Adjunct Profes sor at McGill University in Montreal, Quebec. Dr Jarzem is an orthopaedic surgeon at Montreal Gen eral Hospital and Jewish General Hospital. He is also an Assistant Professor at McGill University in Montreal, Quebec. Major Meredith, a pharmacist, is the second in com mand of Pharmacy Policy and Standards at the Canadian Forces Health Services Group Headquarters in Ottawa. He also works at the Canadian Forces Health Services Centre (Ottawa) as a clinical pharmacist providing direct patient care in an ambulatory care setting. Dr Radhakrishna is with the Division of Physical Medi cine and Rehabilitation, Department of Medicine, and the Alan Edwards Pain Management Unit of the De partment of Anesthesia, Montreal General Hospital. He is also an Associate Professor at McGill University in Montreal, Quebec. LCol Besemann, a physiatrist, is head of the Canadian Forces physical rehabilitation program at the Canadian Forces Health Services Group Headquarters in Ottawa. He also works at the Canadian Forces Health Services Centre and is a lecturer at the University of Ottawa. Dr Elgueta is a Fellow in the Department of Anesthesia, Dr Charghi is an anesthetist at the Jewish General Hospi tal and a pain physician at the Alan Edwards Pain Man agement unit, Montreal General Hospital. She is also an assistant professor at McGill University, Montreal, Quebec. Dr Chankowsky is a neuroradiologist at the McGill Uni versity Health Center. He is also an Associate Professor and Associate Chair of Diagnostic Radiology at McGill University.

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10 http://www .cs.amedd.army .mil/amedd_journal.aspxMajor extremity amputation has a well-documented as sociation with persistent back pain, with rates of chronic low back pain in patients with major extremity amputa tion reported in the range of 35% to 80%.1-8 The effect of back pain on the patient with major extremity amputa tion is known to decrease health-related quality of life and is associated with increased levels of chronic pain development as well as decreased reported levels of ac tivity.2,9,10 It is also suggested that back pain can be more bothersome to the patient with amputation than pain re lated to either the residual limb or phantom limb.4,8 Most studies that have evaluated back pain in the setting of a prior amputation have included diverse populations with variable patient ages, comorbidities, or even amputation etiologies ranging from tumor to infection to trauma in the same cohort.2-5 As a result, based on current pub garding the likelihood of developing disabling back pain for patients with traumatic or posttraumatic amputation. service members sustaining trauma-related major ex tremity amputations.11,12 The most common mechanism of injury leading to amputation in recent US combat op erations has been by high energy blast, which is unique to this retrospective review in comparison to the pub lished reports from civilian trauma settings.13-15 Review of the medical records for this relatively homogenous group of US service members with amputation (SMAs) has created the largest retrospective cohort of trauma-re lated major extremity amputations of which the authors are aware. The focus of this retrospective analysis was to evaluate the prevalence of disabling back pain in ser vice members with traumatic and posttraumatic major extremity amputation following the recent US military of disabling back pain in a military population to the currently published rates. METHODS This retrospective study was conducted under a pro tocol approved by our institutional review board. The Military Amputation Database (Extremity Trauma and Amputation Center of Excellence, Fort Sam Houston, Texas) was used to identify all primary major extremity to the carpals or tarsals, sustained by US service mem bers between December 1, 2002, and July 30, 2011.11,12 The injury characteristics, diagnoses, and other medical ber with a MEA was cross-referenced with the Joint Theater Trauma Registry (US Army Institute of Sur gical Research, Fort Sam Houston, Texas), the Armed Forces Health Longitudinal Technology Application, ing for dates of injury and level of amputation(s), the presence of associated traumatic spine injuries, and any preor postinjury treatment for back pain. military service branch was also queried for each of the Board (PEB) is a medical evaluation process that occurs following a major injury. The PEB determines whether occupational role or restricted duty, requires further recovery time, or must permanently separate from the for their various disabling conditions on a 0 to 100 point scale, where a total rating greater than 75 indicates that a service member is fully disabled.16For the purpose of this study, the presence of a PEB disability diagnosis related to back pain with a rating back pain. This was the primary outcome measure for the current study. Those SMAs treated for back pain pri or to amputation, including narcotic medication, physi cal therapy, or chiropractic manipulation were excluded any fracture or dislocation of the spine requiring surgi cal stabilization, any fracture of the vertebral body, or Low Rate of Early Disabling Back Pain Following Traumatic or Posttraumatic Major Extremity Amputation CPT James N. Foster, MC, USA CPT Richard K. Hurley, Jr, MC, USA MAJ Chad A. Krueger, MC, USA

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October December 2017 11 fracture of the posterior elements with the exception of isolated transverse process or spinous process fractures. The time from initial amputation until completion of the PEB process was calculated for each SMA, as was the a back pain diagnosis in the health record. A Fishers exact test was used for categorical data and a Students t cance set at P less than .05. RESULTS sustaining one or more MEA between December 2002 and July 2011. The most common amputation level was transtibial, followed by unilateral above the knee, bi lateral above the knee, and bilateral transtibial amputa tions as previously characterized by Krueger et al.12 At the time of data collection, 967 of the 1,221 SMAs had ratings available for review. Among these 967 SMAs, 57 and 910 did not. Fifteen of these 910 SMAs without a injury were given a PEB disability rating related to back pain (DDBP), for a rate of 1.65%. Fourteen of the 57 SMAs with a traumatic spine injury received back pain-related disabil ity ratings, for a rate of 24.56% (1.65% vs 24.56%, P= .0001). This distribution is presented in the Figure. Breaking down the SMAs into upper extremity, lower extremity, and combined upper and lower extremity amputation difference in the rate of DDBP when compared to the group as a whole (Table 1). Among those SMAs whose PEB results were avail able for review, 690 included the date of PEB result, including 11 of the 15 SMAs with the primary out come measure, DDBP. The average time from am putation until PEB completion for these 11 SMAs was 817 days, compared to an average of 547 days for the remaining 679 SMAs whose PEB dates were reviewed. This is a difference of 270 days which P =.096). The duration from in back pain-related diagnosis in the health record was also calculated for the 15 SMAs with DDBP and averaged 15.1 months. CO MM ENT We found that in the absence of a traumatic spine injury, the prevalence of early DDBP was 1.65% in this cohort of SMAs. Those SMAs who had sustained a traumatic spine injury were more likely to receive a back pain dis ability rating as part of the PEB process ( P =.0001) than those SMAs without a spine injury. The anatomic loca tion of the major extremity amputation did not appear to directly correlate with the rate of DDBP; however, there were few SMAs with DDBP in total from which concluSMAs with DDBP was longer than those without DDBP. Recent epidemiologic studies have estimated a global point prevalence of back pain at 10% to 33% of the pop ulation, and there have been multiple publications over the past decade reporting an even higher rate of back pain among patients with major extremity amputations (Table 2).17,18 For instance, low back pain (LBP) rates were 64% among surveyed New Zealand patients with transfemoral amputation, and the percentage of pa tients with restrictions in activities of daily living as a result of LBP were 39%.1 While the major ity of literature regard ing back pain in patients with MEA has been based upon survey responses Table 1. Rate of de novo Disabling Back Pain (DDBP).Amputation(s) Total Subjects Subjects with DDBP Rate of DDBP Unilateral upper extremity (UE) 134 2 1 49% Bilateral UE 8 0 0% Unilateral lower extremity (LE) 544 11 2 02% Bilateral LE 187 1 0. 53% Combined UE and LE 37 1 2 .70% All service members with am putation with completed PEB and no spine injury 910 15 1. 65% Distribution of the 1,221 SMA study subjects according to the cri process, and assignment of a spine-related disability rating. Yes15(1 65%) No895(98 35%) Yes14(24. 56%) No43(75 44%) Spine-related disability rating? Spine-related disability rating? Completed PEB Process910(79 1%) Service members with major extremity amputations December 2002-July 20111,221 No associated spine injury1,150 Associated spine injury71 Completed PEB Process57(80 3%)

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12 http://www .cs.amedd.army .mil/amedd_journal.aspxwith patient-reported levels of pain and disability, this study used the results of a medical evaluation, the PEB process, as a quasi-objective measure of disabling back pain.19 This is an important point of distinction when comparing this study to previously reported results, be cause the PEB process attempts to quantify and objec tively measure for the presence of disabling back pain, whereas other published rates on the prevalence of back pain merely report on the presence of chronic back pain as part of a survey, but do not necessarily account for the intensity or the level of disability associated with the back pain.7As previously mentioned, there are several factors which data to the current study. Namely, prior studies have able within the studied cohort, such as multiple etiolo gies of amputation, widely variable patient age groups, or patients ranging from healthy to those with multiple comorbidities. This study included only amputations re sulting from traumatic injury and only included active duty service members aged from 18 to 47 years ( mean 25 years) and only 2% of SMAs over age 40. The lack back pain between the upper extremity, lower extrem ity, or combined amputation groups when compared to the entire cohort was not surprising, given the very low overall number of SMAs developing early DDBP. The average time from amputation to PEB completion was 817485 days, and, in general, the evaluation oc Hence, the short time from amputation to the medical tor in the lower than expected rate of disabling back pain seen in the results. While the short duration between ing cause for the low rate of DDBP found in this study, another potential contribution to the infrequent develop ment of DDBP may be the abundant resources available to the SMAs. This includes highly trained medical, sur gical, and ancillary care providers as well as access to high end prosthetics and rehabilitation, and even a stateof-the-art facility dedicated entirely to rehabilitation of the war-wounded (Center for the Intrepid, Ft Sam Hous ton, Texas).20,21 The lower rate of DDBP is somewhat un expected, particularly when contrasted against Kulkarni et al reporting a 38% prevalence of moderate to severe back pain which limited activity level in patients with Table 2. Summary of the back pain prevalence among patients with amputation in the literature.Study Population Patients With Amputation Amputation Etiology Prevalence of Back Pain Notes Hammarlund et al2Swedish civilian68Trauma, tumor35%: daily or several times per week Lower extremity amputation only, average of 23 years postamputa tion at time of surveys. Ehde et al3US civilian255Trauma, vascular, infection, diabe tes, tumor, other52%: persistent, both ersome back pain of which 25% consid ered the pain severe and interfering with daily activities56% survey response rate. Average time since amputation 14.215.7 years. Reiber et al7US Veterans581Trauma Chronic back pain:36.2% in Vietnam veterans 42.1% in OIF/OEF veterans Mail and telephone surveys. Includes partial hand and partial foot amputations. Mean number of years since initial limb loss was 38.64 years for the Vietnam cohort, and 3.11.2 years for the OIF/OEF cohort. Kulkarni et al8UK civilian202Trauma63%: moderate to severe back pain Back pain more frequent than stump or phantom limb. 20% of participants were examined with MRI Average follow-up was 19 years (range 2-40 years). 60% of amputees who responded reported back pain within 2 years of the amputation. Smith et al5Irish civilian107Trauma, peripheral arterial disease, diabetic vascular disease, malig nancy, osteomyeli tis, other47.7% with chronic back pain, and of those with back pain, 39.2% rated it se verely bothersome. Mean age 51 years. Mean duration since amputation was 17 years. LOW RATE OF EARLY DISABLING BACK PAIN FOLLOWING TRAUMATIC OR POSTTRAUMATIC MAJOR EXTREMITY AMPUTATION

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October December 2017 13 MEA, which we considered to be a correlate to our term 8 Kulkarni et al found that there were no differences in lumbar magnetic resonance im aging between the back pain and pain-free groups, but stability differences, suggesting that early intervention with gait retraining may prevent disabling back pain.8 Although our analysis of these data was not aimed at and retraining, these are early fundamental components of the rehabilitation that service members receive at the Center for the Intrepid. As such, it may help to explain cohort. These resources are not necessarily available to all pa tients with MEA outside of the US military, especially when considering those patients without health insur ance, as is not an uncommon circumstance in the United States. This fact is further highlighted when consider 5 on patients study, survey results of 107 patients with amputation of patients reported back pain, and 31.3% experienced back pain at least 4 times per week. There was no cor relation found regarding amputation level, although they did report that the intensity of back pain increases with age. In their study, 39.2% of surveyed patients reported ties of daily living, which is higher than our cohort of patients, but the prevalence may be overestimated to some extent because the pain may have been related to This study has limitations inherent to retrospective re views, particularly as in this case being limited by the quality and uniformity of the information included in the medical records. This review included multiple elec tronic medical records across several years and as such the methods of documenting various injuries and medi cal diagnoses varied throughout. There is also only a is the presence of a PEB disability rating related to back pain. The PEB analysis to identify patients with disabling back pain can be viewed as a more objective means of determining disability compared to survey analysis; however, it is limited in that it represents a brief snapshot of disability while a service member remains on active duty status. In the current study, the endpoint for determining DDBP was the PEB evaluation for each SMA. That endpoint was, on average, 547 days after amputation for the cohort as a whole, and was 270 days longer for those who developed the primary outcome measure, DDBP, and received a back-related disability rating. It is possible that a larger number of the SMAs would be found to have disabling back pain if their PEB evaluations occurred later following their amputation, as Kulkarni et al found that only 60% of their respon dents reported the onset of back pain within 2 years of amputation.8 It would be potentially very informative to perform a follow-up study of the same population with patient-answered surveys regarding the frequency and severity of back pain experienced by each SMA. Such back pain more in agreement with that reported in the references cited throughout this article. CONCLUSION The prevalence of early disabling back pain in the ab sence of concomitant traumatic spine injury is lower in this cohort of US service members with amputation than would be expected based on currently published literature. Further research or even a follow-up survey of the same cohort may help establish whether this is in fact a lower prevalence of disabling back pain or merely a lower rate of capturing the diagnosis due to the timing of the evaluations and the limitations of the PEB dis ability rating system. REFERENCES 1. Devan H, Tumilty S, Smith C. Physical activity and lower-back pain in persons with traumatic trans femoral amputation: a national cross-sectional sur vey. J Rehabil Res Dev 2012;49:1457-1466. 2. Hammarlund CS, Carlstrom M, Melchior R, et al. Prevalence of back pain, its effect on functional ability and health-related quality of life in lower limb amputees secondary to trauma or tumour: a comparison across three levels of amputation. Prosthet Orthot Int 2011;35:97-105. 3. Ehde DM, Smith DG, Czerniecki, JM et al. Back pain as a secondary disability in persons with lower limb amputations. Arch Phys Med Rehabil 2001;82:731-734. 4. Smith DG, Ehde DM, Legro, MW, Reiber GE, del Aquila M, Boone DA. Phantom limb, residual limb, and back pain after lower extremity amputations. Clin Orthop Relat Res 1999;361:29-38. 5. Smith E, Comiskey C, Ryall N. Prevalence and pat terns of back pain and residual limb pain in lower limb amputees at the National Rehabilitation Hos pital. Ir J Med Sci 2008;177:53-57. 6. Robbins CB, Vreeman DJ, Sothmann MS, et al. A review of the long-term health outcomes as sociated with war-related amputation. Mil Med 2009;174:588-592.

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14 http://www .cs.amedd.army .mil/amedd_journal.aspx7. Reiber GE, McFarland LV, Hubbard S, et al. Ser vice members and veterans with major traumatic limb loss from Vietnam War and OIF/OEF con J Rehabil Res Dev 2010;47:275-298. 8. Kulkarni J, Gaine WJ, Buckley JG, et al. Chronic low back pain in traumatic lower limb amputees. Clin Rehabil 2005;19:81-86. 9. Ma VY, Chan L, Carruthers KJ. Incidence, preva lence, costs, and impact on disability of common conditions requiring rehabilitation in the United States: stroke, spinal cord injury, traumatic brain injury, multiple sclerosis, osteoarthritis, rheuma toid arthritis, limb loss, and back pain. Arch Phys Med Rehabil 2014;95:986-995. 10. Castillo RC, MacKenzie EJ, Wegener ST, et al. Prevalence of chronic pain seven years following limb threatening lower extremity trauma. Pain 2006;124:321-329. 11. Stansbury LG, Lalliss SJ, Branstetter JG, et al. Amputations in U.S. military personnel in the cur J Orthop Trauma 2008;22:43-46. 12. Krueger CA, Wenke JC, Ficke JR. Ten years at war: comprehensive analysis of amputation trends. J Trauma Acute Care Surg 2012;73(6 suppl 5):S438-S444. 13. Owens BD, Kragh JF Jr, Wenke JC, et al. Combat wounds in operation Iraqi Freedom and operation Enduring Freedom. J Trauma 2008;64:295-299. 14. Ramasamy A, Harrisson S, Lasrado I, et al. A review of casualties during the Iraqi insurgency Injury 2009;40:493-497. 15. Belmont PJ Jr, Goodman GP, Zacchilli M, et al. In cidence and epidemiology of combat injuries sus Freedom by and U.S. Army brigade combat team. J Trauma 2010;68:204-210. 16. Schedule for Rating Disabilities. Washington, DC: US Department of Veterans Affairs; 1998. Avail asp. Accessed August 22 2017. 17. Hoy D, Bain C, Williams G, et al. A systematic review of the global prevalence of low back pain. Arthritis Rheum 2012;64(6):2028-2037. 18. Walker BF. The prevalence of low back pain: a sys tematic review of the literature from 1966 to 1998. J Spinal Disord 2000;13:205-217. 19. Army Regulation 635-40: Personnel Separations. Physical Evaluation for Retention, Retirement, or Separation Washington, DC: US Department of the Army; 2017. Available at: http://www.apd.army. mil/epubs/DR_pubs/DR_a/pdf/web/AR635-40_ Web_FINAL.pdf A ccessed August 29, 2017. 20. Fergason J, Keeling JJ, Bluman EM. Recent ad vances in lower extremity amputations and pros thetics for the combat injured patient. Foot Ankle Clin N Am 2010;15:151-174. 21. Granville R, Menetrez J. Rehabilitation of the lower-extremity war-injured at the center for the intrepid. Foot Ankle Clin N Am 2010;15:187-199. AUTHORS CPT Foster is an orthopedic surgeon with Orthopedic Surgery Services, Martin Army Community Hospital, Fort Benning, Georgia. CPT Hurley is an orthopedic surgeon with the Depart ment of Orthopedics and Rehabilitation, Womack Army Medical Center, Fort Bragg, North Carolina. MAJ Krueger is an orthopedic surgeon with the De partment of Orthopaedics, San Antonio Military Medi cal Center, Joint Base San Antonio-Fort Sam Houston, Texas.LOW RATE OF EARLY DISABLING BACK PAIN FOLLOWING TRAUMATIC OR POSTTRAUMATIC MAJOR EXTREMITY AMPUTATION

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October December 2017 15The active duty military population is an athletic com munity that participates in a variety of physically chal lenging activities and is subject to a wide variety of are among the most common injuries, with reported incidence rates as high as 58.4 per 1,000 person-years among cadets at the United States Military Academy, amounting to a 10-fold increase compared to civilian epidemiologic reports.1 Performing a thorough history and physical examination and obtaining appropriate diagnosis of a musculoskeletal complaint. When these modalities fail to elicit an appropriate diagnosis, pri mary care providers are frequently ordering advanced imaging, including magnetic resonance imaging (MRI) studies, prior to referral to specialists.2 Avoiding unnec essary, costly advanced imaging and preventing overuse of MRI in a primary care setting for diagnosing ankle pathology was the goal of a recent process improvement project at a military treatment facility. Magnetic resonance imaging is best used in cases where the differential diagnosis is narrow, and a precise understanding of the pathology is required for preop erative planning.3 Current trends, however, show mag netic resonance imaging being used more frequently as a screening tool.4 Magnetic resonance imaging can be overdiagnosis and treatment.5 Increasing medical costs, decreasing reimbursements, and overuse of imaging modalities have led to a growing interest in processes to decrease use of costly, oftentimes unnecessary, tests.6Concern regarding the use of ankle MRI studies prompt ed fellowship-trained foot and ankle surgeons at our in stitution to hypothesize that ankle MRI was overused in the military setting, and inspired a process improvement initiative. The purpose of the initiative was to: evaluate the use of ankle MRI studies ordered by all health care providers in the military population; correlate the MRI results to their treatment pathway of operative or non operative treatment; and propose solutions to improve use of ankle MRI. To evaluate this, we studied the MRI ordering patterns of both orthopaedic surgeons and non orthopaedic providers (NOPs) from internal medicine, Use of Ankle Magnetic Resonance Imaging in the Active Duty Military Population: The Results of a Process Improvement Project Maj Harold J. Goldstein, USAF, MC CPT Richard K. Hurley, Jr, MC, USA Maj Andrew J. Sheean, USAF, MC Maj Michael Tompkins, USAF, MC Col Patrick M. Osborn, USAF, MC ABSTR A CT Background: Preventing overuse of magnetic resonance imaging (MRI) for diagnosing ankle pathology was the goal of a process improvement project at a military treatment facility. Methods: Ordering patterns for MRI of nonorthopaedic providers and orthopaedic surgeons were evaluated over 2 separate periods. An educational initiative on appropriate use of MRI in evaluating ankle complaints was conducted between the 2 periods. Results: Between October 2009 and March 2010, 230 ankle MRIs were performed at our institution, com pared to 347 ankle MRIs performed between December 2012 and August 2013. A lower number of patients underwent operative procedures after the education process than before (17% versus 25%). Fellowship-trained foot and ankle surgeons produced the highest number of operative patients with their MRI ordering practices (P=.003 and P=.0001 for Phases 1 and 2 respectively). There was no change in the number of ankle MRI stud ies ordered each month following the educational initiative (38.3 and 38.5 for Phases 1 and 2 respectively). Conclusions: The majority of patients undergoing ankle MRI did not undergo operative intervention. Foot and ankle surgeons produce the highest number of operative patients with their MRI ordering practices. Education alone was ineffective in altering ankle MRI ordering patterns.

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16 http://www .cs.amedd.army .mil/amedd_journal.aspxfamily medicine, etc. Further, in an effort to improve overall ankle MRI use, we undertook an educational outreach initiative to improve understanding of NOPs of the clinical utility of advanced imaging. METHODS This process improvement project consisted of 2 phases and was led by the Department of Orthopaedics. The ra diographic database at our institution (Impax) was que ried for all ankle MRI studies performed consecutively from October 1, 2009 to March 31, 2010 (Phase 1). We limited the results of the search to only active duty ser vicemembers aged 18 years and older. The data collect ed from the electronic radiographic database included ankle MRI, date of the MRI, and specialty of provider who ordered the study. Next, the orthopaedic clinical scheduling system (AHLTA) was queried and cross-ref erenced to the list of ankle MRI studies to determine if patients were ultimately referred for orthopaedic evaluation. Finally, the surgery scheduling system (S3) was referenced to determine what surgeries were performed on patients from the ankle MRI studies list. No personal for the MRI and subsequent operative procedure(s) were whether or not the patient underwent an orthopaedic operative intervention. Secondary measures evaluated included the specialty of the provider ordering the study, changes in referral patterns, and whether or not plain radiographs were obtained prior to MRI. The results of Phase 1 of the process improvement project were then presented to hospital leadership, and an education plan was developed and implemented. Approved measures were implemented from August to November 2012 and included updated clinical referral guidelines on the health system intranet available to all providers. not be ordered prior to referral to an orthopaedic surgeon, and included recommendations for ordering plain radio graphs prior to referral to an orthopaedic surgeon. This update was announced to all providers electronically as well as at 3 different professional staff meetings for the hospital. Since quarterly attendance at this meeting is mandated by hospital leadership, it was felt that the in formation would be disseminated appropriately. Finally, the orthopaedic foot and ankle surgeons provided 3 inservices on indications for advanced imaging, including MRI, for outlier clinics and the Departments of Internal Medicine and Family Medicine. Once the education pro cess was completed, the radiographic database was once again searched from December 1, 2012 to August 30, 2013 (Phase 2) with the same criteria as the initial time period. Statistical analysis was performed using Fishers exact test (GraphPad Software, Inc, La Jolla, CA). Sta P<.05. RESULTS Phase 1From October 1, 2009 to March 31, 2010, 230 ankle MRI studies were performed on active duty personnel. Of the 230 active duty servicemembers with ankle MRI stud ies, 143 (62%) patients had an MRI ordered by NOPs and 87 patients (38%) had an MRI ordered by an ortho paedic provider. There were 17 patients (7%) who did not have plain radiographs performed prior to the MRI. Of the 143 MRI scans ordered by the NOPs, 98 patients (69%) were referred to an orthopaedic provider. During Phase 1 of the process improvement initiative, 185 of 230 patients, (80%) of this cohort were evaluated and treated by the orthopaedic surgery department at our fa cility. The most common complaints stated as reasons for obtaining an MRI were pain followed by instability. The most common diagnoses obtained by MRI included chronic injuries to the lateral ankle ligaments, talus os teochondral defects, and Achilles tendinosis. Of the entire cohort of patients undergoing ankle MRI, 59 of 230 patients (25%) were eventually indicated for surgery. Of the 143 patients for which an ankle MRI study was ordered by NOPs, 98 (69%) patients were re ferred to orthopaedics for evaluation, and of those, 33 (23%) underwent an operative procedure (Figure 1). By comparison, the orthopaedic group ordered 87 ankle MRI studies and 26 (30%) patients underwent an opera tive procedure (Figure 2). Within the orthopaedic group, foot and ankle surgeons and podiatrists were evaluated as groups separate from the rest of the orthopaedic de partment. Ankle MRI studies ordered by podiatrists USE OF ANKLE MAGNETIC RESONANCE IMAGING IN THE ACTIVE DUTY MILITARY POPULATION: THE RESULTS OF A PROCESS IMPROVEMENT PROJECTFigure 1. Results from Phase 1: 143 patients with ankle MRI studies ordered by nonorthopaedic providers. N=143 33 patients (23% N) underwent an operative procedure 98 patients (69% N) referred to orthopaedics 45 patients (31% N) not referred to orthopaedics

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October December 2017 17 resulted in 6 out of 40 (15%) patients un dergoing an operative procedure, while 20 of 47 (43%) patients with MRI studies ordered by an orthopaedic surgeon un derwent an operative procedure. When fellowship-trained foot and ankle or thopaedic surgeons were excluded from this analysis, only 8 of 26 patients (30%) underwent an operative procedure. Of the 21 patients evaluated by a fellowshiptrained foot and ankle surgeon, 12 (57%) underwent an operative procedure. When comparing the NOPs to the ortho difference in yield of operative patients with ankle MRI studies between the 2 groups ( P =.28). However, there was tion of patients with ankle MRI associ ated with an eventual operative intervention ordered by fellowship-trained foot and ankle orthopaedic surgeons compared to those with ankle MRI ordered by NOPs ( P =.003). When comparing fellowship-trained foot and ankle orthopaedic surgeons and orthopaedic surgeons, patients with ankle MRI studies between the 2 groups ( P =.08). The most common operative procedures per formed are listed in the Table.Phase 2From December 1, 2012 to August 30, 2013, 347 ankle MRI studies were performed on active duty personnel. Of the 347 active duty servicemembers with ankle MRI studies, 228 (66%) patients had ankle MRI studies or dered by NOPs and 119 patients (34%) had an MRI or dered by an orthopaedic provider. There were 58 patients (17%) who did not have plain radiographs performed prior to the MRI. Of the 228 MRI studies ordered by the NOPs, 143 patients (63%) were referred to an orthopae Phase 1 ( P =.27). There were 262 of 347 (76%) patients evaluated and treated by the orthopaedic surgery depart 1 ( P =.19). Pain and instability remained the most com mon patient complaints, and there were no changes in the most common diagnoses obtained by MRI. Of the entire cohort of patients undergoing ankle MRI, 58 of 347 (17%) patients were eventually indicated for surgery. Of the 228 patients for which an ankle MRI study was ordered by NOPs, 143 (63%) patients were referred to orthopaedics for evaluation, and of those, 29 (13%) underwent an operative procedure (Figure 3). By comparison, the orthopaedic group ordered 119 ankle MRI studies and 29 (24%) patients underwent an op erative procedure (Figure 4). Foot and ankle surgeons as well as podiatrists were evaluated as groups separate from the rest of the orthopaedic department once again. Ankle MRI studies ordered by podiatrists resulted in 4 Figure 2. Results of Phase 1 data collection. Percentages represent the yield of operative patients based on the provider group that ordered the ankle MRI. Included next to percentages are the number of operative patients relative to the Percentage of Patients Undergoing an Operative Procedure 0% 10% 20% 30% 40% 50% 60%Foot and Ankle Surgeons Podiatrists Orthopaedic Surgeons Nonorthopaedic Providers 57% (12/21)* 23% (33/143) 15% (6/40) 30% (8/26) Figure 3. Results from Phase 2: 228 patients with ankle MRI studies ordered by nonorthopaedic providers. 29 patients (13% N) underwent an operative procedure N=228 143 patients (63% N) referred to orthopaedics 85 patients (37% N) not referred to orthopaedics The most common procedures performed on patients with preoperative ankle MRI studies. Lateral ankle ligament reconstruction Ankle arthroscopy with debridement Microfracture of osteochondral defects Reconstruction of cavovarus foot Reconstruction of planovalgus foot Excision of osteophytes

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18 http://www .cs.amedd.army .mil/amedd_journal.aspxout of 29 (14%) of patients undergoing an operative procedure, while 25 out of 90 (28%) of patients with MRI studies or dered by an orthopaedic surgeon under went an operative procedure. When the foot and ankle surgeons were excluded from this analysis, only 9 of 50 patients (18%) underwent an operative procedure. Of the 40 patients with ankle MRI stud ies ordered by foot and ankle surgeons, 16 (40%) had an operative procedure performed. When comparing the NOPs to the ortho higher yield of operative patients ( P =.01) with ankle MRI studies in favor of the or thopaedic group for Phase 2. There con operative patients from the subgroup of patients with an ankle MRI ordered by foot and ankle surgeons compared to those with an ankle MRI ordered by NOPs ( P =.0001). When comparing fellowshiptrained foot and ankle surgeons to orthopaedic surgeons, of operative patients following MRI for Phase 2 ( P =.03). The most common procedures performed during Phase 2 were no different compared to Phase 1. A lower yield of patients underwent an operative proce dure after the education process than before (17% versus Phase 2 in the overall number of operative patients with an ankle MRI study, regardless of which provider or dered the ankle MRI ( P =.01). There was no difference in patient referral rates to orthopaedics in Phase 1 versus Phase 2 following the order of an ankle MRI by NOPs ( P prior to ordering advanced imaging in Phase 2 compared to Phase 1 ( P =.001). There was no change in the number of ankle MRI studies ordered each month (38.3 ordered in the preeducation process, and 38.5 posteducation). CO MM ENT Throughout both phases of the process improvement ini tiative, fellowship-trained foot and ankle surgeons pro duced the highest yield of operative patients with their MRI ordering practices ( P =.003 and P =.0001 for Phase 1 and Phase 2 respectively). Following the educational initiative, there was no decrease in the number of monthly ankle MRI studies performed, fewer patients with ankle MRI studies underwent operative procedures, and fewer radiographs were ordered before advanced imaging. Ad ditionally, the decrease in operative candidates between orthopaedics surgeons and fellowship-trained foot and ankle surgeons in Phase 2 could suggest that the neces sity of ongoing training on the indications for ankle MRI is not isolated to the NOPs, and should include ortho paedic surgeons as well. The fact that referral rates did not change also raises concern that there remains a large group of patients (>30% in both phases) that may have undergone unnecessary advanced imaging. Few studies in the orthopaedic literature evaluate use 201 patients that were evaluated over a 3-month period; 19.9 % had MRI studies of the ankle during their course of treatment, 15.4% presented to the initial visit with a MRI scan from an outside provider, and 4.5% of the patients received an MRI scan ordered by the foot and ankle specialist .3 This study further mentions that 87% of the prereferral MRI scans were thought to be unnec essary, and all 9 MRI studies ordered by the foot and ankle specialist were useful in the care of the patient .3 Bradley et al evaluated the use of MRI in chronic shoul preevaluation MRI scans had no effect on the outcomes further analysis revealed a tendency towards patients with an MRI to choose surgery over nonoperative treat ment when patients had knowledge of pathologic anato my from an advanced imaging modality.4 These authors concluded that routine preevaluation with MRI does not outcome and should not be used as a screening tool for atraumatic shoulder pain before a comprehensive clini cal evaluation of the shoulder.4 When ordering an MRI, caution must also be taken, as false positive results occur USE OF ANKLE MAGNETIC RESONANCE IMAGING IN THE ACTIVE DUTY MILITARY POPULATION: THE RESULTS OF A PROCESS IMPROVEMENT PROJECTFigure 4. Results of Phase 4 data collection. Percentages represent the yield of operative patients based on the provider group that ordered the ankle MRI. Included next to percentages are the number of operative patients relative to the Percentage of Patients Undergoing an Operative Procedure 40% (16/40)* 14% (4/29) 13% (29/228) 18% (9/50) Foot and Ankle Surgeons Nonorthopaedic Providers Orthopaedic Surgeons Podiatrists 0% 10% 20% 30% 40% 50% 60%

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October December 2017 19 and can further alter the perception of the diagnosis and subsequent treatment plan. Saxena et al evaluated 100 patients with asymptomatic ankles who had an ankle MRI performed, and noted that 66% of the patients had no history of an ankle sprain and 34% had a history of at least one ankle sprain.5 Results from the study showed that 30% of asymptomatic pa ligament and peroneal tendons, and 11% had an abnor 5 Schneck et al have documented that 90% of patients with lateral ankle instabil ity can be treated nonoperatively.6 In our process im provement initiative, 93% of patients had a radiographic abnormality, but few underwent an operative procedure. This is further highlighted by the fact that Achilles ten dinosis appeared as one of the most common diagnoses are not among most commonly performed procedures as shown earlier in the Table. The large number of ra diographic abnormalities does not necessarily correlate ing results previously published. Overuse of advanced imaging studies increases medical costs, places undue stresses on the patients time, and can lead to adverse outcomes.7-8 Radiologists have recog nized that more expensive imaging modalities are being overused, and are taking the lead in the reform process by implementing strategies to decrease the unnecessary use .9,10 Solutions have been proposed for improving use of medical imaging which include a national collaborative effort to develop evidence-based appropriateness criteria for imaging, greater use of practice guidelines in request ing and conducting imaging studies, decision support at point of care, education of referring physicians, accredi tation of imaging facilities, management of self-referral and defensive medicine, as well as payment reform.11-14 Decision support at the point of care can include radiolo gist or fellowship-trained specialist approval of advanced imaging concurrent with a patient referral. From 2000 to 2006, Medicare expenditures for diagnostic imaging represented the highest growth rate compared with all other specialties, and spending on imaging studies per 15 Even though solutions have been proposed, overuse of advanced imaging modalities continues to be an area of ongoing concern. This study has several limitations. First, it is possible that patients were indicated for surgery outside the in terval we chose to analyze; however, the percentage of patients evaluated during Phase 1 and Phase 2, 80% and 76% respectively, suggests that the patterns of evalua tion and treatment among groups appear to be relatively similar. Second, the utility of advanced imaging such as an ankle MRI is multifaceted, and this study only considered the value MRI may provide in terms of pre operative planning. We concede that measuring the treatment pathway is an imperfect outcome measure to assess the utility of ankle MRI, but in this process im provement initiative, we did not intend to evaluate the effect of the MRI on surgeon decision making. Third, the process improvement strategy was limited to educa tional initiatives primarily targeted at primary care phy sicians in the clinical decision pathway, but no formal decision support system or imaging approval pathway was implemented to target overuse of MRI. Studies of managed care systems have demonstrated that preauthorization of studies or clinical decision support sys tems can decrease the use of advanced imaging modali ties.11-14 The importance of systematic changes to control overuse is paramount considering the high rates of turn over among military healthcare providers who may be missed by any education program during deployments and frequent changes of station. It is unclear as the ex tent to which provider turnover during the intervals we chose to analyze affected the current results. Finally, the percentage of patients indicated for surgery in the decreased because the foot and ankle service is often and advanced imaging is often required. Results of this process improvement initiative support the assertions of the fellowship-trained foot and ankle surgeons that ad vanced imaging should be obtained at the discretion of the foot and ankle service. CONCLUSION Among servicemembers undergoing ankle MRI, there was a relatively low proportion of patients that ultimately underwent an operative intervention. With this in mind, physicians should reserve advanced imaging of the ankle after conservative treatment measures fail, and the deci sion to order advanced imaging may be best reserved for the fellowship-trained foot and ankle surgeons. More over, these data suggest that a process improvement ini tiative to decrease rates of advanced imaging use through education alone was ineffective in altering practice pat terns among both orthopaedic and NOPs. Future analysis focused on education coupled with decision support sys tems or image utilization pathways may reveal improved use of advanced imaging in a military setting. REFERENCES 1. Waterman BR, Belmont PJ, Cameron KL, et al. Epidemiology of ankle sprain at the United States Military Academy. Am J Sports Med 2010;38(4):797-803.

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20 http://www .cs.amedd.army .mil/amedd_journal.aspx 2. Baldor RA, Quirk ME, Dohan D. Magnetic reso nance imaging use by primary care physicians. J Fam Pract 1993;36:281-285. 3. Tocci SL, Madom IA; Bradley MP, et al. The diag nostic value of MRI in foot and ankle surgery. Foot Ankle Int 2007;28(2):166-168. 4. Bradley MP, Tung G, Green A. Overutilization of shoulder magnetic resonance imaging as a diagnos tic screening tool in patients with chronic shoulder pain. J Shoulder Elbow Surg 2005;14(3):233-237. 5. Saxena A, Luhadiya A, Ewen, B, et al. magnetic eral ankle pathologic features with asymptomatic ankles. J Foot Ankle Surg 2011;50:413-415. 6. Schneck R Jr, Coughlin M. Lateral ankle instabil ity and revision surgery alternatives in the athlete. Foot Ankle Clin North Am 2009;14:205-14. 7. Emery DJ, Shojania KG, Forster AJ, et al. Overuse of magnetic resonance imaging. JAMA Intern Med 2013;173:823-825. 8. Flynn T, Smith B, Chou R. Appropriate use of di agnostic imaging in low back pain: a reminder that unnecessary imaging may do as much harm as good. J Orthop Sports Phys Ther 2011;41(11):838-846. 9. Armao D, Semelka R, Elias J. Radiologys ethical responsibility for healthcare reform: tempering the overutilization of medical imaging and trim ming down a heavyweight. J Magn Reson Imaging 2012;35(3):512-517. 10. Hendee W, Becker G, Borgstede J, et al. Address ing overutilization in medical imaging. Radiology 2010;257(1):240-245. 11. Bernardy M, Ullrich CG, Rawson JV, et al. Strate gies for managing imaging utilization. J Am Coll Radiol 2009;6:844-850. 12. Blachar A, Tal S, Mandel A, et al. Preauthoriza tion of CT and MRI examinations: assessment of a managed care preauthorization program based on the ACR Appropriateness Criteria and the Royal College of Radiology Guidelines. J Am Coll Radiol 2006;3:851-859. 13. Blackmore CC, Mecklenburg RS, Kaplan GS. ef fectiveness of clinical decision support in con trolling inappropriate imaging. J Am Coll Radiol 2011;8:19-25. 14. Lehnert BE, Bree RL. Analysis of appropriateness of outpatient CT and MRI referred from primary care clinics at an academic medical center: how critical is the need for improved decision support?. J Am Coll Radiol 2010;7:192-197. 15. Sura A, Ho A. Enforcing quality metrics over equipment utilization rates as means to reduce cen ters for Medicare and Medicaid services imaging costs and improve quality of care. J Clin Imaging Sci 2011;1(2):28-31. AUTHORS Maj Goldstein is the Orthopedic Surgeon at the Medical Treatment Facilty, Osan Air Base, Republic of Korea. CPT Hurley and Maj Sheean are with the Department of Orthopaedic Surgery, San Antonio Military Medi cal Center, Joint Base San Antonio-Fort Sam Houston, Texas. When this article was written, Maj Tompkins was with the Department of Orthopaedic Surgery, USAF Hospital Langley, Joint Base Langley-Eustis, Virginia. Col Osborn is the Residency Program Director, Depart ment of Orthopaedic Surgery, San Antonio Military Medical Center, Joint Base San Antonio-Fort Sam Hous ton, Texas.USE OF ANKLE MAGNETIC RESONANCE IMAGING IN THE ACTIVE DUTY MILITARY POPULATION: THE RESULTS OF A PROCESS IMPROVEMENT PROJECT Articles published in the Army Medical Department Journal are indexed in MEDLINE, the National Library of Medicines bibliographic database of life sciences and biomedical information. Inclusion in the MEDLINE database ensures that citations to AMEDD Journal to researchers during searches for relevant information using any of several bibliographic search tools, including the National Library of Medicines PubMed service.

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October December 2017 21Methylsulfonylmethane (MSM) is a sulfur-containing compound, a metabolite of dimethyl sulfoxide, and oc curs naturally at low levels in many common foods in cluding fruits and vegetables.1,2 Basic science literature supports that MSM is rapidly absorbed, well distributed, and completely excreted from the body.3Methylsulfonylmethane has been shown to exert some to the use of MSM as a dietary supplement.4-6 Animal in ulcerative colitis and lower extremity edema.7,8 MSM has also shown promise as an ergogenic antioxidant in untrained men and women initiating an exercise regi men.4,6 Recent medical trials in humans with MSM in the treatment of osteoarthritis have demonstrated that MSM was superior to placebo in controlling pain related to mild-to-moderate osteoarthritis of the knee, is at least 3,8 Furthermore, multiple trials have demonstrated multiple positive ef 3,8-10The attrition rate during initial entry military training has become one of the most serious and costly concerns for all military services. Injuries account for 5 to 22fold greater days lost to training than illnesses.11 Among trainees, 80% to 90% of the lost to training days were due to training-related injuries.12 The cumulative inci dence of injuries requiring an outpatient visit in the ini tial 8 weeks of US Army Initial Entry Training is 25% to 55%.12 The cumulative incidence of overuse injuries in trainees was 37% and comprised 80% of all injuries.13 Discharge rates due to injury vary between 0.3% and 8.3% for initial entry Soldiers, but have been reported as high as 36% for Soldiers not completing their initial contractual obligation.11-15 Following this, studies from the US Army Center for Health Promotion and Preven tive Medicine* have demonstrated that intervention strategies can successfully reduce injuries without com promising mission effectiveness.15The purpose of this study was to evaluate the use of 3 mg (750 mg tablets with 2 tablets twice daily) of orally ad ministered MSM to improve patient reported outcome measures at 30 and 60 days. Our hypothesis was that the patients taking the MSM would demonstrate improved patient-reported outcomes at 30 and 60 days following A Randomized Controlled Trial Evaluating Methylsulfonylmethane Versus Placebo to Prevent Knee Pain in Military Initial Entry TraineesCPT David J. Tennent, MC, USA James K. Aden, PhD CPT Christina M. Hylden, MC, USA COL Anthony E. Johnson, MC, USA MAJ Benjamin K. Kocher, SP, USA ABSTR A CT Background: Methylsulfonylmethane (MSM) is a naturally occurring sulfur containing substance that has supplement to improve pain in those patients with knee osteoarthritis have shown superiority compared to placebo. However, these studies are not translatable to active individuals performing high impact activities and have not evaluated MSM as a preventative measure. Methods: A total of 180 subjects ranging in age from 18 to 40 years were enrolled. Subjects were randomized into 2 groups receiving either 3 grams OptiMSM methylsulfonylmethane (Bergstrom Nutrition, Vancouver, WA) or a placebo for 8 weeks. Outcomes measured were the Knee Osteoarthritis Outcome Score (KOOS) and Results: subscales or the 6 POMS subscales at 30 days or 60 days. Conclusion: provement in KOOS or POMS. Redesignated as the US Army Public Health Center in 2016.

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22 http://www .cs.amedd.army .mil/amedd_journal.aspxinitiation of supplementation during their training pro gram as compared to placebo. METHODS A randomized, double-blind, placebo controlled trial was conducted under an Institution Review Board ap proved protocol. A total of 180 men and women ranging in age from 18 to 40 years were enrolled from the Army BAse San Antonio-Fort Sam Houston, Texas. All train ees were invited to participate during the initial week of BOLC, a course that covers approximately 8 weeks Interested subjects were then screened and examined by one of the study investigators. Exclusionary crite ria included a history of cancer, current statin use, use medicine such as narcotics, a history of renal or hepatic dysfunction, a history of cardiac abnormality, current pregnancy, or other medical condition that would pre vent full participation in the study. Randomization was conducted using an un bound random number generator that was main tained by the dispensing pharmacy and blinded from all study investigators until completion of the study. The 2 arms of study intervention consisted of OptiMSM methylsulfonylmethane (Bergstrom Nutrition, Vancouver, WA) and a matched placebo. Both of these were provided in 750 mg tablets and participants were instruct ed to take 2 tablets twice daily for 8 weeks or until the completion of their training program. Patient reported outcome measures were ob tained at the time of study enrollment, at 30-day follow-up and at 60-day follow-up. Measures in cluded were the Knee Osteoarthritis Outcome (POMS). The KOOS consists of 5 subscales: Pain, other Symptoms, Function in Daily Liv ing (ADL), Function in Sport and Recreation, and Knee Related Quality of Life (QOL). The ent mood state (disturbance) by a list of adjec tives. The POMS measures 6 dimensions of af fect or mood, including tension-anxiety, depres sion-dejection, anger-hostility, vigor-activity, fatigue-inertia, and confusion-bewilderment. This study uses the fatigue-inertia subset as an endpoint. The 30-day follow-up was conducted while the tions which include sleeping in tents and performing daily activities such as carrying gear, marching, com for all trainees during their entire BOLC course. The 60-day follow-up was conducted when subjects had re turned to a classroom setting and prior to their gradua tion from the course. Statistical analysis was conducted using descriptive sta tistics, one-way ANOVA with repeated measures, and paired t tests where appropriate. A moderate Bonferroni comparisons being made at 30 and 60 days. The applica tion SAS 9.2 (SAS Institute Inc, Cary, NC) was used for all statistical analysis. RESULTS As shown in the Figure, a total of 180 subjects were en rolled in the study and initiated treatment. Of these, 13 A RANDOMIZED CONTROLLED TRIAL EVALUATING METHYLSULFONYLMETHANE VERSUS PLACEBO TO PREVENT KNEE PAIN IN MILITARY INITIAL ENTRY TRAINEES Completed 60-day follow-up (n=26) Patient discontinued therapy (n=7) Noncompliance (n=6) (n=1) Adverse events (n=0) Lost to follow-up (n=24) Withdrawn (n=1) Completed 30-day follow-up (n=58) Patient discontinued therapy (n=22) Noncompliance (n=11) (n=1) Adverse events (n=10) Lost to follow-up (n=1) Withdrawn (n=1) MSM Randomized (n=89) Received MSM (n=82) Failed to initiate (n=7) Completed 30-day follow-up (n=66) Completed 60-day follow-up (n=36) Patient discontinued therapy (n=17) Noncompliance (n=9) (n=1) Adverse events (n=7) Lost to follow-up (n=0) Patient discontinued therapy (n=3) Noncompliance (n=3) (n=0) Adverse events (n=0) Lost to follow-up (n=27) Placebo Randomized (n=91) Received placebo (n=83) Failed to initiate (n=8) Excluded (n=20) Did not meet enrollment criterion Enrolled and randomized (N=180) Assessed for eligibility (N=200)

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October December 2017 23 subjects randomized to the MSM group and 9 subjects randomized to the placebo group were withdrawn from the study for an adverse event related to an injury sus tained during training. Data was available on 124 sub jects for the 30-day collection and 62 subjects for the 60-day collection. A summary of group demographic characteristics is presented in Table 1. There were no mass index (BMI), or gender. The MSM group was sig POMS subscales at baseline, 30 days, or 60 days (Ta subscale for MSM were seen from baseline to 30 days (3.412.68, P =.0135) or baseline to 60 days (5.813.51, P =.0013), improvement in the quality of life subscale for placebo was seen from baseline to 30 days and baseline to 60 days (Table 3). When analyzing the POMS from baseline to 30 days, subscale worsening was seen for MSM in An ger (3.380.72, P <.0001), Vigor (1.620.70, P =.193), and Fatigue (2.620.51, P <.0001), and for Placebo in Depression (2.280.55, P <.0001), Anger (2.460.69, P =.0004), Vigor (1.640.66, P =.0137), Fatigue (2.830.49, P <.0001), and Confusion (0.820.34, P =.0148) (Table 3). These differences were not seen at baseline to 60 days. CO MM ENT This study found that those patients who took 3 mg MSM daily displayed no improvements in any KOOS or POMS subscale when compared to placebo when taken for 30 days or 60 days in a high-impact, initial entry military training population. Subjects taking MSM sup plementation for 30 days or 60 days also did not have appreciable improvements in either patient-reported outcome measure. No differences were found in adverse events between groups. cacy of MSM as an adjunct for the treatment of osteoar thritis by using the Western Ontario and McMaster Uni versities Osteoarthritis index (WOMAC) as an outcome measure. In a double-blind, randomized, controlled trial, physical function and total scores, and VAS pain scores with 3.375 g MSM orally administered daily.10 Kim pain and physical function impairment when 6 grams of MSM was administered orally.16 Likewise, Pagonis et al 26 weeks with 6 g MSM administered orally.17In contrast to those studies, the current study used the KOOS as a primary outcome measure as it encompasses Table 1. Initial demographics for all subjects.MSM Placebo P value Age (years) 286 .9 26 45 0 041 Height (m) 1 70 .1 1 70 .1 .722 Weight (kg) 75 413 7 74 913 8 368 BMI 24 .93 1 24 73 .1 171 Gender (male/female) 53/36 54/37 843 Table 2. Primary outcomes over 60 day treatment period comparing MSM to placebo ( values presented as meanSD).MSM Placebo Groups ( P value) Baseline 30 Day 60 Day Baseline 30 Day 60 Day Baseline 30 Days 60 Days KOOS Pain 87. 042 78 84 602 96 85 293 .69 87. 962 77 89. 252 87 90 443 48 .6489 0281*. 0477*Symptom 83. 072 79 82 862 96 83. 023. 63 84 672 .78 85 602 .87 87. 183 41 4273 1944 1023 ADL 92 792 11 91. 222 27 91 562 .94 93 422 .10 94 332 19 94 572 .73 .6757 0543 .1420 Sport 79 213 .91 80 294 17 80 125 31 80. 503. 88 82 504 04 85 114 99 6476 4564 4564 QOL 77. 393 92 78 584. 09 78 474 82 79 103 .90 82 504 00 84. 914. 60 5460 1801 0586 POMS Tension 14 01 0. 79 14 620 86 13 211 16 14 132 78 14 .810 .82 13 81. 07 8248 .7579 4635 Depression 16 030. 89 17 160 .98 16 471 38 15 560 88 17 840 .93 16 811 26 4637 3207 7217 Anger 14 801 10 18 .151 21 15 .751 .71 14 890 55 17 351 16 16 351 56 .9055 3493 6117 Vigor 27 061. 31 25 431 41 27 201. 85 25 191 29 23 551 36 25 871 .71 0479*. 0606 3022 Fatigue 11 080. 87 13. 700. 95 10 671 29 11 310 86 14 140 91 10 691 19 7162 5088 .918 Confusion 11 .600 .67 12 010. 72 11 000. 95 11 140 66 11. 970 70 10. 960. 88 3473 .9376 9539 Total Mood 58 372 23 59 062 44 59 753. 42 55 562 19 56 532 34 59 .173 .13 0786 1418 8053KOOS indicates Knee Osteoarthritis Outcome Score; ADL, Function in Daily Living; QOL, Quality of Life. POMS indicates Profile of Moods States. P<.05 with a Bonferroni correction of 2.

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24 http://www .cs.amedd.army .mil/amedd_journal.aspxa greater degree of symptoms and range of injuries and is more responsive than the WOMAC. Using this vali dated patient reported outcome measure, as expected, the scores increased from baseline to the 30-day point, which is related to the increased physical demands tions. Of particular note is that subscale scores were not cebo at either the 30-day or 60-day time points. This difference may be representative of the difference in patient population, the lower total MSM ingestion, or the more demanding activities expected of a military training population compared to the general patient with osteoarthritis. POMS to further assess the physical and mental wellbeing of those individuals taking supplemental MSM. In this study, Anger, Fatigue and Vigor worsened from baseline to 30 days for the MSM group, then again dur ing a time of increased physical and emotional stressed training period. Similar increases in mood abnormali ties were also seen in the placebo group, which corre lates to the physical, mental, and emotional demands that accompany military training. While other studies have evaluated MSM for those pa to evaluate the use of MSM as a preventative adjunct to improve functional outcome measures. However, de spite the enrollment of this study, its conclusions are limited by the loss to follow-up that was ex perienced from 30 to 60 days as a result of chang es in military training needs. This decreased the overall power of this study and may limit the relevant conclusions re garding the effectiveness of MSM over the entire 60-day period. This study was also con ducted in a highly active population with physical demands above those of the average population. As such, the conclusions of this study may be most translatable to a higher level athlete rather than the average person, and further studies evaluating MSM in individuals with average de mands is required. Furthermore, the total daily dosage of MSM used in this study was well below that of previ used different outcome measures. This may limit its CONCLUSIONS The results of this study suggest that 3 grams daily of orally administered MSM does not improve patient re ported outcomes over 30 days or 60 days in this young, healthy, active military population as compared to a pla cebo. The results do not support our tested hypothesis. However, further investigation is warranted to deter mine if higher doses are more effective and if less active populations might exhibit a greater treatment response. ACKNOWLEDG M ENT Study-related materials were received from Bergstrom Nutrition, 1000 W 8th St, Vancouver, Washington, through an educational grant. REFERENCES 1. Magnuson BA, Appleton J, Ames GB. Pharmaco kinetics and distribution of [35S] methylsulfano methane following oral administration to rats. J Agric Food Chem 2007;55(3):1033-1038. PMID: 17263509. 2. Magnuson BA, Appleton J, Ryan B, Matulka RA. Oral developmental toxicity study of meth ylsulfanomethane in rats. Food Chem Toxicol 2007;45(6):977-984. PMID: 17258373.A RANDOMIZED CONTROLLED TRIAL EVALUATING METHYLSULFONYLMETHANE VERSUS PLACEBO TO PREVENT KNEE PAIN IN MILITARY INITIAL ENTRY TRAINEES Table 3. KOOS and POMS scores over study period ( values presented as meanSD) .MSM Placebo Difference0 30 Days P value Difference0 60 Days P value Difference0 30 Days P value Difference0 60 Days P value KOOS Pain 2 44 2 45 0540 1 .75 3 31 3013 1. 29 2 39 2899 2 48 3. 09 1161 Symptom 0 51 1 .95 8617 0. 84 3 .15 9742 0 .93 2 25 4183 2 51 2 .90 0908 ADL 1. 57 2 09 1438 1. 23 2 81 3920 0 .91 2 01 3787 1 .15 2 59 3856 Sport 1. 08 3 .65 5622 0 .91 4 .90 7168 2 01 3 51 2633 4 61 4. 56 049 QOL 1 19 2 .80 4068 1. 07 3 .78 5780 3 41 2 .68 0135* 5 81 3 51 0013* POMS Tension 0 .62 0 45 3494 0. 80 0 .60 3494 0 .72 0 43 1194 0. 57 0 55 5470 Depression 1 .13 0. 58 0512 0 44 0 .76 5612 2 28 0 55 < 0001* 1. 25 0 .70 0763 Anger 3. 38 0 .72 0001* 0 .66 0 .95 3138 2 46 0 .69 < 0004* 1 46 0. 87 0960 Vigor 1. 62 0 .70 0193* 0 14 0 .92 8758 1. 64 0 .66 0137* 0 .68 0 .85 4215 Fatigue 2 .62 0 51 < 0001* 0 41 0 .68 5505 2 .83 0 49 < 0001* 0 61 0 61 3296 Confusion 0 41 0. 35 2438 0 .60 0 47 2026 0. 82 0. 34 0148* 0 .18 0 43 6724 Total Mood 0 691 42 6268 1. 38 1. 87 4622 0 .97 1. 36 4799 3 61 1 .72 0379KOOS indicates Knee Osteoarthritis Outcome Score; ADL, Function in Daily Living; QOL, Quality of Life. *Significance set at P <.05 with a Bonferoni correction of 2.

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October December 2017 25 3. Usha PR, Naidu MU. Randomised, double-blind, parallel, placebo-controlled study of oral glucos amine, methylsulfonylmethane and their com bination in osteoarthritis. Clin Drug Investig 2004;24(6):353-363. PMID: 17516722. 4. Magrans-Courtney T, Wilborn C, Rasmussen C, et al. Effect of diet type and supplementation of glu cosamine, chondroitin, and MSM on body compo sition, functional status, and markers of health in women with knee osteoarthritis initiating a resis tance-based exercise and weight loss program. J Int Soc Sports Nutr 2011;8(1):8. PMID: 21689421. 5. Miller DC, Richardson J, Roberts RW. Clinical Inquires. Does glucosamine relieve arthritis joint pain? J Family Pract 2003;52(8):645-647. PMID: 12899824. 6. Nakhostin-Roohi B, Barmaki S, Khoshkhahesh F, Bohlooli S. Effect of chronic supplementation with methylsulfonylmethane on oxidative stress follow ing acute exercise in untrained men. J Pharm Phar macol 2011;63(10):1290-1294. PMID: 21899544. 7. Amirshahrokhi K, Bohlooli S, Chinifroush MM. The effect of methylsulfonylmethane on the experi mental colitis in the rat. Toxicol Appl Pharmacol 2011;253(3):197-202. PMID: 21463646. 8. Tripathi R, Gupta S, Rai S, Mittal PC. Effect of top ical application of methylsulfanylmethane (MSM), EDTA on pitting edema and oxidative stress in a double blind, placebo-controlled study. Cell Mol Biol 2011;57(1):62-69. PMID: 21366964. 9. Notarnicola A, Tafuri S, Fusaro L, et al. The ME swellic acids in the treatment of gonarthrosis. Adv Ther 2011;28(10):894-906. PMID: 894-906. 10. methylsulfonylmethane supplementation on osteo arthritis of the knee: a randomized controlled study. BMC Complement Altern Med 2011;27(11):50-59. PMID: 21708034. 11. Knapik JJ, Canham-Chervak M, Hauret K, et al. Discharges during US Army Initial Entry Training: injury rates and risk factors. Mil Med 2001;166(7):641-647. PMID: 11469039. 12. Jones BH, Knapik JJ. Physical training and exer cise-related injuries. Surveillance, research and injury prevention in military populations. Sports Med. 1999;27(2):111-125. PMID: 10091275. 13. Jones BH, Cowan DN, Tomlinson JP, et al. Epide miology of injuries associated with physical train ing among young men in the army. Med Sci Sports Exerc 1993;25(2):197-203. PMID: 8450721. 14. Kaufman KR, Brodine S, Shaffer R. Military training-related injuries: Surveillance, research, and prevention. Am J Prev Med 2000;18(3):54-63. PMID: 10736541. 15. outcomes among soldiers. Inj Prev 2004;10(1):3742. PMID: 14760025. 16. methylsulfonylmethane (MSM) in osteoarthritis pain of the knee: a pilot clinical trial. Osteoarthri tis Cartilage 2005;14:286-294. PMID: 16309928. 17. Pagonis TA, Givissis PA, Kritis AC, Christodoulou AC. The effect of methylsulfonylmethane on os teoarthritic large joints and mobility. Int J Orthop 2014;23(1):19-24. Available at: http://www.ghrnet. org/index.php/ijo/article/view/745/862. Accessed August 1, 2017. AUTHORS CPT Tennent, CPT Hylden, and MAJ Kocher are with the Department of Orthopaedics, San Antonio Military Medical Center, Joint Base San Antonio-Fort Sam Hous ton, Texas. Dr Aden is with the US Army Institute of Surgical Re search, Joint Base San Antonio-Fort Sam Houston, Texas. COL Johnson is Chairman, Department of Orthopaedic Surgery, San Antonio Military Medical Center, Joint Base San Antonio-Fort Sam Houston, Texas.

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26 http://www .cs.amedd.army .mil/amedd_journal.aspxNeuropathy of the ulnar nerve at the elbow is one of a number of muscle-related and nerve-related disorders that affect people performing intensive work with their hands and upper extremities, and is the second most prevalent peripheral nerve mononeuropathy.1-7 There medical community for patients with neuropathy of the ulnar nerve at the elbow.6-12 However, few of these clas parameters nerve conduction (NCS) and electromyo graphic (EMG) studies. The ulnar nerve is comprised of the anterior primary rami of the C8 and T1 nerve roots.13-14 In the inferior neck at the level of the anterior and middle scalenes, the C8 and T1 nerve roots form the inferior (lower) trunk and then each trunk of the brachial plexus divides into the anterior and posterior divisions as the plexus passes through the cervico-axillary canal posterior to the clavicle.13-14 The compartments and posterior divisions supply posterior (extensor) compartments. The anterior division of the in ferior trunk continues as the medial cord.13-14The ulnar nerve is the terminal nerve of the medial cord and lies in the anterior compartment of the arm. Proximal to the elbow joint, the ulnar nerve passes into the posterior compartment of the arm and descends be tween the medial epicondyle of the humerus and olec ranon process of the ulna to form the ulnar groove.13-14 Similar to the median nerve, the ulnar nerve does not give rise to branches during its passage through the arm. profundus (FDP D4-D5). After sending motor branches to the FCU and FDP D4-D5, the ulnar nerve continues distally, ultimately terminating into 3 primary distal GEHS Neurophysiological Classification System for Patients with Neuropathy of the Ulnar Nerve at the Elbow David G. Greathouse, PT, PhD Greg Ernst, PT, PhD John S. Halle, PT, PhD COL Scott W. Shaffer, SP, USA ABSTR A CT Background: Neuropathy of the ulnar nerve at the elbow is one of a number of muscle-related and nerve-related disorders that affect people performing intensive work with their hands and upper extremities, and is the sec used by the medical community for patients with neuropathy of the ulnar nerve at the elbow. However, few electromyographic (EMG) studies.Purpose: cation system for patients with neuropathy of the ulnar nerve at the elbow and includes 2 case studies of patients with electrophysiological evidence of neuropathy of the ulnar nerve at the elbow.Case Studies: Two case studies of patients with electrophysiological evidence of neuropathy of the ulnar nerve sion of these case studies.Summary and Clinical Relevance: EMG components of the electrophysiological examination. Availability of expanded electrophysiological data that includes both NCS and EMG testing provides the healthcare team and the patient with more detailed infor mation that may be useful in determining next treatment steps as well as long-term prognosis. Future research warranted.

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October December 2017 27 cial branch of the ulnar nerve; and (3) deep motor branch of the ulnar nerve. The dorsal ulnar cutaneous branch typically bifurcates from the ulnar nerve about 5 cm proximal to the ulnar styloid process and proceeds dor sally and distally to innervate the skin on the dorsum of D5 and the ulnar aspect of D4, along with the adjacent skin over the dorsum of the hand, providing sensation to the skin of that region.13-14 Apart from this branch, the bulk of the ulnar nerve passes through the ulnar canal cial branch which provides motor innervation to the pal maris brevis and skin sensation to the palmar surface of D5 and medial half of D4.13-14 The deep motor branch of the ulnar nerve then innervates the hypothenar muscles nens digiti minimi), lumbricale muscles to D4 and D5, and the ulnar intrinsics including the dorsal and palmar interossei and adductor pollicis.13-14There are 5 anatomic sites of ulnar nerve compromise at the elbow: (1) intermuscular (IM) septum of the dis tal arm (including the Arcade of Struthers, medial IM septum, hypertrophy of medial head of triceps brachii, and snapping of medial head triceps brachii); (2) medial epicondyle secondary to a valgus deformity of the bone; (3) epicondylar groove (lesions within and outside of the groove and subluxation or dislocation of the nerve); (4) cubital tunnel (due to a thickened Osbornes ligament, a heads to the FCU) or as the nerve passes through the proximal edge of the FCU; and (5) as the ulnar nerve exits through the FCU.4In a review of the clinical, electrodiagnostic, and radio graphic features of ulnar neuropathy at the elbow, Lan dau and Campbell5 found that there are 3 main sites of ulnar nerve compromise at the elbow: (1) retrocondylar groove, proximal to the medial epicondyle/olecranon; (2) humero-ulnar aponeurotic arch including cubital tunnel syndrome and as the ulnar nerve passes between the ar cuate ligament spanning the two heads of the FCU; and from beneath the FCU. They stated that the etiology of neuropathy of the ulnar nerve at the elbow is most com monly due to lesions at the level of the ulnar nerve at the retrocondylar groove at or above the medial epicon dyle/olecranon with only 25% occurring distally at the humero-ulnar arcade.5 Furthermore, they suggested that maintaining across-elbow measurements (above elbow to below elbow) greater than 10 cm improves the diag of accessing ulnar neuropathy at the elbow.5 GEHS NEUROPHYSIOLOGIC A L CL A SSIFIC A TION SYSTE M FOR PA TIENTS WITH NEUROP A THY OF THE ULN A R NERVE A T THE ELBOW A thorough history and physical examination are con sidered essential screening tools for detecting signs and symptoms of peripheral neuropathy.1-3 Nerve conduction measurement is often performed on the ulnar nerve to determine whether certain entrapment neuropathies are present, and nerve conduction studies are considered the gold standard by providing criterion-related validation when assessing the electrophysiological status of the pe ripheral nerve.1-3 The electrophysiological examination including both nerve conduction and electromyography studies should identify peripheral nerve dysfunction if pathway, involvement of sensory and/or motor axons, and the presence of myelinopathy and/or axonopathy neuropathic process.1-3Nerve conduction studies and EMG testing have the advantage of providing potential electrophysiological evidence of pathological conditions of the ulnar nerve including demyelination (myelinopathy) and axon loss (axonopathy).1-3 In 2015, a new neurophysiological clas ulnar nerve at the elbow was introduced. The GEHS (Greathouse, Ernst, Halle, Shaffer)15 neurophysiological ulnar nerve at the elbow is comprised of data from both the NCS and EMG components of the electrophysiologi cation system for patients with neuropathy of the ulnar nerve at the elbow, presented in Table 1, provides health care providers an enhanced system of electrophysiologi cal evaluation and grading scale so that they may evaluate and treat their patients with this problem using data that includes both NCS and EMG testing results. Furthermore, this new system provides information and/or motor axons and myelinopathy and/or axonopa for patients with neuropathy of the ulnar nerve at the el bow is presently being used by clinical electrophysiolo gists and has been cited in various research reports.16-19This article describes application of the GEHS neuro ropathy of the ulnar nerve at the elbow in 2 case stud ies of patients with electrophysiological evidence of the disorder.

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28 http://www .cs.amedd.army .mil/amedd_journal.aspx CA SE STUDIES Case 1A 42-year-old right-hand dominant male was referred by his primary care physician for electrophysiological eval uation of a suspected left ulnar nerve neuropathy. The pa tient is a computer software developer. In 2015, he noted intermittent pain and numbness and tingling (N/T) in the left upper extremity (LUE). The patient had no past med ical history of problems affecting either upper extrem ity and denied recent trauma to the neck or either upper extremity. The symptoms in the LUE increased over the month preceding presenting for evaluation. He had pain in the left elbow, medial forearm, wrist, and digits 4 and Table 115EARLY MILD (conduction block) Sensory >40% decrease in SNAP amplitude; eg, 40 V SNAP amplitude BE-W, 20 V SNAP amplitude AE-BE, 20 V SNAP amplitude difference (50%) and/or Motor >20% decrease in CMAP amplitude AE/BE; eg, 8 mV CMAP amplitude BE-W, 4 mV CMAP amplitude AE-BE, 4 mV CMAP amplitude difference (50%). Normal Findings: Normal motor and sensory NCVs and latencies when compared to a Table of Normal NCS Values; normal EMG of ulnar innervated muscles (1st DI, ADM, FDP D4-5 & FCU). MILD (myelin only) Sensory <50 m/sec SNCV AE-BE or >10 m/sec SNCV AE-BE difference when compared to BE-W, SNCV (AEBE SNCV >50 m/sec) >40% decrease in SNAP amplitude AE/BE; Motor <50 m/sec MNCV AE-BE or >10 m/sec MNCV AE-BE difference when compared to BE-W MNCV (AEBE MNCV >50 m/sec) >20% decrease in CMAP amplitude AE/BE; Sensory and Motor EMG : normal EMG of ulnar innervated muscles (1st DI, ADM, FDP D4-5 & FCU). Normal NCS Findings : Normal MNCV and SNCV BE-W and distal motor and sensory latencies and amplitudes when compared to a Table of Normal NCS Values (Table being used in individual lab). MODERATE (myelin and axon) EMG increased insertional activity and presence of abnormal spontaneous electrical activity in one of the following muscles: 1st DI, ADM, FDP D4-D5, or FCU; may have decreased interference pattern on maximum voluntary contraction in one of the ulnar innervated muscles.*Conduction Block normal motor and sensory conduction studies; may have decreased SNAP and/or CMAP amplitudes at the AE Sensory <50 m/sec SNCV AE-BE >40% decrease in SNAP amplitude AE/BE may have abnormal distal sensory latency and/or amplitude when compared to a Table of Normal NCS Values.*Motor <50 m/sec MNCV AE-BE >20% decrease in CMAP amplitude AE/BE* may have abnormal distal motor latency and/or amplitude when compared to a Table of Normal NCS Values.*Normal Findings : Normal distal motor and sensory latencies and amplitudes and normal BE-W MNCV and SNCV when compared to a Table of Normal NCS Values; normal shape, amplitude and duration of MUPs in ulnar innervated muscles. SEVERE (myelin and axon) EMG increased insertional activity and presence of abnormal spontaneous electrical activity in two or more of the following muscles: 1st DI, ADM, FDP D4-D5, or FCU; decreased interference pattern on maximum voluntary contraction in two or more of the ulnar innervated muscles* may have increased amplitude (>10 mV) and/or duration (>15 ms) MUPs in one or more of the ulnar innervated muscles. Conduction Block Normal motor and sensory conduction studies; may have decreased SNAP and/or CMAP amplitudes at the AE Sensory <50 m/sec SNCV abnormal distal sensory latency and/or amplitude when compared to a Table of Normal NCS Values.*Motor <50 m/sec MNCV AE-BE abnormal distal motor latency and/or amplitude when compared to a Table of Normal NCS Values.*Summary of Severe Compared to Moderate:1. Two or more ulnar innervated muscles with EMG changes.2. Sensory and motor changes are abnormal, not based on percentage decreases, but on comparison to Table of Normal NCS Values being used in individual labs.*Electrophysiologic evidence of axonal loss neuropathic process. Glossary ADM abductor digiti minimi EMG electromyography BE below elbow FPD D4-D54 and D5 CMAP compound motor action potential MNCV motor nerve conduction velocity DML distal motor latency MUPs motor unit potentials D4 digit 4 D5 digit 5 1 DSL distal sensory latency W wrist GEHS NEUROPHYSIOLOGICAL CLASSIFICATION SYSTEM FOR PATIENTS WITH NEUROPATHY OF THE ULNAR NERVE AT THE ELBOW

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October December 2017 29 other pain in the LUE. The patient states he had N/T in the palmar and dorsal surfaces of the left D4-D5, but otherwise denied N/T proximal to the wrist in the LUE. The patient denied weakness in the LUE, including hand and digit movements. The patient denied pain, N/T, or weakness in the right upper extremity (RUE) and had no symptoms in either lower extremity. The patient had some stiffness in neck movements but no neck pain or radicular symptoms in either upper extremity. He denied history of headaches, visual or cranial nerve problems. The patient was slightly overweight and is hypertensive (on medication), but otherwise is in good health. The re view of systems was noncontributory for cardiovascular, pulmonary, gastrointestinal, genitourinary, or endocrine problems. He denied having diabetes, heavy metal expo sure, thyroid disease, renal disease, or alcohol abuse, and has no family history of neuromuscular disease. The patient was evaluated in January 2017. On physi cal examination, the patient displayed normal active Table 2. Case 1 Anti Sensory SummarySite NR Peak (ms) Norm Peak (ms) P-T Amp ( V) Norm P-T Amp ( V) Site 1Site 2Delta-P (ms) Dist (cm) Vel (m/s) Norm Vel (m/s) 1st Digit) D1 2.3 <2.7 15.8 >D1Base 1st Digit2.3 10.0 431st Digit) D1 2.0 <2.7 10.8 >D1Base 1st Digit2.0 10.0 50Ortho Sensory SummaryLeft Median Ortho Sensory (Wrist) Palm 2.1 <2.2 180.5 >15Palm Wrist2.1 8.0 38D2 3.4 <3.6 49.2 >15D2Wrist3.4 14.0 41Right Median Ortho Sensory (Wrist) Palm 2.2 <2.2 171.7 >15Palm Wrist2.2 8.0 36D2 3.5 <3.6 28.9 >15D2Wrist3.5 14.0 40Left Ulnar Ortho Sensory (Wrist) Palm 5.6 <2.2 15.1 >10Palm Wrist5.6 8.0 14D5NR<3.5 >10D5Wrist14.0Right Ulnar Ortho Sensory (Wrist) Palm 2.2 <2.2 10.0>10Palm Wrist2.2 8.0 36D5 2.9 <3.5 11.2 >10D5Wrist2.9 14.0 48Motor SummarySite NR Onset (ms) Norm Onset (ms) O-P Amp (mV) Norm O-P Amp (mV) Site 1Site 2Delta-0 (ms) Dist (cm) Vel (m/s) Norm Vel (m/s) Left Median Motor (Abductor Pollicis Brevis) Wrist 3.8 <4.2 9.6 >5Elbow Wrist5.3 28.0 53 >50Elbow 9.1 8.2Right Median Motor (Abductor Pollicis Brevis) Wrist 3.8 <4.2 12.9 >5Elbow Wrist5.6 31.0 55 >50Elbow 9.4 10.2Left Ulnar Motor (Abductor Digiti Minimi) Wrist 3.5 <3.6 4.3 >5B Elbow Wrist5.6 25.5 46 >50B Elbow 9.1 2.1A Elbow B Elbow2.5 13.5 54 >50A Elbow 11.6 4.5Right Ulnar Motor (Abductor Digiti Minimi) Wrist 3.0 <3. 6 7.7 >5B Elbow Wrist5.1 26.0 51 >50B Elbow 8.1 6.6A Elbow B Elbow2.1 12.0 57 >50A Elbow 10.2 6.6GlossaryAmp amplitude D1 digit 1 (thumb) Norm normal P peak A Elbow above elbow D2 digit 2 (index finger) NR no response T trough B Elbow below elbow Dist distance O onset Vel velocity

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30 http://www .cs.amedd.army .mil/amedd_journal.aspxcervical mobility in all planes without neck pain or pain in both upper extremities (BUE). The Spurlings test did not provoke pain in the neck or in either upper extrem ity. He had normal active mobility of bilateral shoulder, elbow, forearm, wrist, and hand motions. The patient had weakness in the left ulnar hypothenar and intrinsic muscles (3+/5) and the left FDP digits 4 and 5 (3+/5). There was normal (5/5) motor strength of the left FCU, extensor pollicis longus (EPL). In addition, there was normal (5/5) motor strength testing of bilateral shoul der, elbow, forearm and wrist motions; and right hand motions. There was no atrophy or clonus noted in BUE. The biceps, triceps, and brachioradialis muscle stretch sensation to light touch (LT) and pain (pin prick) in the dorsal and palmar surfaces of the left ring (D4) and little LT and pain in BUE, including all peripheral nerves and dermatomes (C4-T1). There was a positive Tinels test of the left ulnar nerve at the elbow, but otherwise the Tinels and Phalens tests were negative for bilateral me dian and ulnar nerve involvement at the wrists or elbows. There were normal radial pulses bilaterally for thoracic outlet syndrome in the scalene, costoclavicular, and pec toralis minor/clavipectoral fascia humeral maneuvers. Results of the NCS and EMG studies for case study 1 are presented in Tables 2 and 3, respectively. Clinically cated by shaded cells in Tables 2 and 3. In conclusion of case study 1: this was an abnormal NCS and EMG study of the LUE and a normal NCS study of the RUE. There was electrophysiologic evidence on this examination of a severe, left ulnar nerve mononeuropa thy at the elbow, at or distal to the medial epicondyle/ olecranon and distal to the innervation of the FCU; de myelinating and axonal loss neuropathic process affect ductor digiti minimi (ADM). Electromyographic testing of the left FCU and other muscles tested in the LUE was normal. There was no electrophysiologic evidence on this examination of (1) right ulnar nerve mononeuropa ropathy, including the left median nerve at or distal to the wrist; (3) left C5-T1 radiculopathy in the LUE (cer vical paraspinal muscles not tested); and (4) left brachial plexopathy, including the medial cord and inferior trunk. Based on the above case study 1 results, the GEHS severe mononeuropathy of the left ulnar nerve at the elbow. There was a prolonged left ulnar palmar distal sensory latency (DSL) (5.6 ms, normal <2.2) with a normal amplitude of the sensory nerve action potential (SNAP) (15 V). There was no sensory response for the left ulnar 5th digit (D5) when tested orthodromically or antidromically. There was a normal left ulnar distal mo tor latency (3.5 ms), but the amplitude of the compound motor action potential (CMAP) was reduced at 4.3 mV (normal >5). The motor nerve conduction (MNCV) of the left ulnar nerve in the forearm (below elbow (BE) to wrist) was reduced at 46 m/sec (normal >50) with a reduced CMAP amplitude of 2.1 mV (normal >5) at the BE stimulation site. The MNCV of the left ulnar nerve at across the elbow (above elbow to below elbow (AEBE)) was normal (54 m/sec) with a reduced amplitude CMAP of 4.5 mV (normal >5). On EMG examination, there was increased insertional activity and the pres ence of abnormal spontaneous electrical activity at rest in the left 1st DI and ADM with a 50% reduction in Table 3. Case 1: 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 Left1stDorInt Ulnar C8-T1Incr2+3+ Nml Nml0Reduced50% fib amp <100Left Abd Poll Brev Median C8-T1Nml Nml Nml Nml Nml0Nml Nml Left PronatorTeres Median C6-7Nml Nml Nml Nml Nml0Nml Nml Left Flex Poll Long AIN C8-T1Nml Nml Nml Nml Nml0Nml Nml Left Biceps Musculocut C5-6Nml Nml Nml Nml Nml0Nml Nml Left Triceps Radial C6-7-8Nml Nml Nml Nml Nml0Nml Nml Left Deltoid Axillary C5-6Nml Nml Nml Nml Nml0Nml Nml Left ABD Dig Min Ulnar C8-T1Incr2+3+ Nml Nml0Reduced50% fib amp <100Left FlexCarpiUln Ulnar C8-T1Nml Nml Nml Nml Nml0Nml Nml Left Ext Poll Long Radial (Post Int) C7-8Nml Nml Nml Nml Nml0Nml Nml* Electromyographic testing of the right upper extremity was not performed. Glossary Amp amplitude Fibs fibrillation potentials Ins Act insertional activity Nml normal Recrt recruitment Dur duration Incr increased Int Pat interference pattern Poly polyphasics GEHS NEUROPHYSIOLOGICAL CLASSIFICATION SYSTEM FOR PATIENTS WITH NEUROPATHY OF THE ULNAR NERVE AT THE ELBOW

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October December 2017 31 interference patterns during maximum voluntary con were demonstrated in 2 of the 4 muscles outlined in the outlined in Table 1 was not performed. In this case, ob taining EMG of the FDP to D4 and D5 was deferred. There was normal EMG testing of the left FCU, APB, FPL, EPL, and other muscles tested in the LUE. These myelinating and axonal loss neuropathic process of the left ulnar nerve at the elbow.Case 2A 48-year-old right-hand dominant male was referred by his orthopaedic surgeon for electrophysiological evaluation of a suspected right ulnar nerve neuropathy. The patient is a pool repair technician. In 2015, he noted in termittent pain and N/T in the RUE. The patient had no past medical history of problems affecting either upper extremity and denied recent trauma to the neck or either upper extremity. The symptoms in the RUE increased over the month preceding presenting for evaluation. He had pain in the right elbow. Otherwise, he had no other pain in the RUE. The patient states he had N/T in the palmar and dorsal surfaces of the right D4-D5 (ring and wrist in the RUE. The patient denied weakness in the RUE including hand and digit movements. The patient had occasional N/T in the dorsal and palmar aspects of the left D4-D5 but otherwise denied pain, N/T or weak ness in the LUE and had no symptoms in either lower extremity. The patient denied neck pain or radicular symptoms in either upper extremity. He denied history of headaches, visual or cranial nerve problems. The pa tient is on medication for hypertension but is in good health. Otherwise, the review of systems was noncon tributory for cardiovascular, pulmonary, gastrointesti nal, genitourinary, or endocrine problems. He denied having diabetes, heavy metal exposure, thyroid disease, renal disease, or alcohol abuse, and has no family his tory of neuromuscular disease. The patient was evaluated in May 2016. On physical ex amination, the patient displayed normal active cervical mobility in all planes without neck pain or pain in BUE. The Spurlings test did not provoke pain in the neck or in either upper extremity. He had normal active mobil ity of bilateral shoulder, elbow, forearm, wrist, and hand motions. The patient had weakness in the right ulnar hy pothenar and intrinsic muscles (3+/5), right FDP D4 and There was normal (5/5) motor strength of the right APB, In addition, there was normal (5/5) motor strength testing of bilateral shoulder, elbow, forearm and wrist motions; and left hand motions. There was no atrophy or clonus noted in BUE. The biceps, triceps, and brachioradialis a decreased sensation to LT and pain (pin prick) in the dorsal and palmar surfaces of the right ring (D4) and lit for LT and pain in BUE including all peripheral nerves and dermatomes (C4-T1). There was a positive Tinels test of the right ulnar nerve at the elbow, but otherwise the Tinels and Phalens tests were negative for bilateral median and ulnar nerve involvement at the wrists or el bows. There were normal radial pulses bilaterally for tho racic outlet syndrome in the scalene, costoclavicular, and pectoralis minor/clavipectoral fascia humeral maneuvers. Results of the nerve conduction and electromyography studies for case study 2 are presented in Tables 4 and 5, respectively. Clinically noteworthy NCS and EMG ab 4 and 5. In conclusion of case study 2: this was an abnormal NCS and EMG study of the RUE and a normal NCS study of the LUE. There is electrophysiologic evidence on this examination of a severe right ulnar nerve mononeuropathy at the elbow proximal to the olecranon/medial epicondyle and proximal to the innervation of the right FCU; axonal greater than demyelinating neuropathic process affecting motor and to a lesser extent sensory in the right 1st DI, ADM, and FCU. There was no elec trophysiologic evidence on this examination of (1) left ulnar nerve mononeuropathy; (2) bilateral median or median nerve at or distal to the wrist; (3) right C5-T1 radiculopathy in the RUE (cervical paraspinal muscles not tested); and (4) right brachial plexopathy, including the medial cord and inferior trunk. Based on the above case study 2 results, the GEHS neuvere mononeuropathy of the right ulnar nerve at the el bow. There was a prolonged right ulnar palmar DSL (2.3 ms, normal <2.2), with a normal amplitude of the SNAP normal (3.5 ms) with a normal amplitude of the SNAP (12 V). There was a prolonged right ulnar distal motor latency (3.8 ms, normal <3.6), but the amplitude of the CMAP was normal (7.5 ms). The MNCV of the right ulnar nerve in the forearm (BE to wrist) was normal at 53 m/sec (normal >50), with a normal CMAP amplitude

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32 http://www .cs.amedd.army .mil/amedd_journal.aspxof 7.2 mV (normal >5) at the BE stimulation site. The MNCV of the right ulnar nerve at AE-BE was reduced (45 m/sec, normal >50) with a reduced but normal am plitude CMAP (6.4 mV) at the AE stimulation site. The MNCV of the arm (axilla to AE) was normal at 74 m/sec with a normal CMAP amplitude of 7.0 mV. On EMG ex amination, there was increased insertional activity and the presence of abnormal spontaneous electrical activ ity at rest in the right 1st DI, ADM, and FCU, with a 75% reduction in interference patterns during maximum voluntary contraction in the right 1st DI and ADM. Since 4 of the muscles outlined in Table 1 was not performed. In this case, obtaining EMG of the right FDP to D4 and D5 was deferred. There was normal EMG testing of the right APB, EPL, and other muscles tested in the RUE. a demyelinating and axonal loss neuropathic process of the right ulnar nerve at the elbow. Table 4. Case 2 Anti Sensory SummarySite NR Peak (ms) Norm Peak (ms) P-T Amp ( V) Norm P-T Amp ( V) Site 1Site 2Delta-P (ms) Dist (cm) Vel (m/s) Norm Vel (m/s) 1st Digit) D1 2.6 <2.7 23.9 >D1Base 1st Digit2.6 10.0 381st Digit) D1 2.7 <2.7 20.6 >D1Base 1st Digit2.7 10.0 37Ortho Sensory SummaryLeft Median Ortho Sensory (Wrist) Palm 2.0 <2.2 112.5 >15Palm Wrist2.0 8.0 40D2 3.3 <3.6 20. 0 >15D2Wrist3.3 14.0 42Right Median Ortho Sensory (Wrist) Palm 2.1 <2.2 33 8 >15Palm Wrist2 .1 8.0 38D2 3.5 <3.6 22.6 >15D2Wrist3.5 14.0 40Left Ulnar Ortho Sensory (Wrist) Palm 2 2 <2.2 15.3 >10Palm Wrist2.2 8.0 36D53 5 <3.5 13.3 >10D5Wrist3 5 14.0 40Right Ulnar Ortho Sensory (Wrist) Palm 2.3 <2.2 16 7 >10Palm Wrist2.3 8.0 35D5 3 5 <3.5 12 .4 >10D5Wrist3 5 14.0 40Motor SummarySite NR Onset (ms) Norm Onset (ms) O-P Amp (mV) Norm O-P Amp Site 1Site 2Delta-0 (ms) Dist (cm) Vel (m/s) Norm Vel (m/s) Left Median Motor (Abductor Pollicis Brevis) Wrist 4 0 <4.2 9.0 >5Elbow Wrist5.4 29.0 54 >50Elbow 9.4 9.0Right Median Motor (Abductor Pollicis Brevis) Wrist 4 .1 <4.2 10. 0 >5Elbow Wrist6 .4 33.0 52 >50Elbow 10 5 9 .4Left Ulnar Motor (Abductor Digiti Minimi) Wrist 3.5 <3.6 6. 5 >5B Elbow Wrist4 .7 25.0 53 >50B Elbow 8 2 6 .7A Elbow B Elbow2.0 13.0 65 >50A Elbow 10 2 6 .7Right Ulnar Motor (Abductor Digiti Minimi) Wrist 3.8 <3.6 7.5 >5B Elbow Wrist4 .7 25.0 53 >50B Elbow 8.5 7. 2A Elbow B Elbow2.9 13.0 45 >50A Elbow 11 4 6.4Axilla A Elbow1.9 14.0 74Axilla13 3 7. 0GlossaryAmp amplitude B Elbow below elbow D2 digit 2 (index finger) Norm normal O onset T trough A Elbow above elbow D1 digit 1 (thumb) Dist distance NR no response P peak Vel velocity GEHS NEUROPHYSIOLOGICAL CLASSIFICATION SYSTEM FOR PATIENTS WITH NEUROPATHY OF THE ULNAR NERVE AT THE ELBOW

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October December 2017 33 CO MM ENT The advantage of having information regarding NCS and EMG changes (myelinopathy and axonopathy) for patients with neuropathy of the ulnar nerve at the elbow is that it provides the healthcare team and the patient with information that may be useful in determining next treatment steps as well as long-term prognosis. Nerve conduction studies provide assessment of the periph eral nerve being examined, especially as it relates to myelination or demyelination and location of the site of nerve compromise. In the case of a patient with EMG changes, the combined effects of compression and isch emia are evident with the loss of a subset of axons and the denervation of a segment of the innervated muscle 1-3 and abnormal resting potentials (eg, positive sharp wave, provides the healthcare team with information regard ing the presence, morphology, and recruitment pattern of motor units that is critical for determining the extent phasic or large motor potentials) is truly occurring.1-3 Collectively, the EMG examination affords critical mo healthcare team, in concert with the patient, to carefully consider interventions.1-3 neuropathy of the ulnar nerve at the elbow currently being used by the medical community.6-12,20-22 Howev electrophysiologic parameters (eg, nerve conduction and electromyographic studies). Ulnar nerve at the el bow neuropathy severity scales based on the patients subjective (paresthesia and pain) and physical examina the patient into groups,6 scales,20,22 or grades21 based on amination. The Patient-Rated Ulnar Nerve Evaluation (PRUNE) was developed to assess pain, symptoms, and functional disability in patients with ulnar nerve com pression at the elbow.7 The PRUNE is a patient-reported outcome measure for patients with ulnar nerve com pression that demonstrates strong measurement prop erties.7 Decisional algorithms have been developed for patients with neuropathy of the ulnar nerve at the elbow to assist in selecting the surgical procedure for ulnar nerve entrapment9 and to identify predictors of surgical outcomes.10In a study based on electrophysiologic assessment of the ulnar nerve, Eliaspour et al8 determined the pattern of muscle involvement in patients with ulnar neuropa thy at the elbow. Muscle involvement in patients with neuropathy of the ulnar nerve at the elbow included 1st DI (91.9%), ADM (91.3%), FCU (64.9%), and FDP D4D5 (56.8%). Using a Bayesian analysis, Logigian et al23 determined how electrodiagnostic cutoffs (eg, acrosselbow MNCV slowing and drop in across-elbow ver sus forearm MNCV) assist in assessing patients with ulnar nerve at the elbow neuropathy. They determined that above elbow to below elbow distances and stimula tion sites should be at least 10 cm. Pretest probability was determined at 0.25 (if there is a greater than 23 m/ sec difference between above elbow to below MNCV compared to the below elbow to wrist MNCV, and/or an above elbow to below elbow absolute MNCV value of less than 38 m/sec.23 A less conservative retest probabil ity of 0.75 was also determined (difference greater than 14 m/sec, and an absolute AE-BE MNCV value less than 47 m/sec, respectively).23 In a study comparing the prog nostic value of electrodiagnostic studies for patients with ulnar neuropathy at the elbow and their postsur gical results, a combination of conduction block across the elbow to the 1st DI and a normal distal compound muscle action potential amplitude from the ADM was Table 5. 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 Right1stDorInt Ulnar C8-T1Incr1+2+ Nml Nml0Nml Nml fib amp <100>Right Abd Poll Brev Median C8-T1Nml Nml Nml Nml Nml0Nml Nml Right PronatorTeres Median C6-7Nml Nml Nml Nml Nml0Nml Nml Right Ext Poll Long PIN C8Nml Nml Nml Nml Nml0Nml Nml Right Biceps Musculocut C5-6Nml Nml Nml Nml Nml0Nml Nml Right Triceps Radial C6-7-8Nml Nml Nml Nml Nml0Nml Nml Right Deltoid Axillary C5-6Nml Nml Nml Nml Nml0Nml Nml Right ABD Dig Min Ulnar C8-T1Incr2+2+ Nml Nml0Reduced75% fib amp <100>Right FlexCarpiUln Ulnar C8-T1Incr1+1+ Nml Nml0Reduced75% fib amp <100>* Electromyographic testing of the left upper extremity was not performed. Glossary Amp amplitude Fibs fibrillation potentials Ins Act insertional activity Nml normal Recrt recruitment Dur duration Incr increased Int Pat interference pattern Poly polyphasics

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34 http://www .cs.amedd.army .mil/amedd_journal.aspx strongly associated with recovery in patients.24 Friedrich and Robinson concluded that electrodiagnostic studies provide useful prognostic information in ulnar nerve at the elbow neuropathy, but there are no electrodiagnostic predictors of surgery.24 framework for reporting and categorizing neuropathy of the ulnar nerve at the elbow based on neurophysiologic Additional longitudinal studies examining the predictive regarding various interventions (duty limitations, splint ing, mobilization, injection, and surgical release) is rec ommended. Future trials should also go beyond subjec tive reporting and include various outcomes measures healthcare utilization) and rigorous statistical analysis to SU MMA RY A ND CLINIC A L RELEV A NCE KH\003*\(+\003QHXURSK\)2.2 (VLRORJLFDO\003FODVVL\277FDWLRQ\003V\)2.2 (VWHP\003IRU\003 patients with neuropathy of the ulnar nerve at the elbow equips healthcare providers with an enhanced system of electrophysiological evaluation and grading scale. As such, it now provides clinical electrophysiologists with tem for use when preparing electrophysiological testing reports for patients with this disorder. Availability of ex panded electrophysiological data that includes both NCS and EMG testing provides the healthcare team and the patient with more detailed information that may be use ful in determining next treatment steps as well as longterm prognosis. Future research comparing the psycho metric properties and prognostic utility of the GEHS REFERENCES 1. Dumitru D, Amato AA, Zwarts M. Electrodiag nostic Medicine 2nd ed. Philadelphia, PA: Hanley & Belfus Inc; 2001. 2. Kimura J. Electrodiagnosis in Diseases of Nerve and Muscle 3rd ed. New York, NY: Oxford Uni versity Press, Inc; 2001. 3. American Association of Electrodiagnostic Medi cine, American Academy of Neurology, American Academy of Physical Medicine and Rehabilitation. Practice parameter for electrodiagnostic studies in ulnar neuropathies at the elbow. Muscle Nerve 1999;22(suppl):S171-S205. 4. Posner MA. Compressive ulnar neuropathies at the elbow: I. Etiology and diagnosis. J Am Acad Ortho Surg 1998;6(5):282-288. 5. Landau ME, Campbell WW. Clinical features and electrodiagnosis of ulnar neuropathies. Phys Med Rehab Clin N Am 2013;24(1):49-66. 6. Dawson DM, Hallett M, Millender LH. Entrap ment Neuropathies 2nd ed. Boston, MA: Little, Brown & Co; 1990. 7. MacDermid JC, Grewal R. Development and vali dation of the patient-rated ulnar nerve evaluation. BMC Musculoskeletal Disord 2013;14:146. Avai lable at: https://doi.org/10.1186/1471-2474-14-146. 8. Eliaspour D, Sedighipour L, Hedayati-Moghad dam MR, et al. The pattern of muscle involvement in ulnar neuropathy at the elbow. Neurol India 2012;60(1):36-39. 9. Mandelli C, Baiguini M. Ulnar nerve entrapment neuropathy at the elbow: decisional algorithm and surgical considerations. Neurocirugia (Astur) 2009;20(1):31-38. 10. Burns PB, Kim HM, Gaston RG, et al. Predictors of functional outcomes after simple decompression for ulnar neuropathy at the elbow: a multicenter study by the SUN study group. Arch Phys Med Re habil 2014;95(4):680-685. 11. Chimenti PC, Hammert WC. Ulnar neuropathy at the elbow: an evidence-based algorithm. Hand Clin. 2013;29(3):435-442. 12. Song VV, Waljee JF, Burns PB, et al. An outcome study for ulnar neuropathy at the elbow: a multi center study by the surgery for ulnar nerve (SUN) study group. Neurosurgery 2013;72(6):971-981. 13. Moore KL, Dalley AF, Agur AMR. ClinicallyOriented Anatomy 7th ed. Baltimore, MD: Wolters Kluwer/Lippincott Williams and Wilkins; 2014. 14. Netter FH. Netter Atlas of Anatomy 4th ed. Phila delphia, PA: Elsevier; 2006. 15. with ulnar nerve mononeuropathy at the elbow. Electroneuromyographic Symposium Proceedings Rocky Mountain University of Health Professions; March 27, 2015:50-74. 16. Greathouse DG, Root TM, Carrillo CR, et al. Clini cal and electrodiagnostic abnormalities of the me dian nerve in dental assistants. J Orthop Sports Phys Ther 2009;39(9):693-701. 17. Shaffer SW, Moore R, Foo S, Henry N, Moore JH, Greathouse DG. Clinical and electrodiagnostic ab normalities of the median nerve in U.S. Army den tal assistants at the onset of training. US Army Med Dep J July-September 2012:72-81.GEHS NEUROPHYSIOLOGICAL CLASSIFICATION SYSTEM FOR PATIENTS WITH NEUROPATHY OF THE ULNAR NERVE AT THE ELBOW

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October December 2017 35 18. Shaffer SW, Koreerat NR, Rice L, Santillo DR, Moore JH, Greathouse DG. Median and ul nar neuropathies in U.S. Army Medical Com mand band members. Med Probl Perform Art 2013;28(4):188-194. 19. Shaffer SW, Alexander K, Huffman D, Kambe C, Miller R, Moore JH, Greathouse DG. Median and ulnar neuropathies in US Army dental personnel at Fort Sam Houston, Texas. US Army Med Dep J April-June 2014:1-9. 20. Dellon AL. Diagnosis and treatment of ulnar nerve compression at the elbow. Tech Hand Up Extrem Surg 2000;4(2):127-136. 21. McGowan AJ. The results of transposition of the ulnar nerve for traumatic ulnar neuritis. J Bone Joint Surg Br 1950;32-B(3):293-301. Available at: http://bjj.boneandjoint.org.uk/content/32-B/3/293. full.pdf. Accessed October 4, 2017. 22. Gabel GT, Amadio PL. Reoperation for failed de compression of the ulnar nerve in the region of the elbow. J Bone Joint Surg Am 1990;72(2):213-219. 23. Logigian EL, Villanueva R, Twydell PT, et al. Electrodiagnosis of ulnar neuropathy at the el bow (UNE): a Bayesian approach. Muscle Nerve 2014;49(3):337-344. 24. Friedrich JM, Robinson LR. Prognostic indicators from electrodiagnostic studies for ulnar neuropa thy at the elbow. Muscle Nerve 2011;43(4):596-600. 25. Agnew SP, Minieka MM, Patel RM, Nagle DJ. Correlation between preoperative Kimura inching scopic-assisted decompression of the ulnar nerve at the elbow. Hand (N Y) 2012;7(4):370-373. AUTHORS Dr Greathouse is Director, Clinical Electrophysiol ogy Services, Texas Physical Therapy Specialists, New Braunfels, TX, and Adjunct Professor, US Army-Baylor University Doctoral Program in Physical Therapy, Fort Sam Houston, TX. Dr Ernst is an Associate Professor, Department of Physi cal Therapy, UT Health Science Center, San Antonio, TX, and Clinical electrophysiologist, Hand Center of San Antonio, San Antonio, TX. Dr Halle is a Professor, School of Physical Therapy, Belmont University, Nashville, TN, and a Clinical elec Army Community Hospital, Ft. Campbell, KY. COL Shaffer is Dean, Graduate School and Associate Professor, US Army-Baylor University Doctoral Pro gram in Physical Therapy, Fort Sam Houston, TX, Chief, Physical Therapist Section, and Assistant Chief, Army Medical Specialist Corps, Fort Sam Houston, TX.

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36 http://www.cs.amedd.army.mil/amedd_journal.aspxShoulder injuries affect up to 33% of the general popula tion and comprise 5% of all consultations from general practitioners.1-3 They are also common injuries found in military service members.4-6 In an analysis of US Navy Sailors, upper extremity injuries were the most common majority (23.8%).5 In one study, Soldiers with shoulder injuries were more likely to have limited duty days re lated to the injury.7 Noncombat-related shoulder injuries are also among the most common seen during deploy ment.8 Treatment is often challenging, and the prognosis shoulder pain, less than 25% may have full recovery by 3 months.9 In the longer term, one-year recovery rates range from 32% to 59%.9-12 Even with recovery, recur rence rates are high with 25% of patients experiencing at least one recurrent episode within 12 months.13 These tors that affect prognosis is an area where more research is needed. A variety of factors are associated with a poor prognosis. These factors include pain intensity at initial evaluation, age, gender, prior history of pain, duration of symptoms prior to consulting with a general practitioner, inade illnesses, and level of disability.3,9,14 tors that can be addressed include pain intensity with treatment, elevated kinesiophobia or fear avoidance beliefs, obesity, changes in disability over time, muscle weakness, and smoking.9,14-17Smoking is still common among adults seen in primary care for shoulder pain. Although the Centers for Disease Control and Prevention does report a decline in smok ing, a recent report estimated that 18.1% of American adults were current smokers in 2012, indicating the problem is still relevant.18 Smoking rates remain high in military service members, although reported down to 31% in 200519 from as high as 47% in 1985.20 Even so, the rates are much higher than in the civilian popula tion.20 Smoking is adversely related to functional out comes after injury, independent of the nature or sever ity of injury.14 In military service members, it degrades physical performance,21,22 is a risk factor for musculo skeletal injury,23-25 and is associated with higher rates of attrition from the military.26,27 It is an independent The Influence of Smoking on Recovery from Subacromial Pain Syndrome: A Cohort from the Military Health System MAJ Daniel I. Rhon, SP, USA John S. Magel, PT, DSc, PhD ABSTR A CT Background : Smoking rates are higher in the military population than in the civilian sector. Smoking is as sociated with poor prognosis for many musculoskeletal injuries. The purpose of this study was to investigate the effects of smoking on recovery from a shoulder injury in a prospective cohort seeking care at a military treatment facility. Methods : Secondary analysis of 98 patients referred to physical therapy for unilateral shoulder pain. Patients received a corticosteroid injection or 6 sessions of physical therapy. Sociodemographic and historical variables ence of 12 or more points on the Shoulder Pain and Disability Index following treatment. Results : The mean improvement was almost 50% in both groups and maintained to one year. Smoking was months. Higher levels of disability at baseline and receiving only the treatment originally assigned (not cross Comment der pain. Healthcare providers in the military setting should keep this in mind when educating this patient population and determining their prognosis, especially given high rates of smoking. Further research is needed

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October December 2017 37 risk factor across a variety of populations and medical conditions,28-30 healing and recurrence of pain in shoulder injuries.17,31-34 Smoking is associated with an increased risk of rota tor cuff tears,18 shoulder surgeries.32,35 It has deleterious effects on peak bone mass,36 bone mineral density,37 bone healing,38 and wound healing,39,40 as well as many other general complications.41 However, the majority of the research has been observational and cross-sectional, in patients not receiving treatment. The extent that smoking habits have on outcomes after patients receive treatment for a shoulder injury is still not fully understood. persistent shoulder conditions is necessary in a population with high rates of smokers. Treatment decisions the patient. Therefore, the purpose of this study was to investigate the effects of smoking on recovery from a shoulder injury after receiving treatment. METHODS DesignThis was a secondary analysis from a cohort of 98 sub jects enrolled in a pragmatic randomized clinical trial.42 reported smoking status and improvement in shoul der pain and function. The study was approved by the Madigan Army Medical Center Institutional Review published open access.43 The project was also registered in the National Institutes of Health clinical trial regis try (NCT01190891). All patients provided consent to participate.SettingThe study took place in the Department of Physical Medicine and Rehabilitation at Madigan Army Medical Center, Tacoma, WA, a military hospital within the US Military Health System.SubjectsSubjects that met the inclusion criteria for subacromial pain syndrome were recruited from the physical therapy clinic. Eligible patients had a variety of conditions in cluding rotator cuff pathology, partial thickness rotator cuff tears, and subacromial bursitis. All subjects were adults between the ages of 18 and 65 years with unilat eral shoulder pain, and were eligible to receive medi cal care within the Military Health System. They were screened to exclude symptoms that were referred from the cervical spine and to rule out a diagnosis of adhesive capsulitis.Main Outcome MeasuresPatients had been randomized to receive a one-time cor ticosteroid injection (40 mg triamcinolone acetonide) with instruction on Codmans range of motion exercises or a 6-session protocol of manual physical therapy over 3-weeks. Each patient completed the Shoulder Pain and Disability Index (SPADI) in addition to a social history questionnaire that included questions about smoking: Do you currently smoke? If YES, how many packs a day? If NO, have you quit within the last 6 months? The SPADI is a 100-point, 13-item, self-administered questionnaire, divided into 2 subscales: a 5-item pain subscale and an 8-item disability subscale. It is valid and responsive to change and accurately discriminates between patients who are improving or worsening in status.44,45 It has a minimal clinically important differ ence (MCID) of between 8 to 13 percentage points.46 In this secondary analysis, we dichotomized patients into that did not meet it (<12 point change) at the 4-week and 6-month follow-up points.Data AnalysisDescriptive statistics were used to characterize the sample. Multiple imputation was used to impute miss ing values.47 Baseline and intermediate data were used to predict missing outcome data at 4-week and 6-month follow-up periods. Five separate imputed data sets were created and the results of the pooled analyses were in terpreted. Logistic regression was used to examine the association between being a smoker at baseline and achieving at least 1 MCID on the SPADI at 4 weeks and 6 months. We used a backwards elimination pro cedure to construct the regression models. All potential predictor variables were entered into separate models predicting the outcome at each time point. Starting with all potential confounders, the variable with the largest P value was removed. If the removal resulted in a 10% change in the estimated odds ratio (OR) of the smoking variable, the potential confounder was retained in the model. Each variable was handled in this fashion un til only potential confounders and the smoking variable were retained.48 RESULTS Table 1 displays the descriptive characteristics of the sample. Of the 98 participants (31 female) in the study, 17 were current smokers. The average age of the sample was 40.8 years (SD=12.0) with smokers being approxi mately 8 years younger than nonsmokers. The average baseline disability, pain, and fear avoidance beliefs

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38 http://www .cs.amedd.army .mil/amedd_journal.aspxphysical activity subscale were similar between cur rent smokers and nonsmokers. The mean fear avoidance beliefs work subscale was higher for current smokers. Comorbid conditions, whether the participant followed the treatment protocol and treatment groups displayed by smoking status are also reported in Table 1. gistic regression indicated that after controlling for co MCID at 4 weeks (Table 3) but not at 6 months (Table 4). Interpretation of the OR indicate that in patients re ceiving care for shoulder impingement, those that were smokers at baseline assessment had 0.16 times the log odds of achieving one MCID at 4 weeks compared to those who did not smoke. Although smoking was not as sociated with obtaining a MCID at 6 months, following the study protocol (receiving the treatment initially ran domized to without ever crossing over during the followup period) and baseline SPADI were associated with that result. After controlling for covariates, those that crossed over treatments had 0.17 times the log odds of achieving one MCID at 6 months compared to those that only re ceived the treatment they were initially randomized to. Likewise, those patients that presented with a higher baseline total SPADI score were more likely achieve one MCID on the SPADI at 6 months; for every one point increase in the baseline SPADI score, the log odds of achieving one MCID increased by 1.05. Only 44 (45%) of the subjects in this co hort had received an MRI at the time of enrollment. Therefore, imaging results were not entered as a potential predictor into the model. However, of those that did have an MRI, 11 (25%) had labral tears, 23 (52%) had rotator cuff tears, 5 (11%) had biceps tendon pathology, and 37 (76%) had ACJ OA. Only 6 of the 17 subjects that smoked had an MRI. CO MM ENT Although smoking has been declining, it continues to be the leading cause of pre ventable deaths in the United States,18 and rates of smoking are higher in the US military than in civilian counter parts.19,20 It has a strong association with chronic disease and overall health prognosis. Among military veterans, smoking is linked to chronic pain and veterans who smoke are more likely to receive prescrip tion opiates, and also more likely to abuse them.49 For many of these reasons, and likely others still to be ex plored, smoking is associated with delayed recovery from an injury, and is an independent risk factor for poor prognosis in a variety of other musculoskeletal conditions.50 Therefore, it is not surprising to expect an adverse effect on recovery from shoulder conditions as well. The results from the clinical trial comparing the effec tiveness of physical therapy and corticosteroid injection provements from baseline of 50% after 4 weeks, which was maintained out to one year.42 In the short term (4 recovery than the type of treatment received. It may be that the deleterious effects of smoking play a stronger role during the initial injury phase, or active treatment phase, which in our study was about 3 weeks. In the short term, just as or more important than the actual treatment choice may be the ability to identify and address factors associated with a poor prognosis. Smoking could be one smoking on the short and long term recovery of patients Table 1. Descriptive Characteristic of Sample at Baseline All Patients (N=98) Smoker (n=17) Nonsmoker (n=81) Patient Variables Mean age in years (SD)40. 8 (12 0) 34 1 (11 7) 42 2 (11 6)Female31 (31 6) 4 (23 5) 27 (33 3)Military Beneficiary Category Active Duty Service Member52 (53 1) 12 (70 6) 40 (49 4)National Guard or Reservist8 (8 2) 2 (11 8) 64 (79 0)Family Member/Dependent18 (18 4) 2 (11 8) 16 (19 8)Retired Service Member20 (920 4) 1 (5 9) 19 (23 5)Mean Body Mass Index (SD)28 5 (4 5) 27 .4 (4 .4) 28 7 (4 5)Mean Duration of Symptoms (SD)175 1 (340 7) 185 (213 0) 172 5 (366 7)Mean SPADI45 5 (16 6) 46 5 (15 3) 45 3 (16 8)Mean NPRS3 6 (2 4) 3 8 (2 3) 3 5 (2 4)Mean FABQ Work11 9 (9 9) 17 2 (9 4) 10 9 (9 6)Mean FABQ-PA15 2 (4 9) 16 4 (5 0) 14 .9 (4 .9)Hand Dominance Involvement53 (55 2) 8 (47 1) 45 (57. 0)Pain Affects Sleep90 (92) 14 (82 4) 76 (95 0)Co-morbid Mental Health Condition15 (15 3) 4 (23 5) 11 (13 6)Co-morbid Cardiovascular Condition21 (21 4) 2 (11 8) 19 (23 5)Followed Protocol80 (81 6) 16 (94 1) 64 (79 0)Treatment Group Physical Therapy46 (46 9) 11 (64 7) 35 (43 2)Corticosteroid Injection52 (53 1) 6 (35) 46 (56 8)Note: Values are counts (percentages) unless otherwise indicated. FABQ Work indicates Fear Avoidance Belief Questionnaire Work Subscale FABQ-PA indicates Fear Avoidance Belief Questionnaire Work Physical Activity Subscale. NPRS indicates Numeric Pain Rating Scale. SPADI indicates Shoulder Pain and Disability Index THE INFLUENCE OF SMOKING ON RECOVERY FROM SUBACROMIAL PAIN SYNDROME: A COHORT FROM THE MILITARY HEALTH SYSTEM

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October December 2017 39 receiving treatment for subacromial pain syn drome in the MHS. Smoking plays a detri mental role in musculo skeletal disorders through several proposed mecha nisms, many of which are independent from other variables. Age-related loss of muscle mass (sar copenia) and strength by smoking.50 Impaired muscle metabolism, in to oxidative stress, and overexpression of sarco penia-related genes have been observed in muscle tissue of chronic smok ers.50 Muscle weakness and impairment is also strongly associated with shoulder impingement and rotator cuff tendinopathies.51,52 prior work. Bodin and colleagues found smoking to be an important risk factor for developing a rotator cuff 53 The amount of smoking was positively correlated with the severity of the tear found. Nearly half of our patient cohort (44) had received an MRI prior to enrollment in the study, and of those, 52% had a rotator cuff tear. Only 6 of the 17 smokers had an MRI, but the majority of those with an MRI (83%) had a partial or full-thickness tear. How ever, 50% in the nonsmoking group also had a partial or full-thickness tear. There is also a higher risk for de veloping muscle pain in chronic smokers, and subacro mial pain syndrome is primarily a muscle disorder.50 In between smokers and nonsmokers, but as less smokers reached a clinically meaningful change at 4 weeks, the smoking may have explained the greater persistence of symptoms in this group. Six months after treatment, smoking was no longer asso ciated with poor outcome. With the passage of time, and in the absence of treatment (which did not last more than 3 weeks), there may have been time for additional factors smoking status at 6 months, it is possible that some of the patients had ceased smoking during that time. It may also be that the deleterious effects of smoking are best expressed during active treatment, when pain modula tion and restoring muscle function is the key focus. Laslett and colleagues also found that greater pain and disability at baseline was a predictor of excellent out comes in primary care shoulder pain patients.54 Simi larly, subjects with a higher disability at baseline were more likely to achieve a clinically important difference at 4 weeks and 6 months, regardless of treatment. While our inclusion criteria required a minimum of 20% (100% is maximum disability) on the SPADI to help prevent a these patients had more room to improve. Educating patients on the dangers of smoking continues to be a strong public health initiative. This is especially important in the MHS, where smoking has been identi occurrence of pain.23-25,49,55 The extent to which this education affects the prognosis of musculoskeletal injuries is not well known. However, providers in the MHS should understand that the injurious effects of smoking extend beyond some of the more traditionally known sequelae such as lung cancer. In fact, the latest US Surgeon Gen eral report published by the Centers for Disease Control and Prevention did not focus on any relationships with smoking on respiratory diseases, reproduction, diabetes, cardiovascular health, and cancer.56 Because musculo skeletal injuries are the primary source of disability for the US military, responsible for annual healthcare costs of $500 million and resulting in more than 25 million limited-duty days per year,3,4 providers in the MHS should include discussions with their patients related to the effects of smoking on musculoskeletal injury. An Table 3. Multivariate Adjusted Model for One-month Follow-up.VariableP value aOR (95% CI) Smoker-1 .856 010*0. 16 (0. 38-0. 64)*Treatment Group0 .721 .18 2 06 (0. 72-5. 92)Pain Affects Sleep-1 73 171 0 .18 (0 02-2 .11)FABQ-W-0. 02 .407 0. 98 (0. 93-1 03)*Indicates significant value. FABQ-W indicates Fear Avoidance Belief Questionnaire Work Sub scale. aOR indicates adjusted Odds Ratio. Table 2. Variables Retained for Multiple Regression Modeling.Smoker Age Gender BMI Hand Dominance Treatment Group On Protocol Comorbid Mental Health Diagnosis Comorbid Cardiovascular Diagnosis Pain Effects Sleep Symptom Duration Baseline Pain Baseline FABQ-PA Baseline FABQ-W Baseline SPADIFABQ-W indicates Fear Avoidance Belief Questionnaire Work Subscale. SPADI indicates Shoulder Pain and Dis ability Index. FABQ-PA indicates Fear Avoidance Be lief Questionnaire Work Physical Activ ity Subscale. Table 4. Multivariate Adjusted Model For Reaching MCID at 6 Months.VariableP value aOR (95% CI) Smoker-1 173 097 0. 31 (0. 08-1 24)Followed Protocol-1 791 045*0. 17 (0. 30-0. 96)Age0. 019 414 1. 02 (0 97-1. 07)Comorbid Mental Health2 002 .12 7 45 (0 52-95 83)Baseline SPADI0. 048 016*1. 05 (1. 01-1. 09)*Indicates significant value. MCID indicates Minimally Clinically Important Difference. SPADI in dicates Shoulder Pain and Disability Index. aOR indicates adjusted Odds Ratio. MCID indicates Minimal Clinically Important Difference.

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40 http://www .cs.amedd.army .mil/amedd_journal.aspx informative and shared decision approach when manag ing patients with shoulder conditions should incorporate education related to smoking habits and prognosis. This risk factor is not only associated with general medical health conditions, but it also may delay recovery and corporating smoking education into the management of these patients could positively effect the high prevalence of patients with persistent shoulder pain. Future studies should focus on the effect of smoking education and ces sation programs on functional outcomes for subacromial pain and other musculoskeletal injuries, as well as track longitudinally how smoking habits may change over the course of an injury. LI M IT A TIONS This study did not analyze the effect of smoking in tensity (1 to 2 cigarettes vs 2 packs a day), which may improve the accuracy of the association with prognosis. Smoking history was only collected at baseline upon en rollment in the study and not reevaluated at the 6-month follow-up. It is possible that smoking patterns could have changed during the period, and if enough patients had given up smoking during that time, it may help ex plain why the risk of not recovering was there at 4 weeks, but not at 6 months. CONCLUSION cant improvement in pain and function in patients with shoulder impingement syndrome, regardless of treat ment received. Smoking habits should be accounted for in all future trials evaluating treatments for shoulder conditions, and a more robust sampling of potentially associated risk factors of poor prognosis are also needed to create better risk prediction algorithms. Providers in the MHS should consider this risk factor when manag ing patients with shoulder pain, and also musculoskel etal injury-related content to their smoking education programs. REFERENCES 1. Badcock LJ, Lewis M, Hay EM, et al. Chronic shoul der pain in the community: a syndrome of disabil ity or distress?. Ann Rheum Dis 2002;61(2):128-131. 2. Palmer KT, Cooper C, Walker-Bone K, et al. Use of keyboards and symptoms in the neck and arm: evidence from a national survey. Occup Med 2001;51(6):392-395. 3. Luime JJ, Koes BW, Hendriksen IJM, et al. Preva lence and incidence of shoulder pain in the general population; a systematic review. Scand J Rheuma tol 2004;33(2):73-81. 4. Knapik JJ, Jones SB, Darakjy S, et al. Injury rates and injury risk factors among U.S. Army wheel ve hicle mechanics. Mil Med 2007;172(9):988-996. 5. Lovalekar M, Abt JP, Sell TC, et al. Descriptive epidemiology of musculoskeletal injuries in Naval Special Warfare Sea, Air, and Land Operators. Mil Med. 2016;181(1):64-69. 6. Rudzki SJ. Injuries in Australian Army recruits. Part II: location and cause of injuries seen in re cruits. Mil Med 1997;162(7):477-480. 7. Sammito S, Gundlach N, Bckelmann I. Injuries caused during military duty and leisure sport activ ity. Work 2016;54(1):121-126. 8. Rhon DI. A physical therapist experience, observa tion, and practice with an infantry brigade combat team in support of Operation Iraqi Freedom. Mil Med. 2010;175(6):442-447. 9. Bot SDM, van der Waal JM, Terwee CB, et al. Predictors of outcome in neck and shoulder symp toms: a cohort study in general practice. Spine 2005;30(16):E459-E470. 10. Croft P, Pope D, Silman A. The clinical course of shoulder pain: prospective cohort study in primary care. Primary Care Rheumatology Society Shoul der Study Group. BMJ 1996;313:601-602. 11. van der Windt DA, Koes BW, Boeke AJ, et al. Shoul der disorders in general practice: prognostic indica tors of outcome. Br J Gen Pract 1996;46:519-523. 12. Winters JC, Sobel JS, Groenier KH, et al. The long-term course of shoulder complaints: a pro spective study in general practice. Rheumatology 1999;38(2):160-163. 13. Rekola KE, Levoska S, Takala J, et al. Patients with neck and shoulder complaints and multisite muscu loskeletal symptoms--a prospective study. J Rheu matol 1997;24(12):2424-2428. 14. functioning 1 year after injury: the role of prein jury sociodemographic and health characteristics, health care and injury-related factors. Arch Phys Med Rehabil 2013;94(7):1277-1286. 15. Mintken PE, Cleland JA, Whitman JM, et al. Psy chometric properties of the Fear-Avoidance Beliefs Questionnaire and Tampa Scale of Kinesiophobia in patients with shoulder pain. Arch Phys Med Re habil 2010;91(7):1128-1136. 16. of fear-avoidance beliefs on functional status out comes for people with musculoskeletal conditions of the shoulder. Phys Ther 2012;92(8):992-1005. 17. Rechardt M, Shiri R, Karppinen J, et al. Lifestyle and metabolic factors in relation to shoulder pain and rotator cuff tendinitis: a population-based study. BMC Musculoskelet Disord 2010;11:165. doi: 10.1186/1471-2474-11-165.THE INFLUENCE OF SMOKING ON RECOVERY FROM SUBACROMIAL PAIN SYNDROME: A COHORT FROM THE MILITARY HEALTH SYSTEM

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October December 2017 41 18. Agaku IT, King BA, Dube SR. Current cigarette smoking among adults United States, 2005-2012. MMWR Morb Mortal Wkly Rep 2014;63(2):29-34. 19. Smith EA, Malone RE. Everywhere the soldier itary. Am J Public Health 2009;99(9):1595-1602. 20. Arvey SR, Malone RE. Advance and retreat: to bacco control policy in the U.S. military. Mil Med 2008;173(10):985-991. 21. Teyhen DS, Rhon DI, Butler RJ, et al. Associa tion of physical inactivity, weight, smoking, and prior injury on physical performance in a mili tary setting. J Athl Train 2016. 51(11):866-875. doi:10.4085/1062-6050-51.6.02. 22. Leyk D, Witzki A, Willi G, et al. Even One Is Too Much: Sole Presence of One of the Risk Fac tors Overweight, Lack of Exercise, and Smoking Reduces Physical Fitness of Young Soldiers. J Strength Cond Res 2015;29(suppl 11):S199-S203. 23. Grier TL, Morrison S, Knapik JJ, et al. Risk factors for injuries in the U.S. Army Ordnance School. Mil Med. 2011;176(11):1292-1299. 24. Altarac M, Gardner JW, Popovich RM, et al. Cigarette smoking and exercise-related injuries among young men and women. Am J Prev Med 2000;18(suppl 3):96-102. 25. Teyhen DS, Shaffer SW, Butler RJ, et al. What risk factors are associated with musculoskeletal injury in US Army Rangers? A prospective prognostic study. Clin Orthop Relat Res 2015;473(9):2948-2958. 26. Swedler DI, Knapik JJ, Williams KW, et al. Risk factors for medical discharge from United States Army Basic Combat Training. Mil Med 2011;176(10):1104-1110. 27. Larsson H, Broman L, Harms-Ringdahl K. Individ ual risk factors associated with premature discharge from military service. Mil Med 2009;174(1):9-20. 28. Behrend C, Prasarn M, Coyne E, et al. Smoking cessation related to improved patient-reported pain scores following spinal care. J Bone Joint Surg Am 2012;94(23):2161-2166. 29. Mikkonen P, Leino-Arjas P, Remes J, et al. Is smok ing a risk factor for low back pain in adolescents? A prospective cohort study. Spine 2008;33(5):527-532. 30. Prasarn ML, Horodyski MB, Behrend C, et al. Neg ative effects of smoking, workers compensation, and litigation on pain/disability scores for spine pa tients. Surg Neurol Int 2012;3(suppl 5):S366-S369. 31. Baumgarten KM, Gerlach D, Galatz LM, et al. Cig arette smoking increases the risk for rotator cuff tears. Clin Orthop Relat Res 2010;468(6):1534-1541. 32. Carbone S, Gumina S, Arceri V, et al. The impact of preoperative smoking habit on rotator cuff tear: J Shoulder Elbow Surg 2012;21(1):56-60. 33. Gill TK, Shanahan EM, Taylor AW, et al. Shoulder pain in the community: an examination of associa tive factors using a longitudinal cohort study. Ar thritis Care Res 2013;65(12):2000-2007. 34. Shan Z, Deng G, Li J, et al. How schooling and lifestyle factors affect neck and shoulder pain? A cross-sectional survey of adolescents in China. Spine 2014;39(4):E276-E283. 35. Santiago-Torres J, Flanigan DC, Butler RB, et al. The effect of smoking on rotator cuff and glenoid labrum surgery: a systematic review. Am J Sports Med. 2015;43(3):745-751. 36. Callrus M, McGuigan F, Akesson K. Adverse ef fects of smoking on peak bone mass may be attenu ated by higher body mass index in young female smokers. Calcif Tissue Int 2013;93(6):517-525. 37. Ward KD, Klesges RC. A meta-analysis of the ef fects of cigarette smoking on bone mineral density. Calcif Tissue Int 2001;68(5):259-270. 38. Patel RA, Wilson RF, Patel PA, et al. The effect of smoking on bone healing: A systematic review. Bone Joint Res 2013;2(6):102-111. 39. Bartsch RH, Weiss G, Kstenbauer T, et al. Crucial aspects of smoking in wound healing after breast reduction surgery. J Plast Reconstr Aesthet Surg 2007;60(9):1045-1049. 40. Manassa EH, Hertl CH, Olbrisch RR. Wound healing problems in smokers and nonsmokers af ter 132 abdominoplasties. Plast Reconstr Surg 2003;111(6):2082-2087; discussion 2088-2089. 41. Truntzer J, Vopat B, Feldstein M, et al. Smoking ces sation and bone healing: optimal cessation timing. Eur J Orthop Surg Traumatol 2015;25(2):211-215. 42. Rhon DI, Boyles RB, Cleland JA. One-year out come of subacromial corticosteroid injection com pared with manual physical therapy for the man agement of the unilateral shoulder impingement syndrome: a pragmatic randomized trial. Ann In tern Med. 2014;161(3):161-169. 43. Rhon DI, Boyles RE, Cleland JA, et al. A manual physical therapy approach versus subacromial cor ticosteroid injection for treatment of shoulder im pingement syndrome: a protocol for a randomised clinical trial. BMJ Open 2011;1(2):e000137. 44. Williams JW Jr, Holleman DR Jr, Simel DL. Mea suring shoulder function with the Shoulder Pain and Disability Index. J Rheumatol 1995;22(4):727-732.

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42 http://www .cs.amedd.army .mil/amedd_journal.aspx45. Roach KE, Budiman-Mak E, Songsiridej N, et al. Development of a shoulder pain and disability in dex. Arthritis Care Res 1991;4(4):143-149. 46. Roy JS, MacDermid JC, Woodhouse LJ. Measuring shoulder function: a systematic review of four ques tionnaires. Arthritis Rheum 2009;61(5):623-632. 47. He Y. Missing data analysis using multiple imputa tion: getting to the heart of the matter. Circ Cardio vasc Qual Outcomes 2010;3(1):98-105. 48. Maldonado G, Greenland S. Simulation study of confounder-selection strategies. Am J Epidemiol 1993;138(11):923-936. 49. Chapman SLC, Wu L-T. Associations between cigarette smoking and pain among veterans. Epidemiol Rev 2015;37:86-102. 50. Abate M, Vanni D, Pantalone A, et al. Cigarette smoking and musculoskeletal disorders. Muscles Ligaments Tendons J 2013;3(2):63-69. 51. Celik D, Sirmen B, Demirhan M. The relationship of muscle strength and pain in subacromial im pingement syndrome. Acta Orthop Traumatol Turc 2011;45(2):79-84. 52. Michener LA, Boardman ND, Pidcoe PE, et al. Scapular muscle tests in subjects with shoulder pain and functional loss: reliability and construct validity. Phys Ther 2005;85(11):1128-1138. 53. Bodin J, Ha C, Srazin C, et al. Effects of individu al and work-related factors on incidence of shoulder pain in a large working population. J Occup Health 2012;54(4):278-288. 54. Laslett M, Steele M, Hing W, et al. Shoulder pain patients in primary care--part 1: Clinical outcomes over 12 months following standardized diagnostic workup, corticosteroid injections, and communitybased care. J Rehabil Med. 2014;46(9):898-907. 55. Reynolds K, Cosio-Lima L, Bovill M, et al. A comparison of injuries, limited-duty days, and injury risk factors in infantry, artillery, construc tion engineers, and special forces soldiers. Mil Med 2009;174(7):702-708. 56. National Center for Chronic Disease Prevention Health. The Health Consequences of Smoking50 Years of Progress: A Report of the Surgeon Gen eral Atlanta, GA: Centers for Disease Control and Prevention; 2014. Available at: https://www. surgeongeneral.gov/library/reports/50-years-ofprogress/index.html. Accessed September 25, 2017. AUTHORS When this study was conducted, MAJ Rhon was as signed to the Madigan Army Medical Center, Yakima, Washington. Currently, he is with the Center for the In trepid, Brooke Army Medical Center, Joint Base San An the Army-Baylor University Graduate Program in Physi cal Therapy at the AMEDD Center and School, Fort Sam Houston, Texas. Dr Magel is with the Department of Physical Therapy and Athletic Training, University of Utah, Salt Lake City, Utah.THE INFLUENCE OF SMOKING ON RECOVERY FROM SUBACROMIAL PAIN SYNDROME: A COHORT FROM THE MILITARY HEALTH SYSTEM

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October December 2017 43Musculoskeletal (MSK) injuries have steadily been on tary medical readiness and the military healthcare sys tem.1-3 Musculoskeletal injuries accounted for more than 3 million ambulatory care visits in 2014 for all active component service members.4 They are the number one reason for medical discharge from the US Army and the most common cause of noncombat injuries reported dur ing deployment.5,6 At a time of military force reduction, medical readiness optimization is essential to the sus tainment of successful worldwide military operations.7While the military places a large focus on medical readi ness through periodic health assessments, no standard ized assessment for evaluating MSK readiness exists at this time. Multiple studies suggest that previous injury predisposes individuals to future injury.8-11 Additional research suggest that faulty movement patterns may be associated with higher risk for injury,12,13 although as sessments to date have been fairly subjective and there is currently no consensus on what movements should be assessed. A lower level of optimism has also been found to be related to a higher likelihood of injury occurrence, which suggests that an individuals level of concern for injury should be considered in addition to physical per formance measures.14,15There are several MSK screening tools, such as the Func tional Movement Screen (FMS)9,13 (Functional Movement Systems, Inc., Chatham, VA) and the Y-Balance Real Time Interrater Reliability of a Novel Musculoskeletal Readiness Screening ToolLTC (Ret) Mark D. Thelen, SP, USA CPT Michael U. Bolduc, SP, USA LTC (Ret) Shane L. Koppenhaver, SP, USA 1LT Riley K. Quan, SP, USA CPT Shanee E. Allen, SP, USA LTJG Anne E. Sidwell, MSC, USN ABSTR A CT purpose of this study is to describe the conduct of a novel musculoskeletal readiness screening tool (MRST) and evaluate the real-time interrater reliability of the MRST when scored by raters with differing levels of medical experience. Materials/Methods: This study included a convenience sample of 40 active duty military participants (30 male, 10 female, mean age 29.36.9 years) without any current musculoskeletal injury or pain at the time of enroll ment. The MRST consisted of 5 physical performance tests and one self-report question as follows: (1) weightbearing lunge (WBL), (2) overhead squat, (3) closed kinetic chain upper extremity stability test (CKCUEST), (4) eyes closed forward step down, (5) repeated tuck jump, and (6) individual perceived level of risk for MSK with less than one year didactic training, and a physical therapy technician with approximately 10 years of experience) independently scored each event as 0, 1, or 2 based on the quality of the participants performance. This scoring system allows for a cumulative score ranging from 0 to 12, with lower scores thought to indicate higher risk for future injury. Descriptive, reliability, and chance-corrected agreement statistics were calculated using IBM SPSS. This study was approved by the Brooke Army Medical Center Institutional Review Board at Fort Sam Houston, Texas. Results: The mean composite MRST score for all graders was 7.791.41. Among all 3 raters the overall reliabil ity was moderate (ICC (2,1)=0.75 (0.62, 0.85)). Chance-corrected agreement values for the individual events ranged from slight to almost perfect as follows: WBL ( =0.33-0.44), overhead squat ( =0.57-0.65), CKCUEST ( =0.89-1.0), eyes-closed forward step down ( =0.10-0.42), repeated tuck jump ( =0.39-0.61), individual per ceived level of risk for MSK injury ( =1.0). Conclusions: The MRST showed moderate interrater reliability for the overall composite score with varied levels of agreement for individual events scores. Future research should investigate test-retest reliability and interrater reliability among medical personnel from different disciplines.

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44 http://www .cs.amedd.army .mil/amedd_journal.aspxTest,12,16 that assess movement patterns and identify functional limitations and asymmetries. However, these tools are often used in elite athletic populations9,13 rather than typical military service members, and research these screening tools.8,17,18 Additionally, these tools gen erally require time, equipment, and trained personnel in order to ensure proper administration, all of which may be in limited supply in any given military medical environment. A musculoskeletal readiness screening tool (MRST) that can assess a broad spectrum of movement pat terns commonly encountered by a majority of military service members is necessary.19 Furthermore, this tool completed in any environment, performed using mini mal equipment, and reliably assessed by a broad range of healthcare personnel. The MRST in this study was adapted from a previously reported screening tool in tended to be used to assist medical providers with return to duty decisions.20 A majority of the events from the this study in order to increase the level of challenge and decrease the time and equipment required for adminis tration. Additionally, the authors selected the events and evaluative criteria for the MRST in this study in order to create a tool that would: (1) screen upper and lower extremity strength and mobility, core stability, and tol erance for upper and lower extremity plyometric activ ity, (2) evaluate participants using standardized scoring criteria regardless of gender, and (3) be general enough to apply to all military service members regardless of branch of service and occupational specialty. Because health screening in the military is performed by provid ers of varying levels of MSK expertise (eg, from unit medics to hospital physical therapists), it is necessary that a screening tool be reliable between providers of differing levels of MSK training. Therefore, the primary objective of this study was to describe and assess realtime interrater reliability of the MRST between raters of differing levels of medical training and experience. METHODS ParticipantsA convenience sample of 40 participants was recruited over a 3-month period. All participants were active duty US military personnel stationed at Joint Base San An tonio, TX. A large majority of the participants were en rolled as students in some type of temporary medical training program during the data collection period. The Institutional Review Board at Brooke Army Medical Center, Fort Sam Houston, TX, approved this protocol and the rights of the participants were protected. After consenting, participants completed a screening questionnaire consisting of basic demographic informa tion, including age, sex, height, weight, past medical his tory, branch of service, and military occupation. To be considered eligible, participants had to meet the follow ing inclusion criteria: active duty military service mem bers ranging in age from 18 to 50 years; in no pain (0/10) at the time of enrollment; and read and speak English well enough to understand the informed consent documents, as well as instructions given by researchers. Ex clusion criteria included the following: current musculo skeletal injury of any kind or signs or symptoms thereof; medical condition(s) that preclude rigorous physical activity; known pregnancy; physical restrictions that would preclude performance of MRST events; or any orthopedic surgery within the last 6 months. Real-time interrater reliability was investigated using 3 raters, each representing varying levels of MSK educa tion and training. The raters included the principal inves tigator (Rater 1) who was a licensed physical therapist clinical and functional movement screening experience, year of academic preparation, and an enlisted physical therapy technician (Rater 3) with approximately 10 years of clinical experience. Raters 2 and 3 had minimal prior functional movement screening experience. This combi nation of raters was chosen because it is consistent with Experimental ApproachThis study was a single cohort study, with all partici pants following the same initial assessment protocol. All raters received approximately 5 hours of training to en sure standardized performance of duties related to the protocol. The raters were blinded to one anothers re sults and data was not made available to any rater until all data collection was completed.ProceduresThe MRST consisted of 6 events executed in the fol lowing order: weight-bearing lunge event (WBL), over head squat (OHS), closed kinetic chain upper extremity stability test (CKCUEST), forward step down with eyes closed (FSD), repeated tuck jump (RTJ), and a question regarding the individuals perceived risk for future mus culoskeletal injury (QUEST). Each event was graded as a 0, 1, or 2, resulting in a cumulative score ranging from 0 to 12, with higher scores presumed to indicate a great er level of psychological and musculoskeletal readiness. For all events, with the exception of QUEST, a score of 2 in a single event indicated performance to standard REAL TIME INTERRATER RELIABILITY OF A NOVEL MUSCULOSKELETAL READINESS SCREENING TOOL

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October December 2017 45 substandard performance, and a score of 0 was recorded if a participant demonstrated bilateral dysfunction and/ or noted pain with the event. The participants were not informed about the scoring criteria for each event prior to testing. All participants received a standardized set of instructions for each MRST event that was followed by a live demonstration performed by an investigator not serving as a rater. Each of 3 raters used a similar view point to simultaneously score the MRST events. Weight-bearing Lunge (Figure 1). This event has been reported in several studics21,22 as a method to assess an kle joint mobility. It was performed while wearing socks without shoes. Participants started from a staggered stance position with their feet slightly less than shoulder width apart. The longest toe of the trail foot was placed in line with the heel of the forward foot when viewed from the side. The participant was permitted to place 2 digits per hand against the wall as a balance aid only.22 The longest toe of the forward foot was required to touch the edge of the tape marking the 10 cm distance. Partici pants were instructed to lunge directly forward with the intent of touching the kneecap to the wall, ensuring that the forward heel stayed on the ground throughout the movement.21,22 If obvious compensatory movement of the hip, pelvis, or knee was noted, the trial could be re peated. One to 2 practice trials were permitted to ensure proper performance. If multiple trials were performed on this or any subsequent event, the last performed trial was the one graded by each of the 3 raters. The same procedure was then completed on the opposite lower extremi ty. All raters for this event used a lateral viewpoint. This event has demonstrated excellent in trarater and interrater reliabil ity.21,23 There is some evidence to suggest that it is predictive of lower extremity injuries in Australian football players,24 and that less than 12 cm of mo tion may be considered restrict ed.25,26 The standard of 10 cm distance was used in this study. Scoring criteria for this event and all subsequently described events performed in the MRST are listed in Table 1. Overhead Squat (Figure 2). This event was a modi the FMS27 and similar to the overhead deep squat per formed as part of the Selective Functional Movement Assessment.28 Participants left their shoes off for this event and were instructed to lift the arms overhead in the manner shown in Figure 2 and keep them in this posi tion throughout the duration of the movement. The par ticipants feet were placed in a comfortable position that was approximately at shoulder width. Neutral foot throughout the duration of the movement.27,28 Partici pants were instructed to squat until their thighs were repeated up to 3 times, at the discretion of the raters, in order to determine an accurate score. All raters for this event started with an anterior viewpoint and then moved to a lateral view. This event has demonstrated accept able chance-corrected agreement when evaluated by ex perienced raters29 and has been shown to be predictive of injury risk in at least one study.30Closed Kinetic Chain Upper Extremity Stability Test (Figure 3). This event provided a dynamic challenge primarily to the core and upper extremities. Participants put their shoes on and kept them on for the remainder of the screening. Prior to starting this event, participants were permitted to stretch for up to 30 seconds. Male participants began by assuming the starting position for a standard military push-up position and female par weight-bearing occurred through the knees).31,32. Folded creased comfort during the event. The feet (or knees for position). Their hands were placed 36 inches apart on by white athletic tape. The initial movement consisted of reaching toward the weightbearing hand with the free hand to contact the tape or a part of the weight-bearing hand directly over the tape, before returning to the starting position. Hand contacts occurred alternately and each contact was counted as Figure 1. Weight-bearing lunge. Figure 2. Overhead squat. Figure 3. Closed kinetic chain up per extremity stability test (male).

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46 http://www .cs.amedd.army .mil/amedd_journal.aspxone repetition.31 The stated goal was to complete 20 repetitions within 15 seconds. Participants were required trunk and legs alignment throughout the duration of the event.32 Participants were instructed to stop when 15 seconds had elapsed or 20 correct repetitions were com for all raters was anterior and only a single 15-second trial was completed. This event has demonstrated excel lent reliability in both healthy and injured populations.32 In one study, it was highly predictive of shoulder injuries in football players when using a cut-off score of 21 touches.33 The standard used in this study was reduced to 20 given the increased variability in upper body and core strength found within a given military population. Forward Step Down with Eyes Closed (Figure 4). This event was previously reported20 and demonstrated moderate chance-corrected agreement. The event was condition in order to increase generalizability. Agree ment for rating quality of movement during the for ward step down task under normal lighting conditions has been previously reported as fair to good.34,35 Given that injury risk is potentially elevated during nighttime operations,36 and landing mechanics are unfavorably altered during drop landings with visual compromise,37 the purpose of this event was to grossly simulate disembark ing from a vehicle during op erational low-light conditions. This assessment is similar to the typical step-down func tional assessment routinely performed in the clinical set ting but with the addition of 2 textbooks held at the height of the umbilicus as a challenge to anterior balance and with the eyes closed. Participants began this event with both feet on an 8-inch step. The participant was given 2 hard cover textbooks, weighing 13 pounds collectively, and instructed to hold the books with the elbows bent to 90 degrees without allowing the books to contact the body. The instructor directed the participants to then close their eyes and step down one leg at a time. Participants were instructed not to open their eyes until completing the step down. The event was then completed by perform ing the same movement, but initiating the step-down with their opposite leg. The viewpoint for this event for all raters was anterior. Repeated Tuck Jump (Figure 5). This event consisted of 3 tuck jumps completed in rapid sequence. Although there is minimal evidence regarding reliability and validity, it provided a substantial lower extremity plyometric challenge and is similar to the tuck jump exer cise prescribed as part of the Army Physical Readiness Training program.38 The starting position was an upright straddle stance, and participants were instructed to begin jumping when they felt prepared to do so. The stated goal was for the thighs to achieve at least a 45 angle from the vertical plane. The hands were not permitted to grasp the knees in an effort to draw the thighs closer to the trunk. Each partici pant was reminded to rap idly initiate the next jump after attempting to make a soft landing in the original starting position.39 When a between jumps, the event was repeated. If any partic ipant experienced a sharp pain, they were instructed to stop jumping immedi ately. The viewpoint for this event for all raters was anterior. Individual Perceived Level of Risk for Musculoskeletal Injury. The goal of this event is to assess psychological risk of injury or reinjury.14,15,40,41 Participants were asked to describe their personal concern for developing a mus culoskeletal injury within the next 6 months. The previously reported20 format used a simple verbal question with 3 possible answers.Statistical AnalysisAll data were analyzed using IBM SPSS Version 22. Descriptive statistics were performed to describe the demographic characteristics of the sample. Means and standard deviations were computed for continuous data and frequency distributions were analyzed for categori cal data. It was estimated that data from 40 participants would be required to have adequate precision of inter rater reliability (ICC with 95% CI) estimates. Intra REAL TIME INTERRATER RELIABILITY OF A NOVEL MUSCULOSKELETAL READINESS SCREENING TOOL Figure 4. Forward step down with eyes closed test. Figure 5. Repeated station ary tuck jump.

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October December 2017 47 terrater reliability. The interpretation of the ICCs was consistent with the method described by Portney and Watkins.42 Unweighted Cohens kappa values were used to estimate chance-corrected agreement of individual events and the results were interpreted per the guide lines reported by Landis and Koch.43 Weighted Cohens kappa was not used because having a 2 point difference between raters in a given event was unlikely given that in 4 of 6 tests, the only possibility by which a participant could receive a score of zero is if they reported pain. Also, the probability of rater disagreement when scoring the QUEST was considered extremely low. RESULTS Consent was obtained from 40 participants (30 male, 10 female) with a mean age of 29.36.2 years that met the screening criteria to participate in the study. The mean height and weight of the sample was 175.268.63 cm and 77.5613.52 kg respectively. The MRST compos ite score and individual event score means for each rater are reported in Tables 2 and 3, respectively. Interrater reliability estimates of the composite scores are presented in Table 4. The ICC values for MRST composite scores ranged from 0.68 to 0.82. The level of chance-corrected agreement and percentage agreement is reported in Table 5. Substantial to almost perfect level of agree ment was found with the OHS, CKCUEST, and QUEST amongst all raters with the exception of a moderate agreement in the OHS between the student clinician and the ancillary clinical staff mem ber. All other events (WBL, FSD, and RTJ) had fair to moderate level of agreement with the exception of only a slight agreement in the FSD between the student clinician and the ancillary clinical staff member. CO MM ENT The results of this study indicated that the MRST com posite scores for all raters had moderate overall interrater reliability and could potentially be applied consistently by individuals with varying degrees of MSK training. Chance corrected agreement of the individual events varied from slight to almost perfect, but was generally consistent with respect to percentage agreement. While Table 3. MRST Individual Event Mean Scores (SD).Event RATER 1 RATER 2 RATER 3 WBL 0 38 (0 63) 0. 60 (0. 74) 0. 83 (0. 87) OHS 1 23 (0 53) 1 13 (0 46) 1 25 (0 49) CKC 1 35 (0 48) 1 30 (0 46) 1 35 (0 48) FSD 1 88 (0 33) 1 80 (0 41) 1 83 (0 38) RTJ 1 23 (0 48) 1 13 (0 40) 1 18 (0 45) QUEST 1 65 (0 53) 1 65 (0 53) 1 65 (0 53) Table 2. MRST Composite Scores.Rater Mean (95% CI) SD All 7 79 (6 40, 9 18) 1 41 1 7. 70 1 51 2 7. 60 1. 28 3 8 08 1 46 Table 1. MRST Scoring Criteria.W EIGHT B EARING L UNGE (WBL) 2 Bilateral ability to touch the wall with the kneecap without pain 1 Unilateral ability to touch the wall with the kneecap without pain 0 Pain associated with the movement and/or bilateral inability to touch the wall with the kneecap O VERHEAD S QUAT (OHS) 2 All of the following checkpoints are met: trunk parallel with tibia or toward vertical, arms in line with trunk, thighs at least parallel to floor, knees aligned over feet, and pain-free271 Failure to meet all of the checkpoints above and no pain present 0 Failure to meet all of the checkpoints above and/or pain present C L OSED K INETIC C HAIN U PPER E XTREMITY S TA B I L ITY T EST (CKCUEST) 2 Perform 20 repetitions to standard without pain 1 Perform less than 20 repetitions to standard without pain 0 Pain during or after the event Forward Step Down W ITH E YES C L OSED (FSD) 2 No lower extremity frontal plane deviation, eyes remain closed, no pain experience during movement, and no gross or obvious loss of motor control 1 Any lower extremity frontal plane deviation, loud foot landing indicating lack of control, eyes open, or loss of motor control, and pain-free 0 Pain during or after the event R EPEATED T UCK J UMP (RTJ) 2 Performs 3 successive jumps meeting all checkpoints: thighs at least 45 degrees compared to vertical plane, soft fore-foot to midfoot landing, no frontal plane deviation, and pain-free during all phases of movement 1 Does not meet all checkpoints above without pain 0 Pain during or after event P ERCEIVED L EVE L OF R ISK FOR M USCU L OSKE L ETA L I NJURY (QUEST)20(p17)2 No concern for injury 1 Mild to moderate concern for injury 0 Significant concern for injury Table 4. MRST Composite Score Reliability.Composite Comparison ICC (2,1)95% CI Level of Reliability All Raters 0 .75 0. 62, 0. 85 Moderate Rater 1/30. 82 0. 65, 0. 91 Good Rater 1/20 .76 0. 58, 0. 86 Good Rater 2/30 .68 0. 43, 0. 82 Moderate

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48 http://www .cs.amedd.army .mil/amedd_journal.aspxsome events, such as the QUEST and CKCUEST had almost perfect agreement across all raters, other events, such as the WBL and the FSD, did not achieve above a moderate level of agreement between any pair of raters. The variability in these results may be due to the com plexity of the event, testing protocol, or interpretation of scoring criteria. Although scores were generally consistent across the different raters, agreement was lowest between the 2 less experienced providers (Rater 2 and Rater 3). This may suggest that the level of MSK training does affect screening reliability to some extent. Alternatively, this cians direct involvement with the student raters educa tion and the ancillary staff members continuing educa tion. Therefore, the interrater reliability between these 2 sets of raters might be expected to be better than the interrater reliability between the student clinician and the ancillary staff member. Some reliability studies for the WBL event by other re searchers21,44 have reported an excellent level of agree ment between raters. However, the testing protocol for these studies differed in that the subjects heel was held to the ground throughout their attempt to touch the wall. In the current study, the participants heel was not held stationary; it was at the discretion of the raters to determine if they observed any degree of heel lift. Additionally, the aforementioned studies did not pe nalize participants for proximal compensatory move ments of the knee while the MRST grading criteria did. Essentially, the MRST leaves more room for rater interpretation in scoring the weight-bearing lunge test. Applying external stabilization at the heel could be considered in future studies to potentially eliminate the need to agree on this scoring criterion. Multiple reliability studies have been performed on assessing a squat movement, but many of these stud ies were performed using a video recorder.45-47 One study performed a real-time interrater reliability of the FMS.48 This study looked at the interrater reliabil ity between 2 raters and reported a perfect 1.0 kappa on the squat event. Although only one rater was FMS fewer raters along with having raters of more similar experience could account for the higher kappa value. Park et al35 reported good agreement for the FSD as sessment. This event resulted in the lowest reliability between raters in the current study, with kappa val ues ranging from only a slight to moderate agreement. Reliability was likely affected by a number of differenc es in the grading criteria between the 2 studies. Parks study based their kappa values on agreement within agreed that a particular movement was rated as good, this rating was based on a range of scores. Conversely, the current MRST studys kappa value was based on agreement on the exact score. Additionally, participants in the current MRST study were required to perform the maneuver with their eyes closed while holding 2 textbooks in their arms. This increased load may have and therefore increased potential for error in the way rat ers scored the participants. Despite achieving 72.5% to 85.0% agreement between all rating pairs for this event, all participants scored either a 1 or 2. The kappa value was expected to decrease because agreement is more likely to happen by chance when the scores become di chotomous. Given the low level of impact and minimal physical exertion required for this event, pain is unlikely scoring criteria for a score of 0 that does not involve the presence of pain could be considered in future studies. The evidence regarding reliability of real time jump assessments is limited. One study49 assessed the REAL TIME INTERRATER RELIABILITY OF A NOVEL MUSCULOSKELETAL READINESS SCREENING TOOL Table 5. MRST Individual Event Scoring Agreement.Rater Comparisons by Event Percentage Agreement Kappa Level of Agreement W EIGHT B EARING L UNGE (WBL) Rater 1/2 67. 50 0. 39 Fair Rater 1/3 60. 00 0. 33 Fair Rater 2/365. 00 0 44 Moderate O VERHEAD S QUAT (OHS) Rater 1/2 85. 00 0 .65 Substantial Rater 1/3 82 50 0 61 Substantial Rater 2/382 50 0. 57 Moderate C L OSED K INETIC C HAIN U PPER E XTREMITY S TA B I L ITY T EST (CKCUEST) Rater 1/2 95. 00 0. 89 Almost Perfect Rater 1/3 100. 00 1. 00 Almost Perfect Rater 2/395. 00 0. 89 Almost Perfect Forward Step Down W ITH E YES C L OSED (FSD) Rater 1/2 82 50 0. 36 Fair Rater 1/3 85. 00 0 42 Moderate Rater 2/372 50 0 10 Slight R EPEATED T UCK J UMP (RTJ) Rater 1/2 80. 00 0 45 Moderate Rater 1/3 85. 00 0 61 Substantial Rater 2/380. 00 0. 39 Fair I NDIVIDUA L P ERCEIVED L EVE L OF R ISK FOR M USCU L OSKE L ETA L I NJURY (QUEST) Rater 1/2 100. 00 1. 00 Almost Perfect Rater 1/3 100. 00 1. 00 Almost Perfect Rater 2/3100. 00 1. 00 Almost Perfect

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October December 2017 49 jump-landing technique in real time and reported in terrater reliability ranged from ICC values of 0.72-0.81. Unlike the current MRST study, researchers graded jump performance based on 10 characteristics of a single jump. The 3-point grading system of the MRST that one or more existed. Therefore, in order to achieve a maximum score for the RTJ in this study, all check points must have been met. Since the MRST is intended to be both an individual and large-group screening tool conducted by a variety of personnel, it is initially more important for the screening to identify that an individual The most technically demanding assessments in the MRST were the OHS, FSD, and the RTJ. These events are more dynamic in nature and required the simulta neous assessments of multiple areas. The lowest kappa values observed in those events existed between the rat ers with least experience. More experienced clinicians may be able to distinguish the subtle movement devia tions that less experienced personnel might not observe. Also, the viewpoints for each rater was standardized, but they were not identical, so there is a possibility that slight differences in viewpoint could have affected rater agreement. Similar results were seen in a study where real time assessments were performed.48 The authors of the study stated that the observation location of the rater might have been an integral factor in the low level in the scoring instructions to achieve a more reliable as sessment in those with less clinical movement screening experience. A potential limitation in generalization of this study is the amount of training that the raters received prior to data collection. Although standardized grading criteria were provided for each event, a number of different in terpretations can be made based on the grading criteria used. The ability to decide between 2 grading crite ria when more subtle dysfunctions are present can be challenging and improvement would be expected with subsequent practice. Additionally, all participants were recruited from the same area and the majority were students in a medical training program of some type, so their level of physical activity may not be representative more diverse military population. Future reliability studies are needed to assess interrater and test-retest reliability of the MRST in more diverse military populations using raters from multiple medical and training disciplines that are responsible for assess ing MSK injury risk. They should include a more speFSD events. CONCLUSION the MRST demonstrated moderate interrater reliabil ity for the overall composite score with varied levels of agreement for individual events scores. Future research should investigate test-retest reliability and interrater re liability among personnel from multiple disciplines. REFERENCES 1. Roy TC, Songer T, Ye F, et al. Physical training risk factors for musculoskeletal injury in female sol diers. Mil Med 2014;179(12):1432-1438. 2. Sanders JW, Putnam SD, Frankart C, et al. Impact of illness and non-combat injury during Operations Iraqi Freedom and Enduring Freedom (Afghani stan). Am J Trop Med Hyg 2005;73(4):713-719. 3. Zambraski EJ, Yancosek KE. Prevention and reha bilitation of musculoskeletal injuries during mili tary operations and training. J Strength Cond Res 2012;26(suppl 2):S101-S106. 4. Armed Forces Health Surveillance Branch. Ambu latory visits among members of the active compo nent, US Armed Forces, 2014. Med Surveill Mon Rep 2015;22(4):18-24. 5. Belmont PJ, Goodman GP, Waterman B, DeZee K, Burks R, Owens BD. Disease and nonbattle injuries sustained by a US Army Brigade Combat Team during Operation Iraqi Freedom. Mil Med 2010;175(7):469-476. 6. Hauret KG, Jones BH, Bullock SH, Canham-Cher vak M, Canada S. Musculoskeletal injuries descrip tion of an under-recognized injury problem among military personnel. Am J Prev Med 2010;38(suppl 1):S61-S70. 7. Nindl BC, Williams TJ, Deuster PA, Butler NL, 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;5-23. 8. Bushman TT, Grier TL, Canham-Chervak M, An derson MK, North WJ, Jones BH. The functional movement screen and injury risk: association and predictive value in active men. Am J Sports Med 2016;44(2):297-304. 9. Chorba RS, Chorba DJ, Bouillon LE, Overmyer CA, Landis JA. Use of a functional movement screening tool to determine injury risk in female collegiate athletes. N Am J Sports Phys Ther 2010;5(2):47-54.

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October December 2017 51 35. Park K-M, Cynn H-S, Choung S-D. Musculoskel etal predictors of movement quality for the forward step-down test in asymptomatic women. J Orthop Sports Phys Ther 2013;43(7):504-510. 36. Pirson J, Verbiest E. A study of some factors in Aviat Space Environ Med 1985;56(6):564-567. 37. Chu Y, Sell TC, Abt JP, et al. Air assault soldiers demonstrate more dangerous landing biome chanics when visual input is removed. Mil Med 2012;177(1):41-47. 38. Field Manual 7-22: Army Physical Readiness Training Washington, DC: US Department of the Army; 2012. 39. Myer GD, Brent JL, Ford KR, Hewett TE. Realtime assessment and neuromuscular training feed back techniques to prevent ACL injury in female athletes. Strength Cond J 2011;33(3):21-35. 40. American College of Sports Medicine, American Academy of Family Physicians, American Acad emy of Orthopaedic Surgeons, American Medical Society for Sports Medicine, American Orthopae dic Society for Sports Medicine, American Osteo pathic Academy of Sports Medicine. Psychological issues related to injury in athletes and the team physician: a consensus statement. Med Sci Sports Exerc 2006;38(11):2030-2034. 41. Ardern CL, Taylor NF, Feller JA, Whitehead TS, Webster KE. Sports participation 2 years after an terior cruciate ligament reconstruction in athletes who had not returned to sport at 1 year: a prospec tive follow-up of physical function and psycho logical factors in 122 athletes. Am J Sports Med 2015;43(4):848-856. 42. Portney LG, Watkins MP. Foundations of Clinical Research: Applications to Practice 3rd ed. Phila delphia, PA: F. A. Davis Company; 2015. Available from: https://www.fadavis.com/product/physicaltherapy-foundations-clinical-research-portney3?&RequestId=1497032517. 43. Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics 1977;33(1):159-174. 44. OShea S, Grafton K. The intra and inter-rater reli Man Ther 2013;18(3):264-268. 45. Butler RJ, Plisky PJ, Kiesel KB. Interrater Reli ability of Videotaped Performance on the Func tional Movement Screen Using the 100-Point Scoring Scale. Athl Train Sports Health Care 2012;4(3):103-109. 46. Gulgin H, Hoogenboom B. The functional move ment screening (fms): an inter-rater reliability study between raters of varied experience. Int J Sports Phys Ther 2014;9(1):14-20. 47. Minick KI, Kiesel KB, Burton L, Taylor A, Plisky P, Butler RJ. Interrater reliability of the func tional movement screen. J Strength Cond Res 2010;24(2):479-486. 48. Onate JA, Dewey T, Kollock RO, et al. Real-time intersession and interrater reliability of the func tional movement screen. J Strength Cond Res 2012;26(2):408-415. 49. Padua DA, Boling MC, Distefano LJ, Onate JA, Beutler AI, Marshall SW. Reliability of the landing error scoring system-real time, a clinical assess ment tool of jump-landing biomechanics. J Sport Rehabil 2011;20(2):145-156. AUTHORS At the time this study was conducted, LTC (Ret) Thelen and LTC (Ret) Koppenhaver were instructors at the US Army-Baylor University Doctoral Program in Physical Therapy at Joint Base San Antonio-Fort Sam Houston, Texas. CPT Allen, CPT Bolduc, 1LT Quan, and LTJG Sidwell are students in the US Army-Baylor University Doctoral Program in Physical Therapy at Joint Base San AntonioFort Sam Houston, Texas.

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52 http://www.cs.amedd.army.mil/amedd_journal.aspx Diagnostic and Sta tistical Manual of Mental Disorders1 1 2 4 4 7-9 Cognitive Behavioral Therapy for Insomnia Treatment in a Military Deployed Operational Setting Utilizing Enlisted Combat Medics: A Quality and Process Improvement Project ABSTR A CT ,QVRPQLD\003GLVRUGHU\003LV\003D\003SUHYDOHQW\003FRQGLWLRQ\003HVSHFLDOO\\000DPRQJ\003WKH\003$PHULFDQ\003PLOLWDU\)61.7 (\017\003DIIHFWLQJ\003XS\003WR\003\030\023\b\003RI\003VHU

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October December 2017 53 CBT-I is the recommended initial treatment for adults with chronic insomnia disorder.10CBT-insomnia typically has a combination of psychoed ucation, cognitive (restructuring dysfunctional beliefs), and behavioral (stimulant control, sleep restriction, etc) aspects. The psychoeducation component aims to in crease sleep literacy of the patient. It attempts to increase basic understanding of normal and abnormal sleep, mainly designed to help achieve acceptance from the patient while also targeting attitudinal competency. The cognitive component, in our opinion, is the most techni experience. It aims to identify dysfunctional beliefs held by the patient that negatively affects their expectations and perceptions of their sleep. Once these dysfunctional introduce doubts into these thoughts via the process of cant behavioral component to their CBT-I interventions. These may include stimulant control, sleep restriction, and sleep deprivation to help increase sleep inertia and ponent of progressive relaxation techniques to reduce an ticipative anxiety and tension. The overarching goal is to optimally synchronize the sleeps Process C and Process S, a 2-process model of sleep regulation which is beyond the scope of this paper but can be reviewed elsewhere.11Given the technical competency required to deliver CBTI, it is typically conducted by behavioral health practi tioners. In a deployed setting, however, availability of trained personnel (psychologists, social workers, psychi atrists) is the limiting factor. We experienced these same constraints with only 2 therapists and a single psychia trist caring for a population of approximately 9,400 ser vice members at a remote location. Herein we describe a novel approach to enable enlisted healthcare extenders (behavioral health specialists and combat medics) to de liver CBTI treatment using a PI/QI strategy based on typical Plan, Do, Study, Act (PDSA) cycles. We describe outcomes. A similar approach can be used by deployed healthcare teams such as combat operational stress dence-based therapy for service members with insomnia. MA TERI A LS A ND METHODS The Institutional Review Board for the deployed loca tion in the Middle East reviewed and approved our PI/ QI project for nonresearch determination. During the plan phase, teaching and CBT-I protocol deliverables were prepared by author R.A. Service members re Outcomes as outlined below were reviewed and ana patient outcome measures, enlisted combat medics, and behavioral health specialists were implemented into the original treatment protocol and delivery methods.PlanAuthor R.A. is formally trained in CBT-I and uses vari ous methods and strategies in his clinical practice. How ever, during the development phase, literature search most optimal combination of techniques using cognitive, behavioral, and psychoeducational strategies. No stud ies were found with head-to-head comparison among any of these strategies. There are standardized treat ment protocols,12 however, these were considered not ideal for 2 main reasons: (1) they are copyrighted pro tocols and were cost-prohibitive; (2) the workbooks are designed for experienced therapists and not practical for healthcare extenders such as combat medics. Given this, we developed our own protocol with great est emphasis on behavioral techniques and psychoeducation and a smaller cognitive component. The protocol was designed to enable someone with minimal training to deliver the cognitive, behavioral, and psychoeduca tion of CBT-I. Training of the treating medics relied on use of a checklist. This ensured no steps or components were missed and every patient received a standardized treatment.Protocol sleep intake, initial sleep prescription, initial checklist, constructive worry sheet, dysfunctional beliefs chal lenge scripts, follow-up checklist, follow-up intake and prescription form, provider psychoeducation slides, and sleep log form. All of these items were standalone documents made available electronically to the students. The patient packet contained initial sleep intake, initial sleep prescription, constructive worry sheet, sleep log form, and patient psychoeducation slides. All of these documents were standalone documents made available electronically to the students to print as a packet for a given patient as needed.Training on Using Sleep ProtocolA single, 3-hour training workshop was conducted to educate combat medics and behavioral health specialists on the use of the sleep protocol. Both of these military oc cupational specialties (MOS) in the US Army fall under

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54 http://www.cs.amedd.army.mil/amedd_journal.aspxtraining on supporting basic life functions with knowl behavioral health specialists (MOS 68X) receive train audience consisted mainly of behavioral health special Following the training, a survey of preand posttraining PowerPoint slides were used to begin the workshop, proderstanding the Process C and Process S model of sleep regulation11 and its role in sleep maintenance, normal ing cognitions and behaviors and their effect on sleep focused on assessment of sleep behavior using the initial sleep intake form, and skill to write initial and followup sleep prescription using provided forms within the Dysfunctional Belief Challenge Scripts for cognitive re identify need for referral if there are concerns for organ dents were given templates for documentation of their encounters in the electronic health record and obtaining sleep questions to allow the provider to easily calculate causes of insomnia, sleep satisfaction questions, a Pa tient Health Questionnaire-2,13 suicide screening ques 14 Finally, in order to enable and operationalize tions and dysfunctional beliefs, the Dysfunctional Be scale was originally a 30-item questionnaire that was 15ProcessPatients were entered into treatment by one of 2 distinct brigade aid station with pure sleep complaints with no the checklist, then screened for evidence of depression, tions were positive, the treating medic was instructed to medics were instructed to immediately escort anyone clinic by either a trained behavioral health specialist (MOS 68X) or trained medic (MOS 68W) as the clinic physiology, dysfunctional beliefs and behaviors about cy) and the associated frustration with forcing oneself to fall asleep, as well as sleep deprivation to enhance sons, sleep logs were optional and all treatment deci sions were based on self-reported times averaged over reported total sleep time (adding sleep at night and any one reported sleeping on average 5 hours per night, but physical training or morning military formations into daily wake-up time of 5 AM then, based on the above than 11 PM (5 hours plus one additional hour for a total of COGNITIVE BEHAVIORAL THERAPY FOR INSOMNIA TREATMENT IN A MILITARY DEPLOYED OPERATIONAL SETTING UTILIZING ENLISTED COMBAT MEDICS: A QUALITY AND PROCESS IMPROVEMENT PROJECT

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October December 2017 55 6 hours permitted in bed). It was stressed that they must only go to bed after 11 PM and only if they are sleepy. were still required to wake up at the agreed-upon daily wake-up time. Next, rules for sleep that are listed on the same initial sleep prescription form were reviewed. It emphasizes behaviors of stimulant control and sleep hygiene that highlights behavioral concepts. Finally, the DBAS-16 from the initial intake form was re viewed. The providers were instructed to read verbatim the scripts related to DBAS-16 items that score 6 or more (Dysfunctional Belief Challenge Scripts Packet). This cutoff of 6 or more out of 10 on the Likert scale is in formed by the validation data from the initial study15 on DBAS-16. Identifying and challenging cognitive distor do well. Therefore, the Dysfunctional Belief Challenge Scripts Packet was designed by the authors to challenge all 16 of the dysfunctional beliefs on the scale. The use these beliefs. It also then permitted the provider to select the ones he or she would challenge. Any question with 6 or more points was selected. For example, if a patient was high (scoring 6 or more) on questions 3, 5, and 15, verbatim: I am going to talk to you about some com mon trends of maladaptive thoughts and beliefs that we notice among those people who suffer from sleep prob lems. These thoughts and beliefs can worsen their sleep problems. I would like to highlight some of those for you by reading them aloud and then providing you some ex planations. I am selecting these because you scored high ticular question. The cognitive component of this pro tocol was only addressed at intake. They were, however, given the constructive worry sheet to use on their own if needed. It entailed a column for what their worry might be and a column for potential actions they plan to take to address that concern. The patients were given a sleep log form that they could choose to complete. At follow-up, the Follow-up Sleep Intake and Prescrip This form also provided a decision-tree for the provider: (earliest bedtime is 30 minutes sooner but wake-up time stays the same). utes (earliest bedtime is 30 minutes later but wakeup time stays the same). schedule, follow-up in a week. The plan was to have a patient seen for 3 sessions, in cluding the intake session. All intake and follow-up data was recorded in an electronic medical chart. Cases were supervised on an as-needed basis by author B.W. She also conducted a chart review for each case for safety and accuracy.StudyAn Excel spreadsheet was maintained to account for all outcomes. A total of 25 service members underwent at least one session. The outcomes are discussed later in the Results section. The IBM SPSS application was used for the statistical analysis. Comparisons were done us ing nonparametric methods due to the small number of subjects in order to avoid false assumptions of normality.ActChart review by B.W. was conducted throughout the de ployment to ensure safety and accuracy. Feedback was Table 1. Demographics and Baseline Data for Patients Undergoing Treatment for Insomnia. Demographics and Baseline Data Values SD N (Intake) 25Mean Age (years) 23 8 5 513Male (n=23)92% Rank, E1-E4 (n=21)84% Number of Sessions Attended by Each Patient (n=number of patients attending that many sessions)1 (n=7)28% 2 (n=5)20% 3 (n=7)28% 4 (n=4)16% 5 (n=2)8% Average Number of Sessions2 56 1. 294Average Length of Insomnia (months)13 .96 9 813Type of Insomnia Combined (n=21)84% Initial (n=3)12% Terminal (n=1)4% Baseline Sleep Duration (hours)5 .12 1 716Baseline Time in Bed (hours)8 28 1 .926Baseline Sleep Efficiency*61 80% Desired Sleep Duration (hours)7. 4 0 .766Average Number of Sleep Disruptions/Night2 .84 1 .491Average Number of Naps0 .9 1 291Racing Thoughts on Pillow Present72% Average Daily Caffeine Intake (drinks)1. 32 0 .476Prior Hypnotic Use (n=15)60% Current Hypnotic Use (n=5)20%*Defined as baseline sleep duration/baseline time in bed100

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56 http://www.cs.amedd.army.mil/amedd_journal.aspxelicited about improvement to the Dysfunction al Belief Challenge Scripts Packet where it was noted that the language was too academic and inappropriate for the typical level of education of participants. RESULTS Baseline data and demographics are presented in Table 1. Training evaluation by the medics and behavioral health specialists showed sig nia using newly learned CBT based insomnia treatment skills (Table 2). A total of 25 patients underwent intake for CBT based treatment for insomnia during a 2-month period prior to the redeployment of the unit from the theater. A to sessions per patient. Outcome measures were for all 3 sessions.Outcome MeasuresLearners Training Evaluation 30%) upon completion of the training workshop. Over evaluation (Table 2). Using Wilcoxon Signed-Ranks 2.871; P P <.01) levels Sleep Efficiency 2 ( P <.01). Post-hoc Wilcoxon Signed-Ranks Test with Bonferroni correction indicated that posttest ranks P P <.002) at fol low-up when compared to Session 1. The change in ranks P <.94).Time AsleepTotal self-reported average sleep duration at intake was repeated measures for self-reported sleep duration was 2 value of 3.268 which was P =.195).Total Time in BedAverage total time spent in bed (including both awake and asleep) was 8 hours and 4 minutes at intake. It 2 ( P <.01). A post-hoc Wilcoxon Signed-Ranks Test with Bonferroni correction indicated that post-test ranks P P <.007) in comparison to baseline intake values (Session 1). The P =.11).Perceived Sleep Satisfaction scale with 5 as maximum satisfaction. The baseline (in take) mean satisfaction for perceived sleep duration was 2 value of 16.77 P <.01). A post-hoc Wilcoxon Signed-Ranks Test with Bonferroni correction indi P <.01) and Session 3 Table 2. Post-Training Survey assessing perceived satisfaction and ef fectiveness of training by learners. *Min Max Mean SE SD Effective goal communications4 5 4.70 0.153 0.483Effective learning climate4 5 4.70 0.153 0.483Instructor knowledgeable4 5 4.90 0.100 0.316Didactics important4 5 4.90 0.100 0.316Workshop important2 5 4.50 0.342 1.080Handouts important4 5 4.90 0.100 0.316PRIOR to this training, CONFIDENCE level1 4 2.10 0.314 0.994AFTER this training, CONFIDENCE level3 5 4.40 0.221 0.699PRIOR to this training, SKILLS level1 4 2.10 0.314 0.994AFTER this training, SKILLS level3 5 4.20 0.200 0.632Likelihood of using training3 5 4.40 0.267 0.843Likelihood of implementing training3 5 4.30 0.300 0.949Likelihood of recommending this to patients4 5 4.80 0.133 0.422Likelihood of recommending this to other medical providers3 5 4.50 0.224 0.707This training should be provided to all medics in Advanced Individual Training1 5 4.10 0.433 1.370Overall satisfaction with training4 5 4.80 0.133 0.422Min indicates minimum; Max indicates maximum.*Values from Likert scale: 1=least; 5=most. COGNITIVE BEHAVIORAL THERAPY FOR INSOMNIA TREATMENT IN A MILITARY DEPLOYED OPERATIONAL SETTING UTILIZING ENLISTED COMBAT MEDICS: A QUALITY AND PROCESS IMPROVEMENT PROJECT

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October December 2017 57 (z=-3.03; P <.002) follow-up in comparison to baseline. sion 2 and Session 3 (z=-2.13; P <.03). The baseline (intake) mean for satisfaction for perceived sleep quality was 1.40, SD 0.577 (N=25), Session 2 mean was 2.17, SD 1.15 (N=18), and Session 3 mean was 2.93, SD 1.07 (N=14). A nonparametric Friedmans test of differences among repeated measures for intake, Session 2 and Session 3 (N=14) was conducted and ren 2 P <.001). A post-hoc Wilcoxon Signed-Ranks Test with Bonfer roni correction indicated that post-test ranks were sta P <.001) and Session 3 (z=-3.15; P <.002) follow-up in comparison to baseline. The change in ranks was also P <.002).Process MeasuresThe checklist served as a process measure to ensure the medics applied the methods of behavioral sleep treat ment accurately. All cases seen were reviewed by the sleep prescription. On average, these were performed correctly 86% of the time. Only minor errors related to conversion of minutes were seen.Balancing MeasuresNo sleep deprivation related events were reported. Of the 25 Soldiers who underwent intake for CBT-I, 18 followed-up for a second session. None of these, includ ing those that were lost to follow-up, were involved in behavioral incidents, including acute psychiatric exac erbation or need for medical evacuation. None required acute referral for hypnotic therapy. CO MM ENT We faced the clinical challenge of delivering safe and ef fective nonpharmacological treatment for Soldiers suf fering from insomnia in a limited resource environment. Cognitive behavioral therapy based insomnia treatment has been shown to be an effective treatment.16 Hence, ers who could deliver CBT based insomnia treatment Figure 1 session 1 through sessions 2 and 3. 60 36% 85. 20% 82 28% 1 2 3 0% 20% 40% 60% 80% 100% Treatment Session Sleep Efficiency Figure 3. Sleep quality satisfaction results demonstrate session 1 through sessions 2 and 3. Satisfaction Scale 1 .4 2 93 2 17 0 0. 5 1 1 5 2 .0 2. 5 3 .0 3. 5 4. 0 4. 5 1 2 3 Treatment Session Sleep Quality Figure 2. Sleep duration satisfaction results demon ment session 1 through sessions 2 and 3. 0 0. 5 1 1 5 2 .0 2. 5 3 .0 3. 5 4. 0 1 36 2 57 1 94 1 2 3 Treatment Session Satisfaction ScaleSleep Duration

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58 http://www.cs.amedd.army.mil/amedd_journal.aspxwithout relying on hypnotics. Hypnotics pose safety concerns. During the 4.5-month period of deployment, author R.A. observed one Soldier with priapism and an other with drug-drug interaction,17 both of which were likely due to their use of hypnotic medications. We used formal QI/PI concepts to overcome the clinical obstacles in treatment delivery. We were effectively able to train medics in CBT based insomnia treatment (Table 2). The operationalization of this treatment, which oth perience, was made possible by a checklist procedural approach to treatment delivery. The protocolization of the techniques was likely the most important tool for challenging dysfunctional beliefs of those suffering from insomnia. The use of DBAS-16 as a rapid diagnos verbatim cognitive restructuring scripts, permitted us to easily enable the medics to challenge such dysfunc tional beliefs. Additionally, the protocol with checklistled sleep prescriptions enabled the medics to rapidly ap use algorithmic approach. This was not intended to be a research study, but rather operationalizing evidence-based CBT treatment for in been done in the past, especially in the operational en vironment. The project illustrates one potential answer to manpower constraints by utilizing readily available medical personnel. The nonparametric tests showed sig lated total time spent in bed), as well as satisfaction with the quality and quantity of sleep. Interestingly, these im provements occurred very rapidly after just a single ses session to the second session. Further post-hoc analysis from the intake. Interestingly, although there was not a tion, both satisfaction with sleep quality and duration improved. This supports the perceptual nature of the Given its success in the operational setting, we plan to formally evaluate our checklist-based approach to in somnia treatment using combat medics with a control tocol in nonoperational setting. Appropriate sleep is an important ingredient for both physical and psychological both of these domains, and broader delivery of CBT-I based sleep literacy as primary prevention and wellness similar, checklist-based approach to sleep education. CON C LUSION Insomnia is a major problem in the deployed environ ment. Safer alternatives to pharmacological treatment such as cognitive and behavioral based approaches re quire specialized skilled personnel that are not readily available. This limited resource environment can be medics, behavioral health specialists, or equivalent per sonnel. Our QI/PI project provides a road map that could be replicated early into a deployment or other resourceconstrained environments to effectively deliver cogni tive and behavioral treatment for Soldiers with minimal effort and supervision. AC KNOWLEDGMENT We thank Dr Raywin R. Huang, PhD, and Mr Troy H. Pa tience, Madigan Army Medical Center, Tacoma, Wash sis and review of the project. REFE R ENCES 1. American Psychiatric Association DSM-5 Task Force. Diagnostic and Statistical Manual of Mental Disorders: DSM-5 5th ed. Arlington, VA: Ameri can Psychiatric Association; 2013. 2. Buysse DJ. Insomnia. JAMA 2013;309(7):706-716. doi:10.1001/jama.2013.193. 3. Lee D, Geyer L. Increasing resilience through promotion of healthy sleep among service mem bers. Mil Med 2015;180(1):4-6. doi:10.7205/ MILMED-D-14-00264. 4. Capaldi VF, Kim JR, Grillakis AA, Taylor MR, York CM. Insomnia in the military: application and effectiveness of cognitive and pharmacologic therapies. Curr Psychiatry Rep 2015;17(10):85. doi:10.1007/s11920-015-0622-9. 5. Williams SG, Collen J, Wickwire E, Lettieri CJ, Mysliwiec V. The impact of sleep on soldier per formance. Curr Psychiatry Rep 2014;16(8):459. doi:10.1007/s11920-014-0459-7. 6. Miller NL, Tvaryanas AP, Shattuck LG. Accommo dating adolescent sleep-wake patterns: the effects of shifting the timing of sleep on training effec tiveness. Sleep 2012;35(8):1123-1136. doi:10.5665/ sleep.2002. 7. Chen PL, Lee WJ, Sun WZ, Oyang YJ, Fuh JL. Risk of dementia in patients with insomnia and longterm use of hypnotics: a population-based retro spective cohort study. PloS One 2012;7(11):e49113. doi:10.1371/journal.pone.0049113.COGNITIVE BEHAVIORAL THERAPY FOR INSOMNIA TREATMENT IN A MILITARY DEPLOYED OPERATIONAL SETTING UTILIZING ENLISTED COMBAT MEDICS: A QUALITY AND PROCESS IMPROVEMENT PROJECT

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October December 2017 59 8. Kang DY, Park S, Rhee CW, et al. Zolpidem use and risk of fracture in elderly insomnia patients. J Prev Med Public Health 2012;45(4):219-226. doi:10.3961/jpmph.2012.45.4.219. 9. Chen F, Hahn TJ, Weintraub NT. Do SSRIs play a role in decreasing bone mineral density?. J Am Med Dir Assoc 2012;13(5):413-417. doi:10.1016/j. jamda.2011.09.003. 10. Qaseem A, Kansagara D, Forciea MA, Cooke M, Denberg TD, Clinical Guidelines Committee of the American College of Physicians. Management of chronic insomnia disorder in adults: a clinical practice guideline from the American College of Physicians. Ann Intern Med 2016;165(2):125-133. doi:10.7326/M15-2175. 11. Borbly AA, Daan S, Wirz-Justice A, Deboer T. The two-process model of sleep regulation: a reap praisal. J Sleep Res 2016;25(2):131-143. doi:10.1111/ jsr.12371. 12. Edinger JD, Carney CE. Overcoming Insomnia: A Cognitive-Behavioral Therapy Approach, Work book 2nd ed. New York, NY: Oxford University Press; 2015. Available at: http://alltitles.ebrary.com/ Doc?id=10928274. Accessed February 23, 2017. 13. Kroenke K, Spitzer RL, Williams JBW. The Pa tient Health Questionnaire-2: validity of a two-item depression screener. Med Care 2003;41(11):12841292. doi:10.1097/01.MLR.0000093487.78664.3C. 14. Kroenke K, Spitzer RL, Williams JBW, Monahan PO, Lwe B. Anxiety disorders in primary care: prevalence, impairment, comorbidity, and detec tion. Ann Intern Med 2007;146(5):317-325. 15. Morin CM, Vallires A, Ivers H. Dysfunc tional beliefs and attitudes about sleep (DBAS): validation of a brief version (DBAS-16). Sleep 2007;30(11):1547-1554. 16. Wu JQ, Appleman ER, Salazar RD, Ong JC. Cog nitive behavioral therapy for insomnia comorbid with psychiatric and medical conditions: a metaanalysis. JAMA Intern Med 2015;175(9):1461-1472. doi:10.1001/jamainternmed.2015.3006. 17. Amin R. Fluoxetine and trazodone combination pharmacotherapy resulting in severe irritabil ity, anger, anxiety, and anorexia: probable adverse drug interaction. Prim Care Companion CNS Dis ord 2016;18(4). doi:10.4088/PCC.15l01917. AUTHORS MAJ Amin is Division Psychiatrist, 7th Infantry Divi sion, and Staff Psychiatrist and Internist, Madigan Army Medical Center, Tacoma, Washington. fantry Brigade Combat Team, 3rd Infantry Division, Fort Stewart, Georgia.

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60 http://www .cs.amedd.army .mil/amedd_journal.aspx Phlebotomus fever, is a vector transmitted viral illness with a history of affecting nave military formations that endemic.1-3 We present a series of 4 hospitalized cases ver (SFF) that were admitted to a Role 3 hospital in Af ghanistan for evaluation and treatment following medi cal evacuation from a forward area for marked fevers and malaise. CA SE SERIES The following 4 cases occurred over a 2-week time pe riod during midsummer in a malaria-endemic region of eastern Afghanistan. Through interviews and later investigations, we estimate that at least 3 dozen simi lar cases presented to special operations forces (SOF) medics during this period. However, the 4 patients discussed in the following case studies required medi cal evacuation to our referral hospital given their more marked symptoms. All patients were active duty male Army Soldiers who presented from the same region of eastern Afghanistan. All endorsed sleeping outdoors on the ground, bathing in local streams, and eating local foods. All endorsed repeated insect bites from a variety of insects. All endorsed limited use of necessary per sonal protective equipment to protect exposed skin. All reported strict compliance with doxycycline 100 mg by mouth daily for malarial chemoprophylaxis.Patient APatient A was a 26-year-old active duty male Army Soldier who presented to a SOF medic with 48 hours of subjective fevers, myalgias, headache, and neck stiff ness. He was initially treated by the SOF medic with ac ceived a 2-day oral course of amoxicillin/clavulanic acid for apparent empiric treatment of community acquired pneumonia. Despite these interventions, the patient had ferred to our Role 3 referral hospital for further care. Upon presentation to the hospital, Patient A was afebrile, but endorsed documented fevers as high as 103F earlier in the day. He denied cough, dyspnea, abdominal pain, diarrhea, dysuria, or rash. His examination was largely unremarkable except for a positive jolt accentuation test, indicating possible meningeal irritation. A noncontrast CT head and chest radiograph were both unremarkable. Due to concern for meningitis, a lumbar puncture was performed which demonstrated zero leukocytes, a total protein of 58 mg/dL (normal 12-60 mg/dL), and glucose of 73 mg/dL (normal 40-70 mg/dL) with a negative ce Sandfly Fever in AfghanistanA Sometimes Overlooked Disease of Military Importance: A Case Series and Review of the Literature LTC John W. Downs, MC, USA MAJ Jason A. Constantineau, MS, USA Capt Daniel T. Flood, USAF, MC Capt James W. Caviness, USAF, BSC MAJ Nicholas H. Orr, MC, USA ABSTR A CT that were admitted to a Role 3 hospital in Afghanistan for evaluation and treatment following medical evacutions camp. Response efforts emphasized enforcement of standard vector-borne disease control measures by fever affecting military operations, and present a review of clinical presentation, transmission, management, and prevention.

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October December 2017 61 blood cells (WBCs) per mm3 (normal 4,500-11,000 per mm3). A mild thrombocytopenia of 137,000 per mm3 (normal 150,000-450,000 per mm3) was also noted. His serum creatinine was mildly elevated at 1.40 mg/dL (nor mal 0.80-1.50 mg/dL). A hepatic function panel and uri nalysis were unremarkable. His prothrombin time (PT) and his activated partial thromboplastin time (APTT) were both mildly elevated at 14.4 seconds (normal 8-12 seconds) and 64.9 seconds (normal 20.6-38.6 seconds), respectively. Thick and thin smears for malaria showed negative. Blood cultures drawn at the time of admission showed no growth after 5 days. After an extensive review of other diagnostic consid erations as detailed later in the Investigation section, Patient A was presumptively diagnosed with SFF, and treated with bed rest, acetaminophen, and intravenous hydration. He was discharged after 48 hours of inpa tient monitoring following improvement in his clinical symptoms.Patient BPatient B was a 19-year-old active duty male Army Sol dier who presented to a SOF medic with 48 hours of subjective fevers, myalgias, and a sore throat. He was ids and acetaminophen for 24 hours without improve ment in symptoms, prompting medical evacuation for further workup and management. Upon presentation to the Role 3 hospital, he was afebrile, but noted a fever of 103F earlier in the day. He denied headaches, cough, dyspnea, abdominal pain, diarrhea, dysuria, or rash. His physical examination was remark extremities. Complete blood count was remarkable for a WBC count of 4,500 per mm3 and a platelet count of 122,000 per mm.3 Serum creatinine, hepatic function panel, and urinalysis were unremarkable. The patients PT and APTT were mildly elevated at 13.2 seconds and 43.5 seconds, respectively. A rapid antigen detection and monospot test were both negative. Thick and thin smears for malaria showed no parasites. The day fol lowing admission, the patients WBC count dropped to 2,900 per mm.3 A chest radiograph was unremarkable. Patient B was presumptively diagnosed with SFF and treated with symptomatic management. This included intravenous hydration, ibuprofen, and acetaminophen for 48 hours as an inpatient until his fever defervesced. He was discharged in improved condition.Patient CPatient C was a 21-year-old active duty male Army Sol dier who presented to a SOF medic with 24 hours of dif fuse myalgias, subjective fevers, fatigue, and a mild sore throat. A SOF medic treated Patient C with acetamino phen and intravenous hydration initially, but worsen prompted the decision for medical evacuation. Upon presentation to the Role 3 hospital, the patient was afebrile and hemodynamically stable. He denied head aches, cough, dyspnea, chest pain, abdominal pain, di arrhea, dysuria, or rashes. His physical exam was unre markable except for numerous insect bites on his lower leukopenia with a WBC count of 2,300 per mm3 and thrombocytopenia to 131,000 platelets per mm.3 He had an elevated APTT of 52.5 seconds. His renal function panel and hepatic panel were both unremarkable. Both monospot and rapid strep tests were negative. A respira tory viral polymerase chain reaction (PCR) panel was antibody testing was negative. Thick and thin smears for malaria showed no parasites. Blood cultures showed no growth after 5 days. An erythrocyte sedimentation rate was 5 mm/hour (normal 0-15 mm/hour). His chest ra diograph was unremarkable. A rickettsial panel was sent out of country for testing, but became unacceptable for testing during transit. Coxiella burnetii (Q fever) serol ogy was sent out of country for testing, and eventually returned negative. A serum sample was sent to the Cen ters for Disease Control and Prevention (CDC) Division of Vector-Borne Diseases, Arboviral Diseases Branch, evidence of SFF exposure. During his hospitalization, Patient C had a peak temper ature of 103F. He was treated with intravenous hydra tion, ibuprofen, and acetaminophen. On the recommen dation of infectious disease teleconsultants, the patient was prescribed a 7-day course of doxycycline 100 mg by mouth twice daily for empiric treatment of a poten tially undiagnosed rickettsial illness while we awaited proved over the next 24 hours and was discharged. A week later, a repeat CBC demonstrated resolution of his leukopenia and thrombocytopenia.Patient DPatient D was a 31-year-old active duty male Army Sol dier who presented to a SOF medic with 48 hours of fevers, diffuse myalgias, sore throat, and intermittent aminophen by a SOF medic, but persistent symptoms

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62 http://www .cs.amedd.army .mil/amedd_journal.aspxforced medical evacuation to the Role 3 hospital for fur ther care. Upon presentation to the hospital, Patient D had a tem perature of 100.2F. He denied cough, shortness of breath, abdominal pain, diarrhea, dysuria, and rash. Physical athy without pharyngeal exudate or erythema. He was noted to have multiple lower extremity insect bites with associated pruritus. Comprehensive physical examina tion was otherwise unremarkable. Complete blood count count of 2,300 per mm3 and a mildly decreased platelet count of 133,000 per mm.3 Renal function panel, hepatic function panel, and urinalysis were all unremarkable. A chest radiograph was unremarkable. He had a negative monospot test, rapid strep test, respiratory viral PCR panel, and HIV antibody. Thick and thin smears for ma laria were negative for parasites. Blood cultures showed no growth at 5 days. An erythrocyte sedimentation rate was 5 mm/hour. A rickettsial panel was again sent out of country for testing, but became unacceptable for testing during transit. Coxiella burnetii (Q fever) serology was sent out of country for testing, and eventually returned negative. A serum sample was sent to the CDC Arbovi cally to examine for evidence of SFF exposure. Patient D improved within the next 48 hours and was discharged in improved condition. He was also dis charged with instructions to complete a 7-day course of doxycycline 100 mg by mouth twice daily for em piric treatment of a potentially undiagnosed rickettsial illness. A follow-up CBC performed one week after dis charge demonstrated resolution of his leukopenia and thrombocytopenia. INVESTIG A TION During the admissions of the initial 2 patients (A and B) reported above, the SOF medical leadership and Role 3 hospital clinicians developed a working clinical di agnosis of SFF based on review of possible infectious 4 Particularly relevant was the presence of leukopenia and mild thrombocytopenia noted in all the above cases as had been described by other US mili tary physicians 70 years prior.5 Additional diagnostic considerations included malaria, leptospirosis, Q fever, rickettsial diseases such as scrub typhus, and CrimeanCongo hemorrhagic fever. However, these possibilities were ruled out in many cases by patient history and clinical examination. In all cases, thick and thin smears and point of care rapid diagnostic test were negative for malaria. Additionally, the patients provided reliable histories of adherence to doxycycline for malarial che moprophylaxis. This reported adherence to doxycycline helped to place leptospirosis and rickettsial diseases far lower on the list of differential diagnoses due to pre sumed prophylaxis against these illnesses provided by doxycycline use. as a febrile, viral-like syndrome, lasting 72 to 96 hours, without other overt clinical signs of malarial, rickettsial, or viral hemorrhagic complications occurring in the set then made to send preventive medicine (PM) person nel forward to assess the living conditions of the camp (Camp A) from which the above cases presented. During this mission, the PM detachment collected samples of arthropod vectors in that area and interviewed person nel still living at the camp site for other potential clues. Camp A was a special operations camp located in a re mote valley of eastern Afghanistan. Camp A and the immediate surrounding area housed between 20 to 50 US military personnel along with 15 to 20 partner na from day to day and week to week as US military per sonnel rotated into and out of Camp A frequently. Al though multiple other camps were located within rough ly a 10-kilometer radius of Camp A, the above described cases originated solely from Camp A, suggesting that tion, or arthropod vectors at Camp A were to blame for this cluster of illnesses. Of note, Camp A had only recently been established as an expeditionary location from which to advance operations. As a result, Camp A ing positions and create a secure, functioning camp. Preventive medicine personnel found that approxi mately 50% to 60% of US military personnel living at Camp A described a syndrome of 48 to 96 hours of fever, malaise, headache, and neck stiffness. A formal attack rate was not determined; however, a rough esti mate was an attack rate of more than 60% of personnel who had lived at Camp A for more than 7 days based on monitored service members reporting fever and mal rest when conditions allowed. Medical evacuation was then reserved for patients with fevers exceeding 103 F, refractory symptoms resulting in nonmission capable status, and for patients with symptoms unexplained by SANDFLY FEVER IN AFGHANISTANA SOMETIMES OVERLOOKED DISEASE OF MILITARY IMPORTANCE: A CASE SERIES AND REVIEW OF THE LITERATURE

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October December 2017 63 the SFF working diagnosis. All other cases of febrile illness remained at Camp A, slowly improved over a pe riod of 72 to 96 hours, and then were gradually returned to full duty by the Camp A SOF medic. In total, this febrile syndrome is estimated to have attacked 30 to 40 personnel to varying degrees on Camp A. The estimate produced marked concern of operational commanders at multiple levels that the continuation and spread of this syndrome would cause local military operations to essentially halt until all personnel had fully recovered from their illness. hygiene conditions at Camp A. Human waste disposal was managed with feces collection bags which were then burned for disposal. Bottled water was used for consumption. Food was occasionally procured from the local economy in order to allow engagement with local military Meals, Ready-to-Eat rations. Service members were noted to frequently bathe in a nearby river. Domes tic animals including goats, donkeys, cats, and canines were frequently in close proximity to Camp A. Area vector control measures were not in place. Service mem bers frequently worked during the day without wearing uniform blouses, and were not observed to apply insect repellant to exposed skin. Bed nets were used infre quently, and service members frequently slept outside. Nearly all interviewed members admitted to receiving Preventive medicine personnel collected samples of lo mens to the US Army Public Health Command-Europe for analysis. Results returned approximately one month sults of human blood samples drawn from Patient C and Patient D returned from the CDC Arboviral Diseases Branch with a positive plaque reduction neutralization most likely Sicilian serocomplex. CO MM ENT Phlebotomus ) shown in the Figure. The SFF virus is a member of the Phlebovirus genus of the Bunyaviridae family.6 Three serotypes are generally recognized: Toscana, Naples, and Sicilian. Naples and Sicilian serotypes cause the witnessed in our cases, whereas Toscana serotype has been associated with neurovirulence and encephalitis.6The geographic distribution of the virus is centered around the Mediterranean basin, with notable exten sion into parts of Europe and Central Asia.1 Military formations ranging from Greece to Pakistan have been troubled by the development of SFF outbreaks in recent years.7,8 Afghanistan for many years, but was most notably iden tions of Soviet troops based in eastern Afghanistan.9-11 British troops also suffered from so-called Helmand Afghanistan. In many cases, Helmand fever was later determined to be SFF.12,13 the US National Center for Medical Intelligence as po tentially affecting up to 50% of small groups of suscep tible troops in areas with large populations of infected measures are not taken.14 In the above case series and investigation, we estimate that roughly 50% of the per sonnel at Camp A were affected at some point during their tenure at Camp A or shortly after their return. This tiveness; forcing leaders at multiple levels from tactical to strategic to consider withdrawal from Camp A and the surrounding valley area, simply in hopes to maintain combat power. velops after a 2 to 6 day incubation period following the 5 This clinical presentation of classical SFF has been described as the abrupt onset of fever and malaise. In historical studies, 65% of affected patients had a temperature over 102F, and roughly 8% of affected patients had a temperature between 104F and 104.5F.5 In the cases described above, SOF medics Phlebotomus papatasi Courtesy of Centers for Disease Control and Prevention, Public Health Image Library (https://phil.cdc.gov/phil/details_linked. asp?pid=10277).

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64 http://www .cs.amedd.army .mil/amedd_journal.aspxdeveloped an unwritten operating procedure to attempt to limit the number of medical evacuations from Camp A by establishing a fever over 103F as the deciding fac tor for evacuation to at least Role 2 care or higher. The described fever typically lasts for 72 hours before spon taneous resolution, hence SFF is sometimes referred to 1 Headache, photophobia, and neck stiffness are frequently present as well, which may lead assessing clinicians to believe an infectious meningitis is present. Indeed, our initial hospitalized case under went lumbar puncture upon arrival at the Role 3 facil ity for concern of meningitis. Physical examination has pearance of the face and neck which may resemble a sunburn.5 Despite complaints of neck stiffness, nuchal rigidity and meningeal signs are not to be expected.5 The remainder of the physical examination is generally normal as seen in our hospitalized patients. Our cases were most likely Sicilian serotype SFF which typically manifests as a self-limited, otherwise benign illness, but it should be noted that Toscana serotype SFF can manifest neurovirulence with a prolonged me ningoencephalitis picture.15 On rare occasions, a more pronounced meningoencephalitis presentation has occurred with Sicilian serotype SFF. In 2004, Lesho and colleagues6 reported a case of severe encephalitis secondary to Sicilian serotype SFF in a US Army of Freedom. This case resulted in status epilepticus, a pro longed course of intubation for airway protection, and reported residual neurocognitive defects 3 months after initial presentation. Laboratory evaluation should include complete blood also necessary early on to exclude the diagnosis of bac for our cases treated at a Role 3 facility was leukope nia. In the correct geographic and clinical setting, the patients should prompt the clinician to at least consider ings include thrombocytopenia, and elevated levels of aspartate aminotransferase and alanine aminotransfer ase.16 However, in this small sample of cases, thrombo cytopenia and liver enzyme elevation was not marked as shown in the Table. Clinicians should also consider laboratory evaluation for other tropical infectious diseases associated with the lo cation in which the affected patient was traveling. In our cases, the treating Role 3 clinicians initially performed laboratory evaluation for malaria in all cases. For Pa tients C and D, the evaluation expanded to include test ing for mononucleosis, HIV, Q fever, and rickettsial dis ease. Unfortunately at our location, only malaria test ing (thick and thin smears, and rapid diagnostic tests) was available with expeditious turnaround time. Thus, while serologic testing for the above infections was con sidered, the treating team had to rely primarily on exam disease. For example, several clinicians noted the mark edly similarity of these case presentations with that of dengue fever.17 However, dengue fever is not endemic to Afghanistan and was easily excluded as a possibil ity with this information. This once again highlights the tious disease threats present in the regions in which the troops they support are operating. In general, treatment for SFF is supportive, involving an approximately 72-hour period. On rare occasions, SFF infections manifesting as encephalitis may require supportive care in a critical care setting. Leukopenia appeared to persist for 5 to 7 days following fever de fervescence in our hospitalized patients. Return to full Laboratory Values of Cases.Hospital Day White Cell Count Hemoglobin Platelet Count AST ALT Patient A1 2,700 13 .7 137,000 35 48 2 2,000 13 .7 118,000 35 48 3 2,400 13 8 114,000 6 2,600 16 1 120,000Patient B1 4,500 14 6 122,000 53 69 2 2,900 13 5 107,000 46 61 5 3,100 16 5 121,000 Patient C1 2,300 14 2 131,000 28 30 2 1,900 14 7 126,000 41 44 3 1,900 14 3 105,000 54 44 8 4,200 16 5 165,000 Patient D1 2,300 13 0 133,000 31 45 2 2,200 12 9 129,000 33 46 3 2,900 14 4 148,000 41 55 8 4,900 15 8 198,000 Reference Ranges White Cell Count; 4,500-11,000/mm3Hemoglobin; 12.0-16.0 g/dL Platelet Count; 150,000-450,000/mm3AST indicates aspartate aminotransferase; 9-32 U/Liter ALT indicates alanine aminotransferase; 7-30 U/Liter SANDFLY FEVER IN AFGHANISTANA SOMETIMES OVERLOOKED DISEASE OF MILITARY IMPORTANCE: A CASE SERIES AND REVIEW OF THE LITERATURE

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October December 2017 65 duty may be impaired for as much as 14 to 30 days after initial presentation.1 This could be crippling to military tion of affected troops.2 This effect would be even more dramatic among small special operations teams. The easiest and most effective method of protection from measures.18 ted permethrin-treated uniforms or clothing, and the use of insect repellents containing 30% to 40% N,N-Dieth yl-meta-toluamide (DEET) on any exposed skin. Due to to be attacked while they are sleeping. Unfortunately, these are also the times when proper uniform wear and insect repellent usage are least likely to be followed. Use of permethrin treated bed nets with a small mesh size, both indoors and outdoors, also serves as a protective the lower half of a humans body. Sleeping on elevated tats will reduce the likelihood of being bitten during rest periods.19 medicine personnel described earlier, and subsequent recommendations to strictly enforce these personal protective measures, tactical leaders began to appreci ate that only by enforcing these protective measures would cases cease or at least occur less frequently. In the 2 months that followed, no additional SFF cases from Camp A were evacuated to the Role 3 hospital. We at tributed this reduction in cases to a continued emphasis on personal protective measures by leaders at all levels. den, chemical treatment should be considered to man age the number of insects in the area.19 Residual pesti cides can be applied to most surfaces and effectively kill outcroppings, HESCO barriers (HESCO Bastion Ltd, Leeds, UK), sandbags, rock walls, termite mounds, ani at the base of walls and trees, rubbish, and fecal waste. We assess that the disruption of soil associated with the creation of Camp A likely contributed to a marked in ous bites for unsuspecting service members. CONCLUSION of military importance due to its ability to quickly in capacitate nave military formations in areas where the virus is endemic. Unfortunately, we found this to be true during combat operations on a special operations camp in Afghanistan. We also learned that SFF can be eas ily overlooked as a disease of military importance as it is relatively unknown among many American and European military physicians, and serologic testing is un military physicians and SOF medical providers working in areas surrounding the Mediterranean, and extending east into Asia through Turkey, Iran, Afghanistan, and Pakistan to become familiar with SFF and consider SFF in the differential diagnosis of markedly febrile patients. REFERENCES 1. Fever: A Mini Review. Virol Mycol. 2013;2(1):109. 2. Ellis SB, Appenzeller G, Lee H, et al. Outbreak of Mil Med. 2008;173(10):949-953. 3. Shiraly R, Khosravi A, Farahangiz S. Seropreva personnel on the western border of Iran. J Infect Public Health 2017;10(1):59-63. 4. Wallace MR, Hale BR, Utz GC, et al. Endemic in fectious diseases of Afghanistan. Clin Infect Dis 2002;34(suppl 5):S171-S207. 5. Sabin AB, Philip CB, Paul JR. Phlebotomus (pap portance. Summary of existing knowledge and pre liminary report of original investigations. JAMA. 1944;125(9):603-606. 6. Lesho EP, Ludwig GV, Wortmann G. Encephalitis Report and Review of the Literature. Infect Dis Clin Pract 2004;12(6):352-354. 7. Bryan JP, Iqbal M, Ksiazek TG, et al. Prevalence hemorrhagic fever, and leptospirosis antibod ies in Pakistani military personnel. Mil Med. 1996;161(3):149-153. 8. Konstantinou GN, Papa A, Antoniadis A. Sand still a health problem?. Travel Med Infect Dis 2007;5(4):239-242. 9. Gaidamovich S, Khutoretskaia NV, Aziamov Iu V, Tsiupa VI, Melnikova EE. Virological study of Vopr Virusol Jan-Feb 1990;35(1):45-47. 10. Nikolaev VP, Perepelkin VS, Raevskii KK, Prusa Republic of Afghanistan [in Russian]. Zh Mikro biol Epidemiol Immunobiol 1991 Mar(3):39-41. 11. Korolkov VF, Nikiforov SV, Kozlov SS. The clini co-epidemiological characteristics of natural-focus diseases in the Rukha garrison [in Russian]. Voen Med Zh 1992 Jun(6):64-65.

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66 http://www .cs.amedd.army .mil/amedd_journal.aspx12. Glennie JS, Bailey MS. UK Role 4 military infec tious diseases at Birmingham Heartlands Hospital in 2005-9. J R Army Med Corps 2010;156(3):162-164. 13. Bailey MS, Trinick TR, Dunbar JA, et al. Undif ferentiated febrile illnesses amongst British troops in Helmand, Afghanistan. J R Army Med Corps 2011;157(2):150-155. 14. Infectious Disease Risk Assessment Database, Afghanistan 2017 [database online]; Fort Detrick, MD: National Center for Medical Intelligence; 2017. Updated October 30, 2017. Available at: https://www.ncmi.detrick.army.mil/product/idra_ db.php?co=AFG. Accessed August 7, 2017. 15. Schwarz TF, Gilch S, Jager G. Aseptic meningitis Clin Infect Dis 1995;21(3):669-671. 16. ver virus outbreak in the East Mediterranean region of Turkey. Int J Infect Dis 2012;16(4):e244-e246. 17. Burnett M. Dengue infections. J Spec Oper Med 2013;13(2):64-68. 18. Armed Forces Pest Management Board. Techni cal Guide No. 36 Personal Protective Measures Against Insects and Other Arthropods of Military Silver Spring, MD: Armed Forces Pest Management Board; 2015. 19. Armed Forces Pest Management Board. Technical lance, and Control in Contingency Operations Sil ver Spring, MD: Armed Forces Pest Management Board; 2015. AUTHORS LTC Downs is with the Department of Preventive Medibell, Kentucky. Capt Flood is with the Internal Medicine Clinic, David Grant USAF Medical Center, 60th Medical Group, Travis Air Force Base, California. MAJ Orr is with the 98th Civil Affairs Battalion (Air borne), Fort Bragg, North Carolina. MAJ Constantineau is with the 61st Medical Detachment (Preventive Medicine), Fort Campbell, Kentucky. Capt Caviness is with the Public Health Element, 66th Medical Squadron, Hanscom Air Force Base, Massachusetts.SANDFLY FEVER IN AFGHANISTANA SOMETIMES OVERLOOKED DISEASE OF MILITARY IMPORTANCE: A CASE SERIES AND REVIEW OF THE LITERATURE

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October December 2017 67Destructive periodontitis can neither initiate nor prog ress in the complete absence of a select group of etio logic bacteria. In both chronic and aggressive forms of periodontitis, bacteria appear necessary for initiation of festation.1,2 In fact, the bacteria most associated with periodontitis can also be isolated in small measure from clinically healthy sites and patients.3,4 Evidence suggests a relatively small number of factors identify patients at high risk for periodontal destruction when causative bacteria are present.1,5,6 One of the strongest and most widely studied risk factors for periodontitis is cigarette smoking. Indeed, smoking is estimated to account for fully half of the cases of periodontitis in the United States, and among patients who smoke one pack per day, smoking may account for an astounding 83% of cases.7The biologic basis for the deleterious effect of smoking on the periodontium is largely understood. Some authors have reported that smoking shifts the counts and percentages of the bacterial species present toward a more pathogenic mixture, although other investigators found similar bacterial colonization among smokers and nonsmokers.8-12 In any case, the possible effect of smok ing on the attendant pathogenic ecosystem is probably not the primary mechanism responsible for the majority of the observed tissue destruction. Smoking is known to impair the function of the neutrophil, the key cell in an effective periodontal defense.13,14 Periodontists have long recognized that any hematological or genetic mal ady that precludes an effective neutrophil response con sistently produces severe, often devastating, periodontal destruction.15 Likewise, in patients with localized ag gressive periodontitis, neutrophils exhibit reduced che motaxis and various other functional abnormalities.16 Smoking also induces endothelial dysfunction, a situation with the potential to further hamper the neutro phil response in periodontal tissue.17 In smokers, clinical signs of periodontitis such as bleeding on probing may be suppressed despite advanced underlying bone and connective tissue destruction.18,19Smokers are not only more susceptible to destructive to treat. Researchers have repeatedly shown that smok ers with periodontitis respond less favorably to both nonsurgical and surgical therapy.20-22 A classic, long-term study conducted in a university setting suggested that most of the periodontal breakdown that occurs following surgical treatment of periodontitis tends to cluster within patients who smoke.23-25 dures performed in periodontics, studies directly com paring smokers to nonsmokers appear in the literature. For example, Miller reported 100% correlation between heavy smoking and failure to achieve complete root coverage using free gingival grafts.26 The often quoted study by Erley et al27 demonstrated comparatively infe rior outcomes in smokers treated with subepithelial con nective tissue grafts for root coverage. Numerous studies also show that smoking is particularly unfavorable when bone or periodontal regeneration is attempted.28-31Most chronic periodontitis patients respond favorably to conventional surgical therapy and lose few teeth longterm, given an appropriate maintenance interval after surgery and a proper personal oral hygiene regimen.23,32 However, a relatively small proportion of patients ex perience disease progression despite sound surgical therapy, frequent professional maintenance, and excel lent plaque control.25,32 Many such patients exhibit one or more systemic factors predisposing toward periodon tal destruction. Thus, it is incumbent upon clinicians initiating periodontal therapy. Moreover, high-risk pa tients should be treated and monitored differently than low-risk patients. Smokers respond less favorably to all types of periodontal therapy, experience more sites with periodontal breakdown during the maintenance phase, and have more postoperative complications compared with nonsmokers.20-25 On the other hand, watchful wait and tooth loss. In perspective, patients with untreated periodontitis appear to lose teeth at a rate 3 times higher compared with patients who receive surgical treatment and maintenance, often leading to expensive and timeconsuming approaches to tooth replacement.33 Accord ingly, clinicians should treat high-risk patients aggres sively, but not necessarily invasively. The current Army initiative to offer Nd:YAG laser peri odontal therapy, shown in the Figure, to Soldiers is Smoking and Periodontal Disease LTC Thomas M. Johnson, DC, USA

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68 http://www .cs.amedd.army .mil/amedd_journal.aspxSMOKING AND PERIODONTAL DISEASE helpful to clinicians managing high-risk periodontitis patients, including those who smoke. The laser proto modality, without relegating the patient to a nonsurgical 34 Army clinicians can use the laser for smokers with lim ited risk to the patient, and the treatment itself is mini mally invasive compared with conventional surgical techniques. In vitro and ex vivo experimental models have shown bactericidal activity for some species af ter indirect (noncontact) Nd:YAG laser treatment.35-42 Bacterial kill appears to increase proportionally with power applied.35 Depending upon experimental condi tions, Nd:YAG laser output appears to produce clinically relevant bacterial kill of some species through dentin thicknesses of at least 1 mm.40-42 In periodontal therapy, it is plausible that pulsed Nd:YAG laser irradiation may kill bacteria in privileged sites such as furcations and root surface irregularities where mechanical removal of bacteria is incomplete. However, this hypothesis has not been tested. Unpublished data suggests Nd:YAG laser periodontal therapy is capable of reducing putative peri odontal pathogens below detectable levels immediately following therapy.43 very compelling. Although the host response to bacte colonizing bacteria remain relevant. For example, when Porphyromonas gingivalis and Tannerella forsythia are present in the subgingival plaque, a patient is more likely to develop chronic periodontitis, more likely to progress to advanced periodontal disease, and less likely to experience a successful treatment outcome.3 Two proof-of-principle studies in humans indicate that clinical parameters and producing new bone, cementum, and periodontal ligament on previously diseased root surfaces.44-46 One study conducted in a private practice setting suggests gains made through laser periodontal therapy are stable over at least 6 years of follow-up.47Smoking alters the vascular and immunologic respons es to the bacteria that initiate periodontal disease and present. Regardless of the treatment modality used, it is abundantly clear that nonsmokers respond much more favorably to periodontal therapy compared with smok ers. For any periodontitis patient, optimal therapeutic re sponse must include smoking cessation.48,49 Laser peri odontal therapy may be of clinical interest in the treat ment of smokers because this modality offers ability to intervene early in a minimally invasive fashion. REFERENCES 1. Nunn ME. Understanding the etiology of periodon titis: an overview of periodontal risk factors. Peri odontol 20 2003;32:11-23. 2. Lang NP. Commentary: bacteria play a critical role in the etiology of periodontal disease. J Periodon tol 2014;85(2):211-213. 3. Ezzo PJ, Cutler CW. Microorganisms as risk in dicators for periodontal disease. Periodontol 20 2003;32:24-35. 4. 1996 World Workshop in Periodontics. Consensus report. Periodontal diseases: pathogenesis and mi crobial factors. Ann Periodontol 1996;1(1):926-932. 5. Genco RJ. Current view of risk factors for peri odontal diseases. J Periodontol 1996;67(suppl 10):1041-1049. 6. Van Dyke TE, Sheilesh D. Risk factors for peri odontitis. J Int Acad Periodontol 2005;7(1):3-7. 7. Tomar SL, Asma S. Smoking-attributable periodon III. J Periodontol 2000;71(5):743-751. 8. Stoltenberg JL, Osborn JB, Pihlstrom BL, Herz berg MC, Aeppli DM, Wolff LF, Fischer GE. As sociation between cigarette smoking, bacterial pathogens, and periodontal status. J Periodontol 1993;64(12):1225-1230. 9. Van der Velden U, Varoufaki A, Hutter JW, Xu L, Timmerman MF, Van Winkelhoff AJ, Loos BG. Effect of smoking and periodontal treatment J Clin Periodontol 2003;30(7):603-610. An Nd:YAG laser being used to remove pocket epithelium in a periodontitis patient. In response to pathogenic bacteria and epithelium proliferates laterally and apically. Etiologic bacteria avoid the host immune response by invading epithelial cells, which then serve as a bacterial reservoir. Removal of this epithelium improves access for root debridement and purportedly denies pathogenic bacteria a niche sequestered from the immune response.

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October December 2017 69 10. Bostrm L, Bergstrm J, Dahln G, Linder LE. tal disease. J Clin Periodontol 2001;28(3):212-219. 11. Winkelhoff AV, Bosch-Tijhof CJ, Winkel EG, Reijden WV. Smoking affects the subgingi J Periodontol 2001;72(5):666-671. 12. Joshi V, Matthews C, Aspiras M, Jager M, Ward M, Kumar P. Smoking decreases structural and functional resilience in the subgingival ecosys tem. J Clin Periodontol 2014:1;41(11):1037-1047. 13. Persson L, Bergstrm J, Ito H, Gustafsson A. Tobacco smoking and neutrophil activity in pa tients with periodontal disease. J Periodontol 2001;72:90-95. 14. Ryder MI, Fujitaki R, Johnson G, Hyun W. Al terations of neutrophil oxidative burst by in vitro smoke exposure: implications for oral and sys temic disease. Ann Periodontol 1998;3:76-87. 15. system for periodontal diseases and conditions. Ann Periodontol 1999;4(1):1-6. 16. Kantarci A, Oyaizu K, Dyke TE. Neutrophil-me diated tissue injury in periodontal disease patho odontitis. J Periodontol 2003;1;74(1):66-75. 17. Powell JT. Vascular damage from smoking: dis ease mechanisms at the arterial wall. Vascular Med. 1998;3(1):21-28. 18. Preber H, Bergstrm J. Occurrence of gingival bleeding in smoker and non-smoker patients. Acta Odontologica. 1985;43(5):315-320. 19. Dietrich T, Bernimoulin JP, Glynn RJ. The effect of cigarette smoking on gingival bleeding. J Peri odontol 2004;75:16-22. 20. Preber H, Bergstrm J. The effect of nonsurgical treatment on periodontal pockets in smokers and non-smokers. J Clin Periodontol 1986;13:319-323. 21. Preber H, Bergstrm J. Effect of cigarette smok ing on periodontal healing following surgical therapy. J Clin Periodontol 1990;17:324-328. 22. Riveral-Hidalgo F. Smoking and periodontal dis ease. Periodontol 20 2003;32:50-58. 23. Kaldahl WB, Kalkwarf KL, Patil KD, Molvar MP, Dyer JK. Long-term evaluation of periodon tal therapy: I. Response to 4 therapeutic modali ties. J Periodontol 1996;67(2):93-102. 24. Kaldahl WB, Johnson GK, Patil KD, Kalkwarf KL. Levels of cigarette consumption and re sponse to periodontal therapy. J Periodontol 1996;67(7):675-681. 25. Kaldahl WB, Kalkwarf KL, Patil KD, Molvar MP, Dyer JK. Long-term evaluation of periodon tal therapy: II. Incidence of sites breaking down. J Periodontol 1996;67(2):103-108. 26. Miller PD. Root coverage with the free gingival graft: factors associated with incomplete cover age. J Periodontol 1987;58(10):674-681. 27. Erley KJ, Swiec GD, Herold R, Bisch FC, Pea cock ME. Gingival recession treatment with con nective tissue grafts in smokers and non-smokers. J Periodontol 2006;77(7):1148-1155. 28. Tonetti MS, Pini Prato G, Cortellini P. Effect of cigarette smoking on periodontal healing fol lowing GTR in infrabony defects. A prelimi nary retrospective study. J Clin Periodontol 1995;22:229-234. 29. Tonetti M. Cigarette smoking and periodontal dis eases: etiology and management of disease. Ann Periodontol 1998;3(1)88-101. 30. Patel RA, Wilson RF, Palmer RM. The effect of smoking on periodontal bone regeneration: a sys tematic review and meta-analysis. J Periodontol 2012;83(2):143-155. 31. Lindfors LT, Tervonen EA, Sndor GK, Ylikon tiola LP. Guided bone regeneration using a titani um-reinforced ePTFE membrane and particulate autogenous bone: the effect of smoking and mem brane exposure. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010;109(6):825-830. 32. Hirschfeld L, Wasserman B. A long-term survey of tooth loss in 600 treated periodontal patients. J Periodontol 1978;49(5):225-237. 33. Becker W, Becker BE, Berg LE. Periodontal treat ment without maintenance: a retrospective study in 44 patients. J Periodontol 1984;55(9):505-509. 34. Schallhorn RG, Snider LE. Periodon tal maintenance therapy. J Am Dent Assoc 1981;103(2):227-231. 35. Harris DM, Yessik M. Therapeutic ratio quanti Porphyromonas gingivalis with dental lasers. Lasers Surg Med 2004;35:206-213. 36. Tseng P, Gilkeson CF, Palmer J, Liew V. The bac tericidal effect of a Nd: YAG laser in vitro. J Dent Res 1991;70(4):1991. 37. Gutknecht N, Moritz A, Conrads G, Sievert T, Lampert F. Bactericidal effect of the Nd: YAG la ser in in vitro root canals. J Clin Laser Med Surg 1996;14(2):77-80.

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70 http://www .cs.amedd.army .mil/amedd_journal.aspx38. Pirnat S, Lukac M, Ihan A. Study of the direct bactericidal effect of Nd: YAG and diode laser parameters used in endodontics on pigmented and nonpigmented bacteria. Lasers Med Sci 2011;26(6):755-761. 39. Moritz A, Schoop U, Goharkhay K, Jakolitsch S, Kluger W, Wernisch J, Sperr W. The bactericidal effect of Nd: YAG, Ho: YAG, and Er: YAG laser irradiation in the root canal: an in vitro comparison. J Clin Laser Med Surg 1999;17(4):161-164. 40. Bergmans L, Moisiadis P, Teughels W, Van Meerbeek B, Quirynen M, Lambrechts P. Bac tericidal effect of Nd: YAG laser irradiation on some endodontic pathogens ex vivo. Int Endod J 2006;39(7):547-555. 41. Klinke T, Klimm W, Gutknecht N. Antibacterial effects of Nd: YAG laser irradiation within root ca nal dentin. J Clin Laser Med Surg 1997;15(1):29-31. 42. Schoop U, Kluger W, Moritz A, Nedjelik N, Geor gopoulos A, Sperr W. Bactericidal effect of differ ent laser systems in the deep layers of dentin. La sers Surg Med 2004;35(2):111-116. 43. McCawley TK, McCawley MN, Rams TE. LA NAP immediate effects in vivo on human chronic periodontitis microbiota. Presented at: 43rd Annu al Meeting of the American Association for Dental Research; March 20, 2014; Charlotte, NC. Abstract 428. 44. Nevins ML, Shupbach P, Kim DM. Human clinical and histologic evaluation of laser-assisted new at tachment procedure. Int J Periodontics Restorative Dent 2012;32:497-507. 45. Nevins ML, Kim SW, Camelo, M, Martin IS, Kim D, Nevins M. A prospective 9-month human clini cal evaluation of laser-assisted new attachment procedure (LANAP) therapy. Int J Periodontics Restorative Dent 2014;34:21-27. 46. Yukna RA, Carr RL, Evans GH. Histologic evalu ation of an Nd: YAG laser-assisted new attachment procedure in humans. Int J Periodontics Restor ative Dent 2007;27:577-587. 47. Tilt LV. Effectiveness of LANAP over time as mea sured by tooth loss. Gen Dent 2012;60(2):143-146. 48. Chambrone L, Preshaw PM, Rosa EF, Heasman PA, Romito GA, Pannuti CM, Tu YK. Effects of smoking cessation on the outcomes of non surgical periodontal therapy: a systematic review and indi vidual patient data meta analysis. J Clin Periodon tol 2013;40(6):607-615. 49. Rosa EF, Corraini P, Inoue G, et al. Effect of smok ing cessation on non surgical periodontal therapy: results after 24 months. J Clinical Periodontol 2014;41(12):1145-1153. AUTHOR LTC Johnson is the Assistant Director, US Army Ad vanced Education Program in Periodontics, Army Post graduate Dental School, Uniformed Services University of the Health Sciences, Fort Gordon, Georgia.SMOKING AND PERIODONTAL DISEASEA rmy truck-mounted field dental clinic, circa 1917

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October December 2017 71Hot environments can be challenging for military work ing dog (MWD) teams who must balance mission re quirements against increased heat strain and risk of heat injury. Heat stroke was the third most common cause of stan, affecting 9 MWDs, and was the most common cause of death from nonbattle injury.1 Outside of combat, heat injury is the second most common reason (behind behavioral causes) for discharge from duty of younger (less than 5 years of age) MWDs.2 Not all canines are suited for work in the heat. Factors that could contrib ute to heat intolerance include physical characteristics (thick fur, obesity), medical conditions (cardiovascular or neurological abnormalities, laryngeal paralysis), and unfavorable structure of the upper airway (nares, nasal turbinate, soft palate).3 Despite these potential issues, over 1,500 MWDs in service in the Department of De fense (DoD) successfully perform their missions. One strategy to avoid excessive heat strain is to use work/rest cycles, both to limit the extent and duration of elevated core temperature (Tc) and to allow adequate recovery between successive bouts of work. Although a Tc of 42C (108F) may suggest heat illness in a dog ex posed to heat alone,4 during heavy exercise Tc can reach this level even with very short duration work (10 min utes) under relatively mild (24C, 75F) environmental conditions.5-8 However, a Tc of 43C (109F) may be fatal9; therefore, knowing how quickly temperature in creases during work, what temperature is reached, and how readily recovery occurs are important for judging what duration of work is appropriate and how long a re covery is necessary to minimize risk of heat injury. While several studies have documented thermoregula tory responses of dogs during treadmill running,5,6,10,11 only a few have reported Tc during activities performed outside of laboratory settings. Field studies have includ ed both standardized tasks, such as covering a measured distance, and sport performance, such as retrieving, where work intensity varies among dogs. The most rapid increase in Tc reported was in racing greyhounds who reached 41C after a 400 m sprint lasting only 30 sec onds.12 Sled dogs reached a Tc of approximately 41C to Core Temperature Responses of Military Working Dogs During Training Activities and Exercise Walks Catherine OBrien, MS Anthony J. Karis, BS William J. Tharion, MS, MBA Heather M. Sullivan, BS Reed W. Hoyt, PhD ABSTR A CT Heat strain is common in military working dogs (MWDs), but can be mitigated by limiting duration of activity perature responses during training must be characterized. This study measured body core temperature of 48 MWDs at Lackland Air Force Base, San Antonio, TX. Twenty-four MWDs in training for patrol and detection activities participated under a range of ambient temperatures in August (27C-32C), October (22C-26C) and March (approximately 13C). These MWDs swallowed a telemetric thermometer pill to measure continuous gastrointestinal tract temperature (Tgi). Twenty-four kennel MWDs participated in July (25C-29C). In these dogs rectal temperature (Tre) was measured manually during a standard exercise walk. For the MWDs in train into recovery. Before beginning a second activity 40 to 165 minutes later, Tgi was within 0.5C of initial values for 80% of dogs. For the kennel MWDs, Tre was 39.00.8C (37.7C to 40.7C) at the start and 40.10.6C at the end of the 21.32.8 minute walk. The continuous increase in core temperature during activity of both groups of MWDs indicates that limiting exercise duration is important for minimizing risk of overheating in MWDs. The observation of continued increase in Tgi to a peak after exercise ends suggests that for MWDs sus pected of overheating temperature should be monitored for at least 15 minutes postexercise to ensure recovery.

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72 http://www .cs.amedd.army .mil/amedd_journal.aspxover 42C when pulling carts over distances from 3 to 6 km.13 Three studies reported Tc during exercise in Lab rador retrievers. A Tc of 40.40.6C was reached in a 20 minute, 3.2 km conditioning run14; a Tc of 41.80.3C was reached after 10 minutes of repeated retrieves7; and Tc as high as 42.2C.15 None of these studies included the types of activities performed during MWD training. The purpose of this study was to characterize Tc re sponses in MWDs during training at Lackland Air Force Base, San Antonio, TX. The results of this study will improve understanding of heat storage during ex ercise and recovery of MWDs, and provide a basis for evaluating interventions or guidance for working in hot conditions. METHODS The 341st Training Squadron at Lackland Air Force Base procures and trains MWDs for patrol and detection activities, spending approximately 60 days on each type of training.16 At any time, 140-150 MWDs teams support military operations and their capabilities are used to enhance the effectiveness of the unit. The training includes the following skills: Obedience: Respond to cues of Sit, Down, Heel, Stay Obstacle Course: Negotiate obstacles under control Controlled Aggression: Pursue, bite and hold, re spond to cues of Out, Heel, Stay Building Search: Detect a person, narcotics, or ex plosives hidden inside a building Vehicle Search: Detect narcotics or explosives hid den on a vehicle Scouting: Locate a person by scent, sight, or sound Also at Lackland AFB are MWDs awaiting training, those in the DoD breeding pro gram, and Transportation Securi ty Administration canines. These dogs are walked twice a week on a standard route around the ken nel grounds. A total of 48 MWDs participated in this study, which was approved by the Department of Defense MWD Veterinary Service Insti tutional Animal Care and Use Committee. Twenty-four MWDs in training were tested over 2 consecutive days to obtain measurements during a variety of activities. Six were tested on each of 4 occasions: August and October 2014, March and August 2015. Another 24 MWDs that were in July 2015 during a single exercise walk around the kennel grounds. Testing for MWDs in training was scheduled for dif ferent times of the year to obtain data over a range of ambient temperatures (approximately 15C to 30C). Under these conditions, Tc can be maintained within a normal range at rest,10,17 but increase with exercise. Two data collections occurred in August due to instrument sion. Meteorological conditions, including ambient tem perature, relative humidity (RH), solar radiation, and wind speed were measured (WeatherHawk 500 Series in the same place and at the same time as the MWD activities. Average meteorological conditions during the testing are shown in the Table.MWDs in TrainingOf the 24 MWDs participating in the training portion of this study, 14 were Belgian Malinois and 10 were Ger man Shepherd Dogs. Four were female, all neutered; 20 were male, 3 neutered, the rest intact. Their age was 236 months (range 16-37 months), weight 323 kg (range 26-39 kg), height at withers 626 cm (range 5384 cm) and length 785 cm (range 70-89 cm). All data are presented as meanstandard deviation. Each morning the MWDs were picked up from the kennels and loaded onto a trailer where each dog was transport to the site where training was conducted. The trailers were equipped with air conditioners, but these were not used during any of the training sessions in this study. Dogs rested in their dog box while awaiting their turn to train, and returned to their box afterwards for CORE TEMPERATURE RESPONSES OF MILITARY WORKING DOGS DURING TRAINING ACTIVITIES AND EXERCISE WALKS Average Meteorological Conditions.August 2014October 2014March 2015August 2015July 2015 0800 1100 0800 1100 1300 0800 1100 0800 1100 0700 1100Temperature C 27 32 20 25 27 13 14 24 31 25 29 F 81 90 68 77 81 55 57 75 88 77 84 Relative Humidity 62% 46% 65% 49% 73% 76% 71% 77% 51% 83% 60% Solar Radiation (W/m2) 107 580 45 400 567 18 230 64 528 7 438 Wind Speed (m/s) 0. 2 1. 3 0 4 1. 8 1. 3 2 .7 2 .7 0. 2 1. 3 1. 3 2 2

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October December 2017 73 recovery. They performed between 1 to 3 sessions each day, comprised of a selection of activities from patrol or detection skills. The actual activities performed by the MWDs on each team depended on the particular skills the team was training at that time. Body core temperature in these MWDs was represented by gastrointestinal temperature (Tgi), which was mea sured using an ingestible telemetric thermometer cap sule (VitalSense, Phillips Respironics, Murrysville, PA). The capsule contains electronics that allow transmission of the temperature signal to a data logger worn on a vest around the dogs chest when the dog was working (Sensor Electronics Module (SEM), Equivital, Hidalgo Ltd., Cambridge, UK), or to a data logger placed just outside the dog box when the dog was resting in the trailer (VitalSense Monitor, Phillips Respironics, Mur rysville, PA). The 2 data loggers are shown in Figure 1. The capsule transits the gastrointestinal (GI) tract and is excreted, typically after 12 to 36 hours. Ideally the capsule is ingested at least 4 hours before data collection begins to ensure the capsule is out of the dogs stomach and not affected by water ingestion.18The telemetric thermometer capsule is advantageous due to the continuous temperature data provided with out need for invasive measurement or interruption of activity. However, this method depends on appropriate consumption, and also on the successful transmission of the temperature signal to the data logger. In this study, capsules were administered the day before testing; how ever, some dogs excreted the capsule overnight and a new capsule was administered the morning of testing. activity obscured initial recovery temperature. Overall, recovery temperatures were missed in 13 MWDs due to water consumption and in 11 cases where the MWD was resting at the back of the dog box out of range of the data logger. In August 2014, no recovery Tgi was obtained due to instrumentation failure, therefore this group was repeated in August 2015.Kennel MWDsTwenty-four MWDs participated in this part of the study which was conducted on a single occasion over 2 days during July 2015. This population consisted of 8 Belgian Malinois, 3 German Shepherd Dogs, 5 German Short hair Pointers, 6 Labrador Retrievers, one Flat-coated Retriever, and one Dutch Shepherd. Sixteen were male (3 neutered), and 8 were female (2 neutered). Their age was 3323 months (range 9-96 months), weight 295 kg (range 19-39 kg), height 594 cm (range 53-69 cm), and length 293 cm (range 61-91 cm). This population represented a wider range of breed, age, and body condition than the MWDs in training, but the activity for the kennel MWDs was the same for all. The dogs were walked for about 20 minutes, covering a 750-800 m loop around the kennel facilities. Toward the middle or end of the walk (depending on the loca tion of their kennel on the grounds), the dogs were taken into a climate-controlled (27C, 59% RH) building for grooming that lasted up to 5 minutes. They were then returned to their kennels. Since data were only collected during a single walk for each dog and it was not possible to continue data collection into recovery, body core temperature was represented by rectal temperature (Tre) measured manu ally with a digital thermometer (Adtemp 422, American Diagnostic Corporation, Hauppauge, NY) before the walk, after the initial walk to the grooming building, at the end of grooming, and after return to the kennel. The dogs wore a muzzle for 30 sec onds to one minute while the temperature was taken. RESULTS MWDs in Training tivity was 38.60.5C. All but 3 dogs had resting temperatures between 37.8C and 38.9C, which is within a normal range.17 Two dogs, both of whom tended to spin in their kennels, had elevated Tgi (39.8C and A B Figure 1. The Vital Sense Monitor (A) was used to record Tgi when the dog was resting on the trailer. The vest-mounted Sensor Electronics Module (B) recorded Tgi while the dog was engaged in training.

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74 http://www .cs.amedd.army .mil/amedd_journal.aspxreturned to within normal range after recovery (38.6C, 38.8C, respectively). Both tended to spin less frequently as the training day progressed. One dog during the March sented in Figure 2 for the 4 training groups. Data for one dog from October 2014 was not included in the data pre because his preactivity Tgi was outside even the wide range of normal body temperature presented by Vogelsang.17 For all groups on was 39.80.6C, with a large range (38.4C to 41.4C) due to individual variability and varied intensity and duration of training. Successful performance is typically rein forced by presentation of a toy reward and game of tug, or, in the case of patrol activi ties, chasing a decoy and presentation of a bite sleeve and game of tug. These energetic games contribute to the overall metabolic intensity of a particular activity. The overall duration of training sessions was 11.65.0 minutes The average duration of each activ ity is shown in the legend of Figure 2. Fig ure 3 shows the individual Tgi responses during Obedience training. Since nearly all dogs performed this activity and it occurred provides a good illustration of the variability among dogs. The temperature responses of the dogs with initial Tgi outside of the normal range are shown in Figure 3. Four dogs reached Tgi over 41C during a single activity. In August 2014, one dog reached a Tgi of 41.3C dur ing Vehicle Search; in October 2014, one dog reached 41.2C during Controlled Aggression and another dog reached 41.1C during Obstacle Course; in August, 2015, CORE TEMPERATURE RESPONSES OF MILITARY WORKING DOGS DURING TRAINING ACTIVITIES AND EXERCISE WALKS Figure 2. ing MWDs is shown above each bar. The mean (SD) duration time of each activity is shown in the legend. Preactivity Obedience (12 64 4 min) Controlled Aggression (11 52 8 min) Vehicle Search (12 83 4 min) Scouting (8 93 2 min) Building Search (8 32 6 min) Obstacle Course (16 23 2 min) 39 40 38 41 37 42 Core Temperature (C) 2 3 6 4 6 6 5 5 5 5 5 1 1 2 3 6 6 6 6 6 August 2014 August 2015 March 2015 October 2014 Figure 3. Core temperature response during obedience training. Data are pre sented for all 23 MWDs that participated in this activity. 10 0 20 30 39 40 38 41 37 42 Core Temperature (C) Elapsed Time (minutes)October 2014August 2014August 2015March 2015

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October December 2017 75 one dog reached 41.4C during Con trolled Aggression. Neither of the MWDs with elevated Tgi before be over 41C during training. Peak Tgi typically occurred after the end of activity and the dog had re turned to the trailer box for recovery. Figure 4 presents the Tgi response of a single MWD during the course of a training day where the activities performed were Obedience, Build ing Search, and Controlled Aggres sion. The red line indicates Tgi mea surements during activity, the blue line indicates Tgi measured during recovery while the dog was resting in the trailer box. Note that peak Tgi occurred several minutes after exer cise ceased. For the 36 cases where recovery data was obtained, peak Tgi was 0.40.4C higher than Tgi at the end of activity, and occurred 10.210.6 minutes recovery). The highest peak Tgi was 42.4C, which oc curred 8 minutes after the end of the activity. In only 2 during activity. Three activities were conducted each day in the Octo ber group, 2 in each of the August groups, and only one activity was conducted each day in March. For the 18 MWDs who performed a second activity, 103.536.2 Tgi at the start of the second activity was within 0.5C of initial values for 80% of the dogs. For the 10 MWDs not obscured by water ingestion or out of range of the data logger), Tgi returned to within 0.5C of initial val ues in 44.112.6 minutes.Kennel MWDsThe initial Tre measured in the Kennel MWDs was 39.0C0.8C (37.7C to 40.7C). Eleven of these MWDs had an initial Tre that was higher than 39.2C, which is considered the upper limit of normal.17 These peratures, as some dogs were active in their kennel, pac ing or jumping in anticipation of the mornings activities. Completing the approximately 800 m loop generally re quired about 15 minutes (not counting approximately 5 minutes for grooming), for an average speed of 0.9 m/s. Since the MWDs typically moved back and forth dur ing the walk, they may have covered more distance at a somewhat faster pace. Temperatures for each phase of the walk are shown in Figure 5. After 11.43.3 minutes of walking, Tre was 39.90.6C. The dogs stood qui etly during grooming, then walking back to the kennel was 21.32.8 minutes. One dog reached a temperature minutes), but returned to 40.7C by the end of the session. Four Kennel MWDs were taken for veterinary care, based on the handlers interpretation of signs and/or symptoms of heat strain, including strained breathing or labored panting, and general demeanor (either unusually anxious or subdued). Three of these dogs (a Labrador Retriever, a German Shepherd Dog, and a Belgian Mali nois) had an initial Tre greater than 40C. These events all occurred between 6:30 AM and 7:30 AM when trail ers were arriving at the kennels to load other MWDs for training. This sudden increase in general activity around the kennel excites many of the dogs, some of whom repeatedly jump or spin in their kennels. For the ing. The fourth dog (Labrador Retriever) had a normal initial temperature, but Tre was elevated to 40.5C by second report of overheating. Medical treatment at the veterinary clinic for all 4 dogs included placing the dogs in a large open kennel, spraying them with water, and Figure 4. Example of MWD temperature response over the course of a day, consisting of 3 training sessions. Core Temperature (C)39 40 38 41 37 42Obedience Building Search Controlled AggressionTime of Day (24 hour)15:00 14:00 13:00 12:00 11:00 10:00 9:00 Temperatures during activity Temperatures during rest and recovery

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76 http://www .cs.amedd.army .mil/amedd_journal.aspxplacing a fan in front of the kennel to enhance evapora tive and convective cooling. All recovered without need for further intervention. Only 2 other MWDs reached Tre greater than 40.5C during the walks. CO MM ENT MWDs during training activities and kennel walks. While the data presented here are descriptive, they pro vide a baseline for future studies where comparisons may be made or interventions evaluated. An important in Tgi to a peak 8 to 12 minutes after exercise ended, shown for one dog in Figure 3. This delay in reaching response of the gastrointestinal tract due to decreased tures of the working muscles and central blood,18,19 and continued heat storage even after exercise ends.20 Since rectal temperature is measured in MWDs suspected of overheating, this underscores the importance of mea suring temperature not only when exercise is ceased, but also periodically during recovery until a decrease in temperature is observed. This practice may identify a need for additional cooling such as greater ventila MWDs that require veterinary attention. Although heat injury can occur at a body core tempera ture of 42C with heat exposure alone,4 temperatures this high have occurred during exercise in the heat without adverse effect.5-8 Clearly, caution is advised at temperatures this high, particularly with longer dura tion exposure. A temperature of 43C can be fatal.9 Un der the conditions in the present study, Tgi reached ap proximately 40C at the end of a training session, with only 4 MWDs reaching a temperature over 41C (two in August, two in October). For 2 of these dogs, this oc curred on the last activity of the day. Before beginning the second activity of the day, Tgi had returned to within 0.5C of initial Tgi for all but 4 MWDs in August data collections. This suggests that, under the conditions of this study, the duration of both training sessions and re covery periods were acceptable. Figure 3 shows the con tinuous increase in core temperature during Obedience and illustrates how limiting training duration could be effective for avoiding excessive heat strain. Under con ditions of high heat stress, short sessions can reduce risk of overheating while still meeting mission requirements. Kennel MWDs also reached a Tre of about 40C at the end of their walk, with only one dog reaching a Tre over 41C, excluding 4 Kennel MWDs taken to the veterinary clinic before completing the walk. For the dogs taken to the veterinary clinic, whether the excitement of the ken nel activity had contributed to their elevated tempera tures or whether they were otherwise predisposed to overheating cannot be discerned from this study. The temperatures achieved during this study are similar to what has been reported for other working dogs when the intensity and duration of work are considered. Angle and Gillette14 reported Tgi of approximately 40.51.0C in Labrador Retrievers at the end of a 20-minute run at 2.9 m/s, and Tgi of approximately 40.01.0C after present study. Matwichuk et al7 reported a higher Tre of 41.80.3C in Labrador Retrievers after 10 minutes of work. However, those dogs on average completed 44 re trieves about 40 m long, for a total distance (round trip) of 3,520 m at a speed nearly twice as fast as the dogs in the study of Angle and Gillette.14 Phillips et al13 reported Tre in sled dogs pulling a cart for 3.5 km at a pace of 4.7 to 6.7 m/s reached 39.9C to 41.7C, but when dogs ran for longer distances (16 km) without pulling a load, Tre was lower (39.5C to 40.2C). In that study, Tre reached a plateau after about 25 minutes for the dogs running longer distances. None of these studies reported the delayed peak temper ature observed in the present study. This may be due to the frequency of temperature measurements. For exam ple, Matwichuk et al7 found that Tre was the same after CORE TEMPERATURE RESPONSES OF MILITARY WORKING DOGS DURING TRAINING ACTIVITIES AND EXERCISE WALKSFigure 5. Core temperature for kennel MWDs and elapsed time are shown for the time points of measurements during their walk. The number of MWDs measured for each time point (n) is indicated in the data bar. Two MWDs were taken to the veterinary clinic just before and 2 others just after the initial walk. Final temperature was not measured in 5 MWDs whose kennels were located adjacent to the grooming area. 113 min 0 min 163 min 213 minElapsed Time Initial Walk Post-groom Finish Start 39 40 38 41 37 42 Core Temperature (C) n=24 n=22 n=20 n=15

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October December 2017 77 5 minutes of recovery as it was at the end of exercise, and had decreased only to 41.60.3C after 10 minutes. Likewise, Angle and Gillette reported little change in 14 Whether a peak ery of either of these studies is unknown. For longer duration steady state exercise, a peak temperature during recovery may not be observed, since body temperature would likely have become more uniform.18 LI M IT A TIONS For the MWDs in training, work intensity and duration varied among dogs, yet both are important factors for activities and among conditions, such as climate. At the same time, there are individual differences in tempera ture response, including the initial temperature of the dog. Kennel MWDs walked at the pace of their handler; therefore there was less variability among dogs for the physical work performed. However, nearly half had an initial Tre above a normal resting range. Behaviors ex hibited in the kennels include repetitive leaping, spin ning, and barking, particularly in the morning when the trailers arrived to pick up other MWDs for training. Three of the 4 Kennel MWDs taken for veterinary care had elevated initial Tre. Kennel MWDs also typically receive less exercise than the MWDs in training, and SU MMA RY This study reports body core temperature responses to MWD training activities as well as standard kennel walks. The results of this study suggest that alternating periods of work with adequate recovery is an effective strategy for accomplishing mission-required training while avoiding excessive heat strain. Peak temperature may occur several minutes after work ends; therefore, rest to ensure recovery. ACKNOWLEDG M ENTS The research described in this report was conducted in compliance with the standards and practices set forth in the Guide for the Care and Use of Laboratory Animals : Eighth Edition issued by the Committee on Care and Use of Laboratory Animals of the Institute for Laboratory Animal Research, National Research Council, published by National Academies Press. We are sincerely grateful to the teams of the 341st Train ing Squadron, the Department of Defense Military Working Dog School, as well as to the 48 MWDs who participated in this study. Our appreciation also goes to SSG John Camelo for his dedication to documenting the activities of the MWDs during this study. REFERENCES 1. Miller L. Causes of combat mortality of military working dogs in OIF and OEF, 2007-2012: A pilot study of 109 cases. Presented at: Canine Science and Technology Workshop; August 6, 2014; Ra leigh, NC. 2. Evans RI, Herbold JR, Bradshaw BS, Moore GE. Causes for discharge of military working dogs from service: 268 cases (2000-2004). J Am Vet Med Assoc 2007;231:1215-1220. 3. Hemmelgarn C, Gannon K. Heatstroke: thermo regulation, pathophysiology, and predisposing fac tors. Compend Contin Educ Vet 2013;35(7):E1-E6. 4. Carithers RW, Seagrave RC. Canine hyperther mia with cerebral protection. J Appl Physiol 1976;40(4):543-548. 5. Chapman LW, Baker MA. Cardiac output of dogs exercising in the heat. Am J Physiol 1984;247(1 pt 2):R124-R126. 6. Kruk B, Kaciuba-Uscilko H, Nazar K, et al. Hy pothalamic, rectal, and muscle temperatures in exercising dogs: effect of cooling. J Appl Physiol 1985;58(5):1444-1448. 7. Matwichuk CL, Taylor SM, Shmon CL, et al. Changes in rectal temperature and hematologic, biochemical, blood gas, and acid-base values in healthy Labrador Retrievers before and after stren uous exercise. Am J Vet Res 1999;60:88-92. 8. Young DR, Mosher R, Erve P, Spector H. Body tem perature and heat exchange during treadmill run ning in dogs. J Appl Physiol 1959;14(5):839-843. 9. Shapiro Y, Rosenthal T, Sohar E. Experimen tal heatstroke: a model in dogs. Arch Intern Med 1973;131:688-692. 10. Besch EL, Kadono H, Brigmon RL. Body tempera ture changes in dogs exposed to varying effective temperatures. Lab Anim Sci 1984;34(2):177-180. 11. Musch TI, Friedman DB, Pitetti KH, et al. Re ing graded dynamic exercise. J Appl Physiol 1987;63(6):2269-2277. 12. Rose R, Bloomberg M. Responses to sprint exer cise in the greyhound: effects on haematology, se rum biochemistry and muscle metabolites. Res Vet Sci 1989;47(2):212-218. 13. Phillips CJ, Coppinger RP, Schimel DS. Hyper thermia in running sled dogs. J Appl Physiol 1981;51(1):135-142. 14. Angle TC, Gillette RL. Telemetric measurement of body core temperature in exercising unconditioned Labrador retrievers. Can J Vet Res 2011;75:157-159.

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78 http://www .cs.amedd.army .mil/amedd_journal.aspx15. Steiss JE, Wright JC. Respiratory alkalosis and primary hypocapnia in Labrador retrievers partici conditions. Am J Vet Res 2008;69:1262-1267. 16. Army Regulation 190-12: Military Working Dog Program Washington, DC: US Department of the Army; March 11, 2013. 17. Vogelsang R. Care of the military working dog by medical providers. J Spec Oper Med 2007;7(2):33-47. 18. OBrien C, Hoyt RW, Buller MJ, et al. Telemetry pill measurement of core temperature in humans during active heating and cooling. Med Sci Sports Exerc 1998;30(3):468-472. 19. Saltin B, Hermansen L. Esophageal, rectal, and muscle temperature during exercise. J Appl Physi ol 1966;21(6):1757-1762. 20. Gaesser GA, Brooks GA. Metabolic bases of ex cess post-exercise oxygen consumption: a review. Med Sci Sports Exerc 1984;16(1):29-43. AUTHORS Ms OBrien is a Research Physiologist in the Thermal and Mountain Medicine Division at the US Army Re search Institute of Environmental Medicine, Natick, Massachusetts. Mr Karis is a Research Physical Scientist in the Military Nutrition Division at the US Army Research Institute of Environmental Medicine, Natick, Massachusetts. Mr Tharion is a Research Physiologist in the Biophys ics and Biomedical Modeling Division at the US Army Research Institute of Environmental Medicine, Natick, Massachusetts. Ms Sullivan is a Laboratory Animal Veterinary Tech nician, Veterinary Support and Oversight Branch at the US Army Research Institute of Environmental Medicine, Natick, Massachusetts. Dr Hoyt is a Supervisory Research Physiologist and Chief of the Biophysics and Biomedical Modeling Divi sion at the US Army Research Institute of Environmental Medicine, Natick, Massachusetts.CORE TEMPERATURE RESPONSES OF MILITARY WORKING DOGS DURING TRAINING ACTIVITIES AND EXERCISE WALKS

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October December 2017 79The Army Physical Fitness Test (APFT) is a semiannual training requirement for all Soldiers of the US Army. It consists of 3 events: the 2 minute push-up event, the 2 minute sit-up event, and the timed 2-mile run event. Based on a Soldiers age and gender, a scoring scale is used to convert a raw event score (number of push-up repetitions correctly performed, number of sit-up rep etitions correctly performed, or 2-mile run time) to a scaled event score that ranges from 0 to 100 points for each event. The 3 scaled scores are then summed for a combined score between 0 and 300 points. In order to pass the APFT, Soldiers are required to earn a minimum of 60 points on each event and a total of 180 points. This combination of upper body and trunk anaerobic endurance events (push-ups and sit-ups) and a lower and relatively balanced assessment of overall physical technique on each event is also likely to contribute to an individuals score. Experience shows that seasoned Sol optimize performance on the APFT. However, newer these events, and the scoring standards for each, may them to achieve their personal best scores on the APFT. The training manual1 that governs the execution of PRT is an excellent resource regarding the planning and con duct of a daily exercise regimen that will adequately ad dress the strength, mobility, and endurance needs of the performance. There is currently no required training for Soldiers upon entry into the military that would expose them to infor mation regarding recommended techniques that can be used during the APFT. There are several reasons why a Soldier fails to earn a passing score on the APFT, such as fatigue, injury, inconsistent training regimen, poor nutrition, etc. The use of an exercise technique or motor control strategy that is not biomechanically, physiologi cally, or strategically sound could also adversely affect performance. Therefore, the purpose of this report is to assess the potential value of a technique-focused train ing program when administered by Army physical ther that failed to pass their initial APFT upon matriculation METHODS ParticipantsFrom January 2015 through March 2016, 34 Army at Fort Sam Houston, Texas, participated in an APFT Effects of Technique-Focused Training in Conjunction with Physical Readiness Training on Army Physical Fitness Test Performance LTC (Ret) Mark D. Thelen, SP, USA LTC (Ret) Shane L. Koppenhaver, SP, USA COL Norman W. Gill, SP, USA COL Scott W. Shaffer, SP, USA ABSTR A CT The Army Physical Fitness Test (APFT) is a semiannual requirement. While conducting physical readiness training (PRT) is a requirement for all Soldiers, there is no requirement to train Soldiers on techniques that may their required PRT program subsequent to failing one or more events on their initial APFT. The training con sisted of a 30-minute video lesson and an individualized performance assessment completed by an Army physi cal therapist. Upon retest 10 days after the initial test, 27 (79.4%) participants passed the APFT with a mean improvement of 22.3 points on their overall APFT score. When evaluating change in performance by event based on failing the event initially, the observed improvement was an increase of over 9 push-ups, over 11 situps, and nearly 2 minutes on the run event. The addition of a technique-focused training program to an existing

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80 http://www .cs.amedd.army .mil/amedd_journal.aspxperformance improvement training program. Within APFT performance improvement training program was more events on that APFT. Evaluation and approval of this performance improvement training program by the local Institutional Review Board was not required.APFT EvaluationsThe APFT was administered by BOLC cadre as a part of their normal BOLC schedule. All participants that failed the initial APFT were retested 10 days later by BOLC cadre as dictated by local Army Medical Depart ment Center and School command policy. Grader as signments for the APFT were randomly selected by the command team and no attempt was made to ensure that an assigned grader for the initial APFT was the same grader for the retest.Screening Intervention participated in the special population PRT program per the associated regulation1 under the supervision of their unit leadership. A typical one-week PRT training regi the training regimen often varied based on the company leadership during the time of APFT failure. This group exercise regimen was performed 3 to 5 times a week for 60 to 75 minutes per session. A dynamic warm-up, utes. This was followed by drills aimed at improving anaerobic muscular strength and endurance, overall mo bility, and aerobic conditioning lasting approximately 35 to 45 minutes. Each training session was concluded with a cool down static stretching activity known as the re mance assessment evaluation conducted by local Army physical therapists (PTs). This training was completed within 3 days of their initial APFT, in order to maximize ministration of the APFT. In preparation for this train lesson that outlined common performance detractors observed during the conduct of an APFT. As previously described in an earlier study,2 this training is available to holders of a Department of Defense common access card at the following web address: https://www.milsuite. mil/book/docs/DOC-189640 and has also been previ ously reported. In total, 4 PTs conducted the live training on several training dates during the data collection period. All therapy and all had been serving as active duty Army physical therapists for a minimum of 15 years. The live training program consisted of the following sequence: subjective APFT concerns, observation and analysis of the push-up and sit-up events, and observation and tion of any kind that precluded their ability to provide a good faith effort on the most recent APFT. If no, they were asked to rank order the APFT events from most to were failed and by how many points (if known). Lastly, before starting any physical activity, they were asked if they used any kind of strategy as to how they planned to perform 30 to 60 seconds of push-ups as they would do them on an APFT. The number of repetitions var quired to perform push-up repetitions until muscle fail ure ensued. After a brief rest while feedback on pushup performance was provided, a similar approach was used to assess performance on the sit-up event. Again, after a brief rest while feedback on the sit-up event was provid ed, they completed a run analysis. The run analysis was performed on a com mercial treadmill and was completed in to begin by achieving a moderate walk ing pace for approximately 2 minutes and were then instructed to gradually increase the treadmill speed until they reached a pace commensurate with the pace used on the most recent APFT. The could potentially affect performance on the 2-mile run EFFECTS OF TECHNIQUE-FOCUSED TRAINING IN CONJUNCTION WITH PHYSICAL READINESS TRAINING ON ARMY PHYSICAL FITNESS TEST PERFORMANCE Table 1. Typical 5-Day Physical Readiness Training Schedule.Day Warmup Activities Cooldown1Preparation drill (5 reps)4 for the Core(60 seconds) /conditioning drill #1 (5 reps)/push-up sit-up drill (4 reps x 30 sec) Recovery drill (20 seconds)2Preparation drill (5 reps) Push-up drill, sit-up drills, 1 mile split time training Recovery drill (20 seconds)3Preparation drill (5 reps) Military movement drill #2 (1 rep)/conditioning drill #2/release run by platoon Recovery drill (20 seconds)4Preparation drill (5 reps) Push-up drill, sit up drills, 1 mile split time training Recovery drill (20 seconds)5Preparation drill (5 reps)4 for the Core (60 Seconds); conditioning drill #1 (5 reps); climbing drill #1 (5 reps) Recovery drill (20 seconds)

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October December 2017 81 event. Additionally, a smartphone was then used to take 6 to 8 second slow motion videos from both a poste rior and lateral vantage point. This was done in order to assess more subtle motor control movement patterns in the frontal and sagittal planes and to provide visual tions from each of the 3 training events. For example, a common observation on the push-up event involves the dropping of the head during the down phase, which typ ically leads to inability to achieve the appropriate depth. As a possible correction, the recommendation to keep the head in neutral or slightly extended and leading the encouraged to incorporate any recommendations made during this training event into their unit-led PRT train ing program, but there was no attempt to track use or compliance. The videos were deleted immediately after use and no data was retained by the physical therapist examiners.Data AnalysisUpon completion of the APFT retest, lected by the unit leadership and provided to the primary author for analysis. Descriptive statistics mographics of the cohort and their performance on the APFT. Inferential statistics (paired t test) were performed to determine individual event and overall APFT performance change observed from the initial APFT to the retest. All statistics were calculated using IBM SPSS Statistics 22 and alpha of 0.05. RESULTS Descriptive statistics regarding the demographic data for the 34 participants (14 female, 20 male) in this pro gram are presented in Table 2. Thirty-three participants completed the entire 3-event APFT, whereas one partic the sit-up event and only completed the push-up and run events. The time of year for testing varied for partici pants, but the duration between APFT test dates was 10 days for all participants. Initial overall mean score on the APFT was 189.328.1 points, and 211.624.7 points for the APFT retest administered 10 days later. Individual test and retest scores are shown in the Figure. Upon re test, 27 of 34 (79.4%) participants were able to achieve a passing score on the APFT. The breakdown of numbers of failures by event on the initial APFT was 8, 14, and 22 for the push-up, sit-up, and run events respectively. Table 3 presents a summary of the mean number of repetitions completed or run times as appropriate for each of the events, as well as the overall APFT scores. Table 4 highlights the change in per formance by event based on whether Table 2. Descriptive Statistics (N=34)Range Mean SD Age (years) 22-37 28 .7 4. 3 Height (inches) 62-76 68 2 3 4 Weight (pounds) 122-234 173 .9 32 .1 Body Mass Index 20. 3-33. 8 26 2 3 .6 Graphical comparison of initial and retest overall APFT scores (N=33). 120 140 160 180 200 220 240 260 100 Retest APFT Score Initial APFT Score

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82 http://www.cs.amedd.army.mil/amedd_journal.aspxor not the individual had failed that event on the initial APFT. The overall mean change score for the APFT of 22.3 points improved regardless of which event(s) were provement for the entire cohort observed for the sit-up and run events. When quantifying mean improvements based on whether or not the event was initially failed as presented in Table 4, all events demonstrated statistical ment on the APFT of 42.7 points. COMMENT short-term gains in performance can be made on the APFT when participants are provided a structured PRT program that is augmented with an individualized, tech ment in each of the events comprising the APFT was observed, especially in the sit-up event and even greater in the run event. A mean improvement for the entire co hort of approximately 6 sit-ups and 90 seconds on the 2-mile run in 10 day period is noteworthy. Mean pushup performance, on the other hand, remained unchanged. This could indicate that technique is less important for push-up performance than for sit-ups and running. Al dations that Soldiers received on overall APFT strategy. were encouraged to reduce the number of repetitions at tempted on the push-up event if they passed that event initially. This strategy was employed to allow individuals to conserve energy for the subsequent 2 events for which they may have failed to achieve a passing score on the initial test. Therefore, an analysis of improvement tially failed may provide further insight. Based on the analysis in Table 4, we observed a mean improvement of over 9 push-up repetitions in the group that failed the push-up event initially. When the sit-up and run events were analyzed in a similar manner, we observed mean increases of over 11 sit-ups and nearly 2 minutes faster, respectively. This cumulative increase equated to an in crease of 42.7 points on the overall APFT retest score. This degree of change in a relatively short period of time would argue against the premise that the contin ued PRT alone they were required to perform was solely responsible for the observed improvements. Muscle hy pertrophy and cardiopulmonary adaptations are 2 mech anisms by which APFT performance can be expected to improve.3 either occurred in the limited time between test dates. neural adaptations can occur in a short period of time and subsequently result in improved performance.4,5 For example, Frost et al6 reported an immediate improve ment on the Functional Movement Screen (7 tests repre senting various functional movements) score for a group expected movement patterns on events graded as sub participants were capable of optimizing movement, but were unaware of the best strategy to achieve a better a limited amount of experience with being evaluated on the 3 events of the APFT, potentially limiting their abil ity to develop an optimal movement strategy for each. EFFECTS OF TECHNIQUE-FOCUSED TRAINING IN CONJUNCTION WITH PHYSICAL READINESS TRAINING ON ARMY PHYSICAL FITNESS TEST PERFORMANCE Table 3. Individual Event and Overall APFT Performance Results (N=34).Mean (95% CI) SD P value Push-up Reps Initial 38.5 17.5 Push-up Reps Retest 39.7 14.5 Change in Push-up Reps 1.2 (-1.6,4.0) 8.1 .390 Sit-up Reps Initial 50.9 13.5 Sit-up Reps Retest 56.6 11.5 Change in Sit-up Reps 5.6(2.0,9.3) 10.3 .004*Run Time Initial 19:01 2:22 Run Time Retest 17:32 1:50 Change in Run Time (seconds) -89.5(-68,-110) 58.9 <.001*APFT Total Score Initial 189.3 28.1 APFT Total Score Retest 211.6 24.7 Change in APFT Score 22.3(16.2,28.3) 17.0 <.001**Statistically significant improvement Table 4. APFT Event Performance Comparison by Event Status (N=34).Failed Event n Mean SD P value Change in Push-up Reps NO 26 -1.2 7.0 .001*YES 8 9.1 6.0 Change in Push-up Score NO 26 -1.4 8.0 .001*YES 8 10.6 7.3 Change in Sit-up Reps NO 19 1.5 7.4 .006*YES 14 11.1 11.3 Change in Sit-up Score NO 19 1.7 7.9 .003*YES 14 13.1 12.7 Change in Run Time (seconds) NO 12 -39.5 22.7 <.001*YES 22 -116.7 54.6 Change in Run Score NO 12 5.2 3.8 <.001*YES 22 19.0 8.5*Statistically significant difference

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October December 2017 83 The advice given to the participants in this study was intended to result in improved biomechanical and motor control physiologic strategies. Multiple limitations exist with the design of the cohort study. First, the sample size was small and there was no control or usual training group to compare what, if any, additive effect was provided by the individualized training session. Also, all participants were required to pass the APFT in order to graduate from BOLC and ultimately be allowed to begin their careers as branch vated to improve their performance regardless of the training that they received.7 Further, no attempt was made to account for any additional voluntary training the participants may have done between APFT testing dates. Due to personnel constraints, there was also no attempt to ensure that each participant had their APFTs graded by the same grader. The interrater and intrarater reliability of the push-up event was recently reported to range between 0.10-0.97 and 0.47-0.99 respectively.8 This degree of variability in grading could have affected the outcome on this event. No such reliability data has been previously reported for the sit-up event. Minimal evidence does exist to support the interrater and intra rater reliability of a videotaped qualitative running as sessment.9 Lastly, given that the cohort initially scored receive this training based on their substandard per formance, some regression toward the mean would be expected.10Future studies should include a comparison group that does not receive individualized guidance regarding their performance. Also, this training method should be as sessed in a regular Army unit with a more normal distri bution of APFT scores. PR A CTIC A L APPLIC A TIONS This study provides baseline evidence for the value of vided by a military physical therapist. Given that physi cal therapists are currently assigned in wide variety of positions throughout the military, there is potential for a larger scale implementation of this type of human per formance optimization training program. REFERENCES 1. Field Manual 7-22: Army Physical Readiness Training Washington, DC: US Department of the Army: 2012. 2. Thelen MD, Koppenhaver SL. Performance opti mization and injury prevention strategies for the Int J Sports Phys Ther 2015;10(3):391-401. 3. Weiss LW, Coney HD, Clark FC. Gross measures of exercise-induced muscular hypertrophy. J Or thop Sports Phys Ther 2000;30(3):143-148. 4. Gabriel DA, Kamen G, Frost G. Neural adapta tions to resistive exercise: mechanisms and rec ommendations for training practices. Sports Med 2006;36:133-149. 5. Hedayatpour N, Falla D. Physiological and neu ral adaptations to eccentric exercise: mechanisms and considerations for training. Biomed Res Int 2015;2015:1-7. 6. Frost DM, Beach TA, Callaghan JP, McGill SM. FMS scores change with performers knowledge of the grading criteria-are general whole-body move J Strength Cond Res 2015;29(11):3037-3044. 7. Fisher J, Steele J. Questioning the resistance/ aerobic training dichotomy: a commentary on physiological adaptations determined by effort rather than exercise modality. J Human Kinetics 2014;44:137-142. 8. Fielitz L, Coelho J, Horne T, Brechue W. Inter-rater reliability and intra-rater reliability of assessing the 2-minute push-up test. Mil Med 2016;181(2):167-172. 9. Pipkin A, Kotecki K, Hetzel S, Heiderscheit B. Re liability of a qualitative video analysis for running. J Orthop Sports Phys Ther 2016;46(7):556-561. 10. Portney LG, Watkins MP. Foundation of Clinical Research: Applications to Practice 3rd ed. Upper Saddle River, NJ: Pearson Prentice Hall; 2009. AUTHORS At the time this study was conducted, LTC (Ret) Thelen and LTC (Ret) Koppenhaver were instructors at the US Army-Baylor University Doctoral Program in Physical Therapy at Joint Base San Antonio-Fort Sam Houston, Texas. COL Gill is Director, US Army-Baylor University Doc toral Program in Physical Therapy at Joint Base San An tonio-Fort Sam Houston, Texas. COL Shaffer is Dean of the Graduate School, AMEDD Center and School, Joint Base San Antonio-Fort Sam Houston, San Antonio, Texas. He is also Chief of Army Physical Therapy and Assistant Chief, Army Medical Specialist Corps.

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84 http://www .cs.amedd.army .mil/amedd_journal.aspxLike their private sector counterparts, Department of Defense (DoD) behavioral health providers rely on ev idence-based practice and evidence-based treatment to guide development and delivery of care plans. Unfortunately, most of the evidenced-based treatment protocols involve civilian participants in nonmilitary environ ments, which makes the generalization of interventional strategies and treatment results to military personnel a by a number of providers and organizations both within and outside of the DoD. Another concern is the lack of tary members and their families. This concern was re cently presented in studies conducted by the Institute of Medicine (IOM) of the National Academies. Additional concerns raised by the IOM include (1) the cost of care, (2) the lack of use of established frameworks, and (3) length of treatment.1,2 EFFECTIVENESS OF PSYCHOTHER A PY Broadly, the effectiveness of psychotherapy is indisput able3-6; however, the quality of psychotherapy is not as unambiguous because of dependency upon the therapist.7 Clinical trials have detected differences in outcomes among therapists.8-10 Even with the implementation of evidence-based practice and evidence-based treatment, desired treatment outcomes are not guaranteed since even well-accepted therapies can have harmful effects in some people.11,12 For example, even though relaxation patients, relaxation training can induce panic attacks among a minority of patients.13 Complicating the issue of implementing evidence-based practice is a 20-year lag between knowledge acquired from our best clinical research and the applied use of that knowledge in the mental health sectors.14 SINGLECA SE DESIGNS Also known as single-subject and N-of-1 designs, sin gle-case designs (SCDs) have rarely been taught to students or used by investigators in the behavioral sciences until recently. Consequently, many misconceptions ex ist about conducting SCDs and their value. However, most recently, in applied behavioral research and clini cal settings, SCDs are being more widely and heavily applied.16 Moreover, the increase in the use of SCDs has not been centered on the behavioral sciences. Instead, their use is occurring across a variety of medical and educational settings. In fact, in some disciplines such as special education, the experimental literature has been dominated by sin gle-subject investigations.17-19 Other areas experiencing an increase in single-subject designs include emergency department medicine,20 general medicine,21 early child hood special education,22 special education,23,24 autism,25 speech and language pathology,26 aphasia,27 special edu cation,28,29 students with disabilities,24 behavioral prob lems,30 natural disasters,31 and self-management.32 In written on the use of single-subject designs in clinical use.33-37 Although this list is extensive, it is by no means exhaustive. What has led to the resurgence in the use of SCDs? The answer is as varied as the disciplines employing the designs. One answer derives from an area of psychol ogy known as applied behavior analysis, which focus es on interventions in a number of settings. This area 38 Another answer derives from clinical social work where more and more practitioners have been charged with empiri cally demonstrating the effectiveness of their interven tions.39 In a clinical practice setting, the effectiveness of interventions can most readily be evaluated by SCDs. Additionally, given the fact that social workers are the largest providers of mental health services in the United States,40 it is not surprising that, more and more, SCDs are being used in the delivery of mental health services.41An additional source of support for single-case designs comes from the federal government via the US Depart ment of Education Institute of Education Sciences (IES), which was established under the Education Sciences Re form Act of 2002. This Act provides funds to establish The What Works Clearinghouse (WWC). The WWC has Evidence-based Practice and Single-case Designs in Psychotherapy James M. Georgoulakis, PhD, JD CPT Johanna G. Zollmann, MS, USA Christopher L. Pate, PhD, MPA Amy J. Hallett, LMSW, LCSW

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October December 2017 85 accepted that single-case designs can provide causal evi dence of intervention effects.42 Additionally, professional organizations such as the American Psychological Asso ciation (APA) recommend single-case designs alongside randomized control trials in their clinical evidence stan dards.43 Furthermore, individual social workers have dis cussed the importance of single-case designs in clinical practice,44-46 and the National Association Social Work ers (NASW) Press has published a number of documents related to single-case designs for clinical practice.47 COST CONSIDER A TIONS The cost of health care services and the lack of cost data analysis in health care and mental health services has long been a concern in healthcare.48-49 These concerns may further strain the mental health system beyond its capacity.50 Unfortunately the DoD is not immune to the escalating costs in rendering mental health care and is developing alternative treatment methods to reduce these costs.51-54The use of SCDs allows for a quicker assessment of the costs involved in providing the services, which is ex tremely important given the dramatic shift from inpa tient care to an increase use of ambulatory alternatives and outpatient care. In 1988 inpatient costs were 51% of total mental health care costs for enrollees in the feefor-service medical plan; in 1990 inpatient care costs ac counted for 44% of all payments; and in 1996 inpatient care costs accounted for only 20%.55 This downward trend in costs continues today. Moreover, although the overall rate of outpatient psychotherapy use has not sig psychotherapy visits per patient has decreased.56 This decrease is due to a number of factors including briefer models of therapy, improvement in psychotropic medi cations, changing practice patterns, practice guidelines and payment policies.57-59The use of time series single-subject design permits the tracking of care (eg, number of sessions by diagnosis over time) thus allowing for the development of more Additionally, time series single-subject design permits analyses of when the patient is making progress and when progress may not be cost effective. Applying sin gle-subject designs enables case rates to be developed for outpatient mental health services, which can con tribute to focused attention optimizing both the clinical result and the business result (eg, avoiding unnecessary services and waste). Moreover, this would assist in iden outcomes. Finally, it would assist the DoD in moving payment from volume to value. Information technology lies at the intersection of SCD use, optimization of clinical outcomes, and realization of larger cost-related performance goals (such as cost minimization, cost avoidance, savings, and so on). As an enabler of clinical and patient needs, information technology has the potential to greatly enhance patient outcomes whether SCD is a factor or not; however, in vestments in information technology can be extremely costly, particularly if deployed in a manner that fails to understand the interdependent aspects of clinical care and patient outcomes. Porter asserts that information technology is a key enabler of value, particularly when providing the means to capture and aggregate data across time, providers, and patients,60 which are core and essential ideas associated with SCD and evidencebased practice. Other research has pointed to a sym changes and demonstrate improvements in outcomes.61 ADV A NCE M ENT IN ST A TISTIC A L METHODOLOGIES An additional source of support for the use of single-sub ject designs is the advancement in statistical procedures that evaluate the effectiveness of the treatment in singlesystem designs. A number of researchers have developed and applied various types of statistical procedures in an alyzing single-case designs.15,62-72 Most recently, Vannest et al73 conducted a review of the statistical methods used to analyze single-case research in terms of determining effect size and the certainty of the decision. Their review weighted heavily on the research conducted by Parker and colleagues74 and Parker et al.75 In summary, Vannest and associates concluded that the number and quality of statistical techniques for single case research has dra 73(p38)One of the more useful techniques for behavioral sci ence researchers and especially practitioners provid ing therapy is the use of Improvement Rate Differ between A, the baseline phase, and B, the intervention phaseunderstanding the difference between baseline and intervention phases is what clinicians strive to do on a daily basis. Another more useful statistical technique for therapists is what is referred to as the nonoverlap of all pairs (NAP).76 This method of analysis provides information on the percentage of data (eg, therapy ses sions) that shows improvement from one phase to an other based on all pairwise comparisons across phases A and B. Although the NAP can be calculated by hand, such as NCSS (number crunching statistical system).77 In addition to the development of the new statistical pro cedures, a number of researchers have applied statistical

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86 http://www .cs.amedd.army .mil/amedd_journal.aspxprocedures primarily developed in the business community to single-case designs. For example Davies et al78 used funnel plots to explore variation in cancer mortal ity across primary care trust in southeast England. May er and associates79 have applied funnel plots to surgery. Statistical methods used to evaluate the effectiveness of treatment are naturally aligned with visual analysis, which has been the traditional means of detecting the effect of intervention.80 The steps involved in visual analysis generally involve documentation of a stable baseline period, analysis of within phase data, analysis of between phase data, and integration of results across all phases. Within this analytic framework, researchers use typical statistical measures and concepts to examine data, which include levels (eg, means), within phase rate of change, variability, effect immediacy, overlap, and consistency across phases.80 A straightforward approach to identify change involves use of ideas from statistical process control (SPC). For example, detection of vari ability between baseline to intervention phases can be achieved through creation of intervals (such as 2-stan dard deviations) surrounding mean values in order to identify statistically meaningful changes.81Although SPC concepts were developed in the 1930s and have been hailed among the greatest contributions to the philosophy of science,82-84 these methods have not featured prominently in healthcare research.85 One of the interesting aspects of SPC is that the majority of users of the chart methodology over the last 70 years has been engineers, statisticians, and mathematicians, so it comes as a surprise that members of the behav in statistical validity, which is particularly interesting since the SPC process has been seen as a statisticians technique.86 However, low adoption of SPC methods may be in part due to the lack of understanding on how to use SPC charts in analyzing single-case designs. For example, according to Orme and Cox,87 the only method for constructing an SPC chart described in the social work literature is incorrect. Fortunately, this may not be the case today in view of the growth of articles that have been written to more fully explain the use and inter pretation of SPC charts.87-93 Additionally, many statisti cal software packages to which behavioral science re searchers have access (eg, Minitab, SPSS, SAS) contain procedures that are capable of producing a variety of SPC charts. Bolstering the case for the use and analysis of singlesubject designs and the accompanying robust statistical procedures is the fact that numerous researchers have indicated that despite widespread belief, standard sta tistical methods are not robust when differences exist or when there is an association between random vari ables.20,94-101 departures from normality result in low power when distributions are normal. Heteroscedasticity can seri ously lower the power of standard analysis of variances (ANOVA) and regression methods.101 The practical re sult is many clinical studies would have achieved a level cal procedures had been used. MET A-A N A LYSIS OF SINGLE CA SE DESIGNS Potentially the most important support for single-sub ject designs has been the progress in the development of meta-analysis statistical methodologies for single-sub ject designs. Traditionally evidenced-based treatments refer to interventions that have empirical support in their behalf. The evidence has been derived from rigor ous tests that the treatments relative to various control or other treatment conditions produce therapeutic change.16 Although there are a number of different approaches to rating evidence, one of the most widely used in the med Overholt.102 This system has at the highest level evidence from a systematic review or meta-analysis of all relevant randomized controlled trials (RCTs) or evidence-based clinical practice guidelines based on systematic reviews of randomized controlled trials. Although single-case designs technically will not meet the criteria of random ized controlled trials, the time-series design, including single-case designs as a special case, can be among the strongest nonrandomized experimental designs.103This, coupled with recently developed meta-analysis date, these recently developed statistical methodologies have used regression approaches, especially multilevel modeling and parametric and nonparametric effect-size estimation.69 The results of this effort should make it possible for single-case design researchers to make sig based practice. As previously noted, although single case designs represent a special case of time-series de signs and statistical methods for analyses of long time series designs are well developed, methods for short term analysis are not as well developed. However, this is changing and progress has been made in this area, and some of the methods that have been applied to long term time series designs are also applicable to the short time series designs. Improvements in methods associated with short-term analysis coupled with increased use of EVIDENCE-BASED PRACTICE AND SINGLE-CASE DESIGNS IN PSYCHOTHERAPY

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October December 2017 87 these methods across clinical settings will be especially therapy interventions are reducing the time the patient actually spends in therapy. Although statistical innovation in developing meth odologies for single-case designs is progressing, one area impeding this progress is the overreliance on null Sharpe,104 there are a number of reasons for the overreli ance on NHST. One reason is the lack of awareness of developments in statistical theory and methods. Many researchers focus their attention on applied work and may not keep up with advances in statistical method ologies.105,106 In his provocative article How Many Dis coveries Have Been Lost by Ignoring Modern Statistical 101(p300) Cummings et al107 researched the 10 leading international journals that publish empirical re search and indicated that there is little change in statisti cal procedures and that NHST continues to dominate. vals (CIs) was increasing, albeit slowly, and that CIs are seldom used for interpretation. This is especially inter esting since the APA Task Force on Statistical Inference advocated for improved statistical practices, including 108Another reason for the lack of the application of statisti cal methodologies is the scarcity of personnel trained in quantitative methods, especially the newer more com plex techniques.109 Additionally, with few exceptions, the majority of textbooks in research and statistics focus on NHST with little or no attention paid to single-case designs or especially to statistical methods to evaluate single-system designs.44 CONCLUSION Single-subject designed research has a rich tradition of providing evidence for the effectiveness of interven tions applied to solving a diverse range of human prob lems.15 Over the past decade, advances in this area have included new developments in research design, visual and statistical analyses, and methods for summarizing single-case interventions. In todays military environ ment, with the shortage of mental health personnel and the increase in workload, the need for evidenced-based greater. The time for implementation of single-sub ject clinical research has come. Although the need for traditional research design and analysis remains, the re ality of clinical practice is that patients are provided care on an individual basis. This care takes into account the individual differences of the patients as well as the pro viders. It is important to keep in mind that statistical and 101Looking ahead, it is in the best interest of the DoD to integrate single-case designs as an evaluation tool for clinical mental health services.45 The collection of the reliable data obtained from multiple providers through out the DoD using single-case designs can produce a quality sample to further evaluate. The evaluation of these data through meta-analysis coupled with the use of effective statistical procedures can provide a broader treatments being provided, which is ultimately an ef based on empirically collected and analyzed data. The the budget make this a prime opportunity to employ the 53 REFERENCES 1. Institute of Medicine. Preventing Psychological Disorders in Service Members and Their Families: An Assessment of Programs Washington, DC: The National Academies Press; 2014. 2. Institute of Medicine Committee on the Assess ment of ongoing Effects in the Treatment of Post traumatic Stress Disorder. Treatment of Posttrau matic Stress Disorder in Military and Veteran Populations: Final Assessment Washington, DC: The National Academies Press; 2014. 3. tiveness of psychotherapy. In: Lambert MJ, ed. and Behavior Change 5th ed. New York, NY: Wi ley; 2004:139-193. 4. Smith ML, Glass GV. Meta-analysis of psy chotherapy outcome studies. Am Psychol 1977;32(9):752-760. 5. Wampold BE. Contextualizing psychotherapy as a healing practice: culture history and methods. Appl Prev Psychol 2001;10(2):69-86. 6. Wampold BE. The Great Psychotherapy Debate: Models, Methods and Findings Mahwah, NJ: L Erlbaum Associates; 2001. 7. Tracey TJG, Wampold BE, Lichtenberg JW, Good year RK. Expertise in psychotherapy: an exclusive goal?. Am Psychol 2014; doi: 10.1037/a0035099.

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88 http://www .cs.amedd.army .mil/amedd_journal.aspx8. ings and methods. In: Lambert MJ, ed. Bergin Behavior Change 6th ed. New York, NY: Wiley; 2013:258-297. 9. Crits-Christoph P, Baranackie K, Kurcias J, et al. Meta-analysis of Therapist in Psychotherapy Out come Studies. Psychother Res 1991;1(2):81-91. 10. Kim DM, Wampold BE, Bolt DM. Therapist effects in psychotherapy: A random-effects modeling of the National Institute of Mental Health Treatment of Depression Collaborative research Program data. Psychother Res 2006;16(02):161-172. 11. Lilienfeld SO. Psychological treatments that cause harm. Perspect Psychol Sci 2007;2(1):53-70. 12. Dimidjian S, Hollon SD. How would we know if psychotherapy were harmful?. Am Psychol 2010;65(1):21-33. doi: 10.1037/a0017299. 13. Adler CM, Craske MG, Barlow DH. Relaxationinduce panic (RIP): when resting isnt peaceful. In tegr Psychiatry 1987;5(2):94-100. 14. Brekke JS, Ell K, Palinkas LA. Translational sci ence at the National Institute of Mental Health: can social work take its rightful place?. Res Soc Work Pract 2007;17(1):123-133. 15. Kratochwill TR, Levin JR. Enhancing the scientif ic credibility of single-case intervention research: randomization to the rescue. Psychol Methods 2010;15(2):124-144. 16. Kazdin AE. Single-case Research Designs: Meth ods for Clinical and Applied Settings 2nd ed. New York: Oxford University Press; 2011. 17. Swanson HL, Sachse-Lee CA. Meta-analysis of single-subject-design intervention research for stu dents with LD. Learn Disabil 2000;33(2):114-136. 18. Mooney P, Epstein MH, Reid R, Nelson JR. Sta tus of and trends in academic intervention research for students with emotional disturbance. Remedial Spec Educ 2003;24(5):273-287. 19. Conroy MA, Dunlap G, Clarke S, Alter PJ. A descriptive analysis of positive behavioral inter vention research with young children with chal lenging behavior. Topics Early Child Spec Educ 2005;25(3):157-166. 20. Callahan CD, Griffen DL. Advanced statistics: applying statistical process control techniques to emergency medicine: a primer for providers. Acad Emerg Med 2003;10(8):883-890. 21. Gabler NB, Duan N, Vohra S, Kravitz R. N-of-1 trials in the medical literature: a systemic review. Med Care 2011;49(8):761-768. 22. Odom SL, Strain PS. Evidence-based practice in early intervention/early childhood special educa tion: single-subject design research. J Early Interv 2002;25(2):151-160. 23. Maggin DM, Chafouleas SM. Introduction to the special series issues and advances of synthesiz ing single-case research. Remedial Spec Educ 2013;34(1):3-8. 24. Maggin DM, OKeeffe BV, Johnson AH. A quanti tative synthesis of methodology in the meta-analy sis of single-subject research for students with dis abilities. Exceptionality 2011;19(2):109-135. 25. Odom SL, Brown WH, Frey T, Karasu N, SmithCanter LL, Strain PS. Evidence-based practices for young children with autism contributions for sin gle-subject design research. Focus Autism Other Dev Disabl 2003;18(3):166-175. 26. Ahearn WH, Clark KM, MacDonald RP, Chung BI. Assessing and treating vocal stereotype on children with autism. J Appl Behav Anal 2007;40(2):263-275. 27. Beeson PM, Robey RR. Evaluating single-subject treatment research: Lessons learned from the apha sia literature. Neuropsychol Rev 2006;16(4):161-169. 28. Ardoin SP, McCall M, Klubnik C. Promoting drill versus practice opportunities. Behav Educ 2007;16(1):54-69. 29. Riley-Tillman TC, Burns MK. Evaluating Educa tional Interventions: Single-Case Design for Mea suring Response to Intervention New York: Guil ford Press; 2010. 30. Matur SR, Kavale KA, Quinn MM, Forness SR, Rutherford RB Jr. Social skills interventions with students with emotional and behavioral problems: a quantitative synthesis of single-subject research. Behav Disord 1998;40(1):50-58. 31. Basolglu M, Salcioglu E, Livanou M. Single-case experimental studies of a self-help manual for trau matic stress in earthquake survivors. J Behav Ther Exp Psychiatry 2009; 40(1):50-58. 32. Maggin DM, Briesch AM, Chafouleas SM. An application of the What Works Clearinghouse standards for evaluating single-subject research: synthesis of the self-management literature base. Remedial Spec Educ 2012;34(1):44-58. doi:10/1177/ 0741932511435176. 33. Gast DL. Single Subject Research Methodology in Behavioral Sciences New York, NY; Routledge; 2010. 34. Borckardt JJ, Nash MR, Murphy MD, Moore M, Shaw D, ONeil P. Clinical practice as natural laboratory for psychotherapy research: a guide to case-based time series analysis. Am Psychol 2008;63(2):77-95.EVIDENCE-BASED PRACTICE AND SINGLE-CASE DESIGNS IN PSYCHOTHERAPY

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October December 2017 89 35. Peterson DR. Science, scientism, and profes sional responsibility. Clin Psychol Sci Pract 2004;11(2):196-210. 36. Morgan DL, Morgan RK. Single-participant re search design: Bringing science to managed care. Am Psychol 2001;56(2):119-127. 37. Robey RR, Schultz MC, Crawford AB, Sinner CA. Review: Single-subject clinical-outcome research: designs, data, effect sizes and analyses. Aphasiol ogy 1999;13(6):445-473. 38. Kazdin AE. Evidence-based treatments: chal lenges and properties for practice and research. Child Adoles Psychiatr N Am 2004;13(4):923-940. doi:10:1016/j.chc.2004.04.002. 39. Nuehring EM, Pascone AB. Single-subject evalu ation: a tool for quality assurance. Soc Work 1986;31(5):359-365. 40. NASW Center for Workforce Studies. Licensed so cial workers in the US, 2004, Volume 2 Supplement Washington, DC: National Association of Social Workers; 2004. Available at: http://workforce.so cialworkers.org/studies/supplement.pdf. Accessed September 18, 2017. 41. Di Noia J, Tripodi T. Single-Case Design for Clinical Social Workers 2nd ed. Washington, DC: NASW Press; 2008. 42. Institute of Education Sciences. Procedures and Standards Handbook Version 3.0. Washington, DC: What Works Clearinghouse; 2014. 43. Kratochwill TR, Levin JR, eds. Single-case Inter vention Research: Methodological and Statistical Advances Washington DC: American Psychologi cal Association; 2014. 44. Rubin A, Babbie E. Research Methods for Social Work 7th ed. Belmont, CA: Brooks/Cole; 2011. 45. Artelt T, Shek DT, Thyer BA. Using single-system research designs to evaluate practice potential ap plications for social work in Chinese contexts. Int Soc Work 2003;46(2):163-176. 46. Ruckdeschel RA, Farris BE. Assessing practicea-critical-look at the single case design. Soc Case work J Contemp Soc Work 1981;62(7):413-419. 47. Di Noia J, Tripodi T. A Primer on Single-Subject Design for Clinical Social Works Washington DC: NASW Press; 1994. 48. Kaplan RS, Porter ME. How to solve the cost crisis in health care. Harv Bus Rev 2011;89(9):46-52. 49. health care. Harv Bus Rev 2013;91(10):50-70. 50. Caramenico A. Mental health coverage mandates could strain the system. FierceHealthPayer [serial online]. 2013. 51. Rona RJ, Hyams KC, Wessely S. Screening for psychological illness in military personnel. JAMA 2005;293(10):1257-1260. 52. Barlas S. Shortage of mental health profession als in the military. Psychiatr Times 2007. Avail able at: http://www.psychiatrictimes.com/display/ article/10168/543211. 53. Committee on Armed Services, House of Rep resentatives. Statements of GEN P. W. Chiarelli, Vice Chief of Staff, US Army. Hearing: Proposed Department of Defense Budget Reductions and 2011. Available at: https://babel.hathitrust.org/cgi/ pt?id=umn.31951d034577414;view=1up;seq=25. Accessed September 20, 2017. 54. Jones MD, Etherage JR, Harmon SC, Okiishi JC. Acceptability and cost-effectiveness of military telehealth mental health screening. Psychol Serv 2012;9(2):132-143. 55. Goldman W, McCulloch J, Sturm R. Costs and use of mental health services before and after managed care. Health Aff 1998;17(2):40-52. 56. Olfson M, Marcus SC, Druss B, Pincus HA. Na tional trends in the use of outpatient psychotherapy. Am J Psychiatry 2002;159(11):1914-1920. 57. Olfson M, Marcus SC, Pincus HA. Trends in of Am J Psychiatry 1999;156(3):451-457. 58. formation of the mental health system. Health Aff 2003;22(5):177-188. 59. Mojtabai R, Olfson M. National Trends in Psycho Arch Gen Psychiatry 2008;65(8):962-970. 60. Porter ME. A strategy for health care reform: toward a value-based system. N Engl J Med 2009;361:109-112. doi: 10:1056/NEJMp0904131. 61. Dallery J, Cassidy RN, Raiff BR. Single case ex perimental designs to evaluate novel technologybased health interventions. J Med Internet Res 2013;15(2):e22. doi: 10.2196/jmir.2227. 62. Fisher WW, Kelley ME, Lomas JE. Visual aids and structured criteria for improving visual inspection and interpretation of single-case designs. J Appl Behav Anal 2003;36(3):387-406. 63. Van den Noortgate W, Onghena P. Combining single-case experimental data using hierarchical linear models. Sch Psychol Q 2003;18(3):325-346. 64. Van den Noortgate W, Onghena P. Hierarchical lin ear models for the quantitative integration of effect sizes in single-case research. Behav Res Methods Instrum Comput 2003; 35(1):1-10.

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90 http://www .cs.amedd.army .mil/amedd_journal.aspx65. Olive ML, Smith BW. Effect size calculations and single subject designs. Educ Psychol (Lond). 2005;25(2-3):313-324. 66. Van der Noortgate W, Onghena P. The aggrega tion of single-case results using hierarchical linear modules. Behav Anal Today 2007;8(2):52-57. 67. Van der Noortgate W, Oghena P. A multilevel meta-analysis of single-subject experimental de sign studies. Evid Based Commun Assess Interv 2008;2(3):142-151. 68. Shadish WR, Rindskopf DM. Methods for evi dence-based practice: Quantitative synthesis of sin gle-subject designs. New Dir Eval 2007;(113):95109. doi:10.1002/ev217. 69. Shadish WR, Rindskopf DM, Hedges LV. The state of the science on the meta-analysis of single-case experimental designs. Evid Based Commun Assess Interv 2008;2(3):188-196. 70. Maggin DM, Swaminathan H, Rogers HJ, OKeeffe BV, Sugai G, Horner RH. A generalized least squares regression approach for computing effect sizes in single-case research: application examples. J Sch Psychol 2011;49(3):301-321. 71. Wendt O, Miller B. Quality appraisal of singlesubject experimental designs: an overview and comparison of different appraisal tools. Educ Treat Children 2012; 35(2):235-268. 72. Shadish WR, Kyse EN, Rindskopf DM. Analyz ing data from single-case designs using multi level models: New applications and some agen da items for future research. Psychol Methods 2013;18(3):385-405. 73. Vannest KJ, Parker RI, Davis JL. Single Case Re search in Schools Practical Guidelines for SchoolBased Professionals New York: Routledge; 2013. 74. Parker RI, Vannest KJ, Davis JL. Effect size in single-case research: A review of nine non-overlap techniques. Beh Modif 2011;35(4):303-322. doi: 10.1176/appi.ajp.161.8.1471. 75. Parker RI, Vannest KJ, Brown L. The improvement rate difference for single-case research. Excep Child 2009;75(2):135-150. 76. Parker RI, Vannest K. An improved effect size for the single-case research: Non-overlap of all pairs. Behav Ther 2009;40(4):357-367. 77. Hintze J. NCSS Data Analysis [computer program]. Kaysville, UT: NCSS Statistical Software: 2006. 78. Davies E, Mak V, Ferguson J, Conaty S, Mller H. Using funnel plots to explore variation in cancer mortality across primary care trusts in south-east England. J Public Health 2008;30(3):305-312. 79. Mayer EK, Bottle A, Rao C, Darzi AW, Athanasiou T. Funnel plots and their emerging application in surgery. Ann Surg 2009;249(3):376-383. 80. Ray DC. Single-case research design and anal ysis: counseling applications. J Couns Dev 2015;93(4):395-403. 81. Portney LG, Watkins MP. Foundations of Clinical Research: Applications to Practice Stanford, CT; Appleton &Lange; 1993. 82. Shewart WA. Economic Control of Quality of Man ufactured Product Vol 509. New York, NY: ASQ Quality Press; 1931. 83. Deming WE. Out of the Crisis Cambridge, MA: Massachusetts Institute of Technology Center for Advanced Engineering Study: 1986. 84. Deming, WE. A tribute to Walter A Shewart on the occasion of the 100th anniversary of his birth. SPC INK Knoxville, TN: Statistical Process Controls, Inc; 1991. 85. Mohammed MA. Using statistical process control to improve the quality of health care. Qual Saf Health Care 2004;13(4):243-245. 86. Wilcox M. The philosophy of Shewarts theory of prediction. Paper presented at: 9th Research Semi nar: Deming Scholars Program; February 2003; Fordham University, New York. 87. Orme JG, Cox ME. Analyzing single-subject de sign data using statistical process control charts. Soc Work Res 2001;25(2):115-127. 88. Bloom M, Fischer J. Evaluating Practice: Guide lines for the Accountable Professional Englewood Cliffs, NJ: Prentice-Hall; 1982. 89. Bloom M, Fischer J, Orme JG. Soc Work Res. Needham Heights, MA: Prentice-Hall; 1995. 90. Bloom M, Fischer J, Orme JG. Evaluating Prac tice: Guidelines for the Accountable Professional Boston, MA: Prentice-Hall; 1998. 91. Blythe BJ, Tripodi T. Measurement in Direct So cial Work Practice Newbury Park, CA: Sage; 1989. 92. Rubin A, Babbie E. Research Methods for Social Work Belmont, CA: Wadsworth Publishing Co; 1989. 93. Rubin E, Babbie E. Research Methods for Social Work 94. Birkes D, Dodge Y. Alternative Methods of Regres sion Vol 282. New York: John Wiley & Sons; 1993. 95. Hampel FR, Ronchettie EM, Rousseeuw PJ. Robust tions New York: Wiley; 1986. 96. Hoaglin DC, Mosteller F, Tukey JW, eds. Under standing Robust and Exploratory Data Analysis Vol 3. New York: Wiley; 1983. 97. Hoaglin DC, Mosteller F, Tukey JW. Exploring Data Tables, Trends and Shapes New York: Wiley; 1985.EVIDENCE-BASED PRACTICE AND SINGLE-CASE DESIGNS IN PSYCHOTHERAPY

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October December 2017 91 98. Huber PJ. Robust Statistics New York: Wiley; 1981. 99. Staudte RG, Sheather SJ. Robust Estimation and Testing New York: Wiley: 1990. 100. Wilcox RR. Introduction to Robust Estimation and Hypothesis Testing San Diego, CA: Academic Press; 1997. 101. Wilcox RR. How many discoveries have been lost by ignoring modern statistical methods?. Am Psy chol 1998;52(3):300-314. 102. Melnyk BM, Fineout-Overholt E. Evidence-based Practice in Nursing & Healthcare: A Guide to Best Practice 2nd ed. Philadelphia: Lippincott Wil liams & Wilkins; 2011. 103. Shadish WR, Cook TD, Campbell DT. Experimen tal And Quasi-experimental Designs for General ized Causal Inference 2002. 104. Sharpe D. Why the resistance to statistical innova tions? Bridging the communication gap. Psychol Methods 2013;18(4):572-582. 105. Wilcox RR. Can the weak link in psychological APS Obs 2002;15(4). Available at: https://www.psychologicalscience.org/issue/ april-02. Accessed September 18, 2017. 106. Mills L, Abdulla E, Cribbie RA. Quantitative methodology research: is it on psychologists reading lists?. Tutor Quant Methods Psychol 2010;6(2):52-60. 107. Cumming G, Fidler F, Leonard M, et al. Statistical reform in psychology: is anything changing?. Psy chol Sci 2007;18(3):230-232. 108. Wilkinson L. Statistical methods in psychology journals: guidelines and explanations. Am Psychol 1999;54(8):594-604. 109. Clay R. Too few quantitative in quantitative psy chology. Monit Psychol 2005;36(8):26-28. AUTHORS When this article was written, Dr Georgoulakis was a Clinical Professor, Army-Fayetteville State University Master Social Work Program, US Army Medical Department Center and School, Joint Base San Antonio-Fort Sam Houston, Texas. Dr Georgoulakis died August 26, 2017. lice Brigade, US Army, Grafenwoehr, Germany. Dr Pate is Senior Director of Quality and Performance Improvement, CommUnityCare Health Centers, Austin, Texas. When this article was written, Ms Hallett was a Social Worker in the Family Advocacy Program, US Army Medical Department Activity, Fort Drum, New York.

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92 http://www .cs.amedd.army .mil/amedd_journal.aspx BA CKGROUND War is ninety percent information. Napoleon Bonaparte United States has achieved the lowest recorded case fatality rates for combat casualties in the history of American warfare.1-3 This accomplishment was primar ily due to a reduction in prehospital or killed in action deaths, which in turn was due to improved prehospital treatment and transport of combat casualties. However, in the realm of prehospital mortality.4-7 Optimizing out comes for combat wounded who die in the prehospital setting has proved challenging, especially as resources directed toward this goal remain limited. In 2004, the Department of Defense (DoD) initially cre ated a Joint Theater Trauma System and Joint Theater Trauma Registry (JTTR) to conduct performance im provement on casualties who incurred traumatic injury in the US Central Command (CENTCOM) theater of combat.8,9 The DoD subsequently established the Joint Trauma System (JTS) to provide centralized efforts for multiple theaters and commands worldwide. The DoD further centralized the JTTR to form the DoD Trauma Registry (DoDTR). A desired end-state for this registry was to collect and analyze combat casualty data from the point of injury and throughout the continuum of care. This registry was largely successful in capturing Role 3 (temporary full-capability hospital inside combat zone) and Role 4 (permanent full-capability hospital outside combat zone) data. However, it was initially less success ful in capturing Role 2 (temporary limited-capability A Descriptive Analysis of Data from the Department of Defense Joint Trauma System Prehospital Trauma Registry MAJ Steven G. Schauer, MC, USA LTC Cord W. Cunningham, MC, USA MAJ Michael D. April, MC, USA MAJ Andrew D. Fisher, SP, USAR MAJ Jason F. Naylor, SP, USA COL (Ret) Russ S. Kotwal, MC, USA CPT Joshua J. Oliver, MC, USA ABSTR A CT confusion often extend into the prehospital combat setting with multiple personnel and units involved in the chain of care of casualties. The chaos of the prehospital combat setting has led to limitations in the availability of data for performance improvement and research. The Department of Defense (DoD) Joint Trauma System (JTS) Prehospital Trauma Registry (PHTR) was developed in conjunction with the updated Tactical Combat Casualty Care (TCCC) card and a TCCC after action report (AAR), and currently serves as the prehospital repository and module of the DoD Trauma Registry (DoDTR). We conducted a descriptive analysis of data from the DoDTR PHTR. Methods: The JTS collected trauma-associated data which comprise the PHTR are consolidated from TCCC cards modules in the DoDTR to maximize availability of prehospital data and gain additional information regarding clini cal outcomes. Results: From January 2013 through September 2014, there were 705 patients available for research, of which 94.8% (668/705) had data from TCCC AARs, 3.3% (23/705) had data from TCCC cards, and 2.0% (14/705) had data available from DoDTR collection forms. There were one or more of the following data points per subject: pulse rate (77.4%, n=546), blood pressure (75.9%, n=535), respiratory rate (76.5%, n=539), pulse oximetry (61.8%, n=436), mental status (96.0%, n=677) and pain score (24.5%, n=173). Only 42.4% (647/1,527) of vital sign metrics had an associated time stamp. Documented interventions included limb tourniquets, of which only 27.3% (113/414) had an associated documentation of application time. Only 27.0% (190/705) of patients in the PHTR could be linked to the Conclusions: The PHTR data capture was suboptimal with many patients lacking documentation of vital signs and procedural details. Future efforts to improve prehospital data capture will require ownership and enforcement by unit leadership.

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October December 2017 93 forward-positioned hospital inside combat zone) and Role 1 (prehospital point of injury, casualty collection point, battalion aid station) data. To achieve better capture data from Role 2 facilities, the JTS developed intake forms and a database for use by these facilities. There were no mandates or resources allocated to these efforts and Role 2 personnel ultimate ly collected these data as an additional volunteer duty. Data capture proved to be intermittent and inconsistent within and between facilities.9,10 Although a subsequent mandate to capture these Role 2 data improved capture, the mandate was only partially effective as it lacked personnel resourcing and an enforcement mechanism to ensure adherence. Modeled after successful efforts from the 75th Ranger Regiment,7,11-14 the DoD JTS subsequently developed pre hospital documentation tools and a prehospital trauma registry (PHTR) to facilitate the capture of prehospital data from Role 1 and 2 entities alike.15-17 Using the tacti cal combat casualty care (TCCC) card adopted by the Committee on TCCC18 and based on the 75th Ranger Regiment casualty card, the JTS worked with the De fense Health Agency to update, rename, and replace the DD Form 1380 Field Medical Card dated December 1991 with a new DD Form 1380 Tactical Combat Casualty Care Card dated June 2014. This new card sought to align prehospital documentation with current clinical practice guidelines, to facilitate the documentation of initial care ers, and to standardize prehospital data collection to optimize performance improvement. The intent was to attach the card to the patient to convey vital prehospital information to providers at the next role of care, and to also preserve data for entry into a registry for individual and aggregate analysis and performance improvement. day prehospital combat trauma practices, and followed a ment) format. The JTS also developed a TCCC after ac Ranger Regiment as another opportunity to capture pre hospital data. The TCCC AAR retained similar features of the TCCC card, except with additional detail. The TCCC AAR was to be completed as soon as feasible following a mission and submitted through the chain of care or directly to the JTS. Development of the PHTR occurred in parallel with the TCCC card and TCCC AAR. The design of the PHTR sought to optimize data capture to facilitate prehospi tal performance improvement.17 The Commander, US Forces-Afghanistan issued Fragmentary Order 13-139* in July 2013 which mandated the use of the TCCC card and the TCCC AAR for all combat casualties in Af ghanistan. Simultaneously, the DoD established a pre hospital directorate comprised of physicians, physician assistants, and combat medics with extensive prehospi tal experience who were also trained by the JTS to serve as consultants to build and sustain the PHTR. However, after more than a year of data collection and progress, as forces deployed to Afghanistan were reduced, the DoD withdrew JTS personnel resources from the combat the ater. Prior to this withdrawal, 2 comprehensive reviews were conducted by senior military physicians and re main a source for prehospital combat trauma issues and recommendations.19,20 GO A L OF THIS STUDY The purpose of this study was to provide a descriptive analysis of data within the DoD JTS PHTR. METHODS The JTS collected prehospital TCCC cards and TCCC AARs for casualties injured during combat operations conducted in Afghanistan from January 2013 to Septem ber 2014. Joint Trauma System personnel entered these data into the PHTR. This study met US Army Institute of Surgical Research regulatory requirements (USAISR protocol H-16-013). We analyzed data considered to be side of the card, shown in the Figure.Prehospital Trauma RegistryThe JTS PHTR is a data collection and analytic tool de signed to provide near-real time feedback to command ers. As described by Kotwal and colleagues,12 the pri mary purpose of this tool is to improve casualty visibil ity, augment command decision-making processes, and direct procurement of medical resources. Additionally, this tool seeks to reduce morbidity and mortality through performance improvement in the areas of primary pre vention (tactics, techniques, and procedures), secondary prevention (personal protective equipment), and tertia ry prevention (casualty response system and TCCC).19 The CENTCOM JTS Prehospital Directorate collected TCCC cards and TCCC AARs, and transferred informa tion from these documentation tools into the PHTR.17Department of Defense Trauma RegistryThe DoDTR, which evolved from the JTTR, is a cen tralized data repository for DoD trauma-related injuries. The DoDTR consolidates data and information about demographics, injury-producing incident, diagnosis, *Internal military document not readily accessible by the general public.

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94 http://www .cs.amedd.army .mil/amedd_journal.aspxtreatment, and outcomes of injuries sustained by US and non-US military forces, and US and non-US civilian personnel, in wartime and peacetime from the point of sonnel linked subjects from the PHTR to the DoDTR.Data AnalysisWe performed all statistical analysis using Microsoft Excel Version 10 and IBM SPSS Version 24. We used descriptive statistics to analyze PHTR data availability and completeness. RESULTS From January 2013 through September 2014, 737 documented patient encounters were entered into the PHTR. Excluded from further study were 32 casualties who were either killed in action (24/32), dead on arrival (5/32), or an enemy prisoner of war (3/32). Of the 705 patients available for study, 94.6% (668/705) had data primarily from completed TCCC AARs, 3.3% (23/705) had data primarily from completed TCCC cards, and 2.0% (14/705) had data obtained primarily from DoDTR intake forms completed upon patient arrival at a Role 2 or Role 3 medical treatment facility. Patient encounters were predominantly a result of battle injuries (91.2%, 643/705). As shown in the Table, most patients had documentation of mechanism of injury (100%, 705/705), military service (99.9%, 704/705), gen der (98.2%, 692/705), and military unit (94.3%, 665/705). A full or partial set of prehospital vital signs was avail able for most patients. However, there was no documen tation of prehospital vital signs for 13.7% (97/705) of patients. There were 1,527 full and partial prehospital vital sign sets recorded, including repeat measurements. Additionally, 42.4% (647/1527) of these vital signs had an associated time stamp. There were 501 documented instances of analgesia administration to 56.3% (397/705) of the study population. However, only 43.6% (173/397) of individuals who received analgesia also had DD Form 1380, Tactical Combat Casualty Care Card. A DESCRIPTIVE ANALYSIS OF DATA FROM THE DEPARTMENT OF DEFENSE JOINT TRAUMA SYSTEM PREHOSPITAL TRAUMA REGISTRY

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October December 2017 95 a documented preanalgesia pain score. However, none of these indi viduals had a documented postan algesia pain score. As a surrogate documentation of 414 tourniquets. Of these, only 27.3% (113) included documentation of application time. Of the 705 patients in the PHTR during this period, 190 (27.0%) were linkable to the DoD Trauma Registry. The remaining 515 lacked link the patients between the 2 reg missing or inaccurate. CO MM ENT Documentation of care in the pre hospital combat setting has proven to be challenging for US military 21 The aim of the PHTR was to provide improved capture of data from the prehospital combat setting. In this analysis, we found that most subjects had demographic and evacuation information completed along with at least one vi tal sign. However, pain scores were not routinely avail able. We also found that most tourniquets placed did not have a documented placement time. It is plausible that documentation times occurred via another medium, such as directly onto the tourniquet or the patient. However, there was limited capture of those data into the PHTR. Multiple articles have commented on the inadequacy and need for improved prehospital combat documenta tion and data capture.1,3,4,7,9,12,14,16-26 However, there are limited published data that actually quantify prehospital 14,17,24-26 This analysis prehospital personnel after the implementation of stan dardized TCCC cards and TCCC AARs in Afghanistan. The results of this study demonstrate that TCCC card completion rates were low, with TCCC card data avail able for only 3.3% (23/705) of PHTR encounters from January 2013 through September 2014. This level of ad herence and completion was less than the 7% to 14% previously reported.17,23 The remaining 96.7% (682/705) of PHTR encounters arose from TCCC AARs and backhigher role of medical care (eg, forward surgical team or combat support hospital). The results of this study reaf US military personnel in the pre hospital combat setting. Improving care for casualties in the prehospi tal combat setting requires train ing to a standard. This standard is set through best practice clini cal recommendations outlined by evidence-based guidelines such as optimization of these guidelines occur via analysis of data. Data are reliant on the documentation ef responders must understand the importance of documentation and train to accomplish this vital task. Suboptimal documentation prac tices likely stem from inadequate sis and enforcement. Many Soldiers may perceive documentation of care as relatively unimportant compared to care delivery, particularly for a lone medic treating ing the treatment of future casualties, and reducing mor bidity and mortality, relies on documentation and data collection. Although enemy actions, environmental con practices, documentation nevertheless remains an im portant priority. Training is imperative, and US military leaders should consider implementing several measures to increase prehospital documentation efforts. In concert with practices already implemented by Unit ed Kingdom military forces, both medical and nonmedi cal personnel in combatant units should train to record care on prehospital documentation tools. Combatant units already routinely assign recorders for documenta tion tasks such as collection of enemy information, site exploitation, logging of radio communication transmis As the TCCC card is a relatively simple documentation without needed detailed medical training. Additionally, air and ground prehospital patient transport treatment facility after delivering patients to complete prehospital patient care records. This was the method used in a previous successful prospective investiga tion,23 and also aided in the capture of data for retrospec tive studies.3,16,27,28 Completion of prehospital documen tation at a medical treatment facility should be a shared Documented items for the study population (N=705) recorded in the DoD Joint Trauma System Prehospital Trauma Registry.Item Number Percentage N Evacuation Status661 93 8%Gender692 98 2%Event Time622 88 2%Service704 99 9%Unit665 94. 3%Allergies209 29 6%Mechanism of Injury705 100% Pulse Rate546 77 4% Blood Pressure*535 75 9% Respiratory Rate539 76 5% Pulse Oximetry436 61 8% AVPU677 96 .0% Pain Score173 24 5% *Blood pressures included both standard blood pressure measurements as well as estimated blood pressure measurements (ie, estimated 90 systolic by palpation of radial artery).APVU indicates alert, pain, verbal, unresponsive.

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96 http://www .cs.amedd.army .mil/amedd_journal.aspxresponsibility, with a medical transport crewmember and a medical treatment facility emergency room staff uments before release of prehospital transport person nel for the next mission. As part of quality assurance, dedicated personnel should be available within theater to actively track missing data in a rapid and prospective manner. The 2017 National Defense Authorization Act has placed an emphasis on improving and maintaining operational of TCCC and the development of a trauma care registry. As there is notable variability between TCCC courses taught within the DoD, this lack of standardization could documentation. Technology has contributed to increased survivability through direct patient care; however, it is currently lacking in respect to prehospital documenta tion. A hands-free interface that interacts with communication devices such as smart-phones could greatly en hance documentation in the prehospital setting. SU MMA RY RECO MM END A TIONS All nonmedical personnel within units should under go training to serve as medical recorder for the medic tity and quality while not detracting from the time available for healthcare delivery to combat casualties. Prehospital transport teams should provide prospec tive input into the registry, similar to the method used for DoDTR form completion. Prospective real-time quality assurance methods, including dedicated intheater personnel, should be available to ensure timely and accurate completion of records. There should be a mandate and enforcement for com pletion of medical data collection across the DoD. Commanders should be held accountable for ensur ing this task is completed. A near real-time feedback loop in theater would inform commanders on medical documentation adherence. Development of technology that allows for input of patient chain-of-care should be a priority. CONCLUSIONS The DoD recently updated prehospital documentation tools. The implemented changes sought to align documentation tools to identify compliance with TCCC guidelines, simplify documentation and to facilitate rapid documentation. The PHTR aimed to consolidate and analyze the data collected from these documenta tion tools. The PHTR data capture was suboptimal with many patients lacking documentation of vital signs and procedures. Future efforts to improve prehospital data capture will require ownership and enforcement by unit leadership. ACKNOWLEDGE M ENT We thank the Joint Trauma System Data Analysis Branch for their efforts with data acquisition. REFERENCES 1. Berwick D, Cornett E, eds. A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths Af ter Injury Washington DC: National Academies of Sciences, Engineering, and Medicine Commit tee on Military Trauma Cares Learning Health System and Its Translation to the Civilian Sector; 2016. Available at: http://nationalacademies.org/ hmd/reports/2016/a-national-trauma-care-systemintegrating-military-and-civilian-trauma-systems. aspx. Accessed June 27, 2017. 2. Holcomb JB, Stansbury LG, Champion HR, Wade C, Bellamy RF. Understanding combat casualty care statistics. J Trauma 2006;60(2):397-401. 3. Kotwal RS, Howard JT, Orman JA, et al. The Ef fect of a Golden Hour Policy on the Morbidity and Mortality of Combat Casualties. JAMA Surg 2016;151(1):15-24. 4. Eastridge BJ, Mabry RL, Seguin P, et al. Death on ture of combat casualty care. J Trauma Acute Care Surg 2012;73(6 suppl 5):S431-S437. 5. Holcomb JB, McMullin NR, Pearse L, et al. Causes of death in U.S. Special Operations Forces in the global war on terrorism: 2001-2004. Ann Surg 2007;245(6):986-991. 6. Kelly JF, Ritenour AE, McLaughlin DF, et al. In jury severity and causes of death from Operation Iraqi Freedom and Operation Enduring Freedom: 2003-2004 versus 2006. J Trauma 2008;64(suppl 2):S21-S26; discussion S26-S27. 7. Kotwal RS, Montgomery HR, Kotwal BM, et al. Arch Surg 2011;146(12):1350-1358. 8. Blackbourne LH, Baer DG, Eastridge BJ, et al. Military medical revolution: military trauma sys tem. J Trauma Acute Care Surg 2012;73(6 suppl 5):S388-S394. 9. Haut ER, Mann NC, Kotwal RS. Military Trauma Cares Learning Health System: The Importance of Data Driven Decision Making. Washington, DC: National Academies of Sciences, Engi neering, and Medicine Committee on Military Trauma Cares Learning Health System and Its Translation to the Civilian Sector; 2016. Avail able at: http://nationalacademies.org/hmd/~/me dia/Files/Report%20Files/2016/Trauma-Care/ Importance-of-Data-Driven-Decision-Making-CP. pdf. Accessed June 27, 2017.A DESCRIPTIVE ANALYSIS OF DATA FROM THE DEPARTMENT OF DEFENSE JOINT TRAUMA SYSTEM PREHOSPITAL TRAUMA REGISTRY

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October December 2017 97 10. Mann-Salinas EA, Le TD, Shackelford SA, et al. Evaluation of role 2 (R2) medical resources in the Afghanistan combat theater: Initial review of the joint trauma system R2 registry. J Trauma Acute Care Surg 2016;81(5 suppl 2 Proceedings of the 2015 Military Health System Research Symposium):S121-S127. 11. Kotwal RS, Meyer DE, OConnor KC, et al. Army Ranger casualty, attrition, and surgery rates for airborne operations in Afghanistan and Iraq. Aviat Space Environ Med 2004;75(10):833-840. 12. Kotwal RS, Montgomery HR, Mechler KK. A pre hospital trauma registry for tactical combat casual ty care. US Army Med Dep J April-June 2011:15-17. 13. Kotwal RS, OConnor KC, Johnson TR, Mosely DS, Meyer DE, Holcomb JB. A novel pain manage ment strategy for combat casualty care. Ann Emerg Med. 2004;44(2):121-127. 14. Murray CK, Hospenthal DR, Kotwal RS, Butler bials. J Trauma 2011;71(2 suppl 2):S307-S313. 15. Joint Trauma System [internet]. US Army Institute of Surgical Research Website. Available at: http:// www.usaisr.amedd.army.mil/10_jts.html. Acces sed September 11, 2017. 16. Nohrenberg JL, Tarpey BW, Kotwal RS. Data In forms Operational Decisions: The Tactical Evacu ation Project. US Army Aviat Dig 2014;2(4):17-19. Available at: http://www.rucker.army.mil/aviation digest/images/AVN_DIG_2014_10-12.pdf. Accessed August 4, 2017. 17. Robinson JB, Smith MP, Gross KR, et al. Battle care in Afghanistan. US Army Med Dep J AprilSeptember 2016:87-94. 18. Kotwal RS, Butler FK, Montgomery HR, et al. The Tactical Combat Casualty Care Casualty Card TCCC Guidelines ? Proposed Change 1301. J Spec Oper Med. 2013;13(2):82-87. 19. Kotwal RS, Butler FK, Edgar EP, Shackelford SA, Bennett DR, Bailey JA. Saving Lives on the Battle pital Trauma Care in Combined Joint Operating Area ? Afghanistan (CJOA-A) Executive Summary. J Spec Oper Med 2013;13(1):77-85. 20. Sauer SW, Robinson JB, Smith MP, et al. Saving A Joint Theater Trauma System and Joint Trauma System Review of Prehospital Trauma Care in Combined Joint Operations Area? Afghanistan (CJOA-A) Final Report, 30 May 2014. J Spec Oper Med. 2015;15(2):25-41. 21. Eastridge BJ, Mabry R, Blackbourne LH, Butler FK. We dont know what we dont know: prehospi tal data in combat casualty care. US Army Med Dep J April-June 2011:11-14. 22. Therien SP, Nesbitt ME, Duran-Stanton AM, Ger hardt RT. Prehospital medical documentation in the Joint Theater Trauma Registry: a retrospective study. J Trauma 2011;71(1 suppl):S103-S108. 23. Lairet JR, Bebarta VS, Burns CJ, et al. Prehospital interventions performed in a combat zone: a pro spective multicenter study of 1,003 combat wound ed. J Trauma Acute Care Surg 2012;73(2 suppl 1):S38-S42. 24. Therien SP, Andrews JE 2nd, Nesbitt ME, Mabry R. An observational study assessing completion time and accuracy of completing the tactical com bat casualty care card by combat medic trainees. J Spec Oper Med 2014;14(2):38-45. 25. McGarry AB, Mott JC, Kotwal RS. A study of pre hospital medical documentation by military medi cal providers during precombat training. J Spec Oper Med. 2015;15(1):79-84. 26. Gerhardt RT, Reeves PT, Kotwal RS, Mabry RL, Robinson JB, Butler F. Analysis of Prehospital Doc umentation of Injury-Related Pain Assessment and Analgesic Administration on the Contemporary Prehosp Emerg Care 2016;20(1):37-44. 27. Mabry RL, Apodaca A, Penrod J, Orman JA, Gerhardt RT, Dorlac WC. Impact of critical careduring helicopter evacuation in the current war in Afghanistan. J Trauma Acute Care Surg 2012;73(2 Suppl 1):S32-S37. 28. Maddry JK, Mora AG, Savell S, Reeves LK, Perez CA, Bebarta VS. Combat MEDEVAC: A compari son of care by provider type for en route trauma care in theater and 30-day patient outcomes. J Trauma Acute Care Surg 2016;81(5 suppl 2 Pro ceedings of the 2015 Military Health System Re search Symposium):S104-S110. AUTHORS MAJ Schauer is with the USAF En Route Care Research Center, Joint Base San Antonio-Fort Sam Houston, Texas. MAJ April and CPT Oliver are with the Brooke Army Medical Center, Joint Base San Antonio-Fort Sam Hous ton, Texas. MAJ Naylor is with the 28th Combat Support Hospital, Fort Bragg, North Carolina. LTC Cunningham is with the US Army Institute of Sur gical Research, Brooke Army Medical Center, Joint Base San Antonio-Fort Sam Houston, Texas. MAJ Fisher is a medical student at the Texas A&M University College of Medicine, Temple, Texas. Prior to entering medical school, he was an Army Physician Assistant. COL (Ret) Kotwal is with the US Army Institute of Sur gical Research and the DoD Joint Trauma System, Joint Base San Antonio-Fort Sam Houston, Texas.

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98 http://www .cs.amedd.army .mil/amedd_journal.aspxEndotracheal intubation is a critical skill for emergency physicians. While anesthesiologists have historically taken ownership of the procedure, emergency physi cians are increasingly responsible for performing this intervention. Studies over the past 2 decades estimate the proportion of emergency department (ED) intuba tions performed by emergency physicians ranges from 89% to 95%.1-3 This procedure is of particular impor tance to the military emergency physician as airway emergencies account for 9% of preventable deaths on 4 Adequate experience with this proce dure in garrison will help to ensure physician readiness to execute this life-saving intervention in the deployed environment. As the militarys largest hospital and only level 1 trauma center, Brooke Army Medical Center (BAMC) is an ideal training platform to offer physicians such experi ence in intubation procedures. The size and scope of the capabilities and care responsibilities of BAMC are the result of the closure of the USAF Wilford Hall Medical Center and consolidation of its functions into BAMC as mandated by the Defense Base Closure and Realign ment Commission decisions of 2005.5 It is responsible for the care of active duty and retired military personnel medical care responsibilities with area civilian hospitals for nonmilitary trauma patients received from the sur rounding communities. In 2016, the BAMC ED initiated research-based surveil lance of its intubation practices as part of the National Emergency Airway Registry (NEAR), a multicenter observational intubation registry coordinated through A 12 -Month Descriptive Analysis of Emergency Intubations at Brooke Army Medical Center: A National Emergency Airway Registry StudyMAJ Michael D. April, MC, USA Maj Joseph K. Maddry, USAF, MC MAJ Steven G. Schauer, MC, USA LTC Shane Summers, MC, USA Calvin A. Brown III, MD MAJ Daniel J. Sessions, MC, USA Capt Patrick C. Ng, USAF, MC MAJ Robert M. Barnwell, MC, USA Jessie Fernandez, BS Col Mark Antonacci, USAF, MC Andrea E. Fantegrossi, MPH ABSTR A CT Emergency airway management is a critical skill for military healthcare providers. Our goal was to describe the Emergency Department (ED) intubations at Brooke Army Medical Center (BAMC) over a 12-month period. Material and Methods: Physicians performing endotracheal intubations in the BAMC ED complete data col lection forms for each intubation event as part of the National Emergency Airway Registry, including patient demographics, intubation techniques, success and failure rates, adverse events, and patient disposition. We cross-referenced these forms against the numbers of intubation events reported in the ED nursing daily reports to ensure capture of all intubations. Providers completed forms for every intubation within 6 weeks of the pro cedure. We analyzed data from March 28, 2016, to March 27, 2017. Results: During the study period, providers performed 259 intubations in the BAMC ED. Reasons for intuba tion were related to trauma for 184 patients (71.0%) and medical conditions for 75 patients (29.0%). Overall, laryngoscope for 115 patients (44.4%). One patient underwent cricothyrotomy. The 2 most common induction agents were ketamine (59.8%; 95% CI, 55.2%-67.4%) and etomidate (19.3%; 95% CI, 14.7%-24.7%). The most common neuromuscular blocking agents were rocuronium (62.9%; 95% CI, 56.7%-68.8%) and succinylcho line (18.9%; 95% CI, 14.3%-24.2%). Conclusion: In the BAMC ED, emergency intubation most commonly occurred for trauma indications using

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October December 2017 99 Brigham and Womens Hospital in Boston, Massachusetts.3,6 This article presents an overview of the data BAMC. Our objective was to describe the intubation experiences, practices, and outcomes of the active duty physicians in this unique setting. MA TERI A LS A ND METHODS Study DesignWe conducted a prospective observational study of intubations in the BAMC ED as part of the facilitys partici pation in NEAR.3,6 Data collection began on March 28, 2016. The Brooke Army Medical Center Institutional Review Board approved the study. The US Army Medi cal Research and Material Command approved the data sharing agreement with Brigham and Womens Hospital for participation in NEAR.SettingBrooke Army Medical Center is an urban tertiary care academic hospital and the only level 1 trauma center in the Department of Defense (DoD). The ED sees ap proximately 82,000 patients annually that includes ac ciaries, and nonmilitary trauma patients received from the surrounding communities. Brooke Army Medical Services Health Education Consortium, the largest sponsoring institution for graduate medical education in the military and hence a major training platform for resi dents and fellows within the DoD. The ED hosts a 3-year emergency medicine training program with each class typically comprising 16 residents (48 residents total).Selection of PatientsThis study includes all patients intubated during the the NEAR registry during the period March 28, 2016 through March 27, 2017. All patients intubated in the ED were eligible for inclusion. There were no exclusion criteria.Study MethodologyIntubating providers recorded data about each intuba tion using a data collection form. This form is standard ized across all NEAR sites. Variables included patient demographics, indication for intubation, intubation device, pharmacologic agents, operator characteristics, intubation success or failure, and adverse events. When solicited data on additional attempts (up to 5 attempts tion forms were in accordance with those established by NEAR.3Providers recorded all such data as soon as possible. Providers then deposited completed forms in a secured search assistants cross-referenced complete forms with daily nursing reports of intubations performed in the ED to ensure capture of forms on 100% of ED intubations. These assistants contacted the intubating providers as or in person to obtain missing forms. We considered data missing for intubations performed during the study period if entered more than 6 weeks after the intubation attempt. Upon completion of data entry, we uploaded these data into a centralized webbased data management StudyTRAX Version 3.47.0011 database (ScienceTRAX, Macon, GA). Following up load, NEAR personnel based at Brigham and Womens Hospital reviewed all data using quality assurance algo rithms to minimize occurrence of data entry errors. We retrieved missing data whenever possible by interview of the intubating provider or manual chart review.AnalysisFor the purposes of our analysis, we exported all data to IBM SPSS, Version 22. We used descriptive statistics to describe intubation indications, intubating provider characteristics, intubation methods and devices, drugs dence intervals (CI) for select outcomes. We did not per form a sample size estimate as our intent was to perform a descriptive analysis of the experience of all emergency intubations in our ED during a 12-month period. We did not perform inferential statistical testing. RESULTS During the period of the study, physicians performed daily nursing reports. The mean time from procedure to data entry was 0.2 days (95% CI, 0.1-0.5). The time from intubation to data entry was less than 24 hours for 249 (96.1%) of intubations. Data was captured for each of the other 10 procedures within 6 weeks of occurrence. Indications for intubation were related to trauma for 184 patients (71.0%) and medical conditions for 75 patients (29.0%). As shown in Table 1, the most common trauma indications for intubation included polytrauma (22.3%) and head injury with hemorrhage (19.6%). The most common medical indications for intubation, shown in Table 2, included noningestion-related altered mental status (28%) and cardiac arrest (18.7%). (83.0%; 95% CI, 77.9%-87.4%). The detailed data is

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100 http://www .cs.amedd.army .mil/amedd_journal.aspxpresented in Table 3. One patient who sustained a gun shot wound to his face underwent a primary cricothyrot patient required a cricothyrotomy as a result of a failed compared across alternative study variables. Emergency medicine residents performed 246 of 259 postgraduate year (PGY) 1, 166 were PGY 2, and 34 performed by residents were successful. Of the 13 intubations not managed primarily by emergency medicine residents, 7 were performed by emergency medicine attending physicians and 6 by anesthesiology attend ing physicians. 115 patients (44.4%) and video laryngoscopy for 143 patients (55.2%). The most commonly used device for video laryngoscopy was the Glidescope (Verathon Inc., Bothell, WA), accounting for 137 of these at tempts. First-pass success percentage was 73.0% (95% CI, 64.0%-80.9%) for direct laryngoscopy versus 90.9% (95% CI, 85.0%-94.7%) for video laryngosco attempts included ketamine for 155 patients (59.8%; 95% CI, 55.2%-67.4%) and etomidate for 50 patients (19.3%; 95% CI, 14.7%-24.7%). For neuromuscular blocking agents, providers used rocuronium for 163 patients (62.9%; 95% CI 56.7%-68.8%) and succinyl choline for 49 patients (18.9%; 95% CI ,14.3%-24.2%). Sixty-one of 259 (23.6%) patients intubated experienced tempt (Table 4). The most commonly reported adverse saturation less than 90%. The next most common periintubation adverse events were hypotension reported in 13 patients and cardiac arrest reported in 10 patients. The probability of adverse event was similar for second attempts (23.8%). We observed limited numbers of third subsequent efforts. CO MM ENT Endotracheal intubation is a critical skill for mili tary healthcare providers as part of combat casual ty care in the deployed environment.7-9 We report on 12 months of emergency airway management experiences at BAMC as part of its participa tion in the NEAR registry.3 In total, we reported 259 intubations, of which 83.0% were successful formed most intubations for trauma indications. These data provide an overview of the stateside emergency airway management experience at the militarys largest hospital and only level 1 trauma center. The indications for a majority (71.0%) of intuBAMC trauma programs treatment of civilian trauma patients.10 Our results highlight the sub stantial proportion of our procedural experience arising from our participation in this program. By extension, these results highlight the importance Table 1. Trauma Indications for Intubation (n=184).Indication Number of Patients % n 95% CI Abdomen trauma4 2 2 0 5%-4 3%Burn/inhalation injury16 8 .7 4 .9%-13 0%Chest trauma14 7. 6 3 .8%-12 0%Combative/agitated24 13 0 8 2%-17 .9%Facial trauma8 4 3 1 6%-7. 1%Head injury without hemorrhage14 7. 6 4 3%-12 0%Head injury with hemorrhage36 19 6 14 1%-26 0%Neck trauma3 1. 6 0%-3 8%Polytrauma41 22 3 16 .3%-28 .3%Shock (hemorrhagic)5 2 .7 0 5%-4 .9%Shock (spinal trauma)1 0. 5 0%-1. 6%Traumatic arrest18 9. 8 5 9%-15 0%Total184 100. 0 Table 2. Medical Indications for Intubation (n=75).Indication Number of Patients % n 95% CI Airway obstruction*2 2 .7 0%-6 .7%Asthma1 1. 3 0%-4 0%Cardiac arrest14 18 .7 9 .4%-28 0%Congestive heart failure3 4 0 0%-9 3%COPD2 2 .7 0%-6 .7%Gastrointestinal bleed2 2 .7 0%-6 .7%Intracranial hemorrhage4 5 3 1. 3%-12 0%Myocardial infarction2 2 .7 0%-6 .7%Non-overdose mental status change21 28 0 17. 3%-38 7%Overdose6 8 0 2 .7%-14 .7%Pneumonia4 5 3 1 3%-10 7%Seizure5 6 .7 1 .3%-13 .3%Shock (cardiogenic)2 2 .7 0%-6 .7%Shock (sepsis)4 5 3 1 3%-10 7%Shock (distributive, not sepsis)2 2 .7 0%-6 .7%Stroke1 1. 3 0%-4 0%Total75 100. 0*Not anaphylaxis or angioedema. COPD indicates chronic obstructive pulmonary disease. A 12 -MONTH DESCRIPTIVE ANALYSIS OF EMERGENCY INTUBATIONS AT BROOKE ARMY MEDICAL CENTER: A NATIONAL EMERGENCY AIRWAY REGISTRY STUDY

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October December 2017 101 of our participation in this program in maintaining the medical readiness of our force. is identical to that reported for ED centers nationwide as part of the NEAR registry during 2002-2012.3 This sug gests a comparable level of skill between the military practitioners in our hospital compared to civilian coun of the importance of experience and patient volume for procedural competence.11 Indeed, authors have voiced concerns regarding the potential lack of adequate expo treatment facilities for military healthcare providers to achieve and maintain clinical skills.12,13 suggest that BAMC, together with off-service rotations at outside civilian hospitals, provide the emergency medicine trainees managing the majority of emergency airways at BAMC with adequate procedure volume to maintain airway management competence. While 259 intubations in a 12-month period is sub stantial by the standards of a military treatment fa cility, it is a modest intubation volume by the stan dards of many civilian academic centers. Compara tively, a similar study observing all intubations per formed during one calendar year at the University of California, Davis, Medical Center reported 610 intubations.2 This represents an annual intubation gap of more than 350 procedures between BAMC and busy civilian academic centers. While our data suggest the volume at BAMC is adequate to train emergency physicians to the level of their civilian peers, the gap highlights the ongoing challenges faced by military healthcare providers to maintain procedural competence. This challenge is of partic ular concern at smaller military healthcare facilities seeing much lower patient volumes. Emergency medicine residents managed 95% of mission of the BAMC ED. By way of comparison, previous iterations of NEAR reported the propor tion of ED intubations managed by emergency med icine residents ranging from 77% to 79%.1,3 The residents play a pivotal role in managing airways for critically ill and injured patients presenting to BAMC. Maintaining this focus on resident airway management will be imperative moving forward to ensure the best possible training for military emer gency medicine residents prior to deployment as at tending physicians. Our results highlight that this focus does not come at the expense of clinical out comes or patient safety. There are several notable differences in the intubation practices in our cohort as compared to nationwide sta tistics reported in the NEAR registry.3 First, a larger proportion of intubations in our cohort used video la ryngoscopy55.2% at BAMC versus approximately 10% in the NEAR registry. We suspect this largely re the earlier time period examined by the NEAR registry data (2002-2012), there was a clear trend towards in creasing use of video laryngoscopy. We found a higher laryngoscopy (90.9%) as compared to direct laryngos ings regarding relative intubation success with direct versus video laryngoscopy.14-16 less experience among our intubating providers with di rect laryngoscopy rather than the superiority of video technology.17 Further research on this question using the Table 3. First Attempt Intubation Characteristics and First-Attempt Successes (N=259).Study Variable Number of Patients (n) Successful First Attempts 95% CI Number % n Indications Medical75 58 77. 3 68 0%-86 7%Trauma184 157 85 3 79 .9%-90 2%First Attempt Operator EM146 34 73 .9 60. 9%-87 0%EM2166 141 84 .9 79 5%-90 .4%EM334 29 85 3 73 5%-97. 1%EM attending7 7 100. 0 -Anesthesia6 4 66 .7 -First Attempt Device*Direct laryngoscopy115 84 73. 0 64 0%-80. 9%Video laryngoscopy143 130 90 .9 85. 0%-94 7%First Attempt Method Paralytic and sedative211 184 87. 2 82 .5%-91 .5%Sedative only5 4 80. 0 -Paralytic only2 2 100. 0 -No medications41 25 61 0 43 9%-75 .6%First Attempt Induction Agent Etomidate50 41 82 0 72 .0%-92 .0%Ketamine155 138 89. 0 83. 9%-93. 5%Midazolam2 1 50. 0 -Propofol9 8 88 .9 -None43 27 62 8 48 8%-76 .7%First Attempt Paralytic Agent Rocuronium163 145 89. 0 84 0%-93 3%Succinylcholine49 40 81 6 69 4%-91 8%Vecuronium1 1 100. 0 -None46 29 63. 0 47. 8%-76 1%*One patient underwent first-attempt cricothyrotomy. EM indicates emergency medicine.

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102 http://www .cs.amedd.army .mil/amedd_journal.aspxbroader NEAR registry will be of value to the military and emergency medicine communities. Should such re search conclude superiority of video laryngoscopy, the ses of ensuring widespread availability of such devices for deployed personnel.18Our study also reports a unique distribution of pharma cologic agents used for rapid sequence intubation (RSI). In our cohort, a far higher proportion of patients received ketamine for induction (59.8%) as compared to that re ported by the historic NEAR registry (1.0%).3 ing could indicate a change in national trends as recent literature has suggested better outcomes with ketamine compared with more traditional induction agents (eg, etomidate) among trauma19 and sepsis patients.20 The increased use of ketamine in our population may also use of this medication by military physicians in the de ployed environment and its recommended use for anal gesia by the Tactical Combat Casualty Care guidelines.21 for 62.9% of patients and succinylcholine for only 18.9% of patients is different from what has been reported in previous NEAR reports3 and non-NEAR facilities22 where nearly three quarters of all RSIs involved suc cinylcholine. A growing literature suggests equivalent intubating conditions between these 2 agents when ro curonium is dosed at 1.0-1.2 mg/kg.23 This makes ro curonium an attractive option, particularly given that succinylcholine is contraindicated for use in patients with diseases upregulating skeletal muscle acetylcho line receptors. Examples of such disease processes in clude spinal cord injuries and burns 72 hours or more from the time of injury.24 Given that emergency medi cine physicians may not necessarily be privy to the pres ence of these medical conditions when actively manag ing an airway emergency, it is understandable by the use of this agent is increasingly popular within the specialty of emergency medicine.25This study has several limitations. As an observational study, we are unable to ascertain whether the apparent relation or causation. Moreover, given that it is a single center study, we have inadequate sample size to perform alternative RSI regimens or intubation devices while controlling for potential confounders (eg, regression models, propensity matching). Moreover, given our reli ance upon self-reported data, it is possible that biased re sponses skewed our results towards more favorable out comes. In particular, reporting of some adverse events is more subjective than others and could be susceptible to under-reporting as a result of such reporting bias. Another important limitation is that our results may have limited generalizability. The environment of BAMC is unique. As a military hospital, its experience may not be representative of the experience at civilian hospitals. Simultaneously, as the militarys largest academic hos pital and an urban tertiary care center, our data may not smaller military treatment facilities or in the deployed environment. Nevertheless, generalizability was not our intent. Rather, we sought to describe the garrison experi ence for stateside military healthcare professionals at the epicenter of military medicine. In so doing, we intended to provide military trainees, educators, and leaders alike with a better understanding of the context in which mili tary physicians practice and maintain readiness with re gards to emergency airway management, a skill known 4It is our hope that these data related to endotracheal in tubation will provide yet another building block to the growing literature exploring devices and training for the military related to airway management.26-28 Future re search with the NEAR registry will be useful for clari fying whether some of the trends observed in our study are generalizable to other settings (eg, the superiority airway registries at other military treatment facilities and the deployed environment to ascertain the unique characteristics of airway management in those settings. Table 4. First Attempt Peri-intubation Adverse Events Oc curring in Patients (n=61).Adverse Events Number of Patients % n*95% CI Airway trauma2 3 3 0 3%-11 9%Cardiac arrest10 16 .4 9 0%-27. 8%Dysrhythmia3 4 .9 1 1%-14 0%Esophageal intubation (delayed recognition)2 3 3 0 3%-11 9%Esophageal intubation (immediate recognition)2 3 3 0 3%-11 9%Hypotension13 21 3 12 8%-33 3%Hypoxia36 59 0 46 .5%-70 .5%Main-stem intubation5 8 2 3 .2%-18 .2%Tachy-dysrhythmia1 1. 6 0. 0%-9 6%Vomiting6 9. 8 4 3%-20 2%*Percentages do not total 100% as some patients experienced mul tiple adverse events. A 12 -MONTH DESCRIPTIVE ANALYSIS OF EMERGENCY INTUBATIONS AT BROOKE ARMY MEDICAL CENTER: A NATIONAL EMERGENCY AIRWAY REGISTRY STUDY

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October December 2017 103 In summary, this article reports the experience of emer gency airway management at BAMC over a 12-month period. It highlights robust exposure to airway manage ment opportunity for military healthcare providers at the militarys largest emergency medicine residency. It further reports comparable outcomes in terms of intuba tion success as reported in the civilian literature. Taken together, these data highlight the substrate offered by this institution to maintain military health provider readiness and clinical competence to support the United States armed forces combat operations. REFERENCES 1. Sagarin MJ, Barton ED, Chng YM, Walls RM, Na tional Emergency Airway Registry I. Airway man agement by US and Canadian emergency medicine residents: a multicenter analysis of more than 6,000 endotracheal intubation attempts. Ann Emerg Med 2005;46:328-336. 2. Sakles JC, Laurin EG, Rantapaa AA, Panacek EA. Airway management in the emergency department: a one-year study of 610 tracheal intubations. Ann Emerg Med 1998;31:325-332. 3. Brown CA, 3rd, Bair AE, Pallin DJ, Walls RM, In vestigators NI. Techniques, success, and adverse events of emergency department adult intubations. Ann Emerg Med 2015;65:363-370 e1. 4. Eastridge BJ, Mabry RL, Seguin P, Cantrell (2001-2011):implications for the future of com bat casualty care. J Trauma Acute Care Surg 2012;73:S431-S437. 5. De Lorenzo RA. San Antonio Military Medical Center integration: a case study in organizational leadership design. Mil Med 2008;173:203-209. 6. Walls RM, Brown CA, 3rd, Bair AE, Pallin DJ, In vestigators NI. Emergency airway management: a multi-center report of 8937 emergency department intubations. J Emerg Med 2011;41:347-354. 7. Katzenell U, Lipsky AM, Abramovich A, Huber man D, Sergeev I, Deckel A, et al. Prehospital intubation success rates among Israel Defense Forces providers: epidemiologic analysis and effect on doctrine. J Trauma Acute Care Surg 2013;75:S178-S183. 8. Lairet JR, Bebarta VS, Burns CJ, Lairet KF, Ras mussen TE, Renz EM, et al. Prehospital interven tions performed in a combat zone: a prospective multicenter study of 1,003 combat wounded. J Trauma Acute Care Surg 2012;73:S38-S42. 9. Mabry RL, Frankfurt A. Advanced airway man agement in combat casualties by medics at the point of injury: a sub-group analysis of the reach study. J Spec Oper Med 2011;11:16-19. 10. Phillips RT, Conaway C, Mullarkey D, Owen JL. One years trauma mortality experience at Brooke Army Medical Center: is aeromedical transpor tation of trauma patients necessary? Mil Med 1999;164:361-365. 11. Roth D, Schreiber W, Stratil P, Pichler K, Havel C, Haugk M. Airway management of adult patients without trauma in an ED led by internists. Am J Emerg Med 2013;31:1338-1342. 12. Schauer SG, Varney SM. Providers face challenges maintaining deployment-ready skills at Garrison hospitals. J Spec Oper Med 2015;15:79-80. 13. Schauer SG, Varney SM, Cox KL. Garrison Clinical Setting Inadequate for Maintenance of Procedural Skills for Emergency Medicine Physi cians: A Cross-Sectional Study. J Spec Oper Med 2015;15:67-70. 14. Brown CA, 3rd, Bair AE, Pallin DJ, Laurin EG, Walls RM, National Emergency Airway Regis try I. Improved glottic exposure with the Video Macintosh Laryngoscope in adult emergency de partment tracheal intubations. Ann Emerg Med 2010;56:83-88. 15. Lascarrou JB, Boisrame-Helms J, Bailly A, Le Thuaut A, Kamel T, Mercier E, et al. Video La ryngoscopy vs Direct Laryngoscopy on Success ful First-Pass Orotracheal Intubation Among ICU Patients: A Randomized Clinical Trial. JAMA 2017;317:483-493. 16. Ducharme S, Kramer B, Gelbart D, Colleran C, Ri savi B, Carlson JN. A pilot, prospective, random ized trial of video versus direct laryngoscopy for paramedic endotracheal intubation. Resuscitation 2017;114:121-126. 17. Savino PB, Reichelderfer S, Mercer MP, Wang R, Sporer KA. Direct versus video laryngoscopy for prehospital intubation: a systematic review and me ta-analysis. Acad Emerg Med 2017;24(8):1018-1026. 18. April MD, Murray BP. Cost-effectiveness analysis appraisal and application: an emergency medicine perspective. Acad Emerg Med 2017;24(6):754-768. 19. Upchurch CP, Grijalva CG, Russ S, Collins SP, Semler MW, Rice TW, et al. Comparison of Etomi date and Ketamine for Induction During Rapid Se quence Intubation of Adult Trauma Patients. Ann Emerg Med 2017;69:24-33 e2. 20. Van Berkel MA, Exline MC, Cape KM, Ryder LP, Phillips G, Ali NA, et al. Increased incidence of clinical hypotension with etomidate compared to ketamine for intubation in septic patients: a propen sity matched analysis. J Crit Care 2017;38:209-214. 21. Butler FK, Kotwal RS, Buckenmaier CC, 3rd, Ed gar EP, OConnor KC, Montgomery HR, et al. A triple-option analgesia plan for Tactical Combat Casualty Care: TCCC Guidelines Change 13-04. J Spec Oper Med 2014;14:13-25.

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104 http://www .cs.amedd.army .mil/amedd_journal.aspx22. Laurin EG, Sakles JC, Panacek EA, Rantapaa AA, Redd J. A comparison of succinylcholine and rocuronium for rapid-sequence intubation of emergency department patients. Acad Emerg Med 2000;7:1362-1369. 23. Tran DT, Newton EK, Mount VA, Lee JS, Wells GA, Perry JJ. Rocuronium versus succinylcholine for rapid sequence induction intubation. Cochrane Database Syst Rev 2015:CD002788. 24. Martyn JA, Richtsfeld M. Succinylcholine-induced hyperkalemia in acquired pathologic states: etio logic factors and molecular mechanisms. Anesthe siology 2006;104:158-169. 25. Swaminathan AK, Mallemat H. Rocuronium should be the default paralytic in rapid sequence intubation. Ann Emerg Med In press. 26. Amack AJ, Barber GA, Ng PC, Smith TB, April MD. Comparison of ventilation with one-handed mask seal with an intraoral mask versus con ventional cuffed face mask in a cadaver model: a randomized crossover trial. Ann Emerg Med 2017;69:12-17. 27. Zobrist B, Casmaer M, April MD. Single rescuer ventilation using a bag-valve mask with internal handle: a randomized crossover trial. Am J Emerg Med. 2016;34:1991-1996. 28. Reed P, Zobrist B, Casmaer M, Schauer SG, Kes ter N, April MD. Single rescuer ventilation using a bag valve mask with removable external handle: a randomized crossover trial. Prehosp Disaster Med 2017;15:1-6. Epub ahead of print. AUTHORS MAJ April, Capt Ng, LTC Summers, MAJ Sessions, MAJ Barnwell, and Col Antonacci are with the Depart ment of Emergency Medicine, Brooke Army Medical Center, Joint Base San Antonio-Fort Sam Houston, Texas. Dr Brown and Ms Fantegrossi are with the Department of Emergency Medicine, Brigham and Womens Hospi tal, Boston, Massachusetts. MAJ Schauer, Ms Fernandez, and Maj Maddry are with the USAF En Route Care Research Center, Joint Base San Antonio-Fort Sam Houston, Texas.A 12 -MONTH DESCRIPTIVE ANALYSIS OF EMERGENCY INTUBATIONS AT BROOKE ARMY MEDICAL CENTER: A NATIONAL EMERGENCY AIRWAY REGISTRY STUDY

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October December 2017 105Military executives are faced with a different type of occupational stress than other employees. It is a known fact that executives are mainly confronted with mental challenges and, as a result, can also develop somatic pain, primarily in the cervical vertebral column and shoul ders.1 What is more, executives are an important target group in occupational health promotion,2 and many com panies have launched health promotion projects.3 Execu tives are faced with less physical activity during working hours than other employees. At the same time, military executives are much more active during their leisure time than other military personnel.4 In general, health tional level, with those attaining higher educational lev els showing a more health-conscious lifestyle.5 Another study revealed that work-related travel and commuting executives.2 Particularly prominent risk factors for the development of cardiovascular disorders include high body mass index (BMI), low education level, smoking, excess weight, age, and male sex.6 In addition, people in positions of high responsibility tend to develop nocturnal blood pressure peaks and acute heart disease.6,7 Too little of cardiovascular disease.8 lactate performance test.9 The development of orthopae dic conditions, in particular back pain, is associated with 10 The aim of this study was to determine to what extent risk factors for the develop ment of internal and orthopaedic conditions are present in military executives and how these factors affect phys study will lead to conclusions about how, as part of oc cupational health promotion, improvements can be made MA TERI A L A ND METHODS SubjectsIn total, 122 male subjects took part in the prevention program for executives during the study period. The av erage age was 54.64.2 years. The average BMI was 26.62.8 kg/m, and the average waist circumference was 95.98.2 cm. Prior to equipment-based testing, the subjects were given a standardised questionnaire on the following points: occupation, weekly working hours, al cohol consumption, smoking habits, commuting activ ity, exercise, mental stress, previous internal or ortho paedic disorders, and medications taken. This was fol lowed by a nutritional analysis based on the Freiburger Ernhrungsprotokoll (Freiburg Dietary Record). The subjects then provided a blood sample to determine the parameters glycated haemoglobin (HbA1c), blood count, alanine aminotransferase (ALAT), aspartate An Evaluation of the Significance of Individual Endogenous Risk Factors and Medical and Orthopaedic Conditions on Physical Fitness in Military Executives Maj Christoph Schulze, MD, German Air Force Lt Col Christoph Holtherm, MD, German Army Maj Michael Becker, MD, German Army Lt Col Jens Hinder, MD, German Army Suzanne Finze, MSc Col Andreas Lison, MD, German Army ABSTR A CT As part of occupational health promotion in the Bundeswehr (military services of the Federal Republic of Germany), top-ranking executives were offered a medical examination and training program. The participants were subjected to retrospective evaluation. The aim of this study was to determine to what extent risk factors for the development of internal and orthopaedic conditions are present in military executives and how these tionnaire aimed at evaluating private and occupational stress factors. This process was followed by an internal and orthopaedic examination. A lactate performance test (treadmill or bicycle ergometry) was conducted. The and older age did. It is recommended that executives undergo professionally guided endurance and weight training on a regular basis in order to prevent the development of internal and orthopaedic conditions.

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106 http://www .cs.amedd.army .mil/amedd_journal.aspxcreatinine, urea, blood glucose, total cholesterol, HDL cholesterol, and LDL cholesterol.Lactate Performance TestFor the performance test, 86 patients used a stationary bicycle (Ergometrics 900; ErgoLine; Baden-Wrttem berg, Germany) and 36 patients used a treadmill (ELG 70/200; Woodway; Waukesha WI. ECG; Spacelabs Healthcare, Hawthorne, CA). The choice of exercise equipment was based on whether subjects preferred running or other types of sports. For bicycle ergometry, ual level, with the intensity increasing by 50 watts every was also started at an individual level and the speed in creased by 1 km/h every 3 minutes. Measurement was discontinued when the patient became fatigued. Lactate levels were measured before the exercise, at the end of each 3-minute period of exercise, and during the recov ery phase. Blood samples were taken from the ear. The earlobe was pricked with a lancet (safety lancet, prick depth 1.8 mm; Saarstedt; Nrnbrecht, Germany) and a drop of blood was collected by means of manual com second was collected in a capillary tube (heparin-coat ed end-to-end capillary; EKF; Magdeburg, Germany). This blood sample was stored in an analysis kit (glucose and lactate haemolysis solution; EKF; Magdeburg, Germany). Lactate concentration was then established using a spectrometer (Biosen S-Line; EKF; Magdeburg; Germany). The data obtained was evaluated using Win lactat software (V 4.6.3.21; Mesics GmbH; Mnster, Germany). Performance or speed at 4 mmol/l lactate (p4mmol-L, v4mmol-L) and maximum performance or speed (pmax, vmax) were chosen as comparable parameters for evaluation.11 Following an individual performance anal ysis, the subjects received sports medical advice.Statistical EvaluationA descriptive data analysis was conducted for all groups (establishment of minimum, maximum, mean, and me dian). Group rank sum comparison was conducted by means of the Kruskal-Wallis test. This was followed 2 cance level was set at P >.05. The Mann-Whitney U test was used to conduct pairwise comparisons. The signif icance level was determined at P >.05. For the correla in accordance with Pearsons r The P >.05 value was R2), the standard ized ( of the predictors together with the Pearson correlation r ) and squared semipartial correlation ( sr2) were reported. The statistical data analysis was carried out with IBM SPSS V 21.0 and the effect size was cal culated with G*Power. According to Cohen, the effect size f2 was interpreted as follows: f2=0.02 minor effect, f2=0.15 moderate effect, f2=0.35 major effect.12 RESULTS Effect of Individual Determinants on FitnessAgeTo determine the effect of age on performance, the sub jects were divided into two groups (Group 1, aged 55 years or less; Group 2, aged more than 55 years). As shown in Table 1, the bicycle cardiac stress test revealed gometry also showed this trend. Younger subjects were Body Mass IndexAfter establishing body mass index, the subjects were divided into 3 groups: Group 1, BMI<25 kg/m2 (N=36); Group 2, BMI 25-30 kg/m2 (N=73); Group 3, BMI>30 kg/m2 (N=13). Within the 3 groups, the bicycle ergome the 4 mmol lactate threshold and at maximum perfor mance (Table 2). ence either, but the group with a BMI 25 kg/m tend with increasing BMI, in particular on the treadmill. regression analysis as a predictor for physical activity. The model was signif icant: F=2.473 ( P =.038) and the model equation correlated to R =0.338 with the criterion variable ( R2=0.114; R2 ad justed=0.068; f2=0.129; Power=0.99). The variance in physical activity was AN EVALUATION OF THE SIGNIFICANCE OF INDIVIDUAL ENDOGENOUS RISK FACTORS AND MEDICAL AND ORTHOPAEDIC CONDITIONS ON PHYSICAL FITNESS IN MILITARY EXECUTIVES Table 1. Overview of the performance of subjects by age group at the 4 mmol lac tate threshold and at maximum performance in the bicycle ( p4mmol-L, pmax) in watts, and treadmill ( v4mmol-L, vmax) cardiac stress tests in km/h.Subjects (N=bicycle/treadmill) p4mmol-L W pmax W v4mmol-L km/h vmax km/h Group 1 (N=44/22) 55 years175 .0 (36 3) 243 8 (46 5) 11 (1 6) 13 5 (1 6) Group 2 (N=42/14) Subjects aged >55 years153 7 (34. 0) 200 7 (44 6) 9 9 ( 4) 12 3 (1. 1)P. 003 001 053 033

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October December 2017 107 (=0.624; b=39.559; SE=2.487; P =.003; r =0.294; sr2=0.294). Body mass index accounted for 7.8% of the variance in physical activity.Waist CircumferenceOn the basis of the values measured, the subjects were di vided into 3 groups: Group 1, up to 94 cm (N=46); Group 2, 94-102 cm (N=36); Group 3, <102 cm (N=24). Waist circumference was not recorded for 16 of the subjects. difference between the groups at the 4 mmol lactate was established at maximum performance. Subjects heart rate at the individual anaerobic threshold (144/min (Group 1) vs 136/min (Groups 2 and 3); P =.026). The difference between the groups, which substantiates the result of the bicycle stress test (Table 3). Increased waist circumference in executives has a negative effect on r =-0.281; P =.015).NutritionSubjects who provided information about their eating habits (N=107) were divided on the basis of their eating behavior into the following 4 groups: (1) isocaloric (balanced) (n=45); (2) hy percaloric (balanced) (n=12); (3) hyper caloric (imbalanced) (n=4); (4) hypoca loric (n=46). Table 4 shows the average performance achieved. For the performance test, the cant differences in the groups with the values for p4mmol-L or v4mmol-L. There was Smoking HabitsSubjects were asked about their nicotine consumption and were divided into 2 groups: smokers (N=17) and nonsmokers (N=105). This study did not reveal any proof that smoking habits ecutives (Table 5). It turned out, however, that the major ity of the executives were nonsmokers.Physical Activity Outside of Working Hours gaged in any sports/exercise activity outside of work ing hours. Six persons did not provide any information about their physical activity. Executives who exercised regularly outside of working hours were more physically Effect of Health Conditions on The Physical Fitness of ExecutivesDiabetes MellitusFive of the 122 subjects in the study had diabetes mel not affected by the illness (data not shown).HypercholesterolemiaFifty-eight of the 122 subjects had hy lished between those affected and those not (data not shown).HyperuricemiaOf the 122 subjects, 17 had hyperurice and 12.1% of the generals (n=8) were Table 2. Overview of the performance of subjects by BMI group at the 4 mmol lac tate threshold and at maximum performance in the bicycle ( p4mmol-L, pmax) in watts, and treadmill ( v4mmol-L, vmax) cardiac stress tests in km/h.Subjects(N=bicycle/treadmill)p4mmol-L W pmax W v4mmol-L km/h vmax km/h Group 1 (N=20/16) BMI<25 kg/m2163 .6 (37 .6) 237. 7 (52 9) 11 (1 1) 13 1 (1 3) Group 2 (N=53/20) BMI=25 to 30 kg/m2163. 8 (37 0) 217 4 (8 1) 10 2 (1 8) 12 .9 (1 .9) Group 3 (N=13/0) BMI>30 kg/m2169 4 (35 1) 221 7 (53 9) -P.853 807 08 08 Table 3. Overview of the performance of subjects by waist circumference measure ment at the 4 mmol lactate threshold and at maximum performance in the bicycle ( p4mmol-L, pmax) in watts, and treadmill ( v4mmol-L, vmax) cardiac stress tests in km/h.Subjects(N=bicycle/treadmill)p4mmol-L W pmax W v4mmol-L km/h vmax km/h Group 1 (N=25/21) WC <94 cm167 8 (40 .9) 239 5 (52 5) 11. 1 (1. 3) 13 6 ( 4) Group 2 (N=27/9) WC=94-102 cm160. 4 (33. 3) 214 3 (46 2) 9 4 ( 5) 11 5 (0 9) Group 3 (N=23/1) WC >102 cm160 2 (28 8) 204 3 (39 7) 8 0 10. 0 P. 599 018 012 002

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108 http://www .cs.amedd.army .mil/amedd_journal.aspx and those not (data not shown).HypertensionOf the 122 subjects, 38 had high blood pressure. A sig mance in the treadmill and the bicycle stress tests. Sub than those with high blood pressure. At the 4 mmol lac tate threshold, this could be observed as a trend (Table 7).Orthopaedic Disorders dic disorders. lactate threshold or at maximum performance in the bi cycle cardiac stress test (Table 8). cardiac stress test. Subjects with orthopaedic disorders Mental Disorders by means of a bicycle cardiac stress test. The p4mmol-L who had no mental disorder: 2 subjects with disorder, p4mmol-L 12022.6 W; 84 subjects with no disorder, p4mmol-L 165.736.2 W; P =.057. At maximum perfor mance, the effect rated previously as just a tendency number of subjects: with disorder, pmax 13943.8 W; no disorder: pmax 224.7648.9 W; P =.039. Both subjects mentioned pain in the knee. No internal disorders were detected. The subjects respective BMIs were 22 kg/m2 and 26 kg/m2.Effects of Training AdviceThe subjects returned for a follow-up examination, for which the same procedure was used as for the initial examination. As an example, for reevaluating and pre senting the effect, this study only compares the subjects main parameters (BMI, waist circumference, p4mmol-L, pmax, v4mmol-L, vmax, and heart rate at the individual an aerobic threshold) with the values established during the initial examination. A total of 37 participants took part in a second seminar approximately one year after the second examination had decreased from 27.33.3 kg/ m2 to 26.93.4 kg/m2 ( P Waist circumference had decreased from 98.29.3 ( P =.575). On average, the performance test did not reveal any change in comparison with the previ ous values either. However, a lower heart rate (HR) was established at the individual anaerobic thresh old (HRT0: 140.517.0/min, HRT1: 135.917.1/ min; P =.053). CO MM ENT Risk factors for cardiovascular dis eases and the development of such diseases in executives were found to be less common in our sample than in the normal population.13-15 The ness (age, BMI, waist circumference) were evident.6 What is more, patients who had had an orthopaedic condition AN EVALUATION OF THE SIGNIFICANCE OF INDIVIDUAL ENDOGENOUS RISK FACTORS AND MEDICAL AND ORTHOPAEDIC CONDITIONS ON PHYSICAL FITNESS IN MILITARY EXECUTIVES Table 4. Overview of performance, grouped by nutrition information, at the 4 mmol lactate threshold in the bi cycle ( p4mmol-L) in watts, and treadmill ( v4mmol-L) cardiac stress tests in km/h.Subjects (N=bicycle/treadmill) p4mmol-L W v4mmol-L km/h Group 1 (N=37/8) isocaloric (balanced) 164 32 ( 28 7 ) 10 05 ( 1 8 ) Group 2 (N=7/5) hypercaloric (balanced) 188 29 ( 44 0 ) 9 9 ( 1 2 ) Group 3 (N=3/1) hypercaloric (imbalanced) 168 00 ( 51 4 ) 8 8 Group 4 (N=29/17) hypocaloric 158 72 ( 39 6 ) 10 67 ( 1 5 )P. 215 441 Table 5. Overview of the performance of subjects by smoking status at the 4 mmol lactate threshold in the bicycle ( p4mmol-L) in watts and the treadmill ( v4mmol-L) cardiac stress tests in km/h, and at maximum performance in the bicycle ( pmax) in watts.Subjects(N=bicycle/treadmill)p4mmol-L W v4mmol-L km/h pmax W Smokers (N=11/6) 166 .91 (41 6) 10 32 (1 7) 209 73 (8 2) Nonsmokers (N=75/30) 164 27 (36 0) 10. 59 (1 6) 224 68 (63 4)P.856 51 403 Table 6. Overview of the performance of subjects who exercised outside of working hours (exercisers) and those who did not (nonexercisers) at the 4 mmol lactate thresh old and at maximum performance in the bicycle ( p4mmol-L, pmax) in watts, and treadmill ( v4mmol-L, vmax) cardiac stress tests in km/h.Subjects(N=bicycle/treadmill)p4mmol-L W pmax W v4mmol-L km/h vmax km/h Nonexercisers (N=17/2) 138 76 (3 1) 178 .12 (33 .1) 8 00 (1 0) 11 05 (0. 4) Exercisers (N=65/32) 172 51 (37. 0) 236. 98 (46. 7) 10 63 (1 5) 13. 06 (1 6)P< 001 < 001 028 066

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October December 2017 109 However, at this point it is important to understand that these conditions included sports injuries, and of course tor. The fact that there were many cases of sports injuries and injuries resulting from excessive strain as well of people with high blood pressure who were rated in conditions, also be improved.16 improvement was achieved in the body measurements amination, the tendency was positive, and there was no deterioration in physical condition after receiving train ing advice. This comment, however, is limited to a large degree by the fact that less than a third of the initial sub jects turned up for the second seminar. In part this was due to early retirement of military executives. Another important limiting factor that must be mentioned at this were sometimes detected, it was at times almost impos ences because of the small number of cases in some of the groups. Nevertheless, the difference can still be of clinical relevance. This becomes particularly clear when looking at alterations in the patients mental state. It is tibility to psychological stress.17 Our study showed that subjects who were under psychological stress were not problems, this assertion can only be assessed to a limited extent, even if it is consistent with what is stated in the relevant literature. In summary, we believe that it is nec essary as part of occupational health promotion to intervene in patients ing from hypertonia, high BMI and waist circumference as well as executives with low physical activity level should be addressed by health promo tion programs. These patients should perform regular weight and endur ance training. In order to achieve op timum effects and avoid injuries as a result of excessive strain, this training should initially take place under guid ance. Military executives have the potential to be a multiplier for health promotion in the military units where they are responsible for the wellbeing of their subordinate personnel. REFERENCES 1. Leroux I, Brisson C, Montreuil S. Job strain and neck-shoulder symptoms: a prevalence study of women and men white-collar workers. Occup Med (Lond) 2006;56(2):102-109. doi:10.1093/occmed/ kqj005. 2. Schulze C, Becker M, Finze S, Holtherm C, Hin velopment of medical and orthopaedic conditions in military executives. 2016:3929104. doi:10.1155/2016/3929104. 3. McCoy K, Stinson K, Scott K, Tenney L, New man LS. Health promotion in small business: a and effectiveness of worksite wellness programs. J Occup Environ 2014;56(6):579-587. doi:10.1097/ JOM.0000000000000171. 4. Schulze C, Lindner T, Goethel P, Mller M, Kundt G, Stoll R, Mittelmeier W, Bader R. Evaluation of the physical activity of German soldiers de pending on rank, term of enlistment, and task area. Mil Med 2015;180(5):518-523. doi:10.7205/ MILMED-D-14-00276. 5. Schnohr, Christina, Lise Hjbjerre, Mette Riegels, Luise Ledet, Tine Larsen, Kirsten Schultz-Lars en, Liselotte Petersen, Eva Prescott, and Morten effects of smoking, alcohol, physical activity, and obesity on mortality? A prospective population study. Scand J Public Health 2004;32(4):250-256. doi:10.1080/14034940310019489. Table 7. Overview of the performance of subjects with high blood pressure and those with healthy blood pressure at the 4 mmol lactate threshold and at maximum per formance in the bicycle ( p4mmol-L, pmax) in watts, and treadmill ( v4mmol-L, vmax) cardiac stress tests in km/h.Subjects(N=bicycle/treadmill)p4mmol-L W pmax W v4mmol-L km/h vmax km/h High blood pressure (N=30/8) 158 0 (35. 0) 205 97 (52 3) 9 8 (1 2) 11. 95 (1. 1) Healthy blood pressure (N=56/28) 168 0 (37. 2) 231 77 (47. 1) 10 .7 (1 .7) 13 33 (1 7)P. 223 02 118 037 Table 8. Overview of performance of subjects with and those without orthopaedic disorders at the 4 mmol lactate threshold and at maximum performance in the bicycle ( p4mmol-L, pmax) in watts, and treadmill ( v4mmol-L, vmax) cardiac stress tests in km/h.Subjects(N=bicycle/treadmill)p4mmol-L W pmax W v4mmol-L km/h vmax km/hOrthopaedic disorders (N=81/30) 164 4 (37. 1) 222 1 (49 7) 10 9 (1 5) 13 3 (1 6) No orthopaedic disorders (N=5/8) 167 8 (29 4) 233. 0 (63. 2) 9 0 (1 2) 11. 5 (1. 0)P.644 .657 012 012

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110 http://www .cs.amedd.army .mil/amedd_journal.aspx6. Mc Carthy VJ, Perry IJ, Greiner BA. Job control and ambulatory blood pressure. Scand J Work Environ Health 2014;40(5):457-464. doi:10.5271/ sjweh.3435. 7. Poorabdian, Siamak, Mirlohi AM, Habibi E, Shakerian M. Association between job strain (high demand-low control) and cardiovascular disease risk factors among petrochemical industry workers. Int J Occup Med Environ Health 2013;26(4):555562. doi:10.2478/s13382-013-0127-x. 8. Laukkanen JA, Rauramaa R, Salonen JT, Kurl ness combined with coronary risk evaluation and the risk of cardiovascular and all-cause death. J Intern Med 2007:262(2):263-272. doi:10.1111/j.1365-2796.2007.01807.x. 9. Astrand PO. Measurement of maximal aerobic ca pacity. Can Med Assoc J 1967;96(12):732-735. 10. Chang WD, Lin HY, Lai PT. Core strength training for patients with chronic low back pain. J Phys Ther Sci 2015;27(3):619-622. doi:10.1589/jpts.27.619. 11. Heck H, Mader A, Hess G, Mcke S, Mller R, tate threshold. Int J Sports Med 1985;6(3):117-130. doi:10.1055/s-2008-1025824. 12. Cohen J. Statistical Power Analysis for the Behav ioral Sciences 2nd ed. Hillsdale, NJ: L. Erlbaum Associates; 1988. 13. Janhsen K, Strube H, Starker A. Hypertonie. Ge sundheitsberichterstattung des Bundes 43 Berlin: Robert-Koch-Inst; 2008. 14. Lange C. Daten und Fakten:Ergebnisse der Studie Gesundheit in Deutschland aktuell 2010. Beitrge zur Gesundheitsberichterstattung des Bundes Ber lin: Robert-Koch-Inst; 2012. 15. Health in Germany. Federal Health Reporting Berlin; 2008. 16. McGonagle AK, Beatty JE, Joffe R. Coaching for workers with chronic illness: evaluating an inter vention. J Occup Health Psychol 2014;19(3):385398. doi:10.1037/a0036601. 17. Schwaberger G. Heart rate, metabolic and hor monal responses to maximal psycho-emotional and physical stress in motor car racing drivers. Int Arch Occup Environ Health 1987;59(6):579-604. AUTHORS Maj Schulze is with the Department of Orthopaedics, Rostock University Medical Center, Rostock, Germa Sports Medicine, Warendorf, Germany. Maj Becker is with the Department of Orthopaedics, Rostock University Medical Center, Rostock, Germany. Ms Finze is with the Department of Orthopaedics, Ros tock University Medical Center, Rostock, Germany. Lt Col Holtherm is with the Bundeswehr Centre of Sports Medicine, Warendorf, Germany. Lt Col Hinder is with the Bundeswehr Centre of Sports Medicine, Warendorf, Germany. Col Lison is with the Bundeswehr Centre of Sports Med icine, Warendorf, Germany.AN EVALUATION OF THE SIGNIFICANCE OF INDIVIDUAL ENDOGENOUS RISK FACTORS AND MEDICAL AND ORTHOPAEDIC CONDITIONS ON PHYSICAL FITNESS IN MILITARY EXECUTIVES

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