Restricted Duty Research Articles

Functional outcomes of instrumented posterior lumbar interbody fusion in active-duty US servicemen: A comparison with nonoperative management

Background context: The existing literature lacks a functional outcome study addressing instrumented posterior lumbar fusion surgery in physically active patients. Furthermore, results of operative versus nonoperative treatment in these patients are not clear. Purpose: To evaluate patient-assessed function, pain, and satisfaction and military job performance between servicemen treated operatively and nonoperatively. Study design/setting: This is a nonrandomized analysis of consecutive active-duty military servicemen treated either operatively or nonoperatively for chronic back pain and single-level lumbar disc degeneration with emphasis on functional outcomes. Patient sample: Active-duty US servicemen with chronic low back pain. Outcome measures/methods: Twenty-nine consecutive active-duty US servicemen were treated for chronic back pain and single-level lumbar disc degeneration by the same surgeon at a military spine facility. Fifteen were treated with instrumented posterior lumbar interbody fusion (PLIF), and 14 refused surgery and chose to be treated nonoperatively with spinal extensor muscle-strengthening exercise, medications, and restricted duty. The average follow-up time was 14 months (range, 6 to 24 months). All servicemen completed a functional outcome questionnaire American Academy of Orthopedic Surgeons/Scoliosis Research Society (AAOS/SRS) with emphasis on pre- and posttreatment function, pain, and satisfaction. The two groups were also compared using military job performance parameters. Results: Four of 14 (28%) of the servicemen treated nonoperatively ultimately received a disability discharge from the military for back pain, another 5 of 14 (36%) remained on permanent duty-restriction profiles, and only 5 of 14 (36%) returned to full, unrestricted military duty. In the PLIF group, 12 of 15 soldiers (80%) were able to return to full duty, only 3 of 15 (20%) remained on permanent restrictive duty-limitation profiles, and 0 of 15 (0%) received a disability discharge from the military for back pain. Twelve of 15 (80%) of the PLIF group and 8 of 14 (57%) of the group treated nonoperatively were physically able to complete the posttreatment physical fitness test. No difference was observed between premorbid and posttreatment physical training (PT) test scores in either group. However, scores for patient-assessed posttreatment pain, function, and satisfaction were significantly higher in the PLIF group. Soldiers who were able to return to full military duty did so at an average of 2 months for the group treated nonoperatively (n = 5) and 4 months for the PLIF group (n = 12). Complications in the PLIF group included dural tear (n = 2), unilateral transient lower extremity paresthesia (n = 1), and wound seroma requiring reoperation (n = 1). Conclusions: In this nonrandomized study of 29 active-duty US servicemen with chronic low back pain and single-level lumbar disc degeneration, instrumented PLIF surgery was associated with a high rate of return to full military duty. Servicemen treated with this technique were less likely to receive a back pain disability discharge or a permanent physical limitation profile when compared with servicemen who chose to be treated nonoperatively. Outcomes with respect to postreatment pain, function, and satisfaction were higher in patients treated with instrumented PLIF and were excellent in servicemen who were able to return to full duty regardless of treatment.

Restorative Proctocolectomy in UK Servicemen

To investigate the outcome of restorative proctocolectomy (RPC) in UK Servicemen and to determine the compatibility of this procedure with Service life. All Servicemen undergoing restorative proctocolectomy for ulcerative colitis (UC) or familial adenomatous polyposis (FAP) up to December 31st 2000 were identified from Service records. Patients were reviewed by direct or telephone interview. Pouch function, military duties, medical category or reasons for discharge from the Service were recorded. Fifteen Servicemen (6 Royal Navy, 6 Army, 3 RAF), mean age 30 years, underwent RPC for UC (14) or FAP (1) with a median follow-up of 74 months. Eight remain in their Service, five of whom carry out full duties and three restricted duties. Of the seven who have left the Services only one was medically unfit to continue due to poor pouch function whilst six left voluntarily to pursue active civilian careers. Fourteen patients have acceptable pouch function; one pouch has been excised for intractable pouchitis. Restorative proctocolectomy is compatible with Service life and most individuals are capable of fulfilling active unrestricted military duties.

A Facilitated Early Return to Work Program at a Large Urban Medical Center

An Early Return to Work Program was initiated at The Johns Hopkins Hospital and Associated Schools of Medicine, Hygiene and Nursing in Baltimore, Maryland, in April 1992 as part of a comprehensive effort to control the incidence and costs of work-related illnesses and injuries. The program was similar to others that incorporate employee and supervisory training and job accommodation, but it also included an industrial hygienist trained in ergonomics to facilitate the placement of individuals with restrictions. The return to work program was studied over a 10-year period, comparing the number of lost workday cases, lost workdays, and restricted duty days before (1989 to 1992) and after (1993 to 1999) initiation of the program. A significant decrease (55%) was observed in the rate of lost workday cases before versus after the return to work program. Furthermore, the number of lost workdays decreased from an average of 26.3 per 100 employees before, to 12.0 per 100 employees after, the return to work initiative, and the number of restricted duty days went from an average of 0.63 per 100 employees to 13.4 per 100 employees (a twentyfold increase). The study suggests that a well-structured early return to work program is an integral part of a comprehensive effort to control the duration of disability associated with occupational injuries and illness. It also indicates that to be most effective, an early return to work program must include participation by medical providers, safety professionals, injured employees, and supervisors. Our work suggests that even with these elements in place, the effectiveness of return to work programs may be increased by including an individual trained in ergonomics to facilitate the job placement process.

The Effectiveness of the Parachutist Ankle Brace in Reducing Ankle Injuries in an Airborne Ranger Battalion

The purpose of this study was to determine if the parachutist ankle brace (PAB) decreases the number and severity of ankle injuries in an airborne Ranger battalion. A retrospective study was performed covering a 38-month period. A computer database was used to track all jump injuries with a diagnosis of ankle pain, sprain, or fracture. The frequency was calculated for ankle injuries per 1,000 jumps and the average length of medically restricted duty per ankle injury. A total of 13,782 static line parachute jumps were conducted during the study period. Without the PAB, 35 ankle injuries were seen (4.5/1,000 jumps), with 9 fractures and 316 days of medical restriction per 1,000 jumps. Using the PAB, 9 ankle injuries were seen (1.5/1,000 jumps), with 3 fractures and 71 days of medical restriction per 1,000 jumps. The correct use of the PAB appeared to significantly decrease the incidence of ankle injuries in this battalion.

Interventions for the primary prevention of work-related carpal tunnel syndrome

Objective: To evaluate interventions for the primary prevention of work-related carpal tunnel syndrome (CTS). Selection Criteria: Studies had to include an engineering, administrative, personal, or multiple component intervention applied to a working or working-age population. All study designs that included comparison data were considered. Outcome measures included the incidence, symptoms, or risk factors for CTS, or a work-related musculoskeletal disorder of the upper extremity that included CTS in the definition. Results: Twenty-four studies met our inclusion criteria. Engineering interventions included alternative keyboards, computer mouse designs and wrist supports, keyboard support systems, and tool redesign. Personal interventions included ergonomics training, splint wearing, electromyographic biofeedback, and on-the-job exercise programs. Multiple component interventions (e.g., ergonomic programs) included workstation redesign, establishment of an ergonomics task force, job rotation, ergonomics training, and restricted duty provisions. Multiple component programs were associated with reduced incidence rates of CTS, but the results are inconclusive because they did not adequately control for potential confounders. Several engineering interventions positively influenced risk factors associated with CTS, but the evaluations did not measure disease incidence. None of the personal interventions alone was associated with significant changes in symptoms or risk factors. All of the studies had important methodologic limitations that may affect the validity of the results. Conclusions: While results from several studies suggest that multiple component ergonomics programs, alternative keyboard supports, and mouse and tool redesign may be beneficial, none of the studies conclusively demonstrates that the interventions would result in the primary prevention of carpal tunnel syndrome in a working population. Given the societal impact of CTS, the growing number of commercial remedies, and their lack of demonstrated effec- tiveness, the need for more rigorous and long-term evaluation of interventions is clear. Fund- ing for intervention research should prioritize randomized controlled trials that include: (1) adequate sample size, (2) adjustment for relevant confounding variables, (3) isolation of speci- fic program elements, and (4) measurement of long-term primary outcomes such as the inci- dence of CTS, and secondary outcomes such as employment status and cost.

Back injury and work loss. Biomechanical and psychosocial influences.

The exponential increase in occupational low back pain disability is a problem that is not being addressed adequately in clinical practice. The notion of achieving primary control through ergonomic intervention, based on biomechanics principles, has so far been unhelpful. The traditional secondary prevention strategies of rest and return to restricted work duties are seemingly suboptimal. Biomechanics/ergonomic considerations may be related to the first onset of low back pain, but there is little evidence that secondary control based solely on these principles will influence the risk of recurrence or progression to chronic disability. More promising in this respect are programs that take account of the psychosocial influences surrounding disability. Work organizational issues are clearly important, but so also is the behavior of clinicians. The balance of the available evidence suggests that clinicians generally should adopt a proactive approach to rehabilitation by recommending, whenever possible, early return to normal rather than restricted duties as well as complementary psychosocial advice if the issue of chronic disability is to be successfully tackled.

The Value of In-House Physical Therapy

This article describes the benefits of an in-house physical therapy pilot program. The program was initiated in 1994 to improve employees' functional capacity after occupational and nonoccupational musculoskeletal injury, shorten total disability time, use restrictive duty more productively, and reduce total disability costs. The pilot program's initial success led to the establishment of a permanent program.

Crew pairing at Air France

In the airline industry, crew schedules consist of a number of pairings. These are round trips originating and terminating at the same crew home base composed of legal work days, called duties, separated by rest periods. The purpose of the airline crew pairing problem is to generate a set of minimal cost crew pairings covering all flight legs. The set of pairings must satisfy all the rules in the work convention and all the appropriate air traffic regulations. The resulting constraints can affect duty construction, may restrict each pairing, or be imposed on the overall crew schedule. The pairing problem is formulated as an integer, nonlinear multi-commodity network flow problem with additional resource variables. Nonlinearities occur in the objective function as well as in a large subset of constraints. A branch-and-bound algorithm based on an extension of the Dantzig-Wolfe decomposition principle is used to solve this model. The master problem becomes a Set Partitioning type model, as in the classical formulation, while pairings are generated using resource constrained shortest path subproblems. This primal approach implicitly considers all feasible pairings and also provides the optimality gap value on a feasible solution. A nice feature of this decomposition process is that it isolates all nonlinear aspects of the proposed multi-commodity model in the subproblems which are solved by means of a specialized dynamic programming algorithm. We present the application and implementation of this approach at Air France. It is one of the first implementations of an optimal approach for a large airline carrier. We have chosen a subproblem network representation where the duties rather than the legs are on the arcs. This ensures feasibility relative to duty restrictions by definition. As opposed to Lavoie, Minoux and Odier (1988), the nonlinear cost function is modeled without approximations. The computational experiments were conducted using actual Air France medium haul data. Even if the branch-and-bound trees were not fully explored in all cases, the gaps certify that the computed solutions are within a fraction of one percentage point of the optimality. Our results illustrate that our approach produced substantial improvements over solutions derived by the expert system in use at Air France. Their magnitude led to the eventual implementation of the approach.

Surgical treatment of recalcitrant plantar fasciitis.

Twenty-six patients (35 feet) underwent partial plantar fasciectomy with neurolysis of the nerve to the abductor digiti quinti muscle. Nonsurgical treatment for plantar fasciitis had been unsuccessful in these patients. Patients were followed after surgery for an average of 37.5 months. Six patients were male and 20 patients were female; the average age was 49 years. All patients had failed to respond to nonsurgical treatment for an average of 21.5 months. In addition to routine history and physical examination patients were evaluated before and after surgery with a subjective foot rating system, and a detailed questionnaire was used to assess post-operative functional outcome. Thirty-two patients (92%) had a satisfactory functional outcome, and three patients (8%) had an unsatisfactory result (21 excellent, 11 good, 3 fair, 0 poor). The Maryland Foot Score increased from a preoperative average of 74.8/100 points to a postoperative average of 90.6/100 points. Four patients (11%) had postoperative complications, including superficial wound infection (two patients), deep venous thrombosis (one patient), and superficial phlebitis (one patient), all of which resolved uneventfully with treatment. Ten patients (28.6%) reported some degree of heel pain after surgery. All 10 patients denied limitation in activity related to postoperative pain. The average period before return to daily activity and restricted work duty was 5.6 weeks and to full work duty without restriction was 8.7 weeks. Although the length of time for partial or complete resolution of symptoms is variable, a successful treatment outcome can be expected in most patients who are treated for recalcitrant plantar fasciitis.

The Future Role of Managed Care and Capitation in Workers’ Compensation

A patient of mine, Mrs. Lopez, suffered a lower back injury while lifting heavy equipment. She sustained the injury while working in the housekeeping department at a local college. I telephoned her supervisor and asked him about Mrs. Lopez’s injury. He assured me that he had forwarded an accident report to the benefits department. He said he was unaware of any employer policies or training programs governing heavy lifting. The college did not have an employee health service, but instead relied on a local law firm to handle the administration of its workers’ compensation. When I informed the supervisor that I thought Mrs. Lopez might be able to return to a restricted duty job soon, he said that he did not want Mrs. Lopez to return until “she was 100%.” I told him that this employee would benefit medically from returning to a restricted duty job as soon as it was reasonable rather than waiting until she could perform heavy lifting again. However, the supervisor replied “Don't you worry about returning her to work so soon. Workers’ compensation will pay for it.”

EMPLOYEE HEALTH BY DESIGN: USING EMPLOYEE INVOLVEMENT TEAMS IN ERGONOMIC JOB REDESIGN

An innovative, team‐based, ergonomic job redesign effort in a large Midwest organization is described. Joint management‐labor teams composed of representatives from each department of the plant were formed and trained in team‐building and ergonomic principles. These teams prioritized jobs for ergonomic redesign and developed and implemented solutions. Sources of data for this redesign process included: a physical symptom survey, OSHA logs for cumulative trauma disorders (CTDs), observations, videotapes, and employee interviews about their jobs, tools, and pain experienced at work. Ergonomic changes at the plant resulted in significant reductions in the number and severity of CTDs, lost production time, and restricted duty days. Recommendations based on experiences with this ergonomic intervention are made for HRM practitioners.

An Analysis of Duty Restrictions of Aviation Personnel in the Republic of Korea

Aviation medical records were reviewed from four U.S. Army medical clinics in the Republic of Korea for flying duty restrictions over a 1-year time period. Duty restrictions were catalogued into 1 of 15 different diagnostic categories and compared by parameters of duration, time of year, crew status, age, and sex. Four hundred twenty-eight records were reviewed. Respiratory illnesses were the most common cause of flight restriction, followed by gastrointestinal and musculoskeletal problems. Flight personnel averaged 12.8 days a year on restrictions. Non-crewmembers were frequently not restricted for treatments that should have required restriction, but when restricted, averaged a significantly longer period of time than crewmembers. Females averaged significantly fewer days out for restrictions, and there were large differences in the number of days out by age for certain restrictions, but the numbers were small. There were some seasonal variation noted in patient visits with fewer visits in the spring and summer.

Atrial fibrillation.

Atrial fibrillation is a common arrhythmia and one which may cause pilot incapacitation. In many cases there may be no more than one episode and there will be no organic heart disease. Prediction of the risk of recurrence is not possible. Atrial fibrillation in both paroxysmal and persistent forms should be disqualifying for Class I or unrestricted Class III certification. Individuals with a single episode of atrial fibrillation related to a reversible toxic cause but with no evidence of organic heart disease could be considered for restricted duty subject to echocardiographic and ambulatory electrocardiographic follow up. Atrial flutter and atrial tachycardia should disbar from aircrew duties.

Certificates for restricted duties

Certificates for restricted duties

Allergy practice in the military service

Clinical allergy problems in the military service present some relatively unique facets. These include evaluation of immunization reactions, problems with hyposensitization therapy because of frequent movement of personnel, occasional high allergen exposure, and lack of uniformity of allergen extracts. Administrative problems relate to evaluation of personnel for induction or enlistment, retention, and duty restrictions. Economics and the availability of trained personnel are some factors influencing the mode of practice.

Resident Duty Hours: A Review

Residents are physicians undertaking further training to become independently licensed practitioners. Historically, resident duty hour periods were long and intense. The goal was to maximize learning through high patient volume and to teach doctors how to take responsibility. Recently, concerns over patient and resident safety have led to restricted trainee work hours. The putative justification is to improve resident education, resident well-being, and patient care. In light of this recent shift in the medical culture, resident duty hours have become a controversial topic. Restricted duty hours take many forms. In the United States, the Accreditation Council for Graduate Medical Education (ACGME) mandated junior residents work no longer than 16 consecutive hours, while senior residents could work up to 26 hours.1 In Canada, no nationwide mandate exists and the issue falls within provincial jurisdiction. In Ontario, under the Professional Association of Residents of Ontario agreement, call-periods are no more than 26 consecutive hours in-house, no more than one in four nights in-house, or no more than one in three nights of home-call. After a 2011 Quebec court ruling, resident duty hours were restricted to 16 consecutive hours in that province. This resulted from the court concluding that traditional hours violate the Canadian Charter of Rights and Freedoms. Regardless, the Quebec ruling prompted other Canadian programs to further reduce resident duty hours and consecutive hours on-call. To better understand this complex issue, the following review discusses resident safety, resident performance, resident education, and patient safety. Our goal is to present a balanced, evidence-based discussion, addressing both patient safety and resident fatigue management.

Resection in pulmonary tuberculosis: A report on 125 excisions in 123 cases

Summary A report on 125 consecutive resections in 123 patients at the Army Chest Centre has been presented. The majority of these patients were young and had relatively localised disease. In these, operative mortality was low and the complication rate negligible. Patients were normally discharged from hospital thirteen weeks after resection and returned to restricted duty or light work twenty-one weeks after operation. These times compare favourably with what might have been considered reasonable had medical measures alone been employed.

Age Limit Raised for Restricted Shore Duty in Medical Corps of the Navy

Age Limit Raised for Restricted Shore Duty in Medical Corps of the Navy