Active Duty Military Population Research Articles

Test-Retest Reliability of Four Computerized Neurocognitive Assessment Tools in an Active Duty Military Population

Computerized neurocognitive assessment tools (NCATs) are increasingly used for baseline and post-concussion assessments. To date, NCATs have not demonstrated strong test-retest reliabilities. Most studies have used non-military populations and different methodologies, complicating the determination of the utility of NCATs in military populations. The test-retest reliability of four NCATs (Automated Neuropsychological Assessment Metrics 4 [ANAM4], CNS-Vital Signs, CogState, and Immediate Post-Concussion Assessment and Cognitive Test [ImPACT]) was investigated in a healthy active duty military sample. Four hundred and nineteen Service Members were randomly assigned to take one NCAT and 215 returned after approximately 30 days for retest. Participants deemed to have inadequate effort during one or both testing sessions, according to the NCATs scoring algorithms, were removed from analyses. Each NCAT had at least one reliability score (intraclass correlation) in the "adequate" range (.70-.79), only ImPACT had one score considered "high" (.80-.89), and no scores met "very high" criteria (.90-.99). However, overall test-retest reliabilities in four NCATs in a military sample are consistent with reliabilities reported in the literature and are lower than desired for clinical decision-making.

Intensive Outpatient Prolonged Exposure for Combat-Related PTSD: A Case Study

The prevalence rates for combat-related posttraumatic stress disorder (PTSD) in U.S. military personnel returning from deployments to Iraq and Afghanistan indicate a significant demand for efficacious treatments that can be delivered in military-relevant formats. According to research with civilian and veteran populations, prolonged exposure is a first-line treatment for PTSD. However, research examining the generalizibility of prolonged exposure to active-duty military service members is scarce. Modifications to the standard prolonged exposure protocol may be required to meet military operational needs and to circumvent unique treatment barriers associated with the military. Intensive outpatient or compressed treatment delivered over a short time period has the potential for significant operational utility for active-duty military populations. Intensive outpatient practice formats have been found to be efficacious for the treatment of other anxiety disorders (i.e., specific phobia, obsessive-compulsive disorder). The present case report is the first to evaluate the use of intensive outpatient prolonged exposure for combat-related PTSD in an active-duty military service member. Treatment consisted of 10 full-day outpatient sessions over a 2-week period. The patient’s PTSD, depression, and anxiety were dramatically reduced by the end of treatment, and she no longer met diagnostic criteria for PTSD. She remained in full remission at the 6-month follow-up.

Perceived Insufficient Rest or Sleep among Veterans: Behavioral Risk Factor Surveillance System 2009

Sleep problems are of particular concern among the active duty military population as factors such as inconsistent work hours and deployment may compromise adequate sleep and adversely impact performance. However, few prior studies have investigated whether the prevalence of sleep problems differ between Veterans and demographically similar non-Veterans. The purpose of this study is to investigate whether self-reported insufficient rest or sleep varies in relation to Veteran status and to identify high-risk groups of Veterans. This study used data from the 2009 Behavioral Risk Factor Surveillance System (analyzed in 2011), a state based national telephone survey of non-institutionalized US adults. Insufficient rest was assessed in 411,313 adults aged 21 and older, of whom 55,361 were Veterans. Sleep duration was assessed in 6 states (n = 4,936 Veterans and 30,983 non-Veterans). Model-based direct rate adjustment was used to estimate the prevalence of insufficient rest or sleep while controlling for confounding. Multivariable logistic regression was used to estimate odds ratios of insufficient sleep or rest in subgroups of Veterans. After multivariable adjustment, insufficient rest or sleep (22.7% vs. 21.1%, p < 0.001) and short sleep duration (< 7 h/night, 34.9% vs. 31.3%, p = 0.026) were more common among Veterans than non-Veterans. When the Veteran group was further divided among newly transitioned (≤ 12 months) and longer-term Veterans (> 12 months), the overall test for a difference was not statistically significant between groups, mainly because there was little difference in sleep between the two groups of Veterans. High-risk Veteran subgroups included those who were 21-44 years of age (vs. 65-74), women, non-whites, current smokers, obese, unable to work, and those in poor health. This study suggests that Veterans have a high burden of sleep problems and identifies subgroups that should be targeted to receive interventions and enhanced education regarding insufficient sleep.

Comparison of Functional Outcomes Following Bridge Synostosis with Non-Bone-Bridging Transtibial Combat-Related Amputations

The prevalence of penetrating wartime trauma to the extremities has increased in recent military conflicts. Substantial controversy remains in the orthopaedic and prosthetic literature regarding which surgical technique should be performed to obtain the most functional transtibial amputation. We compared self-reported functional outcomes associated with two surgical techniques for transtibial amputation: bridge synostosis (modified Ertl) and non-bone-bridging (modified Burgess). A review of the prospective military amputee database was performed to identify patients who had undergone transtibial amputation between June 2003 and December 2010 at three military institutions receiving the majority of casualties from the most recent military conflicts; two of those institutions, Walter Reed Army Medical Center and National Naval Medical Center, have since been consolidated. Short Form-36, Prosthesis Evaluation Questionnaire, and functional data questions were completed by twenty-seven modified Ertl and thirty-eight modified Burgess isolated transtibial amputees. The average duration of follow-up after amputation (and standard deviation) was 32 ± 22.7 months, which was similar between groups. Residual limb length was significantly longer in the modified Ertl cohort by 2.5 cm (p < 0.005), and significantly more modified Ertl patients had delayed amputations (p < 0.005). There were no significant differences between groups with regard to any of the Short Form-36 domains or Prosthesis Evaluation Questionnaire subsections. The modified Ertl and Burgess techniques offer similar functional outcomes in the young, active-duty military population managed with transtibial amputation.

Transforaminal Lumbar Interbody Fusion: Prognostic Factors Related to Retention in an Active Duty Military Population

Little information is available regarding patient-based factors that may influence results following transforaminal lumbar interbody fusion (TLIF) in younger, high-demand individuals. A query of all TLIF procedures performed on active duty military personnel at our institution was conducted for the time period 2005 to 2008. Data was abstracted, including age, gender, military rank, preoperative diagnosis, complications, and ability to remain in the military. Favorable outcome was defined as the ability of the patient receiving TLIF to remain on active duty, without medical separation (Medical Evaluation Board [MEB]), at a minimum of 1 year postsurgery. Univariate analysis was conducted to identify potential risk factors for MEB. Factors with a univariate p value <0.2 were included in multivariate analysis and sensitivity testing to identify independent predictors of outcome. The cohort included 143 patients with an average age of 36.3 years and mean follow-up of 34.9 months. Younger age (odds ratio 0.93 per year increase in age; 95% confidence interval 0.87, 0.98) and Junior Enlisted rank (odds ratio 6.42; 95% confidence interval 2.20, 18.74) were found to increase the risk of MEB, and these relationships were maintained in the sensitivity analyses. These findings highlight the potential role of activity level and sociodemographic status in outcomes after TLIF in a military population.

Outcomes Following Cervical Disc Arthroplasty in an Active Duty Military Population

Symptomatic cervical radiculopathy is a common problem in the active duty military population and can cause significant disability leading to limited duty status and loss of operational readiness and strength. Based on their increasing experience with cervical disc arthroplasty (CDA) in this unique patient population, the authors set out to further evaluate the outcomes and complications of CDA in active duty military patients. A retrospective review of a single military tertiary medical center was performed between August 2008 and August 2012 and the clinical outcomes of patients who underwent cervical disc arthroplasty were evaluated. There were 37 active duty military patients, with a total of 41 CDA. The study found good relief of preoperative symptoms (92%) and the ability to maintain operational readiness with a high rate of return to full unrestricted duty (95%) with an average follow-up of 6 months. There was a low rate of complications related to the anterior cervical approach (5%-8%), with no device- or implant-related complications.

Comparison of Complication Rates of Intramedullary Pin Fixation Versus Plating of Midshaft Clavicle Fractures in an Active Duty Military Population

Military service members have increased requirements of shoulder weight bearing to perform duties. Operative intervention has increased for treatment of displaced middle one-third clavicle fractures. Complications of operatively treated clavicle fixation have not been extensively studied. A retrospective, longitudinal cohort chart evaluation was conducted of all active duty members undergoing fixation of middle one-third clavicle fractures, for complications between intramedullary pin fixation and plate constructs. This review found 62 patients meeting inclusion criteria. Thirty-three patients underwent intramedullary pin fixation with Hagie pins and 31 patients underwent precontoured superior clavicle plate fixation of their middle one-third clavicle fractures. Complications included wound infection, skin and/or soft tissue irritation, and need for unplanned hardware removal. The overall complication rate was 31% in the plate fixation group versus 9% in the intramedullary pin group (p = .024). All patients achieved fracture union with return to duty; however, increased overall complications were seen in the plate fixation group.

Self-Reported Mild TBI and Postconcussive Symptoms in a Peacetime Active Duty Military Population

To investigate the potential cumulative impact of mild traumatic brain injury (MTBI) on postconcussive symptoms. A total of 224 active duty soldiers reporting MTBI within 1 year of testing. For 101, this MTBI was their only reported traumatic brain injury (TBI); 123 had sustained at least 1 additional MTBI during their lifetime. A No TBI control group (n = 224) was included for comparison. Self-report symptoms data via questionnaire. Within time since injury subgroups (≤3 months; Post-3 months), symptom endorsement (no symptoms, 1 or 2 symptoms, 3+ symptoms) among soldiers with 1 MTBI was compared with that of soldiers with 2 or more MTBIs. Injured soldiers' symptom endorsement was compared with that of soldiers who had not sustained a TBI. Among the recently injured (≤3 months), those with 2 or more MTBIs endorsed significantly more symptoms than those with 1 MTBI: 67% of soldiers with 2 or more MTBIs reported 3+ symptoms, versus 29% of One MTBI soldiers. Among Post-3 month soldiers, there were no significant differences between MTBI groups. Overall, soldiers with MTBI endorsed significantly more symptoms than those without TBI. Past experience of MTBI may be a risk factor for increased symptom difficulty for several months postinjury. Clinicians should ascertain lifetime history of brain injury when evaluating patients for MTBI.

Healing Touch With Guided Imagery for PTSD in Returning Active Duty Military: A Randomized Controlled Trial

Post-traumatic stress disorder (PTSD) remains a significant problem in returning military and warrants swift and effective treatment. We conducted a randomized controlled trial to determine whether a complementary medicine intervention (Healing Touch with Guided Imagery [HT+GI]) reduced PTSD symptoms as compared to treatment as usual (TAU) returning combat-exposed active duty military with significant PTSD symptoms. Active duty military (n = 123) were randomized to 6 sessions (within 3 weeks) of HT+GI vs. TAU. The primary outcome was PTSD symptoms; secondary outcomes were depression, quality of life, and hostility. Repeated measures analysis of covariance with intent-to-treat analyses revealed statistically and clinically significant reduction in PTSD symptoms (p < 0.0005, Cohen's d = 0.85) as well as depression (p < 0.0005, Cohen's d = 0.70) for HT+GI vs. TAU. HT+GI also showed significant improvements in mental quality of life (p = 0.002, Cohen's d = 0.58) and cynicism (p = 0.001, Cohen's d = 0.49) vs. TAU. Participation in a complementary medicine intervention resulted in a clinically significant reduction in PTSD and related symptoms in a returning, combat-exposed active duty military population. Further investigation of GT and biofield therapy approaches for mitigating PTSD in military populations is warranted.

Clavicle fractures in the United States military: incidence and characteristics.

Although it is generally known that clavicle fractures represent a common injury of the shoulder girdle in the general population, the true incidence in the active duty military population is unknown. Given the implications for such injuries on the ability to perform occupation-specific tasks, determining the incidence in the U.S. military population is worthwhile. The purpose of this study was to determine the incidence of clavicle fractures in the U.S. military and to identify any demographic risk factors for injury. We performed a query of the Defense Medical Epidemiology Database with the code from the International Classification of Diseases, Ninth Revision, for clavicle fractures for the years 1999 through 2008. An overall injury incidence was calculated, in addition to multivariate analysis, to determine independent risk factors among the following demographic considerations: sex, race, branch of military service, rank, and age. During the study period, a total of 12,514 clavicle fractures were documented among an at-risk population of 13,770,767 person-years for an incidence rate (IR) of 0.91 per 1,000 person-years in the U.S. Military. Males, when compared with females, were more than twice as likely to sustain a clavicle fracture (IR ratios [IRR], 2.30; 95% confidence intervals [CI], 2.12-2.49). The peak incidence of clavicle fractures occurred in the age groups of <20 and 20 to 24. Compared to black service members, the white service members were associated with significantly higher rate of clavicle fractures (IRR, 2.45; 95% CI, 2.28-2.63). The service members serving in the Marine Corps were associated with a higher IR of clavicle fractures when compared to those in the Navy (IRR, 1.44; 95% CI, 1.35-1.53). Junior enlisted service members were 34% as likely to sustain a clavicle fracture when compared to senior officers (IRR, 1.46; 95% CI, 1.34-1.60 and IRR, 1.12; 95% CI, 0.99-1.28, respectively). The incidence of clavicle fractures among U.S. military personnel (0.908 per 1,000 person-years) is higher than previous epidemiological reports.

Suicide incidence and risk factors in an active duty US military population.

The goal of this study was to investigate and identify risk factors for suicide among all active duty members of the US military during 2005 or 2007. The study used a cross-sectional design and included the entire active duty military population. Study sample sizes were 2,064,183 for 2005 and 1,981,810 for 2007. Logistic regression models were used. Suicide rates for all services increased during this period. Mental health diagnoses, mental health visits, selective serotonin reuptake inhibitors (SSRIs), sleep prescriptions, reduction in rank, enlisted rank, and separation or divorce were associated with suicides. Deployments to Operation Enduring Freedom or Operation Iraqi Freedom were also associated with elevated odds ratios for all services in the 2007 population and for the Army in 2005. Additional research needs to address the increasing rates of suicide in active duty personnel. This should include careful evaluation of suicide prevention programs and the possible increase in risk associated with SSRIs and other mental health drugs, as well as the possible impact of shorter deployments, age, mental health diagnoses, and relationship problems.

Functional Gait Analysis Before and After Delayed Military Trauma-Related Amputation: A Report of Three Cases.

The current conflicts in Iraq and Afghanistan have produced a large number of service members with severe combat-related injuries. Eighty-two percent of service members with combat-related injuries have sustained extremity trauma, which accounts for 54% of wounds overall1. Of all the lower-extremity amputations performed at military treatment facilities, approximately 13% (125 of 975) were the result of delayed or “elective” procedures2. Recent studies have shown that the outcomes of extensive salvage procedures for severely injured limbs are not necessarily definitive in a nonmilitary population3 and that early amputation can be preferable to limb salvage in many such instances3-12. Some military and nonmilitary population studies have considered a delayed amputation as occurring within as little as twenty-four hours postinjury, while other studies have cited a range over years4,13,14. Up to 15% of combat-related amputations have occurred later than twelve weeks postinjury, and the military medical community has adopted this as a reasonable timeframe during which initial operative efforts at limb salvage can be attempted2,14. Given the incidence of trauma-related amputation in the active duty military population, as well as the likely underreported frequency of similar scenarios in civilian trauma settings3,8,15-17, the goal of this report is to provide an analysis of gait in combat-injured patients before and after delayed amputation. Our institutional review board approved the retrospective review of the data presented in this manuscript. The three patients included in this case series were informed that data would be submitted for publication, and they all gave consent. Case 1. A forty-one-year-old male U.S. Navy navigator was involved in a midair collision and was ejected from his aircraft. Upon landing, he sustained a Gustilo …

Predictors of short-term work-related disability among active duty US Navy personnel: a cohort study in patients with acute and subacute low back pain

Musculoskeletal disorders of the spine in the US military account for the single largest proportion of the absence of sickness causes leading to early termination. We explored if selected psychological and physical factors were associated with poor outcome after episodes of low back pain (LBP). To identify clinical, demographic, and psychological factors predictive of work duty status after a complaint of LBP. A prospective clinical cohort of US Navy personnel treated for LBP. Eligible cases were active duty US Navy or Marine Corps personnel presenting to an emergency clinic or primary care clinic with a complaint of LBP, where the index episode of LBP was no more than 12 weeks duration before enrollment. The subject's work status (full duty, light duty, sick in quarters [SIQ], limited duty, or medically released to full duty) was abstracted from the subject's electronic medical record at approximately 4 weeks and then again 12 weeks after study enrollment. Work status in this study population is assigned by a Navy health-care provider at the time of a clinical visit and based on the health-care provider's determination of medical fitness for duty. This study collapsed work status into two groups, "full duty" (consisting of "full duty" and "medically released to full duty") and "not at full duty" (consisting of "light duty," "SIQ," and "limited duty"). Volunteers completed a baseline questionnaire consisting of recommended well-validated measures, including attitudes and beliefs about LBP and work (Fear-Avoidance Beliefs Questionnaire [FABQ] and the Tampa Scale of Kinesiophobia), distress (the Pain Catastrophizing Scale), clinical depression (The Center for Epidemiologic Studies Depression scale), a numeric pain intensity scale, self-perceived disability (Oswestry Disability Index), and general health status (12-Item Short Form Health Survey). Navy health-care providers conducted a back pain-specific medical evaluation. Associations are expressed as multivariate-adjusted prevalence ratios (PRs) estimated using Poisson regression. Two hundred fifty-three participants were enrolled. Work status outcome was collected for 239 participants. Predictors of "not at full duty" at 4 weeks after enrollment included having back pain for 4 weeks or less before study enrollment (PR, 2.69; 95% CI, 1.21-5.97) and increased FABQ Work subscale score (PR, 1.05; 95% CI, 1.01-1.08). The sole predictor of work status at 12 weeks after enrollment was increased FABQ Physical Activity (FABQ Physical) subscale score (PR=1.14; 95% CI, 1.00-1.30). The findings that fear-avoidance beliefs were predictive of subsequent work status among active duty service personnel in this study population (after adjusting for clinical, demographic, and psychological covariates) suggest the clinical utility of addressing these factors during treatment of back pain episodes in the military. These findings reflect the important role that psychological factors may play in the return to work process in an active duty military population.

Incidence of Osteochondral Lesions of the Talus in the United States Military

Osteochondral lesion of the talus (OCLT) is frequently described as an uncommon diagnosis; however, little is known of its incidence. In light of increased awareness combined with the continued evolution of radiologic and treatment modalities, more attention has been given to this diagnosis. Serving a young, athletic population with unique occupational requirements, we have perceived an increase in the diagnosis of OCLTs. The goal of this study was to determine the incidence of OCLTs in an active duty military population, as well as demographic risk factors for OCLTs. We performed a query of the Defense Medical Epidemiology Database (DMED) of the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code for OCLTs which in the Armed Forces Health Longitudinal Technology Application (AHLTA) system is uniquely assigned the code 732.5. An overall injury incidence was calculated, in addition to multivariate analysis to determine independent risk factors among the following demographic considerations: gender, race, rank, branch of military service, and age. Year of diagnosis was also considered. The overall incidence rate for the 10-year period (1999 to 2008) was 27 OCLTs per 100,000 person-years. Significant demographic risk factors were female gender, white race, enlisted rank, service in the Army and Marines, and age greater than 20 years. Incidence rate was 16 per 100,000 in 2002, with steady annual increases resulting in an incidence rate of 56 per 100,000 person-years in 2008, corresponding to the years of active involvement in global combat operations. The incidence of OCLTs in the active duty military population was higher with female gender, white race, enlisted rank, increased age, and Army or Marine service.

Trends in Testicular Germ Cell Tumors Among U.S. Military Servicemen, 1990–2003

To determine the incidence of testicular germ cell tumors among active duty males and compare it with the incidence in the general U.S. population. The Automated Cancer Tumor Registry and the Surveillance, Epidemiology, and End Results Program data from 1990 to 2003 were analyzed for men aged between 20 and 59 years by histology and stage at diagnosis. Rates were age adjusted using the male active duty military population as the standard. Nonseminoma incidence was significantly lower in the military than in the general population (incidence rate ratio = 0.90, 95% confidence interval = 0.82-0.98). Trends in incidence tended to be similar in both the populations. Increases were observed for both histologic types but were only significant for seminoma (Automated Cancer Tumor Registry: 21% and Surveillance, Epidemiology, and End Results program: 16%; p < 0.05). Increases in incidence were only observed for localized tumors of both histologic types. The lower incidence of nonseminoma in the military and the increased incidence of localized tumors in both populations remain unexplained.

Complex Knee Problems in a Young, Active Duty Military Population. Part II: Posterolateral Corner, Meniscus, and Cartilage Injuries

The following set of articles is part II of II in a series of comprehensive reviews, clinical approaches, and descriptions of surgical techniques from members of the Society of Military Orthopaedic Surgeons (SOMOS). These articles include review articles for the treatment of posterolateral corner injuries and articular cartilage lesions, as well as surgical technique reviews for posterolateral corner injuries and meniscal injuries.

The Incidence of Low Back Pain in Active Duty United States Military Service Members

Epidemiological study. To investigate the incidence and risk factors for developing low back pain in active duty military population to include age, sex, race, and rank, and military service. Low back pain is among the most common musculoskeletal conditions worldwide and is estimated to affect nearly two-thirds of the US population at some point in their lives. Low back pain is a multifactorial disease and many risk factors have been implicated including age, race, sex, and marital status. A query was performed using the US Defense Medical Epidemiology Database (DMED) for the International Classification of Diseases, Ninth Revision, Clinical Modification code for low back pain (724.20). 13,754,261 person-years of data were investigated. Multivariate Poisson regression analysis was used to estimate the rate of low back pain per 1000 person-years, whereas controlling for sex, race, rank, service, age, and marital status. The overall unadjusted incidence rate of low back pain was 40.5 per 1000 person-years. Women, compared with men, had a significantly increased incidence rate ratio for low back pain of 1.45. The incidence rate ratio for the 40+ age group compared with the 20 to 29 years of age group was 1.28. With junior officers as the referent category, junior- and senior-enlisted rank groups had increased incidence rate ratio for low back pain, 1.95 and 1.35, respectively. Each service, when compared with the Marines as the referent category, had a significantly increased incidence rate ratio of low back pain: Army: 2.19, Navy: 1.02, and Air Force: 1.54. Compared with single service members, significantly increased incidence rate ratio for low back pain were seen in married service members: 1.21. Female sex, enlisted rank groups, service in the Army, Navy, or Air Force, age greater than 40 years, and a marital status of married were all risk factors for low back pain.

Special Considerations for ACL Graft Selection in the Young, Active Military Patient

Anterior cruciate ligament (ACL) injury is an extremely common injury in the young, physically demanding active duty military population. The diagnosis of an ACL injury in active duty military personnel often requires special consideration in terms of return to function, reliability, and performance of the knee-often in life-threatening situations when one has to rely on a stable knee for survival. This article outlines the considerations of ACL surgical treatment in the active duty military population, with an emphasis on the young, physically competitive athlete to optimize outcomes. Numerous treatment options and controversies regarding ACL surgery will be reviewed to provide a framework for which to perform a reliable and effective ACL surgery in active duty military personnel.

Complex Knee Problems in a Young, Active Duty Military Population. Part I: ACL Reconstruction, Allograft OATs, and Treatment of Meniscal Injuries

Complex Knee Problems in a Young, Active Duty Military Population. Part I: ACL Reconstruction, Allograft OATs, and Treatment of Meniscal Injuries

Unique Distal Clavicular Fracture in an Active-Duty Military Population

We present a series of distal clavicle fractures in which the coracoclavicular ligaments remain intact to the proximal segment, but the distal aspect of the clavicle is displaced superiorly. The fractures sustained in this series are not described in any of the multiple classification systems currently in use for clavicular fractures. We present a series of 2 active-duty patients who sustained nearly identical distal clavicle fractures during Army combatives training. A 23-year-old male was treated successfully with nonoperative therapy and returned to deployment within 2 months. A 23-year-old female failed nonoperative treatment and was successfully treated with an operative open distal clavicle resection. This rare fracture attributed to a specific mechanism of injury has a potential to be commonly encountered in active-duty patients taking part in mandatory combatives programs.