The Role of US Military Physical Therapists During Recent Combat Campaigns
- Josef H. Moore,
- Stephen L. Goffar,
- Deydre S. Teyhen,
- Timothy L. Pendergrass,
- John D. Childs and
- James R. Ficke
- J.H. Moore, PT, PhD, Graduate School, Academy of Health Sciences, US Army–Baylor University Doctoral Program in Physical Therapy, Army Medical Department Center and School, Fort Sam Houston, TX 78234 (USA).
- S.L. Goffar, PT, PhD, Rehabilitation Service, Landstuhl Regional Medical Center, Landstuhl, Germany, and US Army–Baylor University Doctoral Program in Physical Therapy.
- D.S. Teyhen, PT, PhD, Telemedicine and Advanced Technology Research Center, US Army Medical Research and Materiel Command, Fort Detrick, Maryland, and US Army–Baylor University Doctoral Program in Physical Therapy.
- T.L. Pendergrass, PT, DSc, US Army Office of the Surgeon General Allied Health Staff Office, Falls Church, Virginia.
- J.D. Childs, PT, PhD, MBA, Department of Physical Therapy (MSGS/SGCUY), 81st Medical Group, Keesler Air Force Base, Biloxi, Mississippi.
- J.R. Ficke, MD, Department of Orthopedics and Rehabilitation, San Antonio Military Medical Center, Fort Sam Houston, Texas.
- Address all correspondence to Dr Moore at: josef.moore{at}us.army.mil.
Abstract
US military physical therapists have a proud history of providing medical care during operational deployments ranging from war to complex humanitarian emergencies. Regardless of austerity of environment or intensity of hostility, US military physical therapists serve as autonomous providers, evaluating and treating service members with and without physician referral. This perspective article suggests that the versatility of US military physical therapist practice enables them not only to diagnose musculoskeletal injuries but also to provide a wide range of definitive care and rehabilitation, reducing the need for costly evacuation. War is not sport, but the delivery of skilled musculoskeletal physical therapy services as close to the point of injury as possible parallels the sports medicine model for on- or near-field practice. This model that mixes direct access with near-immediate access enhances outcomes, reduces costs, and allows other health care team members to work at the highest levels of their licensure.
The purpose of this perspective article is to provide a recent historical account for the roles and use of military physical therapists in treating service members with musculoskeletal injuries during Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF). Military physical therapists have established a long and respected tradition of setting the highest clinical practice standards in caring for military beneficiaries (active duty, dependents of active duty, retired, and dependents of retired), the example of which has been used to help develop the physical therapy profession as a whole. Practice standards continue to advance through emerging evidence, newer technology, more informed practice, and evidence-based guidelines.
Over the past 46 years, US Army physical therapists have had the advantage of being able to care for soldiers and other beneficiaries by means of direct access.1 Physical therapists in the US Air Force, and to a limited extent in the US Navy, have served their beneficiary populations in a similar role over the past few decades. The impact of physical therapists on improving the health and military readiness of service members has garnered the support of the military's medical leadership to such a degree that they are regularly credentialed by local military hospitals and health care facilities with clinical privileges to: safely examine patients with and without physician referral; order diagnostic imaging; prescribe medications; order laboratory tests; refer patients to other practitioners; initiate duty limitations; and perform electromyographic and nerve conduction studies.1–6 Military physical therapists are often the first credentialed health care provider in the process of care to diagnose and treat patients with musculoskeletal injuries. Direct access to military physical therapists for treatment of patients with musculoskeletal conditions has proven to be effective, with minimal risk.2–4,7–14
What makes military physical therapist practice in combat worthy of our attention today? US Army physical therapists have served in combat zones during previous wars in our nation's history; however, their contributions were often overlooked and so did not lead to changes in Army medical doctrine or policies that would institutionalize the role of physical therapists in future conflicts. Obviously, combat is not an athletic pursuit; however, the construct of treating service members as athletes provides many strategic advantages. Specifically, treating service members as tactical athletes provides a value model for preventing and treating musculoskeletal injuries closer to the point and time of injury.7 It now adds a rehabilitation capability to the combat zone whereby military physical therapists fully incorporate their vast competencies and capacity to treat patients under the most austere and dangerous environments. Physical therapist practice under these conditions not only entails all facets of evidence-based practice in injury prevention and human performance optimization but also prompt and accurate diagnosis and intervention for musculoskeletal injuries and minor wounds. Treating service members closer to the point and time of injury, particularly in combat, is intended to maximize recovery and minimize secondary or chronic morbidity.1,7
This musculoskeletal injury management practice is not new to physical therapists. It has been a large part of US Army physical therapist practice for more than 4 decades.1 Additionally, it obviates unnecessary medical evacuation within the combat zone or to higher levels of care in Germany or the United States, maintaining organizational integrity and eliminating costly personnel replacement. In general, early access to physical therapy has been demonstrated to result in higher quality of care, reduced costs, improved patient satisfaction, enhanced recovery time, decreased work absenteeism, and prevention of chronic complaints.15–17 The availability of orthopedically oriented physical therapists in the combat zone also has permitted surgeons, other physicians, and physician assistants time to treat service members with more complicated trauma or illness.7 This advance reduces nonsurgical referrals to orthopedic surgeons located at the Combat Support Hospitals (CSHs) and the need for service members to travel in dangerous convoys to seek orthopedic care for mild musculoskeletal injuries.7
Historically, musculoskeletal injuries are the primary cause for ambulatory visits among soldiers to military health care facilities.1,7,18 In 2010, approximately 2.5 million ambulatory visits for musculoskeletal injuries were recorded, accounting for $548 million in direct patient care costs.18 During this period, musculoskeletal injuries seen in all military health care facilities around the world, principally in the United States, represented 67% of all limited duty profiles (adjusted physical work requirements).18 Additionally, >80% of all musculoskeletal injuries were overuse injuries, with lower extremity overuse injuries listed as the number one cause of lost and limited days.18 The musculoskeletal injury rates are not unique to stateside assignments and occur in higher frequency in combat environments.19 In a deployed setting (combat zone), nonbattle musculoskeletal injuries account for 87% of all injuries.19 The rate of musculoskeletal injuries in deployed settings is estimated to occur 6.5 to 7 times more frequently than combat-related injuries.19 More than 75% of all medical evacuations from the OIF/OEF theater of operations were for noncombat musculoskeletal injuries associated with back, knee, foot and ankle, shoulder, hand and wrist, and neck pain.19 Belmont et al20 reported similar findings in a 15-month longitudinal cohort analysis of disease nonbattle injuries sustained by one US Army Brigade Combat Team (BCT). Of the 4,122 soldiers deployed, there were 1,324 disease nonbattle injuries, of which musculoskeletal injuries accounted for 50.4%.20
Although military physical therapists have the capacity to practice autonomously in managing musculoskeletal injuries, they do so as an integral member of an interdependent medical team that includes physicians, physician assistants, nurses, technicians, medics, and administrative personnel.7 Whereas respective military regulations allow a great degree of independence and encourage physical therapists to utilize their advanced practice privileges, local medical leadership might limit or expand the privilege list, depending on the practice setting, provider experience, and available resources. Military physical therapists routinely provide care in traditional settings such as hospitals or clinics in fixed, safe locations. However, today they also function in a variety of nontraditional, and sometimes highly austere, hostile settings with little to no equipment or supplies.7 For example, over the past decade, US Army physical therapists have been assigned to Army Special Operations units (eg, Rangers, Special Forces, Special Operations Aviation Regiments), BCTs, and CSHs.7 They have provided care for military personnel at bases across the United States, Europe, Southwest Asia, and Southeast Asia. Military physical therapists also routinely deploy to austere locations around the world to provide care in combat zones, most recently in Iraq and Afghanistan. In these settings, military physical therapists are primarily providing direct access care for patients with musculoskeletal injuries by use of their advanced practice privileges. The military attempts to define the various medical practice settings by describing levels of care (Tab. 1).
Overview of Settings in Which Military Medicine Is Conducted
Historical Perspective
The origin of physical therapy in the United States dates to utilization of “reconstruction aides” in stateside military hospitals during World War I.21 US Army physical therapists served in every theater of operation in World War II and served during the Korean War.22 During the Vietnam War, their role and responsibilities were expanded as physician extenders. This development came about principally because orthopedic surgeons struggled to manage the high volume of nonsurgical cases in addition to the overwhelming number of surgical cases they faced.1 Between 1966 and 1973, 43 US Army physical therapists served in 3 of the 4 combat zones in Vietnam.22,23 These physical therapists treated soldiers, civilians, and prisoners of war from all allied nations participating in the war, in addition to US soldiers wounded in combat.22,23 These experiences yielded anecdotal evidence that early intervention by a military physical therapist improved the prognosis, outcome, morale, and return-to-duty status of soldiers in a combat environment.22,23
During Operation Desert Shield, nontraumatic orthopedic problems accounted for the highest incidence of primary health care visits.24 Of the 180 patients evacuated from Operation Desert Shield and Desert Storm (ODSS) just to Madigan Army Medical Center in Fort Lewis, Washington, 52% had at least 1 orthopedic diagnosis, 45% did not require surgery and were able to return to duty without further treatment, and 38% had a condition that existed before deployment.25 Despite the negative impact of nontraumatic orthopedic injuries in a deployed setting and the significant contributions by forward- deployed US Army physical therapists during prior combat operations, only 5 physical therapists deployed to Southwest Asia in support of ODSS during the 1990–1991 conflict. One of these physical therapists provided an after-action report indicating he had treated 233 soldiers with musculoskeletal injuries.26 Each patient required an average of only 3 visits, with 90% of these patients returning to duty without requiring any further intervention.26 In comparison with the overall number of soldiers evacuated during ODSS with soft tissue injuries, an average of 21 days was required to evacuate the more than 1,177 soldiers at an estimated per-soldier replacement cost of $836,885.27
US Army physical therapists have been deployed to conflicts in Bosnia and Kosovo, as well as humanitarian operations in El Salvador, Ethiopia, Thailand, and Sri Lanka. While deployed, they provided musculoskeletal evaluations, developed and implemented field-expedient rehabilitation programs, and implemented injury prevention programs.26 In addition, a few US Army physical therapists served as subject matter experts to assist developing nations in the implementation of emerging rehabilitation training programs for physical therapists.26
During a deployment in Bosnia (1996–1997), a total of 3,475 patients were seen by various providers assigned to the 21st CSH. The lone physical therapist provided care to 19.2% (667/3,475) patients, the vast majority being those with musculoskeletal injuries.8 Of these, 78% (522/667) were able to return to duty without restrictions, whereas 20% (133/667) required a temporary duty restriction of a few days.8 Perhaps most important, only 2% (13/667) of the patients seen were required to miss duty, to be medically evacuated, or to be hospitalized overnight.8 In addition to direct patient care, the physical therapist established a multidisciplinary wellness program for deployed soldiers and traveled to remote military compounds to evaluate and treat soldiers at their duty location, mitigating the need of transport to the hospital.
US Army physical therapists were first placed in Army Ranger Battalions in 2000, and the impact of their presence was significant in the first year. Before the physical therapists' arrival, the operational readiness rate averaged 88% of Rangers that were healthy and ready for their wartime mission.26 “Operational readiness” is a general term used to indicate whether a commander feels his or her unit is capable of deploying. Different units use varied metrics (eg, number of soldiers available and not sick or injured, vehicles that are ready and maintenance free, all training requirements current) to determine operational readiness. Twelve percent of the Rangers were unable to deploy or operate under the Command's mission standards.26 Within 10 months, the deployment readiness rate for the Ranger Battalions averaged 95%.26 These successes were attributed to the Ranger physical therapist being able to provide direct access, early intervention, injury prevention and human performance optimization.26
After the success of the Ranger physical therapy model, the US Army Special Operations Command requested assignment of physical therapists to support the Special Forces mission. Beginning in 2003, US Army physical therapists began serving in Army Special Forces Groups. US Army physical therapists assigned to these elite forces blazed remarkable new paths for their profession not only within the Army, but throughout the Armed Forces. Soon thereafter, US Navy physical therapists were assigned on aircraft carriers and are now assigned with the Navy Special Operations Command, Sea, Air and Land (SEAL) teams and US Marine Special Operations Command. US Air Force physical therapists also have been recently assigned to a number of special operations units across the Air Force. On the basis of extensive anecdotal feedback and the continued expansion of the physical therapist's role, there is little question that the military services highly value the “sports medicine on the battlefield” concept.7
Although several US Army physical therapists have been temporarily attached to other Army combat organizations to support deployment since 2005, the practice of permanently assigning physical therapists as a standing member of BCTs and regimental organizations began in 2006.7 In this capacity, 62 US Army physical therapists have deployed during combat operations in Iraq and Afghanistan, and this number continues to grow.7 The National Guard began assigning citizen soldier physical therapists to their combat brigades in 2004, and the US Army Reserves continue to mobilize physical therapists for partner capacity building missions, United Nations efforts, and to support disaster relief in the United States and abroad.
US Military Physical Therapists in OIF/OEF
There are numerous and varied reasons beyond the scope of this article to ascertain why the percentages for combat injuries and loss of life are the lowest of any protracted war in which the United States has engaged.18 Since October 2001, approximately 2 million US service members have served 1 or more times in Iraq or Afghanistan.18 While several US Navy and Air Force physical therapists have served their respective service and nation in both wars, the following descriptive data were reported from US Army organizations.
From November of 2001 through March 2011, 162 US Army physical therapists deployed to one of these combat zones as a health care provider with an estimated 222 deployments.7 The rationale for the number of estimated deployments is that a few physical therapists have deployed more than once, and all US Army physical therapists assigned to the US Army Special Operations Command have deployed multiple times. Was there a need to put US Army physical therapists in either combat zone? The answer would be no if strictly utilized as a prescription service with the use of historical definitions of long-term rehabilitation. However, using the sports medicine model, US Army physical therapists were deemed to be a valuable asset to not only the medical team but equally to the warfighters because of their ability to prevent, diagnose, and manage musculoskeletal injuries while providing an opportunity for the orthopedic surgeons to focus on the multi-trauma surgical cases associated with a war zone.
Reporting and recording of patient injury and illness data were asynchronous throughout both combat zones. This was particularly true in the early years for both conflicts. Unlike electronic centralized medical databases used by the Department of Defense in the United States, vital medical data were captured locally and transferred from hardcopy documents to electronic spreadsheets. Approximately 7 years ago, some CSHs were able to use a version of the Composite Health Care System (CHCS) for maintenance of health records. Later, CHCS was upgraded to the Armed Forces Health Longitudinal Technology Application system but again not used universally or with the same capabilities experienced in the United States.
In early 2004, a decision was made to augment the medical data captured and reported locally by CSHs with additional data points to address the role of US Army physical therapists.7 A single-page data collection sheet was designed and administered to all Army physical therapists in Iraq with data capture and reporting beginning in July 2004.7 The data collection was modified in the summer of 2005 to accommodate the role of US Army physical therapists serving in BCTs.7 These data collection sheets were later transferred to an Excel spreadsheet (Microsoft Corporation, Redmond, Washington) for ease of reporting and data retrieval.7 From July 2004 through March 2011, data were requested from 116 US Army physical therapists assigned to either CSHs or BCTs.7 Of that number, 74 reported data to a central source at the Army Medical Department Center and School, located at Fort Sam Houston, Texas.7
The descriptive data collected by US Army physical therapists assigned to CSHs (Tab. 2) were compiled from July 2004 through December 2010.7 With few exceptions, each CSH only had 1 US Army physical therapist assigned. Nearly every CSH was divided into 2 modular hospital units and geographically separated in different regions of Iraq and Afghanistan. In each case, an additional physical therapist was augmented to the unit to provide care at the second medical site. Over the 6-year surveillance period, a total of 84,790 US military personnel were seen on an outpatient basis by different CSH providers for a variety of diagnoses.7 US Army physical therapists accounted for 45.3% (38,410) of the total outpatient workload. Whereas each CSH had at least 1 orthopedic surgeon, family medicine, and emergency medicine physician on staff, physical therapists treated 91.1% of US service members with musculoskeletal injuries. Because of a heavy and unpredictable surgical workload on orthopedic surgeons, physical therapists were principally used for primary care of outpatients with musculoskeletal injuries. Similar to anecdotal reports from previous wars, patients with musculoskeletal injuries were effectively treated by physical therapists, requiring limited visits.1,21,22,24,26 Of the 38,410 US service members with musculoskeletal injuries treated by US Army physical therapists, 58.4% (22,431) were first-time evaluations, with 44.9% (10,116) seen through direct access. The anatomic distribution of injuries evaluated by CSH physical therapists is listed in Table 3.
Descriptive Data Comparing Outpatient Physical Therapy Workload With All Outpatient Workload From Combat Support Hospitals During Operation Iraqi Freedom From July 2004 to December 2010
Musculoskeletal Injury by Body Part Managed by Combat Support Hospitals Physical Therapists
Despite only seeing US service members a limited number of times, 96.1% (21,602) of first-time evaluations were returned to duty with either no or temporary limited restrictions. In consultation with CSH physicians, it was estimated that 17.7% (3,979) of first-time evaluations would have been evacuated to Germany or the United States had the physical therapists not been present. Today, the actual cost to medically evacuate a service member varies from multiple factors, which prohibits calculating an exact dollar amount. However, the Air Force had an older formula used earlier in the war that provides an overly conservative cost savings estimate of more than $28.7 million. Given the multiple methods and debate around how medical evacuation costs should be calculated, there remains uncertainty regarding the extent to which the costs reported here represent a precise estimate of the total costs. However, the more important point is that whatever the method used, the cost of evacuating even a single service member is substantial, thus assessing opportunities to retain and rehabilitate service members in theater so that they can return to duty as quickly as possible should be a paramount health care priority.
Data for this article were collected by US Army physical therapists assigned to BCTs from August 2005 through March 2011 (Tab. 4). Although this work environment is even more austere than a CSH, with fewer assigned physicians and no orthopedic surgeons, data produced similar trends. Brigade Combat Teams are not designed for major surgical intervention and have no inpatient capability. These units contain the warfighters actually engaged with the enemy and are located throughout the combat zone. During the nearly 6-year surveillance period, a total of 332,197 US Army soldiers were seen by brigade providers, principally physician assistants and combat medics, on an outpatient basis for a variety of diagnoses. US Army physical therapists accounted for 35.8% (118,927) of the total workload, with 41.1% of those soldiers seen on a first-time basis. Of the 48,879 soldiers with new evaluations, 44.3% (21,653) were seen through direct access. Remarkably, 97.9% of the soldiers with first-time evaluations were returned to duty with either no or temporary limited restrictions. The anatomic distribution of injuries evaluated by BCT physical therapists is listed in Table 5. In consultation with brigade physician assistants, it was estimated that 30.9% (15,084) of soldiers with first-time evaluations would have been evacuated to a CSH had the physical therapist not been present.
Descriptive Data Comparing Physical Therapy Workload With Total Workload for Physical Therapists Assigned to Brigade Combat Teams During Operation Iraqi Freedom/Operation Enduring Freedom From August 2005 to March 2011
Musculoskeletal Injury by Body Part Managed by Brigade Combat Team Physical Therapists
What Does It All Mean?
Military physical therapists do not practice independently but work interdependently with orthopedic surgeons, family medicine and emergency care physicians, and physician assistants to help ensure optimal outcomes for military service members and beneficiaries.1,7,8 By functioning in a primary care direct access role to manage orthopedic and musculoskeletal injuries, military physical therapists are able to work more efficiently and effectively, reducing excessive patient visits, initiating evidence-based rehabilitation closer to the location and time of injury, while ensuring that serious injuries are expedited to orthopedic surgeons.2–7 This close working relationship between the physical therapists and all credentialed providers enables the physical therapists to autonomously manage musculoskeletal injuries, providing the orthopedic surgeons, family medicine, and emergency department physicians the opportunity to treat patients with more complex surgical and medical problems. The management of musculoskeletal injuries over several decades by military physical therapists within their respective stateside hospitals enabled these providers an easy transition to administering the same high level of evidence-based care in Iraq and Afghanistan.1,7
“Sports medicine” is an eclectic term, with no medical profession having exclusive rights to the name. Military physical therapists have long practiced sports medicine in their primary care direct access role for managing musculoskeletal injuries, both in stateside hospitals and now combat.1–4,14 We suggest most physical therapists serving their patient population in the management of musculoskeletal injuries through primary care direct access are practicing sports medicine without calling it such. The premise that this level of practice is effective is anecdotally supported by the descriptive musculoskeletal injuries and direct access data reflecting the value added benefit of physical therapists to the team of physicians and other providers in the CSH, plus the physicians and physician assistants in BCTs and battalion aid stations.7 We additionally propose that the efficacy for rehabilitation in an austere environment allows the tactical athlete to continue working in their deployed assignments while reducing the need to medically evacuate those with nonemergent findings. It is further supported when one looks at the high percentages of patients returned to duty.7
The wartime role of military physical therapy is deeply grounded in the vast number of casualties with nonsurgical orthopedic injuries and open wounds and burns requiring definitive on-site care without evacuation.7 The vision for this level of care seems to obviate many unnecessary evacuations and be both a monetary and military readiness benefit.7 The principles on which this vision is based stem from the historical work by numerous deployed physical therapists on operational assignments while serving as musculoskeletal primary care providers.7
Footnotes
Dr Moore, Dr Goffar, Dr Teyhen, Dr Pendergrass, and Dr Childs provided concept/idea/research design. Dr Moore, Dr Goffar, Dr Teyhen, Dr Childs, and Dr Ficke provided writing. Dr Moore, Dr Teyhen, and Dr Pendergrass provided data collection. Dr Moore and Dr Childs provided data analysis. Dr Moore provided project management. Dr Pendergrass, Dr Childs, and Dr Ficke provided consultation (including review of manuscript after submission).
Preliminary findings of this work were presented at the Annual Meeting of the American College of Sports Medicine; June 2–5, 2010; Baltimore, Maryland. An abstract presentation of the work was given at the Combined Sections Meeting of the American Physical Therapy Association; January 21–24, 2013; San Diego, California.
- Received March 28, 2012.
- Accepted April 25, 2013.
- © 2013 American Physical Therapy Association