JOURNAL

THE UNITED STATES ARMY

MEDICAL DEPARTMENT

October–December 2017
JOURNAL

A Professional Publication

of the AMEDD Community THE UNITED STATES ARMY

MEDICAL DEPARTMENT

Online issues of the AMEDD Journal are available at http://www.cs.amedd.army.mil/amedd_journal.aspx

October–December 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 

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GERALD B. O’KEEFE

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Secretary of the Army

Mark A. Milley

General, United States Army

Chief of Staff

DISTRIBUTION: Special 1726903

LTG Nadja Y. West

The Surgeon General

Commander, US Army Medical Command

MG Brian C. Lein

Commander

US Army Medical Department Center and School

US Army Health Readiness Center of Excellence

Edward A. Lindeke

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Borden Institute

Richard Burton

Editor

US Army Medical Department Journal
October – December 2017 i

Antibiotics in the Treatment of Patients With Lower Back Pain Associated With Modic Changes:

A Case Series . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Gaurav Gupta, MD, FRCPC; Peter Jarzem, MD, FRCSC; Major Sean Meredith, Pharm D; et al

Low Rate of Early Disabling Back Pain Following Traumatic or Posttraumatic

Major Extremity Amputation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10

CPT James N. Foster; CPT Richard K. Hurley, Jr; MAJ Chad A. Krueger

Use of Ankle Magnetic Resonance Imaging in the Active Duty Military Population:

The Results of a Process Improvement Project.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Maj Harold J. Goldstein; CPT Richard K. Hurley, Jr; Maj Andrew J. Sheean; et al

A Randomized Controlled Trial Evaluating Methylsulfonylmethane Versus Placebo to Prevent

Knee Pain in Military Initial Entry Trainees. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

CPT David J. Tennent; CPT Christina M. Hylden; MAJ Benjamin K. Kocher; et al

GEHS Neurophysiological Classification System for Patients with Neuropathy

of the Ulnar Nerve at the Elbow. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

David G. Greathouse, PT, PhD; Greg Ernst, PT, PhD; John S. Halle, PT, PhD; COL Scott W. Shaffer

The Influence of Smoking on Recovery from Subacromial Pain Syndrome:

A Cohort from the Military Health System. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

MAJ Daniel I. Rhon; John S. Magel, PT, DSc, PhD

Real Time Interrater Reliability of a Novel Musculoskeletal Readiness Screening Tool. . . . . . . . . . 43

LTC (Ret) Mark D. Thelen; LTC (Ret) Shane L. Koppenhaver; CPT Shanee E. Allen; et al

Cognitive Behavioral Therapy for Insomnia Treatment in a Military Deployed Operational Setting

Utilizing Enlisted Combat Medics: A Quality and Process Improvement Project. . . . . . . . . . . . . 52

MAJ Rohul Amin; CPT Brooke E. Wirtz

Sandfly Fever in Afghanistan–A Sometimes Overlooked Disease of Military Importance:

A Case Series and Review of the Literature. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60

LTC John W. Downs; Capt Daniel T. Flood; MAJ Nicholas H. Orr; et al

Smoking and Periodontal Disease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67

LTC Thomas M. Johnson

Core Temperature Responses of Military Working Dogs During Training Activities

and Exercise Walks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71

Catherine O’Brien, MS; Anthony J. Karis, BS; William J. Tharion, MS, MBA; et al

Effects of Technique-Focused Training in Conjunction with Physical Readiness Training

on Army Physical Fitness Test Performance. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79

LTC (Ret) Mark D. Thelen; LTC (Ret) Shane L. Koppenhaver; COL Noman W. Gill: COL Scott W. Shaffer

Evidence-based Practice and Single-case Designs in Psychotherapy . . . . . . . . . . . . . . . . . . 84

James M. Georgoulakis, PhD, JD; CPT Johanna G. Zollmann; Christopher L. Pate, PhD; Amy J. Hallett

A Descriptive Analysis of Data from the Department of Defense Joint Trauma System

Prehospital Trauma Registry. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92

MAJ Steven G. Schauer; MAJ Michael D. April; MAJ Jason F. Naylor; CPT Joshua J. Oliver; et al

A 12-Month Descriptive Analysis of Emergency Intubations at Brooke Army Medical Center:

A National Emergency Airway Registry Study. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98

MAJ Michael D. April; MAJ Steven G. Schauer; Calvin A. Brown III, MD; Capt Patrick C. Ng; et al

Evaluation of the Significance of Individual Endogenous Risk Factors and Medical

and Orthopaedic Conditions on Physical Fitness in Military Executives . . . . . . . . . . . . . . . . 105

Maj Christoph Schulze, MD, German Air Force; Maj Michael Becker, MD, German Army; et al

US Army Medical Department Journal

October–December 2017
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, Design, Train, Educate, Inspire

Joint Base San Antonio-Fort Sam Houston, Texas
October – December 2017 1

With a worldwide point prevalence of 12%, low back pain 

(LBP) is responsible for significant health care costs and 

lost productivity.1,2 Historically, the classification of LBP 

has been complicated by poorly validated clinical tools 

and nonspecific imaging findings.3,4 Thus, the treatment 

for so-called “nonspecific” LBP has been disappointing 

with various modalities used. This includes, but is not 

limited to lifestyle, rehabilitation, medications, injections, and surgical treatments.5-9

Until recently, the prevailing theoretical framework was 

that nonspecific LBP was a mechanical phenomenon 

complicated by genetic, biopsychosocial, and environmental factors. Similar to previous conceptualizations 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 

to findings found on T1 and T2 weighted sagittal MRI 

scans of the spine that are hyperintense on T2 and hypointense on T1, thought to reflect localized inflammation and edema.12 Using the study protocol of Albert et 

al, patients with low back and/or lower limb pain had 

significant improvement in clinical, imaging, work, and 

medical resource related measures one year after initiating treatment with 100 days of amoxicillin/clavulanate.11

The 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 pathobiology studies 14-17 showed that intervertebral disc herniations 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 colonized with bacteria went on to develop Modic changes 

long-term.14 However, the true culture rate may be significantly higher than what has been reported given the 

technical issues with sampling and bacterial preservation techniques, or lower given the potential risk of contamination.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 herniation, which also showed improved clinical outcomes.19

Antibiotics in the Treatment of Patients

 With Lower Back Pain Associated With

 Modic Changes: A Case Series

Gaurav 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

Abstract

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 antibiotic 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 

generally provide significant improvement in pain and function for patients in this small cohort. Despite early 

excitement regarding this treatment, further research is required.
2 http://www.cs.amedd.army.mil/amedd_journal.aspx

Proprionibacterium acnes is a part of the normal human 

flora, colonizing the mouth and skin, possibly associated with protecting the host against certain cancers.20 It 

can be pathological at sites of injury or indwelling medical devices by precipitating an inflammatory response 

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 tension, and pH. Colonization of a degenerated disc can occur via hematogenous spread, local infection, or a transvenous retrograde pathway from the pelvis.23

Significant discussion ensued following the publication 

by Albert et al.11 It has been clarified that the response 

to treatment was not influenced by injection/surgical 

history.24 Amoxicillin/clavulanate was the selected antibiotic based on its safety profile and ease of administration,24 but the efficacy outcomes could be influenced 

by regional variations in colonizing organisms.24 Furthermore, the authors explained the rationale for the 

antibiotic doses used in the trial, reasons for selecting 

the treatment length,25 issues regarding study design, 

the authors’ potential conflicts of interest,26 the reasons 

behind the creation of MAST (Modic Antibiotic Spine 

Therapy) Medical (http://www.mastmedical.com) and 

related financial interests,27 and why disc biopsy and 

culture should not be undertaken prior to treatment.28

Based 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 McGill 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 physical therapy and anti-inflammatory treatment for at least 

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 

thought to be a significant contributor to distress, if follow up could not be maintained for at least one year following treatment initiation, if there was an allergy/sensitivity to the medication, kidney disease (ie, estimated 

glomerular filtration rate less than 90 ml/min/1.73m2

), 

pregnancy, or breastfeeding.

Patients provided informed consent for the treatment 

protocol after discussion of potential risks including 

clostridum diffiicile infection and death. The data supporting 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 developed 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 

study findings which were retrospectively analyzed. A 

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 actively serving in the Canadian Armed Forces, while 3 

others were followed through clinicians at the McGill 

University Health Centre. Mild Modic changes were defined as less than 30% of the end plate volume, moderate 

between 30% and 60%, and severe greater than 60% of 

volume.12 Figures 1 and 2 show pre- and postantibiotic 

use MRI findings (respectively) in Patient 5.

Tables 1 and 2 present specifics related to patient demographics, baseline, outcomes, and imaging findings. 

Age at initiation of treatment ranged from 37 to 49 years, 

and there were 2 female patients in the series. All patients had LBP for at least 2 years. Prior to treatment 

with antibiotics, all patients had considerable therapy 

including medications, physical therapy, injection treatments, 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
October – December 2017 3

THE ARMY MEDICAL DEPARTMENT JOURNAL

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 (Patients 6, 7, 8, 10, 11). Patient 1 had mixed Modic 

1 and 3 changes.

Optimistically, 9 patients (82%) reported improvement at follow up (Patients 1, 2, 3, 4, 7, 8, 

9, 10, 11). However the time period of improvement 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 disability at 4 months, but was lost to follow up. Patient 4 had greater than 50% resolution for pain 

and a large improvement in function. The improvement may have been the result of physical 

therapy directed at sacroiliac joint mobilization 

and stabilization that were started one year after antibiotic treatment initiation. Patient 7 had 

good improvement in pain, and minor improvement 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 antibiotics. Patient 2 reported a 50% improvement in 

global perception, but objective pain and functional 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 improvement in symptoms after an artificial disc 

replacement done more than one year after the 

initiation of antibiotic treatment. Patient 11 reported an improvement in pain of about 50%, 

but not function, and he attributed his well-being as tied to consistent meditation and exercise 

(cycling).

Main side effects reported were mild gastrointestinal 

symptoms in 3 patients, which did not preclude treatment. There was one case of Hepatitis that required 

cessation of standard treatment, and normalization of 

liver function tests thereafter. Consistent with the earlier 

findings of Albert et al,11 most adverse effects were low 

grade gastrointestinal complaints such as loose bowel 

movements, increased flatus or burping, with less than 

Figure 1. Saggital T1 (image A) and T2 (image B) MRI for Patient 5 preantibiotic 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 postantibiotic use, showing progressive loss of disk height and substance 

as well as increasing T1 signal abnormality, mixed Modic changes, and 

endplate irregularity.
4 http://www.cs.amedd.army.mil/amedd_journal.aspx

3% 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 Modic 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.

Comment

Recent work11 has created a paradigm shift in the treatment 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 regions affected by Modic 1 changes reduced on MRI at 

one year follow-up in only the antibiotic treated group. 

(b) There was an insignificant trend toward more pain 

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 Pre- and Postantibiotic Use (1 of 3, continued).

Patient 1 Patient 2 Patient 3 Patient 4

Demographics

(sex, age) & Pain 

Region -Treatment

Male, 45 y; LBP100 days of 

Doxycycline. 

Had Hepatitis 

with Amox/Clav

Male, 49 y; LBPAmox/Clav, 90 daysMale, 44 y; LBP-Amox/Clav, 

90 days

Female, 37 y; LBP- Amox/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, prolotherapy, Amitryptiline, Nortriptyline, Gabapentin, inversion table

How Long Pain Present 2 years 27 years (worse 3

years ago)

Worse in last 2 years 7 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/L5

L5/S1 Modic 1 with small 

disk herniation

L4/5 & L5/S1 Modic 1.

Disc protrusion L4-L5

Pain and Function Score 

at Treatment Day 0

NRS 2/10

ODI 34%

NRS 3-8/10

ODI 50%

NRS not documented

ODI 34%

NRS 7/10

ODI 42%

Pain and Function

Score after Treatment

At 6 months; 

NRS no change

ODI 26%

At 4 months; improved 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 restrictions 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 up 16 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/S1

Modic 1 unchanged at L5/S1,

mild progression at L4/5

Other 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 activity 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.
October – December 2017 5

THE ARMY MEDICAL DEPARTMENT JOURNAL

group compared to the antibiotic group. (f) Quality of 

life measures improved significantly in the antibiotic 

group, but remained stable in the placebo group. (g) 

Blood CBC, LDH, and alk phos remained normal in 

most cases throughout the trial.11

In our case series, however, only 3 of 11 patients conservatively 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 manage 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 

available follow up imaging. This contradicts the findings of the 2 previous studies using antibiotics to treat 

low back pain in the setting of Modic 1 changes and disc 

herniation.11,18

Factors 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.30

From 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 steroid injections have been shown to be effective for pain 

relief and functional improvements at 6 months in patients with LBP and Modic 1 and 2 changes when compared to placebo.32 While one could argue that steroids 

may relieve the inflammation associated with bacterial 

production of proprionic acid,11 it is surprising that the 

long-term outcomes are not poorer 33 given that the potential anti-immune effects of steroids34 could limit the 

remediation of the infecting organisms. Alternately, in 

a case-controlled series of patients undergoing microdiscecotmy 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 Pre- and Postantibiotic Use (2 of 3, continued).

Patient 5 Patient 6 Patient 7

Demographics

(sex, age) & Pain 

Region -Treatment

Male, 38 y; LBP- Amox/Clav,

100 days

Male, 46 y; Cervicalgia and LBP–

Amox/Clav 90 days

Male, 39 y; LBP–Amox/Clav

90 days

Past Medical

History

Depression, Right knee arthroscopy 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 denervation, NSAIDS, Capsaicin cream, 

acetaminophen, bilateral SI joint 

prolotherapy, physiotherapy

Acetominophen, codeine, NSAIDS NSAIDS, Chiropractics, 

physiotherapy, massage therapy, 

mental health support

How Long Pain Present 3 years 7 years 9 years

Location & Type of

Modic Changes

L5/S1 Modic 1 changes

Disc herniation L5/S1

C5/6 Modic 1 changes. L5-S1;

Modic 1&2. Disc protrusion L5/S

L4/5 Modic 1/2 changes

Disc herniation L4/5

Pain and Function Score 

at Treatment Day 0

NRS 3-5/10

ODI not available

NRS 3-8/10, ODI-?

Difficulty with running, twisting, 

squats, bicep curls, shoveling, 

mowing the lawn, lifting groceries.

NRS 5-7/10

ODI 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/S1 No follow-up available Improved Modic 1 L4/5

Other Treatments/

Considerations,

Postantibiotics

Spinal manipulation therapy, gabapentin- had significant improvement when taking pregabalin (7

months postantibiotic treatment). 

Continued with radiofrequency 

denervation of lumbar facet 

joints.

Most recently treated for thyroid 

cancer.

Significant improvement in lower 

limb, pain, less severe constant 

pain, ongoing limitations for 

sitting and standing. Stopped 

running. Benefit from epidural 

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

A 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 

to Modic 1 changes. When looking specifically at causation, it was felt the criteria for temporal relationship, 

consistency, dose response relationship, and analogy 

was not met in the existing literature. Given that Modic 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.29

Numerous questions regarding the role of antibiotic 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 alleviation 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 patient’s 

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 tolerate standard therapy. Further clarification regarding 

the importance of findings at other spinal levels and the 

significance of other types of Modic changes will be required. Finally, the most important issue is how to manage patients with pain while they are undergoing treatment, waiting for clinical response, or have a suboptimal 

result from antibiotic treatment.36

ANTIBIOTICS IN THE TREATMENT OF PATIENTS WITH LOWER BACK PAIN

ASSOCIATED WITH MODIC CHANGES: A CASE SERIES

Table 1. Patient Clinical Data and Outcomes Pre- and Postantibiotic Use (3 of 3).

Patient 8 Patient 9 Patient 10 Patient 11

Demographics

(sex, age) & Pain 

Region -Treatment

Male, 41 y; LBP–Amox/Clav 

90 days

Female, 39 y; LBP–Amox/

Clav 90 days

Male, 39 y; Amox/Clav 

100 days

Male, 38 y; Amox/Clav 

90 days

Past Medical

History

Left sided hemorrhagic 

stroke 2001, reflux, 

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 3

Has tried physio, 

meds (NSAIDS, 

acetominophen), 

injections no help.

Has tried physio, 

ergotherapy, 

acupunture, injections, 

medications

Physio, core 

strengthening

How Long Pain Present 15 years. Worse in past 5

years. Multiple flares per 

year

3 years. Worse in past 2

years. Patient not at work 

at time of treatment

11 years. Worse in past 

2 years.

4 years

Location & Type of

Modic Changes

L5/S1 Modic 1/2 changes.

Mild disc protrusion L5/S1

Modic 1 changes

Disc herniation level of 

L4-L5

L5-S1 discopathy.

Moderate Modic 1

changes mostly in 

inferior endplate of L5

Moderate to severe mix 

Modic 1-2 at inferior 

endplate of L4.

Minimal Modic 1 at 

superior endplate of L5

Pain and Function Score 

at Treatment Day 0

NRS- 6/10

ODI not done

NRS 9/10

ODI 38%

NRS 6-7/10

ODI 48

NRS 7/10

OSW 30%

Pain and Function

Score after Treatment

Done at 10 months. No 

change in NRS. Reports 

no change in function.

ODI 26%

NRS 9/10

ODI 48%

NRS 6-7/10

ODI 48

At 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 0/10

ODI not available

One year after antibiotic; 

no pain due to cortisone 

injection

15 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 1 No follow-up available No changes from 

previous images

L4-L5 mix Modic 1-2,

increase changes at 

L5 superior endplate 

Modic 1

Other Treatments/

Considerations,

Postantibiotics

Ongoing pain and exercise 

limitations. Not pursuing 

other treatment at this 

time.

Patient feels better with 

yoga, epidural steroid 

injection.

Artificial disc 

replacement, L5/S1

Pain 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.
October – December 2017 7

THE ARMY MEDICAL DEPARTMENT JOURNAL

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 patient’s work productivity 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 analysis 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 landmark randomized controlled trials when applied in other 

clinical settings.37

Therefore, 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 patients with Modic changes and LBP had limited effect 

on reducing long-term pain and clinical outcomes in a 

small case series of patients.

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Table 2. MRI Findings Pre- and Postantibiotic for Available Patients.

Patient Pre-MRI Post-MRI

Patient 1 Mild Modic 1 changes at L4 and L5

Small disk protrusion (improved from 2014)

Moderate Modic 3 changes at L4 endplates 

Unchanged posttreatment 

Patient 2 Mild Modic 1 at T12 and L1

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involvement)

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range)

Slight progression Modic 2 – still in minor range

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Slightly 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 L5

No changes from previous images

Patient 11 Moderate to severe mixed Modic 1-2 at inferior endplate of 

L4. Minimal Modic 1 at superior endplate of L5

Increased Modic 1 changes at L4 superior endplate

L4/5 with small disk herniation
8 http://www.cs.amedd.army.mil/amedd_journal.aspx

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23. Arndt J, Charles YP, Koebel C, Bogorin I, Steib JP. 

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ANTIBIOTICS IN THE TREATMENT OF PATIENTS WITH LOWER BACK PAIN

ASSOCIATED WITH MODIC CHANGES: A CASE SERIES
October – December 2017 9

THE ARMY MEDICAL DEPARTMENT JOURNAL

26. Albert HB, Manniche C. Answer to the letter to 

the editor of Svend Lings entitled “antibiotics for 

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Albert HB et al., Eur Spine J (2013) 22:697-707. Eur 

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August 14, 2017.

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Albert HB et al., Eur Spine J (2013) 22:697-707. 

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JB, Deirmengian CA. Success of lumbar microdiscectomy in patients with modic changes and 

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BSD.0b013e318093e5dc.

36. O’Dowd J, Casey A Antibiotics a cure for back 

pain, a false dawn or a new era? Eur Spine J. 

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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 Professor at McGill University in Montreal, Quebec.

Dr Jarzem is an orthopaedic surgeon at Montreal General 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 command 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 Medicine and Rehabilitation, Department of Medicine, and 

the Alan Edwards Pain Management Unit of the Department 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, 

Montreal General Hospital, and affiliated with the Pontificia Universidad Catolica de Chile.

Dr Charghi is an anesthetist at the Jewish General Hospital and a pain physician at the Alan Edwards Pain Management unit, Montreal General Hospital. She is also 

an assistant professor at McGill University, Montreal, 

Quebec.

Dr Chankowsky is a neuroradiologist at the McGill University Health Center. He is also an Associate Professor 

and Associate Chair of Diagnostic Radiology at McGill 

University.
10 http://www.cs.amedd.army.mil/amedd_journal.aspx

Major extremity amputation has a well-documented association with persistent back pain, with rates of chronic 

low back pain in patients with major extremity amputation reported in the range of 35% to 80%.1-8 The effect of 

back pain on the patient with major extremity amputation 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 activity.2,9,10 It is also suggested that back pain can be more 

bothersome to the patient with amputation than pain related 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 published data, it is difficult to draw useable prognostics regarding the likelihood of developing disabling back pain 

for patients with traumatic or posttraumatic amputation.

The recent military conflicts have resulted in many US 

service members sustaining trauma-related major extremity amputations.11,12 The most common mechanism 

of injury leading to amputation in recent US combat operations has been by high energy blast, which is unique 

to this retrospective review in comparison to the published 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-related 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 service members with traumatic and posttraumatic major 

extremity amputation following the recent US military 

conflicts. We further sought to compare the prevalence 

of disabling back pain in a military population to the 

currently published rates.

Methods

This retrospective study was conducted under a protocol 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 

amputations (MEA), defined as an amputation proximal 

to the carpals or tarsals, sustained by US service members between December 1, 2002, and July 30, 2011.11,12

The injury characteristics, diagnoses, and other medical 

treatment information for each identified service member with a MEA was cross-referenced with the Joint 

Theater Trauma Registry (US Army Institute of Surgical Research, Fort Sam Houston, Texas), the Armed 

Forces Health Longitudinal Technology Application, 

and the Theater Medical Data System, specifically looking for dates of injury and level of amputation(s), the 

presence of associated traumatic spine injuries, and any 

pre- or postinjury treatment for back pain.

The Physical Evaluation Board Liaison Office for each 

military service branch was also queried for each of the 

identified SMAs. In the military, the Physical Evaluation 

Board (PEB) is a medical evaluation process that occurs 

following a major injury. The PEB determines whether 

a service member is fit for duty, requires a change in 

occupational role or restricted duty, requires further 

recovery time, or must permanently separate from the 

military with disability benefits. The PEB process also 

assigns final disability ratings to the service members 

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.16

For the purpose of this study, the presence of a PEB 

disability diagnosis related to back pain with a rating 

greater than zero signified the presence of disabling 

back pain. This was the primary outcome measure for 

the current study. Those SMAs treated for back pain prior to amputation, including narcotic medication, physical therapy, or chiropractic manipulation were excluded 

from final calculations of de novo disabling back pain 

(DDBP). A significant spine injury was considered to be 

any fracture or dislocation of the spine requiring surgical 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
October – December 2017 11

THE ARMY MEDICAL DEPARTMENT JOURNAL

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 

duration from index injury until the first appearance of 

a back pain diagnosis in the health record. A Fisher’s 

exact test was used for categorical data and a Student’s 

t test was used for the subgroup analysis, with significance set at P less than .05.

Results

A total of 1,221 US service members were identified as 

sustaining one or more MEA between December 2002 

and July 2011. The most common amputation level was 

transtibial, followed by unilateral above the knee, bilateral above the knee, and bilateral transtibial amputations as previously characterized by Krueger et al.12 At 

the time of data collection, 967 of the 1,221 SMAs had 

completed a PEB and had final disability diagnoses and 

ratings available for review. Among these 967 SMAs, 57 

sustained a significant spine injury as part of their index 

traumatic injury profile, 

and 910 did not. Fifteen of 

these 910 SMAs without a 

significant traumatic spine 

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 disability 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 

groups failed to show any statistically significant 

difference in the rate of DDBP when compared to 

the group as a whole (Table 1).

Among those SMAs whose PEB results were available for review, 690 included the date of PEB result, 

including 11 of the 15 SMAs with the primary outcome measure, DDBP. The average time from amputation 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 

was not significant (P=.096). The duration from index traumatic injury until the first appearance of a 

back pain-related diagnosis in the health record was 

also calculated for the 15 SMAs with DDBP and 

averaged 15.1 months.

Comment

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 disability rating as part of the PEB process (P=.0001) than 

those SMAs without a spine injury. The anatomic location 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 conclusions could be drawn. Although not statistically significant, the average time of final PEB disability ratings for 

SMAs 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 population, 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 patients with restrictions in 

activities of daily living 

as a result of LBP were 

39%.1

 While the majority of literature regarding 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 amputation with completed PEB

and no spine injury

910 15 1.65%

Distribution of the 1,221 SMA study subjects according to the criteria of associated significant spine injury, completion of the PEB 

process, and assignment of a spine-related disability rating.

Yes

15(1.65%)

No

895(98.35%)

Yes

14(24.56%)

No

43(75.44%)

Spine-related disability rating? Spine-related disability rating?

Completed PEB Process

910(79.1%)

Service members with major extremity amputations

December 2002-July 2011

1,221

No associated spine injury

1,150

Associated spine injury

71

Completed PEB Process

57(80.3%)
12 http://www.cs.amedd.army.mil/amedd_journal.aspx

with 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, because the PEB process attempts to quantify and objectively 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.7

As previously mentioned, there are several factors which 

make it difficult to extrapolate previously published 

data to the current study. Namely, prior studies have 

almost uniformly included at least one significant variable within the studied cohort, such as multiple etiologies of amputation, widely variable patient age groups, 

or patients ranging from healthy to those with multiple 

comorbidities. This study included only amputations resulting 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 

of a significant difference in the rate of early disabling 

back pain between the upper extremity, lower extremity, 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 817±485 days, and, in general, the evaluation occurs several months prior to the issuance of final results. 

Hence, the short time from amputation to the medical 

evaluation may be a rather significant confounding factor in the lower than expected rate of disabling back pain 

seen in the results. While the short duration between 

amputation and final evaluation may be one contributing cause for the low rate of DDBP found in this study, 

another potential contribution to the infrequent development of DDBP may be the abundant resources available 

to the SMAs. This includes highly trained medical, surgical, 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 Houston, Texas).20,21 The lower rate of DDBP is somewhat unexpected, 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 al2 Swedish civilian 68 Trauma, tumor 35%: daily or several 

times per week

Lower extremity amputation only, 

average of 23 years postamputation at time of surveys.

Ehde et al3 US civilian 255 Trauma, vascular, 

infection, diabetes, tumor, other

52%: “persistent, bothersome back pain” of 

which 25% considered the pain severe 

and interfering with 

daily activities

56% survey response rate. Average 

time since amputation 14.2±15.7

years.

Reiber et al7 US Veterans 581 Trauma 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 38.6±4 years for the Vietnam 

cohort, and 3.1±1.2 years for the 

OIF/OEF cohort.

Kulkarni et al8 UK civilian 202 Trauma 63%: 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 al5 Irish civilian 107 Trauma, peripheral 

arterial disease, 

diabetic vascular 

disease, malignancy, osteomyelitis, other

47.7% with chronic 

back pain, and of 

those with back pain, 

39.2% rated it severely bothersome.

Mean age 51 years. Mean duration 

since amputation was 17 years.

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TRAUMATIC OR POSTTRAUMATIC MAJOR EXTREMITY AMPUTATION
October – December 2017 13

THE ARMY MEDICAL DEPARTMENT JOURNAL

MEA, which we considered to be a correlate to our term 

“disabling back pain.” 8

 Kulkarni et al found that there 

were no differences in lumbar magnetic resonance imaging between the back pain and pain-free groups, but 

did find differences in gait asymmetries and standing 

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 

showing definitive correlation to the early rehabilitation 

components, specifically with respect to gait analysis 

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 

the difference in disabling back pain in this specific 

cohort.

These resources are not necessarily available to all patients with MEA outside of the US military, especially 

when considering those patients without health insurance, as is not an uncommon circumstance in the United 

States. This fact is further highlighted when considering the published findings of Smith et al 5

 on patients 

attending outpatient prosthetic fitting clinics. In their 

study, survey results of 107 patients with amputation 

that attended outpatient prosthetic fitting clinics, 47.7% 

of patients reported back pain, and 31.3% experienced 

back pain at least 4 times per week. There was no correlation 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 

“disabling” back pain, or pain that interfered with activities 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 

prosthetic fitting issues.

This study has limitations inherent to retrospective reviews, particularly as in this case being limited by the 

quality and uniformity of the information included in 

the medical records. This review included multiple electronic medical records across several years and as such 

the methods of documenting various injuries and medical diagnoses varied throughout. There is also only a 

single definitive value for back pain in this study, which 

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 respondents 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 

a study may support the findings from the current study 

or could potentially find patient-reported prevalence of 

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 absence 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 disability rating system.

References

1. Devan H, Tumilty S, Smith C. Physical activity and 

lower-back pain in persons with traumatic transfemoral amputation: a national cross-sectional survey. 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 patterns of back pain and residual limb pain in lower 

limb amputees at the National Rehabilitation Hospital. 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 associated with war-related amputation. Mil Med. 

2009;174:588-592.
14 http://www.cs.amedd.army.mil/amedd_journal.aspx

7. Reiber GE, McFarland LV, Hubbard S, et al. Service members and veterans with major traumatic 

limb loss from Vietnam War and OIF/OEF conflicts: survey methods, participants, and summary 

findings. 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, prevalence, costs, and impact on disability of common 

conditions requiring rehabilitation in the United 

States: stroke, spinal cord injury, traumatic brain 

injury, multiple sclerosis, osteoarthritis, rheumatoid 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 current conflicts in Afghanistan and Iraq. 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 

2006: a British field hospital experience. Injury. 

2009;40:493-497.

15. Belmont PJ Jr, Goodman GP, Zacchilli M, et al. Incidence and epidemiology of combat injuries sustained during “the surge” portion of operation Iraqi 

Freedom by and U.S. Army brigade combat team. J 

Trauma. 2010;68:204-210.

16. Veterans Benefits Administration. 38 CFR Book C, 

Schedule for Rating Disabilities. Washington, DC: 

US Department of Veterans Affairs; 1998. Available at: http://www.benefits.va.gov/warms/bookc.

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 systematic 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. Accessed August 29, 2017.

20. Fergason J, Keeling JJ, Bluman EM. Recent advances in lower extremity amputations and prosthetics 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 Department of Orthopedics and Rehabilitation, Womack Army 

Medical Center, Fort Bragg, North Carolina.

MAJ Krueger is an orthopedic surgeon with the Department of Orthopaedics, San Antonio Military Medical Center, Joint Base San Antonio-Fort Sam Houston, 

Texas.

LOW RATE OF EARLY DISABLING BACK PAIN FOLLOWING

TRAUMATIC OR POSTTRAUMATIC MAJOR EXTREMITY AMPUTATION
October – December 2017 15

The active duty military population is an athletic community that participates in a variety of physically challenging activities and is subject to a wide variety of 

musculoskeletal injuries. Specifically, ankle injuries 

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 

radiographs should be the first step in identifying the 

diagnosis of a musculoskeletal complaint. When these 

modalities fail to elicit an appropriate diagnosis, primary care providers are frequently ordering advanced 

imaging, including magnetic resonance imaging (MRI) 

studies, prior to referral to specialists.2

 Avoiding unnecessary, 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 preoperative planning.3

 Current trends, however, show magnetic resonance imaging being used more frequently as 

a screening tool.4

 Magnetic resonance imaging can be 

overly sensitive in demonstrating findings that are not 

clinically significant, and can lead to misdiagnosis or 

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.6

Concern regarding the use of ankle MRI studies prompted fellowship-trained foot and ankle surgeons at our institution 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 nonoperative treatment; and propose solutions to improve 

use of ankle MRI. To evaluate this, we studied the MRI 

ordering patterns of both orthopaedic surgeons and nonorthopaedic 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

Abstract

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, compared 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 studies 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.
16 http://www.cs.amedd.army.mil/amedd_journal.aspx

family 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 radiographic database at our institution (Impax) was queried 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 servicemembers aged 18 years and older. The data collected from the electronic radiographic database included 

the chief complaint, clinical indication, findings of the 

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-referenced 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 

patient identifiers were recorded. The clinical indication 

for the MRI and subsequent operative procedure(s) were 

assessed with the primary outcome measure defined by 

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. 

This update specifically stated that ankle MRIs should 

not be ordered prior to referral to an orthopaedic surgeon, 

and included recommendations for ordering plain radiographs 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 information 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 process 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 Fisher’s 

exact test (GraphPad Software, Inc, La Jolla, CA). Statistical significance was set at P<.05.

Results

Phase 1

From 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 studies, 143 (62%) patients had an MRI ordered by NOPs 

and 87 patients (38%) had an MRI ordered by an orthopaedic 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 facility. 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 osteochondral 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 referred 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 operative procedure (Figure 2). Within the orthopaedic group, 

foot and ankle surgeons and podiatrists were evaluated 

as groups separate from the rest of the orthopaedic department. Ankle MRI studies ordered by podiatrists 

USE OF ANKLE MAGNETIC RESONANCE IMAGING IN THE ACTIVE DUTY MILITARY POPULATION:

THE RESULTS OF A PROCESS IMPROVEMENT PROJECT

Figure 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
October – December 2017 17

THE ARMY MEDICAL DEPARTMENT JOURNAL

resulted in 6 out of 40 (15%) patients undergoing an operative procedure, while 

20 of 47 (43%) patients with MRI studies 

ordered by an orthopaedic surgeon underwent an operative procedure. When 

fellowship-trained foot and ankle orthopaedic 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 orthopaedic group, there was no significant 

difference in yield of operative patients 

with ankle MRI studies between the 

2 groups (P=.28). However, there was 

a significant difference in the proportion of patients with ankle MRI associated 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, 

there was no significant difference in yield of operative 

patients with ankle MRI studies between the 2 groups 

(P=.08). The most common operative procedures performed are listed in the Table.

Phase 2

From 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 ordered by NOPs and 119 patients (34%) had an MRI ordered 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 orthopaedic provider, which was not significantly different from 

Phase 1 (P=.27). There were 262 of 347 (76%) patients 

evaluated and treated by the orthopaedic surgery department, which was not significantly different from Phase 

1 (P=.19). Pain and instability remained the most common 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 operative 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 

total number of ankle MRIs ordered. Note: * indicates statistical significance.

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

out of 29 (14%) of patients undergoing an 

operative procedure, while 25 out of 90 

(28%) of patients with MRI studies ordered by an orthopaedic surgeon underwent 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 studies ordered by foot and ankle surgeons, 

16 (40%) had an operative procedure 

performed.

When comparing the NOPs to the orthopaedic group, there was a significantly 

higher yield of operative patients (P=.01) 

with ankle MRI studies in favor of the orthopaedic group for Phase 2. There continued to be a significantly higher yield of 

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, 

foot and ankle surgeons had a significantly higher yield 

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 procedure after the education process than before (17% versus 

25%). There was a significant decrease from Phase 1 to 

Phase 2 in the overall number of operative patients with 

an ankle MRI study, regardless of which provider ordered 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=.27). Significantly fewer plain films were ordered 

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).

Comment

Throughout both phases of the process improvement initiative, fellowship-trained foot and ankle surgeons produced 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. Additionally, the decrease in operative candidates between 

orthopaedics surgeons and fellowship-trained foot and 

ankle surgeons in Phase 2 could suggest that the necessity of ongoing training on the indications for ankle MRI 

is not isolated to the NOPs, and should include orthopaedic 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 

of MRI. In a study by Tocci et al, researchers identified 

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 unnecessary, 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 shoulder pain patients and identified that the majority of the 

preevaluation MRI scans had no effect on the outcomes 

of the patients, and although not statistically significant, 

further analysis revealed a tendency towards patients 

with an MRI to choose surgery over nonoperative treatment when patients had knowledge of pathologic anatomy from an advanced imaging modality.4 These authors 

concluded that routine preevaluation with MRI does not 

appear to have a significant effect on the treatment or 

outcome and should not be used as a screening tool for 

atraumatic shoulder pain before a comprehensive clinical 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 PROJECT

Figure 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 

total number of ankle MRIs ordered. Note: * indicates statistical significance.

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%
October – December 2017 19

THE ARMY MEDICAL DEPARTMENT JOURNAL

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 patients had abnormal findings with the anterior talofibular 

ligament and peroneal tendons, and 11% had an abnormal calcaneofibular ligament.5

 Schneck et al have documented that 90% of patients with lateral ankle instability can be treated nonoperatively.6 In our process improvement initiative, 93% of patients had a radiographic 

abnormality, but few underwent an operative procedure. 

This is further highlighted by the fact that Achilles tendinosis appeared as one of the most common diagnoses 

based on MRI findings. However, Achilles procedures 

are not among most commonly performed procedures 

as shown earlier in the Table. The large number of radiographic abnormalities does not necessarily correlate 

with the necessity for operative intervention, confirming results previously published.

Overuse of advanced imaging studies increases medical 

costs, places undue stresses on the patient’s time, and 

can lead to adverse outcomes.7-8 Radiologists have recognized 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 requesting and conducting imaging studies, decision support at 

point of care, education of referring physicians, accreditation 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 radiologist 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 

beneficiary nearly doubled.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 interval 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 evaluation 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 preoperative planning. We concede that measuring the 

treatment pathway is an imperfect outcome measure to 

assess the utility of ankle MRI, but in this process improvement initiative, we did not intend to evaluate the 

effect of the MRI on surgeon decision making. Third, 

the process improvement strategy was limited to educational initiatives primarily targeted at primary care physicians 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 systems can decrease the use of advanced imaging modalities.11-14 The importance of systematic changes to control 

overuse is paramount considering the high rates of turnover among military healthcare providers who may be 

missed by any education program during deployments 

and frequent changes of station. It is unclear as the extent 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 

foot and ankle surgeon subgroup may also be artificially 

decreased because the foot and ankle service is often 

called upon as the final authority to rule out a diagnosis, 

and advanced imaging is often required. Results of this 

process improvement initiative support the assertions of 

the fellowship-trained foot and ankle surgeons that advanced 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 decision to order advanced imaging may be best reserved for 

the fellowship-trained foot and ankle surgeons. Moreover, these data suggest that a process improvement initiative to decrease rates of advanced imaging use through 

education alone was ineffective in altering practice patterns among both orthopaedic and NOPs. Future analysis 

focused on education coupled with decision support systems 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.
20 http://www.cs.amedd.army.mil/amedd_journal.aspx

2. Baldor RA, Quirk ME, Dohan D. Magnetic resonance imaging use by primary care physicians. J 

Fam Pract. 1993;36:281-285.

3. Tocci SL, Madom IA; Bradley MP, et al. The diagnostic 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 diagnostic 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 

resonance imaging and incidental findings of lateral ankle pathologic features with asymptomatic 

ankles. J Foot Ankle Surg. 2011;50:413-415.

6. Schneck R Jr, Coughlin M. Lateral ankle instability 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 diagnostic 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. Radiology’s ethical 

responsibility for healthcare reform: tempering 

the overutilization of medical imaging and trimming down a heavyweight. J Magn Reson Imaging. 

2012;35(3):512-517.

10. Hendee W, Becker G, Borgstede J, et al. Addressing overutilization in medical imaging. Radiology. 

2010;257(1):240-245.

11. Bernardy M, Ullrich CG, Rawson JV, et al. Strategies for managing imaging utilization. J Am Coll 

Radiol. 2009;6:844-850.

12. Blachar A, Tal S, Mandel A, et al. Preauthorization 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. effectiveness of clinical decision support in controlling 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 centers 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 Medical 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, Department of Orthopaedic Surgery, San Antonio Military 

Medical Center, Joint Base San Antonio-Fort Sam Houston, 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 Medicine’s bibliographic database 

of life sciences and biomedical information. Inclusion in the MEDLINE 

database ensures that citations to AMEDD Journal content will be identified 

to researchers during searches for relevant information using any of several 

bibliographic search tools, including the National Library of Medicine’s 

PubMed service.
October – December 2017 21

Methylsulfonylmethane (MSM) is a sulfur-containing 

compound, a metabolite of dimethyl sulfoxide, and occurs naturally at low levels in many common foods including fruits and vegetables.1,2 Basic science literature 

supports that MSM is rapidly absorbed, well distributed, 

and completely excreted from the body.3

Methylsulfonylmethane has been shown to exert some 

anti-inflammatory and antioxidant effects, which has led 

to the use of MSM as a dietary supplement.4-6 Animal 

and human studies have demonstrated beneficial effects 

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 regimen.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 

as effective as celecoxib and significantly reduces the patient’s need for anti-inflammatory drugs.3,8 Furthermore, 

multiple trials have demonstrated multiple positive effects with no significant adverse effects of MSM use.3,8-10

The 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 22-

fold 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 incidence of injuries requiring an outpatient visit in the initial 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 Preventive Medicine* have demonstrated that intervention 

strategies can successfully reduce injuries without compromising mission effectiveness.15

The purpose of this study was to evaluate the use of 3 mg 

(750 mg tablets with 2 tablets twice daily) of orally administered 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

 Trainees

CPT 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

Abstract

Background: Methylsulfonylmethane (MSM) is a naturally occurring sulfur containing substance that has 

been shown to have anti-inflammatory and antioxidative properties. Previous studies using MSM as an oral 

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 

the Profile of Moods States (POMS).

Results: Three grams of MSM administered daily did not provide significant improvements in the 5 KOOS 

subscales or the 6 POMS subscales at 30 days or 60 days.

Conclusion: Although 3 grams of MSM daily can be used safely, there does not appear to be a significant improvement in KOOS or POMS.

*Redesignated as the US Army Public Health Center in 2016.
22 http://www.cs.amedd.army.mil/amedd_journal.aspx

initiation of supplementation during their training program as compared to placebo.

Methods

A randomized, double-blind, placebo controlled trial 

was conducted under an Institution Review Board approved protocol. A total of 180 men and women ranging 

in age from 18 to 40 years were enrolled from the Army 

initial Basic Officer Leadership Course (BOLC) at Joint 

BAse San Antonio-Fort Sam Houston, Texas. All trainees were invited to participate during the initial week 

of BOLC, a course that covers approximately 8 weeks 

of training, including 4 weeks spent in field conditions. 

Interested subjects were then screened and examined 

by one of the study investigators. Exclusionary criteria included a history of cancer, current statin use, use 

of other anti-inflammatories such as NSAIDS or pain 

medicine such as narcotics, a history of renal or hepatic 

dysfunction, a history of cardiac abnormality, current 

pregnancy, or other medical condition that would prevent full participation in the study.

Randomization was conducted using an unbound random number generator that was maintained 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 instructed to take 2 tablets twice daily for 8 weeks or 

until the completion of their training program.

Patient reported outcome measures were obtained at the time of study enrollment, at 30-day 

follow-up and at 60-day follow-up. Measures included were the Knee Osteoarthritis Outcome 

-Score (KOOS) and the Profile of Moods States 

(POMS). The KOOS consists of 5 subscales: 

Pain, other Symptoms, Function in Daily Living (ADL), Function in Sport and Recreation, 

and Knee Related Quality of Life (QOL). The 

Profile of Mood States (POMS) measures present mood state (disturbance) by a list of adjectives. The POMS measures 6 dimensions of affect or mood, including tension-anxiety, depression-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 

subjects were in the middle of their field-training 

exercises. These involve 4 weeks spent in field conditions which include sleeping in tents and performing 

daily activities such as carrying gear, marching, combatives training, rifle and handgun firing, land navigation, and more. Physical fitness training was included 

for all trainees during their entire BOLC course. The 

60-day follow-up was conducted when subjects had returned to a classroom setting and prior to their graduation from the course.

Statistical analysis was conducted using descriptive statistics, one-way ANOVA with repeated measures, and 

paired t tests where appropriate. A moderate Bonferroni 

correction was used and significance set at 0.025 due to 

comparisons being made at 30 and 60 days. The application 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 enrolled 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

CONSORT flow diagram.

Completed 60-day follow-up (n=26)

Patient discontinued therapy (n=7)

• Noncompliance (n=6)

• Conflicting medication (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)

• Conflicting medication (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)

• Conflicting medication (n=1)

• Adverse events (n=7)

Lost to follow-up (n=0)

Patient discontinued therapy (n=3)

• Noncompliance (n=3)

• Conflicting medication (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)
October – December 2017 23

THE ARMY MEDICAL DEPARTMENT JOURNAL

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 sustained during training. Data was available on 124 subjects 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 

significant differences in height (m), weight (kg), body 

mass index (BMI), or gender. The MSM group was significantly older (28 vs 26 years) than the placebo group.

There were no significant differences in any KOOS or 

POMS subscales at baseline, 30 days, or 60 days (Table 2). Whereas no significant changes in the KOOS 

subscale for MSM were seen from baseline to 30 days 

(3.41±2.68, P=.0135) or baseline to 60 days (5.81±3.51, 

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 Anger (3.38±0.72, P<.0001), Vigor (1.62±0.70, P=.193), 

and Fatigue (2.62±0.51, P<.0001), and for Placebo in 

Depression (2.28±0.55, P<.0001), Anger (2.46±0.69, 

P=.0004), Vigor (1.64±0.66, P=.0137), Fatigue 

(2.83±0.49, P<.0001), and Confusion (0.82±0.34, 

P=.0148) (Table 3). These differences were not seen at 

baseline to 60 days.

Comment

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 supplementation 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.

Several studies have previously demonstrated the efficacy of MSM as an adjunct for the treatment of osteoarthritis by using the Western Ontario and McMaster Universities Osteoarthritis index (WOMAC) as an outcome 

measure. In a double-blind, randomized, controlled trial, 

Debbi et al displayed significant differences in WOMAC 

physical function and total scores, and VAS pain scores 

with 3.375 g MSM orally administered daily.10 Kim 

et al also displayed significant decreases in WOMAC 

pain and physical function impairment when 6 grams of 

MSM was administered orally.16 Likewise, Pagonis et al 

found significant decreases in all WOMAC subscales at 

26 weeks with 6 g MSM administered orally.17

In 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) 28±6.9 26.4±5.0.041

Height (m) 1.7±0.1 1.7±0.1.722

Weight (kg) 75.4±13.7 74.9±13.8.368

BMI 24.9±3.1 24.7±3.1.171

Gender (male/female) 53/36 54/37.843

Table 2. Primary outcomes over 60 day treatment period comparing MSM to placebo (values presented as mean±SD).

MSM Placebo Significance Between 

Groups (P value)

Baseline 30 Day 60 Day Baseline 30 Day 60 Day Baseline 30 Days 60 Days 

KOOS

Pain 87.04±2.78 84.60±2.96 85.29±3.69 87.96±2.77 89.25±2.87 90.44±3.48.6489.0281*.0477*

Symptom 83.07±2.79 82.86±2.96 83.02±3.63 84.67±2.78 85.60±2.87 87.18±3.41.4273.1944.1023

ADL 92.79±2.11 91.22±2.27 91.56±2.94 93.42±2.10 94.33±2.19 94.57±2.73.6757.0543.1420

Sport 79.21±3.91 80.29±4.17 80.12±5.31 80.50±3.88 82.50±4.04 85.11±4.99.6476.4564.4564

QOL 77.39±3.92 78.58±4.09 78.47±4.82 79.10±3.90 82.50±4.00 84.91±4.60.5460.1801.0586

POMS

Tension 14.01± 0.79 14.62±0.86 13.21±1.16 14.13±2.78 14.81±0.82 13.8±1.07.8248.7579.4635

Depression 16.03±0.89 17.16±0.98 16.47±1.38 15.56±0.88 17.84±0.93 16.81±1.26.4637.3207.7217

Anger 14.80±1.10 18.15±1.21 15.75±1.71 14.89±0.55 17.35±1.16 16.35±1.56.9055.3493.6117

Vigor 27.06±1.31 25.43±1.41 27.20±1.85 25.19±1.29 23.55±1.36 25.87±1.71.0479*.0606.3022

Fatigue 11.08±0.87 13.70±0.95 10.67±1.29 11.31±0.86 14.14±0.91 10.69±1.19.7162.5088.918

Confusion 11.60±0.67 12.01±0.72 11.00±0.95 11.14±0.66 11.97±0.70 10.96±0.88.3473.9376.9539

Total Mood 58.37±2.23 59.06±2.44 59.75±3.42 55.56±2.19 56.53±2.34 59.17±3.13.0786.1418.8053

KOOS indicates Knee Osteoarthritis Outcome Score; ADL, Function in Daily Living; QOL, Quality of Life.

POMS indicates Profile of Moods States.

*Significance set at P<.05 with a Bonferroni correction of 2. 
24 http://www.cs.amedd.army.mil/amedd_journal.aspx

a greater degree of symptoms and range of injuries and 

is more responsive than the WOMAC. Using this validated patient reported outcome measure, as expected, 

the scores increased from baseline to the 30-day point, 

which is related to the increased physical demands 

placed on the subjects during their time in field conditions. Of particular note is that subscale scores were not 

significantly improved when compared directly to placebo 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.

To our knowledge, this is the first study that uses the 

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 during a time of increased physical and emotional stressed 

placed on the subjects as part of their field military 

training period. Similar increases in mood abnormalities were also seen in the placebo group, which correlates to the physical, mental, and emotional demands 

that accompany military training.

While other studies have evaluated MSM for those patients with documented knee pain, this is the first study 

to evaluate the use of MSM as a preventative adjunct 

to improve functional outcome measures. However, despite the enrollment of this study, its conclusions are 

limited by the loss to 

follow-up that was experienced from 30 to 60 

days as a result of changes in military training 

needs. This decreased 

the overall power of this 

study and may limit the 

relevant conclusions regarding the effectiveness 

of MSM over the entire 

60-day period.

This study was also conducted 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 demands is required. Furthermore, the total daily dosage 

of MSM used in this study was well below that of previous studies finding functional improvements, and also 

used different outcome measures. This may limit its 

comparability to findings reported in previous literature.

Conclusions

The results of this study suggest that 3 grams daily of 

orally administered MSM does not improve patient reported outcomes over 30 days or 60 days in this young, 

healthy, active military population as compared to a placebo. The results do not support our tested hypothesis. 

However, further investigation is warranted to determine if higher doses are more effective and if less active 

populations might exhibit a greater treatment response.

Acknowledgment

Study-related materials were received from Bergstrom 

Nutrition, 1000 W 8th St, Vancouver, Washington, 

through an educational grant.

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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 mean±SD).

MSM Placebo

Difference

0-30 Days

P

value

Difference

0-60 Days

P

value

Difference

0-30 Days

P

value

Difference

0-60 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 0.69±1.42.6268 1.38±1.87.4622 0.97±1.36.4799 3.61±1.72.0379

KOOS indicates Knee Osteoarthritis Outcome Score; ADL, Function in Daily Living; QOL, Quality of Life.

POMS indicates Profile of Moods States.

*Significance set at P<.05 with a Bonferoni correction of 2.
October – December 2017 25

THE ARMY MEDICAL DEPARTMENT JOURNAL

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methylsulfonylmethane (MSM) in osteoarthritis 

pain of the knee: a pilot clinical trial. Osteoarthritis Cartilage. 2005;14:286-294. PMID: 16309928.

17. Pagonis TA, Givissis PA, Kritis AC, Christodoulou 

AC. The effect of methylsulfonylmethane on osteoarthritic 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 Houston, Texas.

Dr Aden is with the US Army Institute of Surgical Research, 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.
26 http://www.cs.amedd.army.mil/amedd_journal.aspx

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 second most 

prevalent peripheral nerve mononeuropathy.1-7 There 

are several classification systems currently used by the 

medical community for patients with neuropathy of the 

ulnar nerve at the elbow.6-12 However, few of these classification systems include the clinical electrophysiologic 

parameters nerve conduction (NCS) and electromyographic (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 

anterior divisions of the trunks supply anterior (flexor) 

compartments and posterior divisions supply posterior 

(extensor) compartments. The anterior division of the inferior trunk continues as the medial cord.13-14

The 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 between the medial epicondyle of the humerus and olecranon 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. 

In the forearm, the first muscle innervated by the ulnar 

nerve is the flexor carpi ulnaris (FCU) followed by the 

ulnar half (ring and little finger) of the flexor digitorum 

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

Abstract

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 second most prevalent peripheral nerve mononeuropathy. There are several classification systems currently being 

used by the medical community for patients with neuropathy of the ulnar nerve at the elbow. However, few 

of these classification systems include the clinical electrophysiologic parameters nerve conduction (NCS) and 

electromyographic (EMG) studies.

Purpose: This article describes the GEHS (Greathouse, Ernst, Halle, and Shaffer) neurophysiological classification 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 

at the elbow are presented. The GEHS neurophysiological classification system is incorporated into the discussion of these case studies.

Summary and Clinical Relevance: This article describes the GEHS neurophysiological classification system 

for patients with neuropathy of the ulnar nerve at the elbow which incorporates findings for both the NCS and 

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 information that may be useful in determining next treatment steps as well as long-term prognosis. Future research 

comparing the psychometric properties and prognostic utility of the GEHS neurophysiologic classifications is 

warranted.
October – December 2017 27

THE ARMY MEDICAL DEPARTMENT JOURNAL

branches; (1) dorsal ulnar cutaneous nerve; (2) superficial 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 dorsally 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 

(Guyon’s canal) at the wrist and divides into a superficial branch which provides motor innervation to the palmaris 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 

(abductor digiti minimi, flexor digiti minimi, and opponens digiti minimi), lumbricale muscles to D4 and D5, 

and the ulnar intrinsics including the dorsal and palmar 

interossei and adductor pollicis.13-14

There are 5 anatomic sites of ulnar nerve compromise 

at the elbow: (1) intermuscular (IM) septum of the distal 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 Osborne’s ligament, a 

fibrous fascia running between the humeral and ulnar 

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.4

In a review of the clinical, electrodiagnostic, and radiographic features of ulnar neuropathy at the elbow, Landau and Campbell 5

 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 arcuate ligament spanning the two heads of the FCU; and 

(3) flexor/pronator aponeurosis as the ulnar nerve exits 

from beneath the FCU. They stated that the etiology of 

neuropathy of the ulnar nerve at the elbow is most commonly due to lesions at the level of the ulnar nerve at 

the retrocondylar groove at or above the medial epicondyle/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 diagnostic specificity at the expense of decreased sensitivity 

of accessing ulnar neuropathy at the elbow.5

GEHS Neurophysiological Classification System

for Patients with Neuropathy of the Ulnar

Nerve at the Elbow

A thorough history and physical examination are considered 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 peripheral nerve.1-3 The electrophysiological examination 

including both nerve conduction and electromyography 

studies should identify peripheral nerve dysfunction if 

present, along with the specific location in the nerve 

pathway, involvement of sensory and/or motor axons, 

and the presence of myelinopathy and/or axonopathy 

neuropathic process.1-3

Nerve 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 classification system for patients with neuropathy of the 

ulnar nerve at the elbow was introduced. The GEHS 

(Greathouse, Ernst, Halle, Shaffer) 15 neurophysiological 

classification system for patients with neuropathy of the 

ulnar nerve at the elbow is comprised of data from both 

the NCS and EMG components of the electrophysiological examination. The GEHS neurophysiological classification system for patients with neuropathy of the ulnar 

nerve at the elbow, presented in Table 1, provides healthcare providers an enhanced system of electrophysiological 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 

which includes specific abnormal findings of sensory 

and/or motor axons and myelinopathy and/or axonopathy. The GEHS neurophysiological classification system 

for patients with neuropathy of the ulnar nerve at the elbow is presently being used by clinical electrophysiologists and has been cited in various research reports.16-19

This article describes application of the GEHS neurophysiological classification system for patients with neuropathy of the ulnar nerve at the elbow in 2 case studies of patients with electrophysiological evidence of the 

disorder.
28 http://www.cs.amedd.army.mil/amedd_journal.aspx

Case Studies

Case 1

A 42-year-old right-hand dominant male was referred by 

his primary care physician for electrophysiological evaluation of a suspected left ulnar nerve neuropathy. The patient 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 medical history of problems affecting either upper extremity 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 

5 (ring and little finger; D4-D5). Otherwise, he had no 

Table 1. GEHS Neurophysiological Classification System for Patients with Neuropathy of the Ulnar Nerve at the Elbow.15

EARLY MILD (conduction block)

Sensory - >40% decrease in SNAP amplitude; eg, 40 μV SNAP amplitude BE-W, 20 μV SNAP amplitude AE-BE, 20 μV 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 (AE- BE 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 (AE- BE MNCV >50 m/sec) 

>20% decrease in CMAP amplitude AE/BE;

Sensory and Motor - abnormal findings as listed above for both motor and sensory fibers.

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 

stimulation site; abnormal EMG findings as presented above.

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 

stimulation site; abnormal EMG findings as presented above.

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

AE – above elbow FCU – flexor carpi ulnaris

BE – below elbow FPD D4-D5 – flexor digitorum profundus D4 and D5 (ring and little fingers)

CMAP – compound motor action potential MNCV – motor nerve conduction velocity

DML – distal motor latency MUPs – motor unit potentials

D4 – digit 4 (ring finger) NCS – nerve conduction studies

D5 – digit 5 (little finger) SNAP – sensory nerve action potential

1st DI – first dorsal interosseous SNCV – sensory nerve conduction velocity

DSL – distal sensory latency W – wrist

GEHS NEUROPHYSIOLOGICAL CLASSIFICATION SYSTEM FOR PATIENTS

WITH NEUROPATHY OF THE ULNAR NERVE AT THE ELBOW
October – December 2017 29

THE ARMY MEDICAL DEPARTMENT JOURNAL

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 review of systems was noncontributory for cardiovascular, 

pulmonary, gastrointestinal, genitourinary, or endocrine 

problems. He denied having diabetes, heavy metal exposure, thyroid disease, renal disease, or alcohol abuse, and 

has no family history of neuromuscular disease.

The patient was evaluated in January 2017. On physical examination, the patient displayed normal active 

Table 2. Case 1: Nerve Conduction Study Results. Note: clinically noteworthy values identified by shaded data cells.

Anti Sensory Summary

Site NR Peak (ms) Norm Peak 

(ms)

P-T Amp 

(μV)

Norm P-T Amp

(μV)

Site 1 Site 2 Delta-P (ms) Dist 

(cm)

Vel 

(m/s)

Norm Vel 

(m/s)

Left Superficial Radial Anti Sensory (Base 1st Digit)

D1 2.3 <2.7 15.8 > D1 Base 1st Digit 2.3 10.0 43

Right Superficial Radial Anti Sensory (Base 1st Digit)

D1 2.0 <2.7 10.8 > D1 Base 1st Digit 2.0 10.0 50

Ortho Sensory Summary

Left Median Ortho Sensory (Wrist)

Palm 2.1 <2.2 180.5 >15 Palm Wrist 2.1 8.0 38

D2 3.4 <3.6 49.2 >15 D2 Wrist 3.4 14.0 41

Right Median Ortho Sensory (Wrist)

Palm 2.2 <2.2 171.7 >15 Palm Wrist 2.2 8.0 36

D2 3.5 <3.6 28.9 >15 D2 Wrist 3.5 14.0 40

Left Ulnar Ortho Sensory (Wrist)

Palm 5.6 <2.2 15.1 >10 Palm Wrist 5.6 8.0 14

D5 NR <3.5 >10 D5 Wrist 14.0

Right Ulnar Ortho Sensory (Wrist)

Palm 2.2 <2.2 10.0 >10 Palm Wrist 2.2 8.0 36

D5 2.9 <3.5 11.2 >10 D5 Wrist 2.9 14.0 48

Motor Summary

Site NR Onset (ms) Norm Onset

(ms)

O-P Amp

(mV)

Norm O-P Amp

(mV)

Site 1 Site 2 Delta-0 (ms) Dist 

(cm)

Vel 

(m/s)

Norm Vel 

(m/s)

Left Median Motor (Abductor Pollicis Brevis)

Wrist 3.8 <4.2 9.6 >5 Elbow Wrist 5.3 28.0 53 >50

Elbow 9.1 8.2

Right Median Motor (Abductor Pollicis Brevis)

Wrist 3.8 <4.2 12.9 >5 Elbow Wrist 5.6 31.0 55 >50

Elbow 9.4 10.2

Left Ulnar Motor (Abductor Digiti Minimi)

Wrist 3.5 <3.6 4.3 >5 B Elbow Wrist 5.6 25.5 46 >50

B Elbow 9.1 2.1 A Elbow B Elbow 2.5 13.5 54 >50

A Elbow 11.6 4.5

Right Ulnar Motor (Abductor Digiti Minimi)

Wrist 3.0 <3.6 7.7 >5 B Elbow Wrist 5.1 26.0 51 >50

B Elbow 8.1 6.6 A Elbow B Elbow 2.1 12.0 57 >50

A Elbow 10.2 6.6

Glossary

Amp – 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
30 http://www.cs.amedd.army.mil/amedd_journal.aspx

cervical mobility in all planes without neck pain or pain 

in both upper extremities (BUE). The Spurling’s test did 

not provoke pain in the neck or in either upper extremity. 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, 

abductor pollicis brevis (APB), opponens pollicis, flexor 

pollicis longus (FPL), flexor digitorum profundus D2-

D3 (index and middle fingers), extensor indicis, and 

extensor pollicis longus (EPL). In addition, there was 

normal (5/5) motor strength testing of bilateral shoulder, 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 

reflexes were present and equal in BUE. The Hoffman 

reflex was absent in both hands. There was a decreased 

sensation to light touch (LT) and pain (pin prick) in the 

dorsal and palmar surfaces of the left ring (D4) and little 

(D5) fingers. Otherwise, sensory testing was normal for 

LT and pain in BUE, including all peripheral nerves and 

dermatomes (C4-T1). There was a positive Tinel’s test 

of the left ulnar nerve at the elbow, but otherwise the 

Tinel’s and Phalen’s tests were negative for bilateral median and ulnar nerve involvement at the wrists or elbows. 

There were normal radial pulses bilaterally for thoracic 

outlet syndrome in the scalene, costoclavicular, and pectoralis 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 

noteworthy NCS and EMG abnormal findings are indicated 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 mononeuropathy at the elbow, at or distal to the medial epicondyle/

olecranon and distal to the innervation of the FCU; demyelinating and axonal loss neuropathic process affecting both motor and sensory fibers; and chronic denervation of the left first dorsal interosseous (1st DI) and abductor 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 mononeuropathy; (2) bilateral median or superficial radial mononeuropathy, including the left median nerve at or distal to 

the wrist; (3) left C5-T1 radiculopathy in the LUE (cervical 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 

neurophysiological classification system category was 

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 μV). There was no sensory response for the 

left ulnar 5th digit (D5) when tested orthodromically or 

antidromically. There was a normal left ulnar distal motor 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 presence 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

Left 1stDorInt Ulnar C8-T1 Incr 2+ 3+ Nml Nml 0 Reduced 50% fib amp <100

Left Abd Poll Brev Median C8-T1 Nml Nml Nml Nml Nml 0 Nml Nml

Left PronatorTeres Median C6-7 Nml Nml Nml Nml Nml 0 Nml Nml

Left Flex Poll Long AIN C8-T1 Nml Nml Nml Nml Nml 0 Nml Nml

Left Biceps Musculocut C5-6 Nml Nml Nml Nml Nml 0 Nml Nml

Left Triceps Radial C6-7-8 Nml Nml Nml Nml Nml 0 Nml Nml

Left Deltoid Axillary C5-6 Nml Nml Nml Nml Nml 0 Nml Nml

Left ABD Dig Min Ulnar C8-T1 Incr 2+ 3+ Nml Nml 0 Reduced 50% fib amp <100

Left FlexCarpiUln Ulnar C8-T1 Nml Nml Nml Nml Nml 0 Nml Nml

Left Ext Poll Long Radial (Post Int) C7-8 Nml Nml Nml Nml Nml 0 Nml 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
October – December 2017 31

THE ARMY MEDICAL DEPARTMENT JOURNAL

interference patterns during maximum voluntary contraction in both of these muscles. Since EMG findings 

were demonstrated in 2 of the 4 muscles outlined in the 

“Severe” section of Table 1, EMG of all 4 of the muscles 

outlined in Table 1 was not performed. In this case, obtaining 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 

findings are electrophysiological evidence of both a demyelinating and axonal loss neuropathic process of the 

left ulnar nerve at the elbow.

Case 2

A 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 intermittent 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 

little fingers), but otherwise denied N/T proximal to the 

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 weakness 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 patient is on medication for hypertension but is in good 

health. Otherwise, the review of systems was noncontributory for cardiovascular, pulmonary, gastrointestinal, genitourinary, or endocrine problems. He denied 

having diabetes, heavy metal exposure, thyroid disease, 

renal disease, or alcohol abuse, and has no family history of neuromuscular disease.

The patient was evaluated in May 2016. On physical examination, the patient displayed normal active cervical 

mobility in all planes without neck pain or pain in BUE. 

The Spurling’s test did not provoke pain in the neck or 

in either upper extremity. He had normal active mobility of bilateral shoulder, elbow, forearm, wrist, and hand 

motions. The patient had weakness in the right ulnar hypothenar and intrinsic muscles (3+/5), right FDP D4 and 

D5 (ring and little fingers) (3+/5), and right FCU (4/5). 

There was normal (5/5) motor strength of the right APB, 

opponens pollicis, FPL, flexor digitorum profundus D2-

D3 (index and middle fingers), extensor indicis, and EPL. 

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 

muscle stretch reflexes were present and equal in BUE. 

The Hoffman reflex was absent in both hands. There was 

a decreased sensation to LT and pain (pin prick) in the 

dorsal and palmar surfaces of the right ring (D4) and little (D5) fingers. Otherwise, sensory testing was normal 

for LT and pain in BUE including all peripheral nerves 

and dermatomes (C4-T1). There was a positive Tinel’s 

test of the right ulnar nerve at the elbow, but otherwise 

the Tinel’s and Phalen’s tests were negative for bilateral 

median and ulnar nerve involvement at the wrists or elbows. There were normal radial pulses bilaterally for thoracic 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 abnormal findings are indicated by shaded cells in Tables 

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 

fibers; and a mixture of acute and chronic denervation 

in the right 1st DI, ADM, and FCU. There was no electrophysiologic evidence on this examination of (1) left 

ulnar nerve mononeuropathy; (2) bilateral median or 

superficial radial mononeuropathy, including the right 

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 neurophysiological classification system category was severe mononeuropathy of the right ulnar nerve at the elbow. There was a prolonged right ulnar palmar DSL (2.3 

ms, normal <2.2), with a normal amplitude of the SNAP 

(17 μV). The right D5 (little finger) DSL latency was 

normal (3.5 ms) with a normal amplitude of the SNAP 

(12 μV). 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 
32 http://www.cs.amedd.army.mil/amedd_journal.aspx

of 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 amplitude 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 examination, there was increased insertional activity and 

the presence of abnormal spontaneous electrical activity 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 

EMG findings were demonstrated in 3 of the 4 muscles 

outlined in the “Severe” section of Table 1, EMG of all 

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. 

These findings are electrophysiological evidence of both 

a demyelinating and axonal loss neuropathic process of 

the right ulnar nerve at the elbow.

Table 4. Case 2: Nerve Conduction Study Results. Note: clinically noteworthy values identified by shaded data cells.

Anti Sensory Summary

Site NR Peak (ms) Norm Peak 

(ms)

P-T Amp 

(μV)

Norm P-T Amp

(μV)

Site 1 Site 2 Delta-P (ms) Dist 

(cm)

Vel 

(m/s)

Norm Vel 

(m/s)

Left Superficial Radial Anti Sensory (Base 1st Digit)

D1 2.6 <2.7 23.9 > D1 Base 1st Digit 2.6 10.0 38

Right Superficial Radial Anti Sensory (Base 1st Digit)

D1 2.7 <2.7 20.6 > D1 Base 1st Digit 2.7 10.0 37

Ortho Sensory Summary

Left Median Ortho Sensory (Wrist)

Palm 2.0 <2.2 112.5 >15 Palm Wrist 2.0 8.0 40

D2 3.3 <3.6 20.0 >15 D2 Wrist 3.3 14.0 42

Right Median Ortho Sensory (Wrist)

Palm 2.1 <2.2 33.8 >15 Palm Wrist 2.1 8.0 38

D2 3.5 <3.6 22.6 >15 D2 Wrist 3.5 14.0 40

Left Ulnar Ortho Sensory (Wrist)

Palm 2.2 <2.2 15.3 >10 Palm Wrist 2.2 8.0 36

D5 3.5 <3.5 13.3 >10 D5 Wrist 3.5 14.0 40

Right Ulnar Ortho Sensory (Wrist)

Palm 2.3 <2.2 16.7 >10 Palm Wrist 2.3 8.0 35

D5 3.5 <3.5 12.4 >10 D5 Wrist 3.5 14.0 40

Motor Summary

Site NR Onset (ms) Norm Onset

(ms)

O-P Amp

(mV)

Norm O-P Amp Site 1 Site 2 Delta-0 (ms) Dist 

(cm)

Vel 

(m/s)

Norm Vel 

(m/s)

Left Median Motor (Abductor Pollicis Brevis)

Wrist 4.0 <4.2 9.0 >5 Elbow Wrist 5.4 29.0 54 >50

Elbow 9.4 9.0

Right Median Motor (Abductor Pollicis Brevis)

Wrist 4.1 <4.2 10.0 >5 Elbow Wrist 6.4 33.0 52 >50

Elbow 10.5 9.4

Left Ulnar Motor (Abductor Digiti Minimi)

Wrist 3.5 <3.6 6.5 >5 B Elbow Wrist 4.7 25.0 53 >50

B Elbow 8.2 6.7 A Elbow B Elbow 2.0 13.0 65 >50

A Elbow 10.2 6.7

Right Ulnar Motor (Abductor Digiti Minimi)

Wrist 3.8 <3.6 7.5 >5 B Elbow Wrist 4.7 25.0 53 >50

B Elbow 8.5 7.2 A Elbow B Elbow 2.9 13.0 45 >50

A Elbow 11.4 6.4 Axilla A Elbow 1.9 14.0 74

Axilla 13.3 7.0

Glossary

Amp – 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
October – December 2017 33

THE ARMY MEDICAL DEPARTMENT JOURNAL

Comment

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 peripheral 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 ischemia are evident with the loss of a subset of axons and 

the denervation of a segment of the innervated muscle 

fibers.1-3 The EMG examination specifically provides 

information regarding motor fiber denervation as confirmed by the presence of increased insertional activity 

and abnormal resting potentials (eg, positive sharp wave, 

fibrillations potentials). Additionally, EMG examination 

provides the healthcare team with information regarding the presence, morphology, and recruitment pattern 

of motor units that is critical for determining the extent 

of motor fiber involvement and if reinnervation (polyphasic or large motor potentials) is truly occurring.1-3

Collectively, the EMG examination affords critical motor fiber neurophysiologic information that allows the 

healthcare team, in concert with the patient, to carefully 

consider interventions.1-3

There are several classification systems for patients with 

neuropathy of the ulnar nerve at the elbow currently 

being used by the medical community.6-12,20-22 However, few of these classification systems include clinical 

electrophysiologic parameters (eg, nerve conduction 

and electromyographic studies). Ulnar nerve at the elbow neuropathy severity scales based on the patient’s 

subjective (paresthesia and pain) and physical examination findings (sensory and motor strength changes) place 

the patient into groups,6

 scales,20,22 or grades 21 based on 

the severity of symptoms and findings on physical examination. The Patient-Rated Ulnar Nerve Evaluation 

(PRUNE) was developed to assess pain, symptoms, and 

functional disability in patients with ulnar nerve compression at the elbow.7

 The PRUNE is a patient-reported 

outcome measure for patients with ulnar nerve compression that demonstrates strong measurement properties.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 entrapment 9

 and to identify predictors of surgical 

outcomes.10

In a study based on electrophysiologic assessment of 

the ulnar nerve, Eliaspour et al 8

 determined the pattern 

of muscle involvement in patients with ulnar neuropathy 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 D4-

D5 (56.8%). Using a Bayesian analysis, Logigian et al 23

determined how electrodiagnostic cutoffs (eg, acrosselbow MNCV slowing and drop in across-elbow versus forearm MNCV) assist in assessing patients with 

ulnar nerve at the elbow neuropathy. They determined 

that above elbow to below elbow distances and stimulation 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 probability 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 prognostic value of electrodiagnostic studies for patients 

with ulnar neuropathy at the elbow and their postsurgical 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

Right 1stDorInt Ulnar C8-T1 Incr 1+ 2+ Nml Nml 0 Nml Nml fib amp <100>

Right Abd Poll Brev Median C8-T1 Nml Nml Nml Nml Nml 0 Nml Nml

Right PronatorTeres Median C6-7 Nml Nml Nml Nml Nml 0 Nml Nml

Right Ext Poll Long PIN C8 Nml Nml Nml Nml Nml 0 Nml Nml

Right Biceps Musculocut C5-6 Nml Nml Nml Nml Nml 0 Nml Nml

Right Triceps Radial C6-7-8 Nml Nml Nml Nml Nml 0 Nml Nml

Right Deltoid Axillary C5-6 Nml Nml Nml Nml Nml 0 Nml Nml

Right ABD Dig Min Ulnar C8-T1 Incr 2+ 2+ Nml Nml 0 Reduced 75% fib amp <100>

Right FlexCarpiUln Ulnar C8-T1 Incr 1+ 1+ Nml Nml 0 Reduced 75% 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
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

Although the GEHS classification scheme provides a 

framework for reporting and categorizing neuropathy of 

the ulnar nerve at the elbow based on neurophysiologic 

findings, further research regarding the predictive and 

prognostic value of the classification schemes is needed. 

Additional longitudinal studies examining the predictive 

and prognostic value of the GEHS classification scheme 

regarding various interventions (duty limitations, splinting, mobilization, injection, and surgical release) is recommended. Future trials should also go beyond subjective reporting and include various outcomes measures 

(surgical findings, self-report, strength, sensation, serial 

NCS/EMG findings, physical performance testing, and 

healthcare utilization) and rigorous statistical analysis to 

determine the prognostic utility and cost/benefit of this 

classification scheme.

Summary and Clinical Relevance

The GEHS neurophysiological classification system for 

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 

a more complete neurophysiological classification system for use when preparing electrophysiological testing 

reports for patients with this disorder. Availability of expanded electrophysiological data that includes both NCS 

and EMG testing provides the healthcare team and the 

patient with more detailed information that may be useful in determining next treatment steps as well as longterm prognosis. Future research comparing the psychometric properties and prognostic utility of the GEHS 

neurophysiologic classifications is warranted.

References

1. Dumitru D, Amato AA, Zwarts M. Electrodiagnostic 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 University Press, Inc; 2001.

3. American Association of Electrodiagnostic Medicine, 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. Entrapment Neuropathies. 2nd ed. Boston, MA: Little, 

Brown & Co; 1990.

7. MacDermid JC, Grewal R. Development and validation of the patient-rated ulnar nerve evaluation. 

BMC Musculoskeletal Disord. 2013;14:146. Available at: https://doi.org/10.1186/1471-2474-14-146.

8. Eliaspour D, Sedighipour L, Hedayati-Moghaddam 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 Rehabil. 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 multicenter 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. Philadelphia, PA: Elsevier; 2006.

15. Greathouse DG. A classification system for patients 

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. Clinical and electrodiagnostic abnormalities of the median 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 abnormalities of the median nerve in U.S. Army dental assistants at the onset of training. US Army Med 

Dep J. July-September 2012:72-81.

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WITH NEUROPATHY OF THE ULNAR NERVE AT THE ELBOW
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THE ARMY MEDICAL DEPARTMENT JOURNAL

18. Shaffer SW, Koreerat NR, Rice L, Santillo DR, 

Moore JH, Greathouse DG. Median and ulnar neuropathies in U.S. Army Medical Command 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 decompression 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 elbow (UNE): a Bayesian approach. Muscle Nerve. 

2014;49(3):337-344.

24. Friedrich JM, Robinson LR. Prognostic indicators 

from electrodiagnostic studies for ulnar neuropathy at the elbow. Muscle Nerve. 2011;43(4):596-600.

25. Agnew SP, Minieka MM, Patel RM, Nagle DJ. 

Correlation between preoperative Kimura inching 

studies and intraoperative findings during endoscopic-assisted decompression of the ulnar nerve at 

the elbow. Hand (N Y). 2012;7(4):370-373.

Authors

Dr Greathouse is Director, Clinical Electrophysiology 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 Physical 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 electrophysiologist, Department of Neurology, Blanchfield 

Army Community Hospital, Ft. Campbell, KY.

COL Shaffer is Dean, Graduate School and Associate 

Professor, US Army-Baylor University Doctoral Program in Physical Therapy, Fort Sam Houston, TX, Chief, 

Physical Therapist Section, and Assistant Chief, Army 

Medical Specialist Corps, Fort Sam Houston, TX.
36 http://www.cs.amedd.army.mil/amedd_journal.aspx

Shoulder injuries affect up to 33% of the general population 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 

(38.1%), and specifically shoulder injuries made up the 

majority (23.8%).5

 In one study, Soldiers with shoulder 

injuries were more likely to have limited duty days related to the injury.7

 Noncombat-related shoulder injuries 

are also among the most common seen during deployment.8

 Treatment is often challenging, and the prognosis 

is uncertain for many patients. After a first episode of 

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, recurrence rates are high with 25% of patients experiencing 

at least one recurrent episode within 12 months.13 These 

findings suggest that shoulder pain frequently becomes 

a chronic problem. Identification of modifiable risk factors 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, inadequate household income, presence of additional chronic 

illnesses, and level of disability.3,9,14 Modifiable risk factors 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.9,14-17

Smoking 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 smoking, 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 population.20 Smoking is adversely related to functional outcomes after injury, independent of the nature or severity of injury.14 In military service members, it degrades 

physical performance,21,22 is a risk factor for musculoskeletal 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

Abstract

Background: Smoking rates are higher in the military population than in the civilian sector. Smoking is associated 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 

were analyzed to assess their influence on whether a patient achieved the minimally clinically important difference 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 

associated with not achieving a clinically significant improvement in disability scores at 4 weeks, but not 6 

months. Higher levels of disability at baseline and receiving only the treatment originally assigned (not crossing over) were associated with achieving clinically significant changes at both 4 weeks and 6 months.

Comment: Smoking is a modifiable variable that may help explain lack of improvement in patients with shoulder 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 

to validate these findings and determine their influence on other musculoskeletal injuries.
October – December 2017 37

THE ARMY MEDICAL DEPARTMENT JOURNAL

risk factor across a variety of populations and medical 

conditions,28-30 but specifically associated with delayed 

healing and recurrence of pain in shoulder injuries.17,31-34

Smoking is associated with an increased risk of rotator cuff tears,18 and negatively influences healing after 

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.

A better understanding of the influence of smoking on 

persistent shoulder conditions is necessary in a population with high rates of smokers. Treatment decisions 

could be influenced based on the smoking habits of 

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

Design

This was a secondary analysis from a cohort of 98 subjects enrolled in a pragmatic randomized clinical trial.42

It was a prospective assessment on the influence of selfreported smoking status and improvement in shoulder pain and function. The study was approved by the 

Madigan Army Medical Center Institutional Review 

Board and specific details of the protocol have been 

published open access.43 The project was also registered 

in the National Institutes of Health clinical trial registry (NCT01190891). All patients provided consent to 

participate.

Setting

The 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.

Subjects

Subjects that met the inclusion criteria for subacromial 

pain syndrome were recruited from the physical therapy 

clinic. Eligible patients had a variety of conditions including rotator cuff pathology, partial thickness rotator 

cuff tears, and subacromial bursitis. All subjects were 

adults between the ages of 18 and 65 years with unilateral shoulder pain, and were eligible to receive medical 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 Measures

Patients had been randomized to receive a one-time corticosteroid injection (40 mg triamcinolone acetonide) 

with instruction on Codman’s 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 difference (MCID) of between 8 to 13 percentage points.46 In 

this secondary analysis, we dichotomized patients into 

those that met the MCID (≥12 point change) and those 

that did not meet it (<12 point change) at the 4-week and 

6-month follow-up points.

Data Analysis

Descriptive statistics were used to characterize the 

sample. Multiple imputation was used to impute missing 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 interpreted. 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 procedure 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 until 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 approximately 8 years younger than nonsmokers. The average 

baseline disability, pain, and fear avoidance beliefs 
38 http://www.cs.amedd.army.mil/amedd_journal.aspx

physical activity subscale were similar between current 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.

Potential variables for inclusion in the final models are 

listed in Table 2. The results of the final multivariate logistic regression indicated that after controlling for covariates, smoking was significantly associated with the 

MCID at 4 weeks (Table 3) but not at 6 months (Table 

4). Interpretation of the OR indicate that in patients receiving 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 associated with obtaining a MCID at 6 months, following 

the study protocol (receiving the treatment initially randomized 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 received 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 cohort 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.

Comment

Although smoking has been declining, it 

continues to be the leading cause of preventable deaths in the United States,18

and rates of smoking are higher in the 

US military than in civilian counterparts.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 prescription opiates, and also more likely to abuse them.49 For 

many of these reasons, and likely others still to be explored, 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 effectiveness of physical therapy and corticosteroid injection 

treatments for the shoulder demonstrated significant improvements from baseline of 50% after 4 weeks, which 

was maintained out to one year.42 In the short term (4 

weeks), smoking had a stronger negative influence on 

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 

of these. Our study was the first to assess the effect of 

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)

Female 31 (31.6) 4 (23.5) 27 (33.3)

Military Beneficiary Category

Active Duty Service Member 52 (53.1) 12 (70.6) 40 (49.4)

National Guard or Reservist 8 (8.2) 2 (11.8) 64 (79.0)

Family Member/Dependent 18 (18.4) 2 (11.8) 16 (19.8)

Retired Service Member 20 (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 SPADI 45.5 (16.6) 46.5 (15.3) 45.3 (16.8)

Mean NPRS 3.6 (2.4) 3.8 (2.3) 3.5 (2.4)

Mean FABQ Work 11.9 (9.9) 17.2 (9.4) 10.9 (9.6)

Mean FABQ-PA 15.2 (4.9) 16.4 (5.0) 14.9 (4.9)

Hand Dominance Involvement 53 (55.2) 8 (47.1) 45 (57.0)

Pain Affects Sleep 90 (92) 14 (82.4) 76 (95.0)

Co-morbid Mental Health Condition 15 (15.3) 4 (23.5) 11 (13.6)

Co-morbid Cardiovascular Condition 21 (21.4) 2 (11.8) 19 (23.5)

Followed Protocol 80 (81.6) 16 (94.1) 64 (79.0)

Treatment Group 

Physical Therapy 46 (46.9) 11 (64.7) 35 (43.2)

Corticosteroid Injection 52 (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
October – December 2017 39

THE ARMY MEDICAL DEPARTMENT JOURNAL

receiving treatment for 

subacromial pain syndrome in the MHS.

Smoking plays a detrimental role in musculoskeletal disorders through 

several proposed mechanisms, many of which are 

independent from other 

variables. Age-related 

loss of muscle mass (sarcopenia) and strength 

is significantly affected 

by smoking.50 Impaired 

muscle metabolism, increased inflammation due 

to oxidative stress, and 

overexpression of sarcopenia-related genes have 

been observed in muscle 

tissue of chronic smokers.50 Muscle weakness and impairment is also strongly 

associated with shoulder impingement and rotator cuff 

tendinopathies.51,52 Our findings support findings from 

prior work. Bodin and colleagues found smoking to be 

an important risk factor for developing a rotator cuff 

tear confirmed via arthroscopic surgery.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. However, 50% in the nonsmoking group also had a partial 

or full-thickness tear. There is also a higher risk for developing muscle pain in chronic smokers, and subacromial pain syndrome is primarily a muscle disorder.50 In 

our cohort, baseline pain was not significantly different 

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 associated 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 

to also influence prognosis. Because we did not reassess 

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 modulation 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 outcomes in primary care shoulder pain patients.54 Similarly, 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 

ceiling effect, the greater improvements may reflect that 

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 identified as a risk factor for musculoskeletal injury and greater 

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 General report published by the Centers for Disease Control 

and Prevention did not focus on any relationships with 

musculoskeletal conditions, but rather the influence of 

smoking on respiratory diseases, reproduction, diabetes, 

cardiovascular health, and cancer.56 Because musculoskeletal 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.

Variable β P value aOR (95% CI)

Smoker -1.856.010* 0.16 (0.38-0.64)*

Treatment Group 0.721.18 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 Subscale. 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 SPADI

FABQ-W indicates Fear Avoidance Belief 

Questionnaire Work Subscale.

SPADI indicates Shoulder Pain and Disability Index.

FABQ-PA indicates Fear Avoidance Belief Questionnaire Work Physical Activity Subscale.

Table 4. Multivariate Adjusted Model For Reaching MCID at 

6 Months.

Variable β P 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)

Age 0.019.414 1.02 (0.97-1.07)

Comorbid Mental Health 2.002.12 7.45 (0.52-95.83)

Baseline SPADI 0.048.016* 1.05 (1.01-1.09)

*Indicates significant value.

MCID indicates Minimally Clinically Important Difference. SPADI indicates Shoulder Pain and Disability Index. aOR indicates adjusted 

Odds Ratio. MCID indicates Minimal Clinically Important Difference.
40 http://www.cs.amedd.army.mil/amedd_journal.aspx

informative and shared decision approach when managing 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 

limit the benefit of treatment for shoulder injuries. Incorporating 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 cessation 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.

Limitations

This study did not analyze the effect of smoking intensity (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 enrollment 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 explain why the risk of not recovering was there at 4 weeks, 

but not at 6 months.

Conclusion

Smoking was associated with a lack of clinically significant improvement in pain and function in patients with 

shoulder impingement syndrome, regardless of treatment 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 managing patients with shoulder pain, and also musculoskeletal injury-related content to their smoking education 

programs.

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THE INFLUENCE OF SMOKING ON RECOVERY FROM SUBACROMIAL PAIN SYNDROME:

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Authors

When this study was conducted, MAJ Rhon was assigned to the Madigan Army Medical Center, Yakima, 

Washington. Currently, he is with the Center for the Intrepid, Brooke Army Medical Center, Joint Base San Antonio-Fort Sam Houston, Texas. He is also affiliated with 

the Army-Baylor University Graduate Program in Physical 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
October – December 2017 43

Musculoskeletal (MSK) injuries have steadily been on 

the rise and present a significant challenge to both military medical readiness and the military healthcare system.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 during deployment.5,6 At a time of military force reduction, 

medical readiness optimization is essential to the sustainment of successful worldwide military operations.7

While the military places a large focus on medical readiness through periodic health assessments, no standardized 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 assessments 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 individual’s level of concern for 

injury should be considered in addition to physical performance measures.14,15

There are several MSK screening tools, such as the Functional 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 Tool

LTC (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

Abstract

Military service members receive regular screenings for a variety of health conditions, but a field-expedient 

and military-specific screening tool that identifies an individual’s risk for injury has not yet been identified. The 

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 29.3±6.9 years) without any current musculoskeletal injury or pain at the time of enrollment. 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 

injury. Three raters (a board certified physical therapist with 15 years of experience, a physical therapy student 

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 participant’s 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 7.79±1.41. Among all 3 raters the overall reliability 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 (κ=0.33-0.44), overhead squat (κ=0.57-0.65), CKCUEST 

(κ=0.89-1.0), eyes-closed forward step down (κ=0.10-0.42), repeated tuck jump (κ=0.39-0.61), individual perceived level of risk for MSK injury (κ=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.
44 http://www.cs.amedd.army.mil/amedd_journal.aspx

Test,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 

findings to date are mixed on the predictive capacity of 

these screening tools.8,17,18 Additionally, these tools generally 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 patterns commonly encountered by a majority of military 

service members is necessary.19 Furthermore, this tool 

must be configured in such a way that it can be readily 

completed in any environment, performed using minimal equipment, and reliably assessed by a broad range 

of healthcare personnel. The MRST in this study was 

adapted from a previously reported screening tool intended to be used to assist medical providers with return 

to duty decisions.20 A majority of the events from the 

previous screening tool were modified or replaced in 

this study in order to increase the level of challenge and 

decrease the time and equipment required for administration. 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 tolerance for upper and lower extremity plyometric activity, (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 providers 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

Participants

A 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 Antonio, TX. A large majority of the participants were enrolled 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 information, including age, sex, height, weight, past medical history, branch of service, and military occupation. To be 

considered eligible, participants had to meet the following inclusion criteria: active duty military service members 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. Exclusion criteria included the following: current musculoskeletal 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 education and training. The raters included the principal investigator (Rater 1) who was a licensed physical therapist 

and a board-certified clinical specialist with 15 years of 

clinical and functional movement screening experience, 

a doctoral physical therapy student (Rater 2) in the first 

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 combination of raters was chosen because it is consistent with 

many military physical therapy clinic-staffing models.

Experimental Approach

This study was a single cohort study, with all participants following the same initial assessment protocol. All 

raters received approximately 5 hours of training to ensure standardized performance of duties related to the 

protocol. The raters were blinded to one another’s results and data was not made available to any rater until 

all data collection was completed.

Procedures

The MRST consisted of 6 events executed in the following order: weight-bearing lunge event (WBL), overhead 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 individual’s perceived risk for future musculoskeletal 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 greater 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 

as defined in the scoring rubrics. A score of 1 indicated 

REAL TIME INTERRATER RELIABILITY OF A NOVEL MUSCULOSKELETAL READINESS SCREENING TOOL
October – December 2017 45

THE ARMY MEDICAL DEPARTMENT JOURNAL

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 viewpoint to simultaneously score the MRST events.

Weight-bearing Lunge (Figure 1). This event has been 

reported in several studics 21,22 as a method to assess ankle 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. Participants 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 repeated. 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 extremity. All raters for this event used 

a lateral viewpoint. This event 

has demonstrated excellent intrarater and interrater reliability.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 motion may be considered restricted.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 modified version of the deep squat performed as a part of 

the FMS27 and similar to the overhead deep squat performed 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 position throughout the duration 

of the movement. The participant’s feet were placed 

in a comfortable position 

that was approximately at 

shoulder width. Neutral foot 

rotation and foot flat contact 

with the floor was expected 

throughout the duration of 

the movement.27,28 Participants were instructed to squat until their thighs were 

at least parallel with the floor. The movement could be 

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 acceptable chance-corrected agreement when evaluated by experienced raters29 and has been shown to be predictive 

of injury risk in at least one study.30

Closed 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 participants used a modified push-up position (lower body 

weight-bearing occurred through the knees).31,32. Folded 

towels were provided in the modified position for increased comfort during the event. The feet (or knees for 

the modified position) were no further than 12 inches 

apart (feet were raised off the ground in the modified 

position). Their hands were placed 36 inches apart on 

the floor, as marked 

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 upper extremity stability test (male).
46 http://www.cs.amedd.army.mil/amedd_journal.aspx

one repetition.31 The stated goal was to complete 20 repetitions within 15 seconds. Participants were required 

to have at least one hand on the floor and maintain their 

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 completed, whichever came first. The viewpoint of this event 

for all raters was anterior and only a single 15-second 

trial was completed. This event has demonstrated excellent 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 

modified from a low-light condition to an eyes-closed 

condition in order to increase generalizability. Agreement for rating quality of movement during the forward 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 disembarking from a vehicle during operational low-light conditions. 

This assessment is similar to 

the typical step-down functional assessment routinely 

performed in the clinical setting 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 hardcover 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 performing 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 exercise 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 participant was reminded to rapidly initiate the next jump 

after attempting to make a 

soft landing in the original 

starting position.39 When a 

significant delay occurred 

between jumps, the event 

was repeated. If any participant experienced a sharp 

pain, they were instructed 

to stop jumping immediately. 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 

confidence in return-to-duty capability and perceived 

risk of injury or reinjury.14,15,40,41 Participants were asked 

to describe their personal concern for developing a musculoskeletal injury within the next 6 months. The previously reported20 format used a simple verbal question 

with 3 possible answers.

Statistical Analysis

All 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 categorical data. It was estimated that data from 40 participants 

would be required to have adequate precision of interrater reliability (ICC with 95% CI) estimates. Intraclass correlation coefficient (ICC 2, 1) and associated 

REAL TIME INTERRATER RELIABILITY OF A NOVEL MUSCULOSKELETAL READINESS SCREENING TOOL

Figure 4. Forward step 

down with eyes closed test.

Figure 5. Repeated stationary tuck jump.
October – December 2017 47

THE ARMY MEDICAL DEPARTMENT JOURNAL

confidence intervals were calculated to estimate interrater reliability. The interpretation of the ICCs was 

consistent with the method described by Portney and 

Watkins.42 Unweighted Cohen’s kappa values were used 

to estimate chance-corrected agreement of individual 

events and the results were interpreted per the guidelines reported by Landis and Koch.43 Weighted Cohen’s 

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 29.3±6.2 years that met the 

screening criteria to participate in the study. The mean 

height and weight of the sample was 175.26±8.63 cm and 

77.56±13.52 kg respectively. The MRST composite 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 agreement 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 member. 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.

Comment

The results of this study indicated that the MRST composite 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.

Weight Bearing Lunge (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

Overhead Squat (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-free27

1 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

Closed Kinetic Chain Upper Extremity Stability Test (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 with Eyes Closed (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

Repeated Tuck Jump (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

Perceived Level of Risk for Musculoskeletal Injury (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 1/3 0.82 0.65, 0.91 Good

Rater 1/2 0.76 0.58, 0.86 Good

Rater 2/3 0.68 0.43, 0.82 Moderate
48 http://www.cs.amedd.army.mil/amedd_journal.aspx

some 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 complexity 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 

finding may be attributable to the experienced clinician’s direct involvement with the student rater’s education and the ancillary staff member’s continuing education. 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 researchers21,44 have reported an excellent level of agreement between raters. However, the testing protocol for 

these studies differed in that the subject’s heel was held 

to the ground throughout their attempt to touch the wall. 

In the current study, the participant’s 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 penalize participants for proximal compensatory movements 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 studies 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 reliability between 2 raters and reported a perfect 1.0 kappa 

on the squat event. Although only one rater was FMS 

certified, both had similar levels of experience as certified strength and conditioning specialists. Having 

fewer raters along with having raters of more similar 

experience could account for the higher kappa value.

Park et al 35 reported good agreement for the FSD assessment. This event resulted in the lowest reliability 

between raters in the current study, with kappa values ranging from only a slight to moderate agreement. 

Reliability was likely affected by a number of differences in the grading criteria between the 2 studies. Park’s 

study based their kappa values on agreement within 

a specific range. While raters in that study may have 

agreed that a particular movement was rated as good, 

this rating was based on a range of scores. Conversely, 

the current MRST study’s 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 

influenced the difficulty of movement for the subjects 

and therefore increased potential for error in the way raters 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 dichotomous. Given the low level of impact and minimal 

physical exertion required for this event, pain is unlikely 

to occur in a healthy population. Modification of the 

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

Weight Bearing Lunge (WBL)

Rater 1/2 67.50 0.39 Fair

Rater 1/3 60.00 0.33 Fair

Rater 2/3 65.00 0.44 Moderate

Overhead Squat (OHS)

Rater 1/2 85.00 0.65 Substantial

Rater 1/3 82.50 0.61 Substantial

Rater 2/3 82.50 0.57 Moderate

Closed Kinetic Chain Upper Extremity Stability Test (CKCUEST)

Rater 1/2 95.00 0.89 Almost Perfect

Rater 1/3 100.00 1.00 Almost Perfect

Rater 2/3 95.00 0.89 Almost Perfect

Forward Step Down with Eyes Closed (FSD)

Rater 1/2 82.50 0.36 Fair

Rater 1/3 85.00 0.42 Moderate

Rater 2/3 72.50 0.10 Slight

Repeated Tuck Jump (RTJ)

Rater 1/2 80.00 0.45 Moderate

Rater 1/3 85.00 0.61 Substantial

Rater 2/3 80.00 0.39 Fair

Individual Perceived Level of Risk for Musculoskeletal Injury (QUEST)

Rater 1/2 100.00 1.00 Almost Perfect

Rater 1/3 100.00 1.00 Almost Perfect

Rater 2/3 100.00 1.00 Almost Perfect
October – December 2017 49

THE ARMY MEDICAL DEPARTMENT JOURNAL

jump-landing technique in real time and reported interrater 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 

did not assess what types of deficiencies existed, only 

that one or more existed. Therefore, in order to achieve 

a maximum score for the RTJ in this study, all checkpoints 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 

is at increased risk for injury, rather than a specific error.

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 simultaneous assessments of multiple areas. The lowest kappa 

values observed in those events existed between the raters with least experience. More experienced clinicians 

may be able to distinguish the subtle movement deviations 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 

of interrater reliability for one specific event. This indicates the need for more training and/or more specificity 

in the scoring instructions to achieve a more reliable assessment 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 interpretations can be made based on the grading criteria 

used. The ability to decide between 2 grading criteria 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 

of a wider population. Therefore, the deficiencies identified in their performance may not be indicative of a 

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 assessing MSK injury risk. They should include a more specific training protocol for its raters and possibly slight 

modifications to the scoring criteria for the WBL and/or 

FSD events.

Conclusion

When applied by raters in the field of physical therapy, 

the MRST demonstrated 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 personnel from multiple disciplines.

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Scoring Scale. Athl Train Sports Health Care. 

2012;4(3):103-109.

46. Gulgin H, Hoogenboom B. The functional movement screening (fms)TM: 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 functional 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 functional 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 assessment 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.
52 http://www.cs.amedd.army.mil/amedd_journal.aspx

Insomnia disorder is defined in the Diagnostic and Statistical Manual of Mental Disorders1

 as dissatisfaction 

with sleep quantity or quality related to difficulty initiating or maintaining sleep or early morning waking with 

inability to return to sleep. These symptoms result in 

distress and dysfunction with additional criteria of occurring at least 3 nights per week, lasting over 3 months. 

The period of the existence of symptoms is important to 

distinguish it from normal transient symptoms that are 

considered normal human experience. An important criterion is the requirement of having adequate opportunity 

to sleep. Given insomnia is a diagnostic criterion in various psychiatric disorder,1

 insomnia disorder requires absence of other sleep-wake disorders and ruling out explanation of symptoms by other coexisting mental disorders.

Despite the rigid diagnostic criteria, insomnia disorder 

is still prevalent, estimated to affect 6 to 10% of adults.2

The prevalence of insomnia in the military is reported 

to be 50%.3

 The association of insomnia with health is 

well established. Sleep is frequently disturbed in posttraumatic stress disorder and traumatic brain injury,4

 the 

2 signature health concerns from Global War on Terror. 

Additionally, there are concerns of insomnia affecting 

military operations. For example, Williams et al found 

that active duty Soldiers perceive 50% of their mistakes 

attributed to insomnia.5

 Their study also revealed that 

half of pilots surveyed reported falling asleep in the 

cockpit. While the presence of insomnia is concerning 

for Soldier performance, there is some evidence of improvement in military performance when interventions 

are made to improve sleep. In one study,6

 a comparison 

of 2 units was made, allowing the intervention unit accommodation of adolescent phase-delayed sleep regimen. Results showed improved marksmanship, sleep 

quality, mood, reduced sleep fatigue, and increased 

sleep duration.6

The prevalence of insomnia and perceived concern for 

reduced functioning is apparent in high prevalence (up 

to 20%) of hypnotic use among Soldiers.4

 There are obvious arguments against to the use of hypnotics in the 

military setting, such as potential impairment of psychomotor skills, sedation, and other adverse effects. 

Long-term use is also associated with concern for possible dementia and fractures.7-9 Based on the risk and benefit appraisals, alternative treatments to pharmacotherapy have been evaluated. The greatest evidence comes 

from treatment strategies based on cognitive behavioral 

therapy (CBT) informed interventions. While there are 

heterogenous techniques and variations, these are often referred to as CBT-insomnia (CBT-I). At present, 

Cognitive Behavioral Therapy for Insomnia

 Treatment in a Military Deployed Operational

 Setting Utilizing Enlisted Combat Medics:

 A Quality and Process Improvement Project

MAJ Rohul Amin, MC, USA

CPT Brooke E. Wirtz, MS, USA

Abstract

Insomnia disorder is a prevalent condition especially among the American military, affecting up to 50% of service members. It is shown to affect military performance. Guidelines recommend the use of nonpharmacologic 

approaches as initial treatment of insomnia. Cognitive behavioral therapy informed insomnia treatment (CBTI) has the greatest evidence, however it requires specialized training. While deployed in the Middle East in support of US military operations, we faced a resource challenge while caring for service members with insomnia. 

In order to meet the needs of the population, we created a checklist based CBT-I informed treatment to enable 

our health extenders, including combat medics and behavioral health specialists. Following institutional review 

board determination of this project as nonresearch, we implemented this as a Quality Improvement/Process 

Improvement Project (QI/PI). Here we describe the 4 phases of this QI/PI and our outcomes. This process can 

be easily reproduced in either the deployed or garrison setting with minimum efforts and resources, enabling 

delivery of high quality, evidence-and guidelines-based treatment while using combat medics and behavioral 

health specialists to their maximum potential.
October – December 2017 53

THE ARMY MEDICAL DEPARTMENT JOURNAL

CBT-I is the recommended initial treatment for adults 

with chronic insomnia disorder.10

CBT-insomnia typically has a combination of psychoeducation, cognitive (restructuring dysfunctional beliefs), 

and behavioral (stimulant control, sleep restriction, etc) 

aspects. The psychoeducation component aims to increase 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 technical aspect of CBT-I, requiring significant expertise and 

experience. It aims to identify dysfunctional beliefs held 

by the patient that negatively affects their expectations 

and perceptions of their sleep. Once these dysfunctional 

beliefs are identified, the next step is to challenge and 

introduce doubts into these thoughts via the process of 

cognitive restructuring. Most clinicians have a significant behavioral component to their CBT-I interventions. 

These may include stimulant control, sleep restriction, 

and sleep deprivation to help increase sleep inertia and 

improve sleep efficiency. There might also be some component of progressive relaxation techniques to reduce anticipative anxiety and tension. The overarching goal is to 

optimally synchronize the sleep’s 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.11

Given the technical competency required to deliver CBTI, it is typically conducted by behavioral health practitioners. In a deployed setting, however, availability of 

trained personnel (psychologists, social workers, psychiatrists) is the limiting factor. We experienced these same 

constraints with only 2 therapists and a single psychiatrist caring for a population of approximately 9,400 service members at a remote location. Herein we describe 

a novel approach to enable enlisted healthcare extenders 

(behavioral health specialists and combat medics) to deliver CBT- I treatment using a PI/QI strategy based on 

typical Plan, Do, Study, Act (PDSA) cycles. We describe 

the PDSA cycles of our project and report our significant 

outcomes. A similar approach can be used by deployed 

healthcare teams such as combat operational stress 

teams (or equivalent) to help extend the first-line, evidence-based therapy for service members with insomnia.

Materials and Methods

The Institutional Review Board for the deployed location 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 received treatment during the “Do” phase of the project. 

Outcomes as outlined below were reviewed and analyzed during the “Study” phase. Finally, feedback from 

patient outcome measures, enlisted combat medics, and 

behavioral health specialists were implemented into the 

original treatment protocol and delivery methods.

Plan

Author R.A. is formally trained in CBT-I and uses various methods and strategies in his clinical practice. However, during the development phase, literature search 

of the MEDLINE database was undertaken to find the 

most optimal combination of techniques using cognitive, 

behavioral, and psychoeducational strategies. No studies were found with head-to-head comparison among 

any of these strategies. There are standardized treatment protocols,12 however, these were considered not 

ideal for 2 main reasons: (1) they are copyrighted protocols 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 greatest 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 psychoeducation 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

The protocol consisted of a “provider packet” and “patient packet.” The provider packet contained an initial 

sleep intake, initial sleep prescription, initial checklist, 

constructive worry sheet, dysfunctional beliefs challenge 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 Protocol

A 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 occupational specialties (MOS) in the US Army fall under 

the “68 series.” The combat medics (MOS 68W) receive 
54 http://www.cs.amedd.army.mil/amedd_journal.aspx

training on supporting basic life functions with knowledge of medical care under fire and trauma care. The 

behavioral health specialists (MOS 68X) receive training on providing psychological first aid under the supervision of a behavioral health specialist. Neither of these 

2 specialties have any training in CBT-I. The workshop 

audience consisted mainly of behavioral health specialists and combat medics assigned to an armor brigade. 

Following the training, a survey of pre- and posttraining 

confidence and satisfaction metrics were assessed.

PowerPoint slides were used to begin the workshop, providing an overview of both provider and patient packets. 

The first hour was spent on didactics which targeted understanding the Process C and Process S model of sleep 

regulation11 and its role in sleep maintenance, normal 

sleep physiology, evidence for CBT-I, and understanding cognitions and behaviors and their effect on sleep 

and development of insomnia. For the second and third 

hour, cases were used to illustrate specific competencies 

necessary to effectively deliver the protocol. Training 

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 

provider packet. The students also learned to use the 

Dysfunctional Belief Challenge Scripts for cognitive restructuring. Additionally, students learned to assess and 

identify need for referral if there are concerns for organic sleep problems or psychiatric disorders. Finally, students were given templates for documentation of their 

encounters in the electronic health record and obtaining 

supervision from a supervising therapist.

The training underscored the accurate, exact, and unwavering use of the checklist. For example, the first item 

on the checklist is “Initial Intake Form completed.” The 

initial intake form consisted of demographics, specific 

sleep questions to allow the provider to easily calculate 

sleep efficiency, review of systems to look for organic 

causes of insomnia, sleep satisfaction questions, a Patient Health Questionnaire-2,13 suicide screening question, and a Generalized Anxiety Disorder Questionnaire-2.14 Finally, in order to enable and operationalize 

a novice provider in tackling the most difficult part of 

CBT-I, identifying and challenging cognitive distortions and dysfunctional beliefs, the Dysfunctional Beliefs and Attitudes about Sleep (DBAS) was used. This 

scale was originally a 30-item questionnaire that was 

later validated in its shortened form as DBAS-16.15

Process

Patients were entered into treatment by one of 2 distinct 

routes. One route involved patients presenting to the 

brigade aid station with pure sleep complaints with no 

additional psychiatric symptoms. Those patients were 

offered CBT-I, receiving treatment in a private room inside the aid station. The intake form was completed using 

the checklist, then screened for evidence of depression, 

anxiety, or organic sleep problems. If any of the conditions were positive, the treating medic was instructed to 

refer those patients to a credentialed provider. However, 

medics were instructed to immediately escort anyone 

with acute suicidality to the behavioral health providers. 

The other route for treatment was through the behavioral 

health clinic. During routine intake for behavioral health 

treatment, patients citing sleep difficulties were offered 

CBT-I treatment in addition to other psychiatric services. 

The treatment was delivered inside the behavioral health 

clinic by either a trained behavioral health specialist 

(MOS 68X) or trained medic (MOS 68W) as the clinic 

had a shortage of behavioral health specialists.

The initial checklist component was psychoeducation. 

The provider used his or her “provider psychoeducation 

slides” while the patient followed with their “patient psychoeducation slides.” Both were identical slides on basic 

physiology, dysfunctional beliefs and behaviors about 

sleep, introduction to CBT-I concepts, and evidence 

for this modality. The provider version contained boxes 

with text and providers were instructed to read those 

verbatim as they lead the patient through the 12 slides.

The second component on the checklist focused on behavioral interventions. The provider was tasked to calculate the sleep efficiency and provide the patient with 

exact wake-up time and earliest bed-time. The idea was 

to reduce time in bed awake (improving sleep efficiency) and the associated frustration with forcing oneself 

to fall asleep, as well as sleep deprivation to enhance 

sleep inertia. The initial sleep prescription form took 

information from the intake form. For practical reasons, sleep logs were optional and all treatment decisions were based on self-reported times averaged over 

a week. The initial sleep prescription took baseline selfreported total sleep time (adding sleep at night and any 

additional naps), and added one hour to this time. This 

was total permitted time in bed. For example, if someone reported sleeping on average 5 hours per night, but 

spent 8 hours in bed, then their sleep efficiency is 63% 

(5/8×100). Using this example, the patient was asked 

about best daily wake-up time. They were required to 

wake up at this specific time for the next week even if 

they were not working. Patients were encouraged to take 

physical training or morning military formations into 

account. If, for example, the patient were to settle on 

daily wake-up time of 5 am, then, based on the above 

example, they were permitted to go to sleep no earlier 

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
October – December 2017 55

THE ARMY MEDICAL DEPARTMENT JOURNAL

6 hours permitted in bed). It was stressed that they must 

only go to bed after 11 pm and only if they are sleepy. 

Regardless of what time they finally went to bed, they 

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 reviewed. 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 informed by the validation data from the initial study15 on 

DBAS-16. Identifying and challenging cognitive distortions require a significant amount of clinical expertise to 

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 

of the scale permitted identification of the majority of 

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, 

the provider would first read the introduction statement 

verbatim: “I am going to talk to you about some common trends of maladaptive thoughts and beliefs that we 

notice among those people who suffer from sleep problems. 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 explanations. I am selecting these because you scored high 

on these.” Next, the provider would read the question 

and then our provided “challenge script” for that particular question. The cognitive component of this protocol 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 Prescription” form was used to record sleep data to calculate 

sleep efficiency, and self-reported sleep satisfaction. 

This form also provided a decision-tree for the provider:

• If Sleep Efficiency is 85% or greater, add 30 minutes 

(earliest bedtime is 30 minutes sooner but wake-up 

time stays the same).

• If Sleep Efficiency is 65% or less, subtract 30 minutes (earliest bedtime is 30 minutes later but wakeup time stays the same).

• If Sleep Efficiency is 66% to 84%, keep the same 

schedule, follow-up in a week.

The plan was to have a patient seen for 3 sessions, including 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.

Study

An 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 using nonparametric methods due to the small number of 

subjects in order to avoid false assumptions of normality.

Act

Chart review by B.W. was conducted throughout the deployment 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) 25

Mean Age (years) 23.8 5.513

Male (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 Sessions 2.56 1.294

Average Length of Insomnia (months) 13.96 9.813

Type of Insomnia

Combined (n=21) 84%

Initial (n=3) 12%

Terminal (n=1) 4%

Baseline Sleep Duration (hours) 5.12 1.716

Baseline Time in Bed (hours) 8.28 1.926

Baseline Sleep Efficiency* 61.80%

Desired Sleep Duration (hours) 7.4 0.766

Average Number of Sleep Disruptions/Night 2.84 1.491

Average Number of Naps 0.9 1.291

Racing Thoughts on Pillow Present 72%

Average Daily Caffeine Intake (drinks) 1.32 0.476

Prior Hypnotic Use (n=15) 60%

Current Hypnotic Use (n=5) 20%

*Defined as baseline sleep duration/baseline time in bed×100.
56 http://www.cs.amedd.army.mil/amedd_journal.aspx

elicited about improvement to the Dysfunctional 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 significant satisfaction, perceived improvement in 

skill, and confidence in the treatment of insomnia 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 total of 64 sessions were delivered, averaging 2.56 

sessions per patient. Outcome measures were 

calculated for intake (Session 1), Session 2 and 

Session 3, with total of 15 patients having data 

for all 3 sessions.

Outcome Measures

Learner’s Training Evaluation

A training evaluation survey was completed (N=10, 

30%) upon completion of the training workshop. Overall, there was positive response on postinstructional 

evaluation (Table 2). Using Wilcoxon Signed-Ranks 

Test, the pre- versus posttraining perceived skill (z=-

2.871; P<.01) and confidence (z=-2.844; P<.01) levels 

to treat insomnia significantly improved.

Sleep Efficiency

Mean sleep efficiency significantly improved (Figure 1). 

A nonparametric Friedman’s test of differences among 

repeated measures for sleep efficiency was conducted 

and rendered a χ2

 value of 19.54 which was significant 

(P<.01). Post-hoc Wilcoxon Signed-Ranks Test with 

Bonferroni correction indicated that posttest ranks 

were statistically significantly higher for Session 2

(z=-3.68; P<.01) and Session 3 (z=-3.11; P<.002) at follow-up when compared to Session 1. The change in ranks 

was nonsignificant between Session 2 and Session 3

(z=-0.08; P<.94).

Time Asleep

Total self-reported average sleep duration at intake was 

4 hours, 32 minutes; Session 2 was 4 hours, 53 minutes 

and Session 3 was 5 hours and 11 minutes. However, 

nonparametric Friedman’s test of differences among 

repeated measures for self-reported sleep duration was 

conducted and rendered a χ2

 value of 3.268 which was 

nonsignificant (P=.195).

Total Time in Bed

Average total time spent in bed (including both awake 

and asleep) was 8 hours and 4 minutes at intake. It 

significantly decreased to (Session 2) 5 hours, 46 

minutes, and (Session 3) 6 hours and 5 minutes. Significance was measured using nonparametric Friedman’s test of differences among repeated measures, 

rendering a χ2

 value of 14.68 which was significant 

(P<.01). A post-hoc Wilcoxon Signed-Ranks Test with 

Bonferroni correction indicated that post-test ranks 

were statistically significantly lower for Session 2

(z=-3.43; P<.01) and Session 3 (z=-2.68; P<.007) in 

comparison to baseline intake values (Session 1). The 

change in ranks was nonsignificant between Session 2 

and Session 3 (z=-1.59; P=.11).

Perceived Sleep Satisfaction

Subjective satisfaction with duration (Figure 2) and 

quality (Figure 3) of sleep was measured on a Likert 

scale with 5 as maximum satisfaction. The baseline (intake) mean satisfaction for perceived sleep duration was 

1.36, SD 0.57 (N=25), Session 2 mean was 1.94, SD 0.64 

(N=18), and Session 3 mean was 2.57, SD 1.01 (N=14). 

A nonparametric Friedman’s test of differences among 

repeated measures for intake, Session 2 and Session 3 

(N=14) was conducted and rendered a χ2

 value of 16.77 

which was significant (P<.01). A post-hoc Wilcoxon 

Signed-Ranks Test with Bonferroni correction indicated that posttest ranks were statistically significantly higher for Session 2 (z=-2.97; P<.01) and Session 3

Table 2. Post-Training Survey assessing perceived satisfaction and effectiveness of training by learners.*

Min Max Mean SE SD

Effective goal communications 4 5 4.70 0.153 0.483

Effective learning climate 4 5 4.70 0.153 0.483

Instructor knowledgeable 4 5 4.90 0.100 0.316

Didactics important 4 5 4.90 0.100 0.316

Workshop important 2 5 4.50 0.342 1.080

Handouts important 4 5 4.90 0.100 0.316

PRIOR to this training, CONFIDENCE level 1 4 2.10 0.314 0.994

AFTER this training, CONFIDENCE level 3 5 4.40 0.221 0.699

PRIOR to this training, SKILLS level 1 4 2.10 0.314 0.994

AFTER this training, SKILLS level 3 5 4.20 0.200 0.632

Likelihood of using training 3 5 4.40 0.267 0.843

Likelihood of implementing training 3 5 4.30 0.300 0.949

Likelihood of recommending this to 

patients

4 5 4.80 0.133 0.422

Likelihood of recommending this to other

medical providers

3 5 4.50 0.224 0.707

This training should be provided to all

medics in Advanced Individual Training

1 5 4.10 0.433 1.370

Overall satisfaction with training 4 5 4.80 0.133 0.422

Min 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
October – December 2017 57

THE ARMY MEDICAL DEPARTMENT JOURNAL

(z=-3.03; P<.002) follow-up in comparison to baseline. 

The change in ranks was nonsignificant between Session 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 Friedman’s 

test of differences among repeated measures for intake, 

Session 2 and Session 3 (N=14) was conducted and rendered a χ2

 value of 19.41 which was significant (P<.001). 

A post-hoc Wilcoxon Signed-Ranks Test with Bonferroni correction indicated that post-test ranks were statistically significantly higher for Session 2 (z=-2.75; 

P<.001) and Session 3 (z=-3.15; P<.002) follow-up in 

comparison to baseline. The change in ranks was also 

significant between Session 2 and Session 3 (z=-3.05; 

P<.002).

Process Measures

The checklist served as a process measure to ensure the 

medics applied the methods of behavioral sleep treatment accurately. All cases seen were reviewed by the 

authors with focus on calculation of sleep efficiency and 

sleep prescription. On average, these were performed 

correctly 86% of the time. Only minor errors related to 

conversion of minutes were seen.

Balancing Measures

No 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, including those that were lost to follow-up, were involved in 

behavioral incidents, including acute psychiatric exacerbation or need for medical evacuation. None required 

acute referral for hypnotic therapy.

Comment

We faced the clinical challenge of delivering safe and effective nonpharmacological treatment for Soldiers suffering from insomnia in a limited resource environment. 

Cognitive behavioral therapy based insomnia treatment 

has been shown to be an effective treatment.16 Hence, 

the root cause of this situation was insufficient providers who could deliver CBT based insomnia treatment 

Figure 1. Sleep efficiency (mean) results demonstrate 

significant continuous improvement from treatment 

session 1 through sessions 2 and 3. Sleep Efficiency

60.36% 82.28% 85.20%

1 2 3

0%

20%

40%

60%

80%

100%

Treatment Session

Sleep

Efficiency

Figure 3. Sleep quality satisfaction results demonstrate 

significant continuous improvement from treatment 

session 1 through sessions 2 and 3. Satisfaction Scale

1.4 2.17 2.93

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 demonstrate significant continuous improvement from treatment 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 1.94 2.57

1 2 3

Treatment Session

Satisfaction Scale

Sleep

Duration
58 http://www.cs.amedd.army.mil/amedd_journal.aspx

without relying on hypnotics. Hypnotics pose safety 

concerns. During the 4.5-month period of deployment, 

author R.A. observed one Soldier with priapism and another 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 otherwise requires a significant amount of training and experience, 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 diagnostic tool in identification of such cognitions, followed by 

verbatim cognitive restructuring scripts, permitted us 

to easily enable the medics to challenge such dysfunctional beliefs. Additionally, the protocol with checklistled sleep prescriptions enabled the medics to rapidly approach sleep efficiency-based decisions with an easy to 

use algorithmic approach.

This was not intended to be a research study, but rather 

operationalizing evidence-based CBT treatment for insomnia by healthcare extenders (medics) that has not 

been done in the past, especially in the operational environment. The project illustrates one potential answer 

to manpower constraints by utilizing readily available 

medical personnel. The nonparametric tests showed significant improvements in both sleep efficiency (and related total time spent in bed), as well as satisfaction with 

the quality and quantity of sleep. Interestingly, these improvements occurred very rapidly after just a single session. Data analysis for both sleep efficiency and satisfaction showed significant improvements from intake’s first 

session to the second session. Further post-hoc analysis 

showed that a third session maintained the significance 

from the intake. Interestingly, although there was not a 

statistically significant increase in the actual sleep duration, both satisfaction with sleep quality and duration 

improved. This supports the perceptual nature of the 

insomnia experience.

Given its success in the operational setting, we plan to 

formally evaluate our checklist-based approach to insomnia treatment using combat medics with a control 

group to study the feasibility and efficacy of our protocol in nonoperational setting. Appropriate sleep is an 

important ingredient for both physical and psychological 

fitness on which mission success relies. Sleep can affect 

both of these domains, and broader delivery of CBT-I 

based sleep literacy as primary prevention and wellness 

strategy could be the next step with broader use of a 

similar, checklist-based approach to sleep education.

Conclusion

Insomnia is a major problem in the deployed environment. Safer alternatives to pharmacological treatment 

such as cognitive and behavioral based approaches require specialized skilled personnel that are not readily 

available. This limited resource environment can be 

mitigated by using healthcare extenders such as combat 

medics, behavioral health specialists, or equivalent personnel. Our QI/PI project provides a road map that could 

be replicated early into a deployment or other resourceconstrained environments to effectively deliver cognitive and behavioral treatment for Soldiers with minimal 

effort and supervision.

Acknowledgment

We thank Dr Raywin R. Huang, PhD, and Mr Troy H. Patience, Madigan Army Medical Center, Tacoma, Washington, for their expert assistance with statistical analysis and review of the project.

References

1. American Psychiatric Association DSM-5 Task 

Force. Diagnostic and Statistical Manual of Mental 

Disorders: DSM-5. 5th ed. Arlington, VA: American Psychiatric Association; 2013.

2. Buysse DJ. Insomnia. JAMA. 2013;309(7):706-716. 

doi:10.1001/jama.2013.193.

3. Pedersen ER, Troxel WM, Shih RA, Pinder E, 

Lee D, Geyer L. Increasing resilience through 

promotion of healthy sleep among service members. 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 performance. Curr Psychiatry Rep. 2014;16(8):459. 

doi:10.1007/s11920-014-0459-7.

6. Miller NL, Tvaryanas AP, Shattuck LG. Accommodating adolescent sleep-wake patterns: the effects 

of shifting the timing of sleep on training effectiveness. 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 retrospective 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
October – December 2017 59

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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. Borbély AA, Daan S, Wirz-Justice A, Deboer T. 

The two-process model of sleep regulation: a reappraisal. 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, Workbook. 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 Patient Health Questionnaire-2: validity of a two-item 

depression screener. Med Care. 2003;41(11):1284-

1292. doi:10.1097/01.MLR.0000093487.78664.3C.

14. Kroenke K, Spitzer RL, Williams JBW, Monahan 

PO, Löwe B. Anxiety disorders in primary care: 

prevalence, impairment, comorbidity, and detection. Ann Intern Med. 2007;146(5):317-325.

15. Morin CM, Vallières A, Ivers H. Dysfunctional 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. Cognitive 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 irritability, anger, anxiety, and anorexia: probable adverse 

drug interaction. Prim Care Companion CNS Disord. 2016;18(4). doi:10.4088/PCC.15l01917.

Authors

MAJ Amin is Division Psychiatrist, 7th Infantry Division, and Staff Psychiatrist and Internist, Madigan Army 

Medical Center, Tacoma, Washington.

CPT Wirtz is Brigade Behavioral Health Officer, 2nd Infantry Brigade Combat Team, 3rd Infantry Division, Fort 

Stewart, Georgia.
60 http://www.cs.amedd.army.mil/amedd_journal.aspx

Sandfly fever, sometimes known as pappataci fever or 

Phlebotomus fever, is a vector transmitted viral illness 

with a history of affecting naïve military formations that 

travel through or fight in areas where the infection is 

endemic.1-3 We present a series of 4 hospitalized cases 

(2 presumptive, 2 laboratory confirmed) of sandfly fever (SFF) that were admitted to a Role 3 hospital in Afghanistan for evaluation and treatment following medical evacuation from a forward area for marked fevers 

and malaise.

Case Series

The following 4 cases occurred over a 2-week time period during midsummer in a malaria-endemic region 

of eastern Afghanistan. Through interviews and later 

investigations, we estimate that at least 3 dozen similar cases presented to special operations forces (SOF) 

medics during this period. However, the 4 patients 

discussed in the following case studies required medical 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 personal protective equipment to protect exposed skin. All 

reported strict compliance with doxycycline 100 mg by 

mouth daily for malarial chemoprophylaxis.

Patient A

Patient 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 stiffness. He was initially treated by the SOF medic with acetaminophen and intravenous fluids. The patient also received a 2-day oral course of amoxicillin/clavulanic acid 

for apparent empiric treatment of community acquired 

pneumonia. Despite these interventions, the patient had 

no significant improvement in symptoms. He was transferred 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 103°F 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 cerebrospinal fluid gram stain. His complete blood count 

Sandfly Fever in Afghanistan–A 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

Abstract

Sandfly fever, sometimes known as pappataci fever or Phlebotomus fever, is a vector transmitted viral illness 

with a history of affecting naïve military formations that travel through or fight in areas in which the infection 

is endemic. We present a series of 4 hospitalized cases of sandfly fever (2 presumptive, 2 laboratory confirmed) 

that were admitted to a Role 3 hospital in Afghanistan for evaluation and treatment following medical evacuation from a forward area for marked fevers and malaise. Laboratory evaluation of these cases was significant 

for leukopenia and thrombocytopenia, consistent with historical descriptions of sandfly fever. In the correct 

geographic and clinical setting, the finding of mild leukopenia among a cluster of febrile patients should prompt 

the clinician to at least consider a diagnosis of sandfly fever. A cluster investigation conducted by preventive 

medicine personnel identified numerous other presumed cases of sandfly fever in this forward special operations camp. Response efforts emphasized enforcement of standard vector-borne disease control measures by 

operational leadership in order to limit effect on tactical operations. We review historical instances of sandfly 

fever affecting military operations, and present a review of clinical presentation, transmission, management, 

and prevention.
October – December 2017 61

THE ARMY MEDICAL DEPARTMENT JOURNAL

(CBC) was significant for a leukopenia to 2,700 white 

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 (normal 0.80-1.50 mg/dL). A hepatic function panel and urinalysis 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 

no parasites. A mononuclear spot (“monospot”) test was 

negative. Blood cultures drawn at the time of admission 

showed no growth after 5 days.

After an extensive review of other diagnostic considerations 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 inpatient monitoring following improvement in his clinical 

symptoms.

Patient B

Patient B was a 19-year-old active duty male Army Soldier who presented to a SOF medic with 48 hours of 

subjective fevers, myalgias, and a sore throat. He was 

initially treated by the SOF medic with intravenous fluids and acetaminophen for 24 hours without improvement 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 103°F earlier in the day. He denied 

headaches, cough, dyspnea, abdominal pain, diarrhea, 

dysuria, or rash. His physical examination was remarkable for diffuse, noninflamed insect bites on his lower 

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 patient’s 

PT and APTT were mildly elevated at 13.2 seconds and 

43.5 seconds, respectively. A rapid antigen detection 

test for streptococcal pharyngitis (“rapid strep” test) 

and monospot test were both negative. Thick and thin 

smears for malaria showed no parasites. The day following admission, the patient’s 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 C

Patient C was a 21-year-old active duty male Army Soldier who presented to a SOF medic with 24 hours of diffuse myalgias, subjective fevers, fatigue, and a mild sore 

throat. A SOF medic treated Patient C with acetaminophen and intravenous hydration initially, but worsening symptoms, including a confirmed fever of 104°F, 

prompted the decision for medical evacuation.

Upon presentation to the Role 3 hospital, the patient was 

afebrile and hemodynamically stable. He denied headaches, cough, dyspnea, chest pain, abdominal pain, diarrhea, dysuria, or rashes. His physical exam was unremarkable except for numerous insect bites on his lower 

extremities. Complete blood count was significant for 

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 respiratory viral polymerase chain reaction (PCR) panel was 

unremarkable. Human immunodeficiency virus (HIV) 

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 radiograph was unremarkable. A rickettsial panel was 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 Centers for Disease Control and Prevention (CDC) Division 

of Vector-Borne Diseases, Arboviral Diseases Branch, 

in Fort Collins, Colorado, specifically to examine for 

evidence of SFF exposure.

During his hospitalization, Patient C had a peak temperature of 103°F. He was treated with intravenous hydration, ibuprofen, and acetaminophen. On the recommendation 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 potentially undiagnosed rickettsial illness while we awaited 

the results of further confirmatory testing. Patient C improved over the next 24 hours and was discharged. A 

week later, a repeat CBC demonstrated resolution of his 

leukopenia and thrombocytopenia.

Patient D

Patient D was a 31-year-old active duty male Army Soldier who presented to a SOF medic with 48 hours of 

fevers, diffuse myalgias, sore throat, and intermittent 

headaches. He received intravenous fluids and acetaminophen by a SOF medic, but persistent symptoms 
62 http://www.cs.amedd.army.mil/amedd_journal.aspx

forced medical evacuation to the Role 3 hospital for further care.

Upon presentation to the hospital, Patient D had a temperature of 100.2°F. He denied cough, shortness of breath, 

abdominal pain, diarrhea, dysuria, and rash. Physical 

examination was significant for cervical lymphadenopathy without pharyngeal exudate or erythema. He was 

noted to have multiple lower extremity insect bites with 

associated pruritus. Comprehensive physical examination was otherwise unremarkable. Complete blood count 

analysis was significant for leukopenia with a WBC 

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 malaria 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 Arboviral Diseases Branch in Fort Collins, Colorado, specifically to examine for evidence of SFF exposure.

Patient D improved within the next 48 hours and was 

discharged in improved condition. He was also discharged with instructions to complete a 7-day course 

of doxycycline 100 mg by mouth twice daily for empiric treatment of a potentially undiagnosed rickettsial 

illness. A follow-up CBC performed one week after discharge demonstrated resolution of his leukopenia and 

thrombocytopenia.

Investigation

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 diagnosis of SFF based on review of possible infectious 

disease threats in the area, clinical findings, and laboratory findings.4

 Particularly relevant was the presence of 

leukopenia and mild thrombocytopenia noted in all the 

above cases as had been described by other US military 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 chemoprophylaxis. This reported adherence to doxycycline 

helped to place leptospirosis and rickettsial diseases far 

lower on the list of differential diagnoses due to presumed prophylaxis against these illnesses provided by 

doxycycline use.

A working case definition of SFF was developed from 

these 4 patients. The case definition was defined broadly 

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 setting of known exposure to sand flies. The decision was 

then made to send preventive medicine (PM) personnel 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 personnel still living at the camp site for other potential clues.

Camp A was a special operations camp located in a remote 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 nation force personnel. The population varied significantly 

from day to day and week to week as US military personnel rotated into and out of Camp A frequently. Although multiple other camps were located within roughly a 10-kilometer radius of Camp A, the above described 

cases originated solely from Camp A, suggesting that 

some aspect of the specific living conditions, sanitation, 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 

lacked significant infrastructure. Disruption of soil was 

required in order to build and reinforce defensive fighting positions and create a secure, functioning camp.

Preventive medicine personnel found that approximately 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 estimate was an attack rate of more than 60% of personnel 

who had lived at Camp A for more than 7 days based on 

the aforementioned SFF case definition. Using this case 

definition as a guide, the Camp A SOF medic closely 

monitored service members reporting fever and malaise, treating those patients with fluid resuscitation and 

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 AFGHANISTAN–A SOMETIMES OVERLOOKED DISEASE

OF MILITARY IMPORTANCE: A CASE SERIES AND REVIEW OF THE LITERATURE
October – December 2017 63

THE ARMY MEDICAL DEPARTMENT JOURNAL

the SFF working diagnosis. All other cases of febrile 

illness remained at Camp A, slowly improved over a period 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.

Preventive medicine personnel found rudimentary field 

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 

officials. However, the majority of food consumed were 

military Meals, Ready-to-Eat rations. Service members 

were noted to frequently bathe in a nearby river. Domestic animals including goats, donkeys, cats, and canines 

were frequently in close proximity to Camp A. Area 

vector control measures were not in place. Service members frequently worked during the day without wearing 

uniform blouses, and were not observed to apply insect 

repellant to exposed skin. Bed nets were used infrequently, and service members frequently slept outside. 

Nearly all interviewed members admitted to receiving 

frequent bites from flying insects.

Preventive medicine personnel collected samples of local sandflies and mosquitoes, and submitted these specimens to the US Army Public Health Command-Europe 

for analysis. Results returned approximately one month 

later confirmed the presence of the SFF virus in sandflies collected at Camp A. Almost simultaneously, results of human blood samples drawn from Patient C and 

Patient D returned from the CDC Arboviral Diseases 

Branch with a positive plaque reduction neutralization 

test indicating prior infection with a sandfly fever virus, 

most likely Sicilian serocomplex.

Comment

Sandfly fever virus is transmitted through the bite of 

an infected phlebotomine sandfly (genus 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 

typical influenza-like febrile illness that has been traditionally described as sandfly fever, and was most likely 

witnessed in our cases, whereas Toscana serotype has 

been associated with neurovirulence and encephalitis.6

The geographic distribution of the virus is centered 

around the Mediterranean basin, with notable extension 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 Sandfly fever has been known to be endemic in 

Afghanistan for many years, but was most notably identified during the 1980s Soviet occupation of Afghanistan when SFF was known to attack significant proportions of Soviet troops based in eastern Afghanistan.9-11

British troops also suffered from so-called “Helmand 

fever” during their most recent experience in southern 

Afghanistan. In many cases, Helmand fever was later 

determined to be SFF.12,13 Sandfly fever is described by 

the US National Center for Medical Intelligence as potentially affecting up to 50% of small groups of susceptible troops in areas with large populations of infected 

sandflies if adequate and appropriate precautionary 

measures are not taken.14 In the above case series and 

investigation, we estimate that roughly 50% of the personnel at Camp A were affected at some point during 

their tenure at Camp A or shortly after their return. This 

resulted in a significant reduction of unit combat effectiveness; 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.

As noted in our patients, clinically significant SFF develops after a 2 to 6 day incubation period following the 

bite of an infected sandfly.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 102°F, and roughly 8% 

of affected patients had a temperature between 104°F 

and 104.5°F.5

 In the cases described above, SOF medics 

Phlebotomus papatasi sandfly, the vector of sandfly fever. 

Courtesy of Centers for Disease Control and Prevention, Public 

Health Image Library (https://phil.cdc.gov/phil/details_linked.

asp?pid=10277).
64 http://www.cs.amedd.army.mil/amedd_journal.aspx

developed an unwritten operating procedure to attempt 

to limit the number of medical evacuations from Camp 

A by establishing a fever over 103°F as the deciding factor for evacuation to at least Role 2 care or higher. The 

described fever typically lasts for 72 hours before spontaneous resolution, hence SFF is sometimes referred to 

as “3 days fever.” 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 underwent lumbar puncture upon arrival at the Role 3 facility for concern of meningitis. Physical examination has 

been reported to be remarkable for a marked flushed appearance 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 meningoencephalitis picture.15 On rare occasions, a more 

pronounced meningoencephalitis presentation has 

occurred with Sicilian serotype SFF. In 2004, Lesho 

and colleagues 6

 reported a case of severe encephalitis 

secondary to Sicilian serotype SFF in a US Army officer serving during the early stages of Operation Iraqi 

Freedom. This case resulted in status epilepticus, a prolonged course of intubation for airway protection, and 

reported residual neurocognitive defects 3 months after 

initial presentation.

Laboratory evaluation should include complete blood 

count, renal/metabolic panel, hepatic profile panel, and 

coagulation profile at a minimum. Lumbar puncture 

with cerebrospinal fluid collection and analysis may be 

also necessary early on to exclude the diagnosis of bacterial meningitis. The most notable laboratory finding 

for our cases treated at a Role 3 facility was leukopenia. In the correct geographic and clinical setting, the 

finding of mild leukopenia among a cluster of febrile 

patients should prompt the clinician to at least consider 

a diagnosis of SFF. Additional frequent laboratory findings include thrombocytopenia, and elevated levels of 

aspartate aminotransferase and alanine aminotransferase.16 However, in this small sample of cases, thrombocytopenia 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 location 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 Patients C and D, the evaluation expanded to include testing for mononucleosis, HIV, Q fever, and rickettsial disease. Unfortunately at our location, only malaria testing (thick and thin smears, and rapid diagnostic tests) 

was available with expeditious turnaround time. Thus, 

while serologic testing for the above infections was considered, the treating team had to rely primarily on exam 

and patient history to exclude the presence of a specific 

disease. For example, several clinicians noted the markedly 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 possibility with this information. This once again highlights the 

need for SOF medical providers to remain proficient in 

the identification of, and initial treatment for, the infectious disease threats present in the regions in which the 

troops they support are operating.

In general, treatment for SFF is supportive, involving 

convalescence, and fluid resuscitation as needed over 

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 defervescence in our hospitalized patients. Return to full 

Laboratory Values of Cases.

Hospital

Day

White Cell

Count

Hemoglobin Platelet

Count

AST ALT

Patient A

1 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 16.1 120,000

Patient B

1 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 C

1 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 D

1 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/mm3

Hemoglobin; 12.0-16.0 g/dL

Platelet Count; 150,000-450,000/mm3

AST indicates aspartate aminotransferase; 9-32 U/Liter

ALT indicates alanine aminotransferase; 7-30 U/Liter

SANDFLY FEVER IN AFGHANISTAN–A SOMETIMES OVERLOOKED DISEASE

OF MILITARY IMPORTANCE: A CASE SERIES AND REVIEW OF THE LITERATURE
October – December 2017 65

THE ARMY MEDICAL DEPARTMENT JOURNAL

duty may be impaired for as much as 14 to 30 days after 

initial presentation.1

 This could be crippling to military 

operations for military units with a significant proportion 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 

sandfly bites is through proper use of personal protective 

measures.18 This includes the proper wear of loosely fitted permethrin-treated uniforms or clothing, and the use 

of insect repellents containing 30% to 40% N,N-Diethyl-meta-toluamide (DEET) on any exposed skin. Due to 

the nocturnal nature of sandflies, people are most likely 

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 

barrier to prevent sandfly biting. In addition, sandflies 

are known weak fliers and tend to target exposed skin on 

the lower half of a human’s body. Sleeping on elevated 

surfaces (3 feet or higher) from expected sandfly habitats will reduce the likelihood of being bitten during rest 

periods.19 Following the field investigation by preventive 

medicine personnel described earlier, and subsequent 

recommendations to strictly enforce these personal 

protective measures, tactical leaders began to appreciate 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 attributed this reduction in cases to a continued emphasis 

on personal protective measures by leaders at all levels.

If sandfly populations are abundant enough to be a burden, chemical treatment should be considered to manage the number of insects in the area.19 Residual pesticides can be applied to most surfaces and effectively kill 

sandflies. The following areas should be targeted: rocky 

outcroppings, HESCO barriers (HESCO Bastion Ltd, 

Leeds, UK), sandbags, rock walls, termite mounds, animal burrows, cracks in floors/walls, any loose soil, soil 

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 increase in sandfly activity in the area, resulting in numerous bites for unsuspecting service members.

Conclusion

Sandfly fever has historically been considered a disease 

of military importance due to its ability to quickly incapacitate naïve 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 easily overlooked as a disease of military importance as it 

is relatively unknown among many American and European military physicians, and serologic testing is unlikely to be available to confirm or deny. We encourage 

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. Kocak Tufan Z, Tasyaran MA, Guven T. Sandfly 

Fever: A Mini Review. Virol Mycol. 2013;2(1):109.

2. Ellis SB, Appenzeller G, Lee H, et al. Outbreak of 

sandfly fever in central Iraq, September 2007. Mil 

Med. 2008;173(10):949-953.

3. Shiraly R, Khosravi A, Farahangiz S. Seroprevalence of sandfly fever virus infection in military 

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 infectious diseases of Afghanistan. Clin Infect Dis. 

2002;34(suppl 5):S171-S207.

5. Sabin AB, Philip CB, Paul JR. Phlebotomus (pappataci or sandfly) fever: a disease of military importance. Summary of existing knowledge and preliminary report of original investigations. JAMA. 

1944;125(9):603-606.

6. Lesho EP, Ludwig GV, Wortmann G. Encephalitis 

and Sandfly Fever (Sicilian) Virus Infection: Case 

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 

of sand fly fever, West Nile, Crimean-Congo 

hemorrhagic fever, and leptospirosis antibodies in Pakistani military personnel. Mil Med. 

1996;161(3):149-153.

8. Konstantinou GN, Papa A, Antoniadis A. Sandfly-fever outbreak in Cyprus: are phleboviruses 

still a health problem?. Travel Med Infect Dis. 

2007;5(4):239-242.

9. Gaidamovich S, Khutoretskaia NV, Aziamov Iu 

V, Tsiupa VI, Mel’nikova EE. Virological study of 

cases of sandfly fever in Afghanistan [in Russian]. 

Vopr Virusol. Jan-Feb 1990;35(1):45-47.

10. Nikolaev VP, Perepelkin VS, Raevskii KK, Prusakova ZM. A natural focus of sandfly fever in the 

Republic of Afghanistan [in Russian]. Zh Mikrobiol Epidemiol Immunobiol. 1991 Mar(3):39-41.

11. Korol’kov VF, Nikiforov SV, Kozlov SS. The clinico-epidemiological characteristics of natural-focus 

diseases in the Rukha garrison [in Russian]. Voen 

Med Zh. 1992 Jun(6):64-65.
66 http://www.cs.amedd.army.mil/amedd_journal.aspx

12. Glennie JS, Bailey MS. UK Role 4 military infectious 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. Undifferentiated 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 

caused by sandfly fever virus, serotype Toscana. 

Clin Infect Dis. 1995;21(3):669-671.

16. Guler S, Guler E, Caglayik DY, et al. A sandfly fever 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. Technical Guide No. 36 Personal Protective Measures 

Against Insects and Other Arthropods of Military 

Significance. Silver Spring, MD: Armed Forces 

Pest Management Board; 2015.

19. Armed Forces Pest Management Board. Technical 

Guide No. 49 Sand Flies: Significance, Surveillance, and Control in Contingency Operations. Silver Spring, MD: Armed Forces Pest Management 

Board; 2015.

Authors

LTC Downs is with the Department of Preventive Medicine, Blanchfield Army Community Hospital, Fort Campbell, 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 (Airborne), 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 AFGHANISTAN–A SOMETIMES OVERLOOKED DISEASE

OF MILITARY IMPORTANCE: A CASE SERIES AND REVIEW OF THE LITERATURE
October – December 2017 67

Destructive periodontitis can neither initiate nor progress in the complete absence of a select group of etiologic bacteria. In both chronic and aggressive forms of 

periodontitis, bacteria appear necessary for initiation of 

inflammatory periodontal tissue destruction, but mere 

presence of bacteria is insufficient for disease manifestation.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.7

The 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 smoking 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 malady that precludes an effective neutrophil response consistently produces severe, often devastating, periodontal 

destruction.15 Likewise, in patients with localized aggressive periodontitis, neutrophils exhibit reduced chemotaxis and various other functional abnormalities.16

Smoking also induces endothelial dysfunction, a situation with the potential to further hamper the neutrophil 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.18,19

Smokers are not only more susceptible to destructive 

periodontal disease; they are also much more difficult 

to treat. Researchers have repeatedly shown that smokers 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 For many of the specific procedures performed in periodontics, studies directly comparing 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 inferior outcomes in smokers treated with subepithelial connective tissue grafts for root coverage. Numerous studies 

also show that smoking is particularly unfavorable when 

bone or periodontal regeneration is attempted.28-31

Most 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 experience disease progression despite sound surgical 

therapy, frequent professional maintenance, and excellent plaque control.25,32 Many such patients exhibit one 

or more systemic factors predisposing toward periodontal destruction. Thus, it is incumbent upon clinicians 

to first identify systemic risk factors like smoking and 

modify such influences to the extent possible prior to 

initiating periodontal therapy. Moreover, high-risk patients 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 waiting” in patients with identified systemic risk factors will 

often lead to clinically significant disease progression 

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 Accordingly, clinicians should treat high-risk patients aggressively, but not necessarily invasively.

The current Army initiative to offer Nd:YAG laser periodontal therapy, shown in the Figure, to Soldiers is 

Smoking and Periodontal Disease

LTC Thomas M. Johnson, DC, USA
68 http://www.cs.amedd.army.mil/amedd_journal.aspx

SMOKING AND PERIODONTAL DISEASE

helpful to clinicians managing high-risk periodontitis 

patients, including those who smoke. The laser protocol allows clinicians to treat smokers using a definitive 

modality, without relegating the patient to a nonsurgical 

program or “compromise periodontal maintenance.”34

Army clinicians can use the laser for smokers with limited risk to the patient, and the treatment itself is minimally invasive compared with conventional surgical 

techniques. In vitro and ex vivo experimental models 

have shown bactericidal activity for some species after indirect (noncontact) Nd:YAG laser treatment.35-42

Bacterial kill appears to increase proportionally with 

power applied.35 Depending upon experimental conditions, 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 periodontal pathogens below detectable levels immediately 

following therapy.43 If confirmed, this finding would be 

very compelling. Although the host response to bacteria is critical in periodontitis pathogenesis, the specific 

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 

a specific laser-based protocol is capable of improving 

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.47

Smoking alters the vascular and immunologic responses to the bacteria that initiate periodontal disease and 

may negatively affect the composition of the microflora 

present. Regardless of the treatment modality used, it is 

abundantly clear that nonsmokers respond much more 

favorably to periodontal therapy compared with smokers. For any periodontitis patient, optimal therapeutic response must include smoking cessation.48,49 Laser periodontal therapy may be of clinical interest in the treatment of smokers because this modality offers ability to 

intervene early in a minimally invasive fashion.

References

1. Nunn ME. Understanding the etiology of periodontitis: an overview of periodontal risk factors. Periodontol 202003;32:11-23.

2. Lang NP. Commentary: bacteria play a critical role 

in the etiology of periodontal disease. J Periodontol. 2014;85(2):211-213.

3. Ezzo PJ, Cutler CW. Microorganisms as risk indicators for periodontal disease. Periodontol 

202003;32:24-35.

4. 1996 World Workshop in Periodontics. Consensus 

report. Periodontal diseases: pathogenesis and microbial factors. Ann Periodontol. 1996;1(1):926-932.

5. Genco RJ. Current view of risk factors for periodontal diseases. J Periodontol. 1996;67(suppl 

10):1041-1049.

6. Van Dyke TE, Sheilesh D. Risk factors for periodontitis. J Int Acad Periodontol. 2005;7(1):3-7.

7. Tomar SL, Asma S. Smoking-attributable periodontitis in the United States: findings from NHANES 

III. J Periodontol. 2000;71(5):743-751.

8. Stoltenberg JL, Osborn JB, Pihlstrom BL, Herzberg MC, Aeppli DM, Wolff LF, Fischer GE. Association 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 

on the subgingival microflora. 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 

the ensuing inflammatory response, the normal junctional 

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.
October – December 2017 69

THE ARMY MEDICAL DEPARTMENT JOURNAL

10. Boström L, Bergström J, Dahlén G, Linder LE. 

Smoking and subgingival microflora in periodontal disease. J Clin Periodontol. 2001;28(3):212-219.

11. Winkelhoff AV, Bosch-Tijhof CJ, Winkel EG, 

Reijden WV. Smoking affects the subgingival microflora in periodontitis. 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 ecosystem. J Clin Periodontol. 2014:1;41(11):1037-1047.

13. Persson L, Bergström J, Ito H, Gustafsson A. 

Tobacco smoking and neutrophil activity in patients with periodontal disease. J Periodontol. 

2001;72:90-95.

14. Ryder MI, Fujitaki R, Johnson G, Hyun W. Alterations of neutrophil oxidative burst by in vitro 

smoke exposure: implications for oral and systemic disease. Ann Periodontol. 1998;3:76-87.

15. Armitage GC. Development of a classification 

system for periodontal diseases and conditions. 

Ann Periodontol. 1999;4(1):1-6.

16. Kantarci A, Oyaizu K, Dyke TE. Neutrophil-mediated tissue injury in periodontal disease pathogenesis: findings from localized aggressive periodontitis. J Periodontol. 2003;1;74(1):66-75.

17. Powell JT. Vascular damage from smoking: disease mechanisms at the arterial wall. Vascular 

Med. 1998;3(1):21-28.

18. Preber H, Bergström 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 Periodontol. 2004;75:16-22.

20. Preber H, Bergström J. The effect of nonsurgical 

treatment on periodontal pockets in smokers and 

non-smokers. J Clin Periodontol. 1986;13:319-323.

21. Preber H, Bergström J. Effect of cigarette smoking on periodontal healing following surgical 

therapy. J Clin Periodontol. 1990;17:324-328.

22. Riveral-Hidalgo F. Smoking and periodontal disease. Periodontol 202003;32:50-58.

23. Kaldahl WB, Kalkwarf KL, Patil KD, Molvar 

MP, Dyer JK. Long-term evaluation of periodontal therapy: I. Response to 4 therapeutic modalities. J Periodontol. 1996;67(2):93-102.

24. Kaldahl WB, Johnson GK, Patil KD, Kalkwarf 

KL. Levels of cigarette consumption and response 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 periodontal 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 coverage. J Periodontol. 1987;58(10):674-681.

27. Erley KJ, Swiec GD, Herold R, Bisch FC, Peacock ME. Gingival recession treatment with connective 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 following GTR in infrabony defects. A preliminary retrospective study. J Clin Periodontol. 

1995;22:229-234.

29. Tonetti M. Cigarette smoking and periodontal diseases: 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 systematic review and meta-analysis. J Periodontol. 

2012;83(2):143-155.

31. Lindfors LT, Tervonen EA, Sándor GK, Ylikontiola LP. Guided bone regeneration using a titanium-reinforced ePTFE membrane and particulate 

autogenous bone: the effect of smoking and membrane 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 treatment without maintenance: a retrospective study 

in 44 patients. J Periodontol. 1984;55(9):505-509.

34. Schallhorn RG, Snider LE. Periodontal maintenance therapy. J Am Dent Assoc. 

1981;103(2):227-231.

35. Harris DM, Yessik M. Therapeutic ratio quantifies laser antisepsis: ablation of Porphyromonas 

gingivalis with dental lasers. Lasers Surg Med. 

2004;35:206-213.

36. Tseng P, Gilkeson CF, Palmer J, Liew V. The bactericidal 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 laser in in vitro root canals. J Clin Laser Med Surg. 

1996;14(2):77-80.
70 http://www.cs.amedd.army.mil/amedd_journal.aspx

38. 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. Bactericidal 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 canal dentin. J Clin Laser Med Surg. 1997;15(1):29-31.

42. Schoop U, Kluger W, Moritz A, Nedjelik N, Georgopoulos A, Sperr W. Bactericidal effect of different laser systems in the deep layers of dentin. Lasers Surg Med. 2004;35(2):111-116.

43. McCawley TK, McCawley MN, Rams TE. LANAP immediate effects in vivo on human chronic 

periodontitis microbiota. Presented at: 43rd Annual 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 attachment 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 clinical 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 evaluation of an Nd: YAG laser-assisted new attachment 

procedure in humans. Int J Periodontics Restorative Dent. 2007;27:577-587.

47. Tilt LV. Effectiveness of LANAP over time as measured 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 individual patient data meta‐analysis. J Clin Periodontol. 2013;40(6):607-615.

49. Rosa EF, Corraini P, Inoue G, et al. Effect of smoking 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 Advanced Education Program in Periodontics, Army Postgraduate Dental School, Uniformed Services University 

of the Health Sciences, Fort Gordon, Georgia.

SMOKING AND PERIODONTAL DISEASE

Army truck-mounted field dental clinic, circa 1917.
October – December 2017 71

Hot environments can be challenging for military working dog (MWD) teams who must balance mission requirements against increased heat strain and risk of heat 

injury. Heat stroke was the third most common cause of 

death in MWDs during conflicts in Iraq and Afghanistan, 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 contribute 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 Defense (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 42°C (108°F) may suggest heat illness in a dog exposed to heat alone,4

 during heavy exercise Tc can reach 

this level even with very short duration work (10 minutes) under relatively mild (24°C, 75°F) environmental 

conditions.5-8 However, a Tc of 43°C (109°F) may be 

fatal 9

; therefore, knowing how quickly temperature increases 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 recovery is necessary to minimize risk of heat injury.

While several studies have documented thermoregulatory 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 included 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 41°C after a 400 m sprint lasting only 30 seconds.12 Sled dogs reached a Tc of approximately 41°C to 

Core Temperature Responses of Military

 Working Dogs During Training Activities

 and Exercise Walks

Catherine O’Brien, MS

Anthony J. Karis, BS

William J. Tharion, MS, MBA

Heather M. Sullivan, BS

Reed W. Hoyt, PhD

Abstract

Heat strain is common in military working dogs (MWDs), but can be mitigated by limiting duration of activity 

to avoid overheating and allowing sufficient time for recovery. To determine work/rest times for MWDs, temperature 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 (27°C-32°C), October (22°C-26°C) and 

March (approximately 13°C). These MWDs swallowed a telemetric thermometer pill to measure continuous 

gastrointestinal tract temperature (Tgi). Twenty-four kennel MWDs participated in July (25°C-29°C). In these 

dogs rectal temperature (Tre) was measured manually during a standard exercise walk. For the MWDs in training, Tgi before the first activity was 38.5±0.5°C (mean±SD) and final Tgi was 39.8±0.6°C after sessions that 

lasted 13.1±4.9 minutes (5.4 to 26.3 minutes). Peak Tgi, 0.4±0.4°C above final Tgi, occurred 8 to 12 minutes 

into recovery. Before beginning a second activity 40 to 165 minutes later, Tgi was within 0.5°C of initial values 

for 80% of dogs. For the kennel MWDs, Tre was 39.0±0.8°C (37.7°C to 40.7°C) at the start and 40.1±0.6°C 

at the end of the 21.3±2.8 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 suspected of overheating temperature should be monitored for at least 15 minutes postexercise to ensure recovery.
72 http://www.cs.amedd.army.mil/amedd_journal.aspx

over 42°C when pulling carts over distances from 3 to 6 

km.13 Three studies reported Tc during exercise in Labrador retrievers. A Tc of 40.4±0.6°C was reached in a 20 

minute, 3.2 km conditioning run14; a Tc of 41.8±0.3°C 

was reached after 10 minutes of repeated retrieves 7

; and 

during field trials Tc reached 40.7±0.2°C, with one dog’s 

Tc as high as 42.2°C.15 None of these studies included 

the types of activities performed during MWD training.

The purpose of this study was to characterize Tc responses in MWDs during training at Lackland Air 

Force Base, San Antonio, TX. The results of this study 

will improve understanding of heat storage during exercise 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 

are undergoing this training. Once certified, MWD 

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, respond to cues of Out, Heel, Stay

 Building Search: Detect a person, narcotics, or explosives hidden inside a building

 Vehicle Search: Detect narcotics or explosives hidden on a vehicle

 Scouting: Locate a person by scent, sight, or sound

 Gunfire: Remain calm and attentive while weapons 

are fired

Also at Lackland AFB are MWDs awaiting training, 

those in the DoD breeding program, and Transportation Security Administration canines. These 

dogs are walked twice a week on 

a standard route around the kennel grounds.

A total of 48 MWDs participated 

in this study, which was approved 

by the Department of Defense 

MWD Veterinary Service Institutional 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 

not currently in training (“kennel MWDs”) were tested 

in July 2015 during a single exercise walk around the 

kennel grounds.

Testing for MWDs in training was scheduled for different times of the year to obtain data over a range of 

ambient temperatures (approximately 15°C to 30°C). 

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 

failure during recovery measurements on the first occasion. Meteorological conditions, including ambient temperature, relative humidity (RH), solar radiation, and 

wind speed were measured (WeatherHawk 500 Series 

weather station, Campbell Scientific, Inc, Logan, UT) 

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 Training

Of the 24 MWDs participating in the training portion of 

this study, 14 were Belgian Malinois and 10 were German Shepherd Dogs. Four were female, all neutered; 

20 were male, 3 neutered, the rest intact. Their age was 

23±6 months (range 16-37 months), weight 32±3 kg 

(range 26-39 kg), height at withers 62±6 cm (range 53-

84 cm) and length 78±5 cm (range 70-89 cm). All data 

are presented as mean±standard deviation.

Each morning the MWDs were picked up from the 

kennels and loaded onto a trailer where each dog was 

housed in an individual compartment (“dog box”) for 

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 2014 October 2014 March 2015 August 2015 July 2015

0800 1100 0800 1100 1300 0800 1100 0800 1100 0700 1100

Temperature

°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
October – December 2017 73

THE ARMY MEDICAL DEPARTMENT JOURNAL

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 measured using an ingestible telemetric thermometer capsule (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 dog’s 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, Murrysville, 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 dog’s stomach 

and not affected by water ingestion.18

The telemetric thermometer capsule is advantageous 

due to the continuous temperature data provided without need for invasive measurement or interruption of 

activity. However, this method depends on appropriate 

timing of pill ingestion to avoid the influence of water 

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; however, some dogs excreted the capsule overnight and a 

new capsule was administered the morning of testing. 

In those cases, water consumption after the first training 

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 MWDs

Twenty-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 Shorthair 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 33±23 months (range 9-96 months), weight 29±5 kg 

(range 19-39 kg), height 59±4 cm (range 53-69 cm), and 

length 29±3 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 location of their kennel on the grounds), the dogs were taken 

into a climate-controlled (27°C, 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 manually 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 seconds to one minute while the temperature 

was taken.

Results

MWDs in Training

Initial Tgi just before beginning the first activity was 38.6±0.5°C. All but 3 dogs had 

resting temperatures between 37.8°C and 

38.9°C, which is within a normal range.17

Two dogs, both of whom tended to spin in 

their kennels, had elevated Tgi (39.8°C and 

39.3°C) before the first activity, but both 

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

returned to within normal range after recovery (38.6°C, 

38.8°C, respectively). Both tended to spin less frequently 

as the training day progressed. One dog during the March 

session had a low Tgi (37.4°C) before the first activity.

Initial and final Tgi for each training activity are presented in Figure 2 for the 4 training groups. Data for one 

dog from October 2014 was not included in the data presented on this figure for Obedience and Building Search 

because his preactivity Tgi was outside even 

the wide range of normal body temperature 

presented by Vogelsang.17 For all groups on 

both days, Tgi at the end of the first activity 

was 39.8±0.6°C, with a large range (38.4°C 

to 41.4°C) due to individual variability and 

varied intensity and duration of training. 

Successful performance is typically reinforced by presentation of a toy reward and 

game of tug, or, in the case of patrol activities, 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 11.6±5.0 

minutes The average duration of each activity is shown in the legend of Figure 2. Figure 3 shows the individual Tgi responses 

during Obedience training. Since nearly all 

dogs performed this activity and it occurred 

as the first activity on a particular day, this 

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 41°C during a single activity. 

In August 2014, one dog reached a Tgi of 41.3°C during Vehicle Search; in October 2014, one dog reached 

41.2°C during Controlled Aggression and another dog 

reached 41.1°C during Obstacle Course; in August, 2015, 

CORE TEMPERATURE RESPONSES OF MILITARY WORKING DOGS

DURING TRAINING ACTIVITIES AND EXERCISE WALKS

Figure 2. Initial and final temperatures (mean±SD) are shown for each group of MWDs and each activity. The number of participating MWDs is shown above each bar. The mean (±SD) duration time of each activity is shown in the legend.

Preactivity

Obedience (12.6±4.4 min)

Controlled Aggression (11.5±2.8 min)

Vehicle Search (12.8±3.4 min)

Scouting (8.9±3.2 min)

Building Search (8.3±2.6 min)

Obstacle Course (16.2±3.2 min)

Gunfire (11.5±4.9 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 October 2014 March 2015

Figure 3. Core temperature response during obedience training. Data are presented for all 23 MWDs that participated in this activity.

0 10 20 30

39

40

38

41

37

42

Core Temperature (°C)

Elapsed Time (minutes)

October 2014

August 2014

August 2015

March 2015
October – December 2017 75

THE ARMY MEDICAL DEPARTMENT JOURNAL

one dog reached 41.4°C during Controlled Aggression. Neither of the 

MWDs with elevated Tgi before beginning the first activity reached Tgi 

over 41°C during training.

Peak Tgi typically occurred after the 

end of activity and the dog had returned 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, Building Search, and Controlled Aggression. The red line indicates Tgi measurements 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 exercise ceased. For the 36 cases where 

recovery data was obtained, peak 

Tgi was 0.4±0.4°C higher than Tgi 

at the end of activity, and occurred 10.2±10.6 minutes 

into recovery (typically during the first 8-12 minutes of 

recovery). The highest peak Tgi was 42.4°C, which occurred 8 minutes after the end of the activity. In only 2 

cases was peak Tgi the same as the final Tgi measured 

during activity.

Three activities were conducted each day in the October 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, 103.5±36.2 

minutes elapsed since the end of the first activity. For 

most dogs, there was sufficient time for recovery, and 

Tgi at the start of the second activity was within 0.5°C 

of initial values for 80% of the dogs. For the 10 MWDs 

with continuous recovery data after the first activity (ie, 

not obscured by water ingestion or out of range of the 

data logger), Tgi returned to within 0.5°C of initial values in 44.1±12.6 minutes.

Kennel MWDs

The initial Tre measured in the Kennel MWDs was 

39.0°C±0.8°C (37.7°C to 40.7°C). Eleven of these 

MWDs had an initial Tre that was higher than 39.2°C, 

which is considered the upper limit of normal.17 These 

readings would not be considered true “resting” temperatures, as some dogs were active in their kennel, pacing or jumping in anticipation of the morning’s activities.

Completing the approximately 800 m loop generally required 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 during 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 11.4±3.3 minutes 

of walking, Tre was 39.9±0.6°C. The dogs stood quietly during grooming, then walking back to the kennel 

where f﻿﻿inal Tre was 40.1±0.6°C and total elapsed time 

was 21.3±2.8 minutes. One dog reached a temperature 

over 41°C during the first walk period (41.3°C after 12 

minutes), but returned to 40.7°C 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 Malinois) had an initial Tre greater than 40°C. These events 

all occurred between 6:30 am and 7:30 am when trailers 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 

Belgian Malinois, it was the fifth occasion of overheating. The fourth dog (Labrador Retriever) had a normal 

initial temperature, but Tre was elevated to 40.5°C by 

the end of the first walk period. For that dog, it was the 

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

42

Obedience

Building

Search

Controlled

Aggression

Time of Day (24 hour)

9:00 10:00 11:00 12:00 13:00 14:00 15:00

Temperatures during activity

Temperatures during rest and recovery
76 http://www.cs.amedd.army.mil/amedd_journal.aspx

placing a fan in front of the kennel to enhance evaporative and convective cooling. All recovered without need 

for further intervention. Only 2 other MWDs reached 

Tre greater than 40.5°C during the walks.

Comment

This is the first study to report core temperature in 

MWDs during training activities and kennel walks. 

While the data presented here are descriptive, they provide a baseline for future studies where comparisons 

may be made or interventions evaluated. An important 

finding in the present study was the continued increase 

in Tgi to a peak 8 to 12 minutes after exercise ended, 

shown for one dog in Figure 3. This delay in reaching 

peak Tgi may reflect both a transient lag in temperature 

response of the gastrointestinal tract due to decreased 

blood flow during exercise, compared to the temperatures 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 measuring 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 ventilation, or could potentially allow earlier identification of 

MWDs that require veterinary attention.

Although heat injury can occur at a body core temperature of 42°C 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 duration exposure. A temperature of 43°C can be fatal.9

 Under the conditions in the present study, Tgi reached approximately 40°C at the end of a training session, with 

only 4 MWDs reaching a temperature over 41°C (two 

in August, two in October). For 2 of these dogs, this occurred on the last activity of the day. Before beginning 

the second activity of the day, Tgi had returned to within 

0.5°C 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 recovery periods were acceptable. Figure 3 shows the continuous increase in core temperature during Obedience 

and illustrates how limiting training duration could be 

effective for avoiding excessive heat strain. Under conditions of high heat stress, short sessions can reduce risk 

of overheating while still meeting mission requirements. 

Kennel MWDs also reached a Tre of about 40°C at the 

end of their walk, with only one dog reaching a Tre over 

41°C, 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 kennel activity had contributed to their elevated temperatures 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 40.5±1.0°C 

in Labrador Retrievers at the end of a 20-minute run 

at 2.9 m/s, and Tgi of approximately 40.0±1.0°C after 

12.5 minutes of work, comparable to findings in the 

present study. Matwichuk et al7

 reported a higher Tre of 

41.8±0.3°C in Labrador Retrievers after 10 minutes of 

work. However, those dogs on average completed 44 retrieves 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 39.9°C to 41.7°C, but when dogs ran 

for longer distances (16 km) without pulling a load, Tre 

was lower (39.5°C to 40.2°C). 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 temperature observed in the present study. This may be due to 

the frequency of temperature measurements. For example, Matwichuk et al7

 found that Tre was the same after 

CORE TEMPERATURE RESPONSES OF MILITARY WORKING DOGS

DURING TRAINING ACTIVITIES AND EXERCISE WALKS

Figure 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.

0 min 11±3 min 16±3 min 21±3 min Elapsed

Time

Start Initial Walk Post-groom Finish

39

40

38

41

37

42

Core Temperature (°C)

n=24 n=22 n=20 n=15
October – December 2017 77

THE ARMY MEDICAL DEPARTMENT JOURNAL

5 minutes of recovery as it was at the end of exercise, 

and had decreased only to 41.6±0.3°C after 10 minutes. 

Likewise, Angle and Gillette reported little change in 

Tgi in the first 5 minutes of recovery.14 Whether a peak 

in Tre had occurred within the first 5 minutes of recovery 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

Limitations

For the MWDs in training, work intensity and duration 

varied among dogs, yet both are important factors for 

heat storage. This makes it difficult to compare among 

activities and among conditions, such as climate. At the 

same time, there are individual differences in temperature 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 exhibited in the kennels include repetitive leaping, spinning, 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 

may therefore be less fit or heat acclimatized.

Summary

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, 

Tre should be monitored during the first 15 minutes of 

rest to ensure recovery.

Acknowledgments

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 Training 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; Raleigh, 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: thermoregulation, pathophysiology, and predisposing factors. Compend Contin Educ Vet. 2013;35(7):E1-E6.

4. Carithers RW, Seagrave RC. Canine hyperthermia 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. Hypothalamic, 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 strenuous exercise. Am J Vet Res. 1999;60:88-92.

8. Young DR, Mosher R, Erve P, Spector H. Body temperature and heat exchange during treadmill running in dogs. J Appl Physiol. 1959;14(5):839-843.

9. Shapiro Y, Rosenthal T, Sohar E. Experimental heatstroke: a model in dogs. Arch Intern Med. 

1973;131:688-692.

10. Besch EL, Kadono H, Brigmon RL. Body temperature 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. Regional distribution of blood flow of dogs during graded dynamic exercise. J Appl Physiol. 

1987;63(6):2269-2277.

12. Rose R, Bloomberg M. Responses to sprint exercise in the greyhound: effects on haematology, serum biochemistry and muscle metabolites. Res Vet 

Sci. 1989;47(2):212-218.

13. Phillips CJ, Coppinger RP, Schimel DS. Hyperthermia 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.
78 http://www.cs.amedd.army.mil/amedd_journal.aspx

15. Steiss JE, Wright JC. Respiratory alkalosis and 

primary hypocapnia in Labrador retrievers participating in field trials in high-ambient-temperature 

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. O’Brien 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 Physiol. 1966;21(6):1757-1762.

20. Gaesser GA, Brooks GA. Metabolic bases of excess post-exercise oxygen consumption: a review. 

Med Sci Sports Exerc. 1984;16(1):29-43.

Authors

Ms O’Brien is a Research Physiologist in the Thermal 

and Mountain Medicine Division at the US Army Research 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 Biophysics and Biomedical Modeling Division at the US Army 

Research Institute of Environmental Medicine, Natick, 

Massachusetts.

Ms Sullivan is a Laboratory Animal Veterinary Technician, 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 Division at the US Army Research Institute of Environmental 

Medicine, Natick, Massachusetts.

CORE TEMPERATURE RESPONSES OF MILITARY WORKING DOGS

DURING TRAINING ACTIVITIES AND EXERCISE WALKS
October – December 2017 79

The 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 Soldier’s 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 repetitions 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 

body aerobic endurance event (run) creates an efficient 

and relatively balanced assessment of overall physical 

fitness. While performance on the APFT is predominately determined by a Soldier’s physical fitness level, 

technique on each event is also likely to contribute to an 

individual’s score. Experience shows that seasoned Soldiers usually develop efficient technique strategies that 

optimize performance on the APFT. However, newer 

Soldiers that have not had significant prior exposure to 

these events, and the scoring standards for each, may 

find it challenging to develop a technique that allows 

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 conduct of a daily exercise regimen that will adequately address the strength, mobility, and endurance needs of the 

Soldier, but does not provide specific tips to optimize 

performance.

There is currently no required training for Soldiers upon 

entry into the military that would expose them to information 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, physiologically, or strategically sound could also adversely affect 

performance. Therefore, the purpose of this report is to 

assess the potential value of a technique-focused training program when administered by Army physical therapists to a group of Army Medical Command officers 

that failed to pass their initial APFT upon matriculation 

into the Basic Officer Leadership Course (BOLC).

Methods

Participants

From January 2015 through March 2016, 34 Army 

Medical Command officers who were enrolled in BOLC 

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

Abstract

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 

help to optimize their performance on the APFT. A cohort of 34 officers that attended the Army Medical Department Basic Officer Leadership Course completed a technique-focused training program in conjunction with 

their required PRT program subsequent to failing one or more events on their initial APFT. The training consisted of a 30-minute video lesson and an individualized performance assessment completed by an Army physical 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 

PRT program can result in significant short-term improvement for those with substandard APFT performance.
80 http://www.cs.amedd.army.mil/amedd_journal.aspx

performance improvement training program. Within 

one week of arrival at the course, all student officers 

are required to take a “record” APFT. Completion of an 

APFT performance improvement training program was 

mandated for any individual officer that failed one or 

more events on that APFT. Evaluation and approval of 

this performance improvement training program by the 

local Institutional Review Board was not required.

APFT Evaluations

The 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 Department Center and School command policy. Grader assignments 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

Regardless of which event(s) were failed, all officers 

participated in the special population PRT program per 

the associated regulation1

 under the supervision of their 

unit leadership. A typical one-week PRT training regimen is presented in Table 1, however, the specifics of 

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, 

known as the “preparation drill,” consisted of 10 exercises and was conducted first for approximately 15 minutes. This was followed by drills aimed at improving 

anaerobic muscular strength and endurance, overall mobility, and aerobic conditioning lasting approximately 35 

to 45 minutes. Each training session was concluded with 

a cool down static stretching activity known as the “recovery drill,” lasting approximately 10 minutes.

The officers were also required to attend an APFT performance assessment evaluation conducted by local Army 

physical therapists (PTs). This training was completed 

within 3 days of their initial APFT, in order to maximize 

training time and possible benefit prior to the next administration of the APFT. In preparation for this training, all officers were required to view a 30-minute video 

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 previously reported.

In total, 4 PTs conducted the live training on several 

training dates during the data collection period. All 

were board certified in orthopedic and/or sports physical 

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 

analysis of the running event. Each officer was first 

asked to confirm that they did not have a medical condition 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 

least challenging and to specifically state which events 

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 execute each of the 3 events. Each officer was asked 

to perform 30 to 60 seconds of push-ups as they would 

do them on an APFT. The number of repetitions varied from officer to officer to allow for assessment of 

the pacing, breathing, position modifications, depth of 

movement, and rest positions used. No officers were required to perform push-up repetitions until muscle failure 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 provided, they completed a run analysis. The 

run analysis was performed on a commercial treadmill and was completed in 

less than 5 minutes. Officers were asked 

to begin by achieving a moderate walking 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 

PT would first perform a real-time assessment focusing on any noteworthy visual or auditory findings that 

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 Cooldown

1 Preparation 

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)

2 Preparation 

drill (5 reps)

Push-up drill, sit-up drills, 1 mile split time 

training

Recovery drill 

(20 seconds)

3 Preparation 

drill (5 reps)

Military movement drill #2 (1 rep)/conditioning 

drill #2/release run by platoon

Recovery drill 

(20 seconds)

4 Preparation 

drill (5 reps)

Push-up drill, sit up drills, 1 mile split time 

training

Recovery drill 

(20 seconds)

5 Preparation 

drill (5 reps)

4 for the Core (60 Seconds); conditioning drill #1

(5 reps); climbing drill #1 (5 reps) 

Recovery drill 

(20 seconds)
October – December 2017 81

THE ARMY MEDICAL DEPARTMENT JOURNAL

event. Additionally, a smartphone was then used to take 

6 to 8 second slow motion videos from both a posterior 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 

and auditory feedback for the observed officer. Each officer was given an information sheet that reflected the 

findings specific to that individual, and recommendations 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 typically 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 

down phase with the chest may be given. Officers were 

encouraged to incorporate any recommendations made 

during this training event into their unit-led PRT training 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 Analysis

Upon completion of the APFT retest, 

de-identified APFT scores were collected by the unit leadership and 

provided to the primary author 

for analysis. Descriptive statistics 

were calculated to define the demographics 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 program are presented in Table 2. Thirty-three participants 

completed the entire 3-event APFT, whereas one participant had a permanent profile precluding performance of 

the sit-up event and only completed the push-up and run 

events. The time of year for testing varied for participants, but the duration between APFT test dates was 10 

days for all participants. Initial overall mean score on the 

APFT was 189.3±28.1 points, and 211.6±24.7 points for 

the APFT retest administered 10 days later. Individual 

test and retest scores are shown in the Figure. Upon retest, 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 performance 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
82 http://www.cs.amedd.army.mil/amedd_journal.aspx

or 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 

failed initially. There were statistically significant improvement 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 statistically significant improvement with a cumulative improvement on the APFT of 42.7 points.

Comment

The results of this program suggest that significant 

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, technique-specific evaluation and training session. Improvement 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 cohort 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. Alternatively, this finding could be due to the recommendations that Soldiers received on overall APFT strategy. 

Specifically, during their training sessions, individuals 

were encouraged to reduce the number of repetitions attempted 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 

based specifically on whether or not the event was initially 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 increase 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 continued PRT alone they were required to perform was solely 

responsible for the observed improvements. Muscle hypertrophy and cardiopulmonary adaptations are 2 mechanisms by which APFT performance can be expected 

to improve.3

 It is unlikely that a significant degree of 

either occurred in the limited time between test dates. 

In contrast, changes in motor control patterns through 

neural adaptations can occur in a short period of time 

and subsequently result in improved performance.4,5 For 

example, Frost et al 6

 reported an immediate improvement on the Functional Movement Screen (7 tests representing various functional movements) score for a group 

of firefighters given immediate feedback regarding 

expected movement patterns on events graded as substandard. This study indicated that following feedback, 

participants were capable of optimizing movement, but 

were unaware of the best strategy to achieve a better 

score. Similarly, the participants in this study likely had 

a limited amount of experience with being evaluated on 

the 3 events of the APFT, potentially limiting their ability 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
October – December 2017 83

THE ARMY MEDICAL DEPARTMENT JOURNAL

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 

qualified officers. Therefore, they were strongly motivated 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 intrarater reliability of a videotaped qualitative running assessment.9

 Lastly, given that the cohort initially scored 

poorly on the APFT and were specifically selected to 

receive this training based on their substandard performance, some regression toward the mean would be 

expected.10

Future studies should include a comparison group that 

does not receive individualized guidance regarding their 

performance. Also, this training method should be assessed in a regular Army unit with a more normal distribution of APFT scores.

Practical Applications

This study provides baseline evidence for the value of 

technique specific APFT performance feedback provided by a military physical therapist. Given that physical 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 performance 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 optimization and injury prevention strategies for the 

Army physical fitness test: technique matters. 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 Orthop Sports Phys Ther. 2000;30(3):143-148.

4. Gabriel DA, Kamen G, Frost G. Neural adaptations to resistive exercise: mechanisms and recommendations for training practices. Sports Med. 

2006;36:133-149.

5. Hedayatpour N, Falla D. Physiological and neural 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 movement screens capturing “dysfunction”?. 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. Reliability 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 Doctoral Program in Physical Therapy at Joint Base San Antonio-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.
84 http://www.cs.amedd.army.mil/amedd_journal.aspx

Like their private sector counterparts, Department of 

Defense (DoD) behavioral health providers rely on evidence-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 environments, which makes the generalization of interventional 

strategies and treatment results to military personnel a 

challenge. “Treatment generalization” has been raised 

by a number of providers and organizations both within 

and outside of the DoD. Another concern is the lack of 

evaluation in the efficacy of treatment provided to military members and their families. This concern was recently 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 Psychotherapy

Broadly, the effectiveness of psychotherapy is indisputable 3-6; 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 

training has been demonstrated to be beneficial for most 

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

Single-Case Designs

Also known as single-subject and N-of-1 designs, single-case designs (SCDs) have rarely been taught to students or used by investigators in the behavioral sciences 

until recently. Consequently, many misconceptions exist about conducting SCDs and their value. However, 

most recently, in applied behavioral research and clinical 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 single-subject investigations.17-19 Other areas experiencing 

an increase in single-subject designs include emergency 

department medicine,20 general medicine,21 early childhood special education,22 special education,23,24 autism,25

speech and language pathology,26 aphasia,27 special education,28,29 students with disabilities,24 behavioral problems,30 natural disasters,31 and self-management.32 In 

the mental health field, a number of researchers have 

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 psychology known as applied behavior analysis, which focuses on interventions in a number of settings. This area 

has firmly established the utility of the SCD.38 Another 

answer derives from clinical social work where more 

and more practitioners have been charged with empirically demonstrating the effectiveness of their interventions.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.41

An additional source of support for single-case designs 

comes from the federal government via the US Department of Education Institute of Education Sciences (IES), 

which was established under the Education Sciences Reform 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
October – December 2017 85

THE ARMY MEDICAL DEPARTMENT JOURNAL

accepted that single-case designs can provide causal evidence of intervention effects.42 Additionally, professional 

organizations such as the American Psychological Association (APA) recommend single-case designs alongside 

randomized control trials in their clinical evidence standards.43 Furthermore, individual social workers have discussed the importance of single-case designs in clinical 

practice,44-46 and the National Association Social Workers (NASW) Press has published a number of documents 

related to single-case designs for clinical practice.47

Cost Considerations

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.51-54

The use of SCDs allows for a quicker assessment of the 

costs involved in providing the services, which is extremely important given the dramatic shift from inpatient 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 accounted 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 significantly changed over the last decade, the number of 

psychotherapy visits per patient has decreased.56 This 

decrease is due to a number of factors including briefer 

models of therapy, improvement in psychotropic medications, changing practice patterns, practice guidelines 

and payment policies.57-59

The 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 

accurate cost estimates for specific types of disorders. 

Additionally, time series single-subject design permits 

analyses of when the patient is making progress and 

when progress may not be cost effective. Applying single-subject designs enables case rates to be developed 

for outpatient mental health services, which can contribute to focused attention optimizing both the clinical 

result and the business result (eg, avoiding unnecessary 

services and waste). Moreover, this would assist in identifying providers who are efficient and receive desirable 

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, investments 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 “symbiosis” between information technologies and SCD as 

relating to the ability to efficiently capture behavioral 

changes and demonstrate improvements in outcomes.61

Advancement in Statistical Methodologies

An additional source of support for the use of single-subject 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 analyzing single-case designs.15,62-72 Most recently, Vannest 

et al 73 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 colleagues 74 and Parker et al.75 In summary, Vannest 

and associates concluded that the “number and quality 

of statistical techniques for single case research has dramatically increased in the last decade.”73(p38)

One of the more useful techniques for behavioral science researchers and especially practitioners providing therapy is the use of Improvement Rate Difference (IRD). Briefly, IRD is the difference in behavior 

between A, the baseline phase, and B, the intervention 

phase—understanding 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 sessions) that shows improvement from one phase to another based on all pairwise comparisons across phases 

A and B. Although the NAP can be calculated by hand, 

the most efficient method is to use a statistical package 

such as NCSS (number crunching statistical system).77

In addition to the development of the new statistical procedures, a number of researchers have applied statistical 
86 http://www.cs.amedd.army.mil/amedd_journal.aspx

procedures primarily developed in the business community to single-case designs. For example Davies et al78

used funnel plots to explore variation in cancer mortality across primary care trust in southeast England. Mayer and associates 79 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 variability between baseline to intervention phases can be 

achieved through creation of intervals (such as 2-standard deviations) surrounding mean values in order to 

identify statistically meaningful changes.81

Although 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 behavioral science community find the methodology lacking 

in statistical validity, which is particularly interesting 

since the SPC process has been seen as a statistician’s 

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 interpretation of SPC charts.87-93 Additionally, many statistical software packages to which behavioral science researchers 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 statistical methods are not robust when differences exist 

or when there is an association between random variables.20,94-101 More specifically, even arbitrarily small 

departures from normality result in low power when 

distributions are normal. Heteroscedasticity can seriously lower the power of standard analysis of variances 

(ANOVA) and regression methods.101 The practical result is many clinical studies would have achieved a level 

of significance if less traditional but more robust statistical procedures had been used.

Meta-analysis of Single Case Designs

Potentially the most important support for single-subject designs has been the progress in the development of 

meta-analysis statistical methodologies for single-subject designs. Traditionally evidenced-based treatments 

refer to interventions that have empirical support in 

their behalf. The evidence has been derived from rigorous 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 medical field has been developed by Melnyk and FineoutOverholt.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 randomized controlled trials, the time-series design, including 

single-case designs as a special case, can be among the 

strongest nonrandomized experimental designs.103

This, coupled with recently developed meta-analysis 

statistical procedures, should increase the confidence in 

the findings derived by single-case design studies. To 

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 significant contributions to the advancement of evidencedbased practice. As previously noted, although single 

case designs represent a special case of time-series designs 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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THE ARMY MEDICAL DEPARTMENT JOURNAL

these methods across clinical settings will be especially 

beneficial in psychotherapy where advances in psychotherapy interventions are reducing the time the patient 

actually spends in therapy.

Although statistical innovation in developing methodologies for single-case designs is progressing, one 

area impeding this progress is the overreliance on null 

hypothesis significance testing (NHST). According to 

Sharpe,104 there are a number of reasons for the overreliance 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 methodologies.105,106 In his provocative article “How Many Discoveries Have Been Lost by Ignoring Modern Statistical 

Methods,” Wilcox asserts that many psychological journals “are littered with nonsignificant results that would 

have been significant if a more modern method had 

been used.” 101(p300) Cummings et al 107 researched the 10 

leading international journals that publish empirical research and indicated that there is little change in statistical procedures and that NHST continues to dominate. 

They also noted that the reporting of confidence intervals (CIs) was increasing, albeit slowly, and that CIs are 

seldom used for interpretation. This is especially interesting since the APA Task Force on Statistical Inference 

advocated for improved statistical practices, including 

reporting effect sizes and confidence intervals.108

Another reason for the lack of the application of statistical methodologies is the scarcity of personnel trained in 

quantitative methods, especially the newer more complex 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 interventions applied to solving a diverse range of human problems.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 today’s military environment, with the shortage of mental health personnel and 

the increase in workload, the need for evidenced-based 

practices, as well as efficacy in practice, has never been 

greater. The time for implementation of single-subject clinical research has come. Although the need for 

traditional research design and analysis remains, the reality 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 providers. It is important to keep in mind that statistical and 

research design resistance to progress has not benefited 

the mental health field.101

Looking 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 throughout 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 

understanding of the most beneficial and cost-effective 

treatments being provided, which is ultimately an efficient and effective way to create changes to policies 

based on empirically collected and analyzed data. The 

current circumstances of both the mental health field and 

the budget make this a prime opportunity to employ the 

use of single-case designs to become more efficient.53

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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.

CPT Zollmann is Social Work Officer, 18th Military Police 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.
92 http://www.cs.amedd.army.mil/amedd_journal.aspx

Background

War is ninety percent information.

Napoleon Bonaparte

During the recent conflicts in Afghanistan and Iraq, the 

United States has achieved the lowest recorded case 

fatality rates for combat casualties in the history of 

American warfare.1-3 This accomplishment was primarily 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, 

preventable death studies during these same conflicts 

identified additional room for improvement, particularly 

in the realm of prehospital mortality.4-7 Optimizing outcomes 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 created a Joint Theater Trauma System and Joint Theater 

Trauma Registry (JTTR) to conduct performance improvement 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 successful 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

Abstract

The active battlefield is an environment of chaos and confusion. Depending on the scale of combat, the chaos and 

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 

and TCCC AARs. Where possible (requires 2 patient identifiers), JTS linked data from the PHTR module to other 

modules in the DoDTR to maximize availability of prehospital data and gain additional information regarding clinical 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 

DoDTR due to missing identifiers.

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.
October – December 2017 93

THE ARMY MEDICAL DEPARTMENT JOURNAL

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 ultimately 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 prehospital 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 tactical 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 Defense 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 

provided by both nonmedical and medical first responders, 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.

The new DD Form 1380 TCCC card reflected modern 

day prehospital combat trauma practices, and followed a 

“MIST” (mechanism, injury, signs and symptoms, treatment) format. The JTS also developed a TCCC after action report (AAR) adapted and modified from the 75th 

Ranger Regiment as another opportunity to capture prehospital 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 prehospital 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 Afghanistan. Simultaneously, the DoD established a prehospital directorate comprised of physicians, physician 

assistants, and combat medics with extensive prehospital 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 theater. Prior to this withdrawal, 2 comprehensive reviews 

were conducted by senior military physicians and remain a source for prehospital combat trauma issues and 

recommendations.19,20

Goal 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 September 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 

“required” items on TCCC cards as listed on the front 

side of the card, shown in the Figure.

Prehospital Trauma Registry

The JTS PHTR is a data collection and analytic tool designed to provide near-real time feedback to commanders. As described by Kotwal and colleagues,12 the primary purpose of this tool is to improve casualty visibility, 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 prevention (tactics, techniques, and procedures), secondary 

prevention (personal protective equipment), and tertiary prevention (casualty response system and TCCC).19

The CENTCOM JTS Prehospital Directorate collected 

TCCC cards and TCCC AARs, and transferred information from these documentation tools into the PHTR.17

Department of Defense Trauma Registry

The DoDTR, which evolved from the JTTR, is a centralized 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.
94 http://www.cs.amedd.army.mil/amedd_journal.aspx

treatment, 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 

injury to final disposition. When possible, the JTS personnel linked subjects from the PHTR to the DoDTR.

Data Analysis

We 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), gender (98.2%, 692/705), and military unit (94.3%, 665/705). 

A full or partial set of prehospital vital signs was available for most patients. However, there was no documentation 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
October – December 2017 95

THE ARMY MEDICAL DEPARTMENT JOURNAL

a documented preanalgesia pain 

score. However, none of these individuals had a documented postanalgesia pain score. As a surrogate 

marker of data gaps, we identified 

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 

the required 2 patient identifiers to 

link the patients between the 2 registries as the identifiers were either 

missing or inaccurate.

Comment

Documentation of care in the prehospital combat setting has proven 

to be challenging for US military 

forces during the conflicts in Afghanistan and Iraq.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 vital sign. However, pain scores were not routinely available. 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 documentation and data capture.1,3,4,7,9,12,14,16-26 However, there are 

limited published data that actually quantify prehospital 

combat documentation deficiencies.14,17,24-26 This analysis 

was unique in that we identified and quantified these deficiencies in the documentation provided by US military 

prehospital personnel after the implementation of standardized TCCC cards and TCCC AARs in Afghanistan.

The results of this study demonstrate that TCCC card 

completion rates were low, with TCCC card data available for only 3.3% (23/705) of PHTR encounters from 

January 2013 through September 2014. This level of adherence 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 backfilling of data from DoDTR forms upon reaching a 

higher role of medical care (eg, forward surgical team or 

combat support hospital). The results of this study reaffirm the need for improved documentation practices by 

US military personnel in the prehospital combat setting. Improving 

care for casualties in the prehospital combat setting requires training to a standard. This standard 

is set through best practice clinical recommendations outlined by 

evidence-based guidelines such as 

TCCC. Validation, refinement, and 

optimization of these guidelines 

occur via analysis of data. Data are 

reliant on the documentation efforts of prehospital first responders. 

Thus, medical and nonmedical first 

responders must understand the 

importance of documentation and 

train to accomplish this vital task.

Suboptimal documentation practices likely stem from inadequate 

time and insufficient leader emphasis and enforcement. Many Soldiers may perceive documentation of care as relatively unimportant compared 

to care delivery, particularly for a lone medic treating 

combat casualties during a firefight. However, improving the treatment of future casualties, and reducing morbidity and mortality, relies on documentation and data 

collection. Although enemy actions, environmental conditions, and patient acuity can influence documentation 

practices, documentation nevertheless remains an important 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 United Kingdom military forces, both medical and nonmedical personnel in combatant units should train to record 

care on prehospital documentation tools. Combatant 

units already routinely assign recorders for documentation tasks such as collection of enemy information, site 

exploitation, logging of radio communication transmissions, and filling out 9-line medical evacuation requests. 

As the TCCC card is a relatively simple documentation 

tool, recorders can easily become proficient with its use 

without needed detailed medical training.

Additionally, air and ground prehospital patient transport 

personnel should briefly stay at the receiving military 

treatment facility after delivering patients to complete 

prehospital patient care records. This was the method 

used in a previous successful prospective investigation,23 and also aided in the capture of data for retrospective studies.3,16,27,28 Completion of prehospital documentation 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 Status 661 93.8%

Gender 692 98.2%

Event Time 622 88.2%

Service 704 99.9%

Unit 665 94.3%

Allergies 209 29.6%

Mechanism of Injury 705 100%

≥1 Pulse Rate 546 77.4%

≥1 Blood Pressure* 535 75.9%

≥1 Respiratory Rate 539 76.5%

≥1 Pulse Oximetry 436 61.8%

≥1 AVPU† 677 96.0%

≥1 Pain Score 173 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.
96 http://www.cs.amedd.army.mil/amedd_journal.aspx

responsibility, with a medical transport crewmember 

and a medical treatment facility emergency room staff 

member pre-identified for compliance assurance of documents before release of prehospital transport personnel 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 

medical force readiness—specifically, standardization 

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 

be a significant contributor to the lack of prehospital 

documentation. Technology has contributed to increased 

survivability through direct patient care; however, it is 

currently lacking in respect to prehospital documentation. A hands-free interface that interacts with communication devices such as smart-phones could greatly enhance documentation in the prehospital setting.

Summary Recommendations

3⁄4 All nonmedical personnel within units should undergo training to serve as medical recorder for the medic 

and medical officers to improve documentation quantity and quality while not detracting from the time 

available for healthcare delivery to combat casualties.

3⁄4 Prehospital transport teams should provide prospective 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.

3⁄4 There should be a mandate and enforcement for completion of medical data collection across the DoD. 

Commanders should be held accountable for ensuring this task is completed. A near real-time feedback 

loop in theater would inform commanders on medical 

documentation adherence.

3⁄4 Development of technology that allows for input of 

data with rapid movement of the data “forward” in the 

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 documentation 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.

Acknowledgement

We thank the Joint Trauma System Data Analysis Branch 

for their efforts with data acquisition.

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C, Bellamy RF. Understanding combat casualty 

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4. Eastridge BJ, Mabry RL, Seguin P, et al. Death on 

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Surg. 2012;73(6 suppl 5):S431-S437.

5. Holcomb JB, McMullin NR, Pearse L, et al. Causes 

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7. Kotwal RS, Montgomery HR, Kotwal BM, et al. 

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Arch Surg. 2011;146(12):1350-1358.

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Military medical revolution: military trauma system. J Trauma Acute Care Surg. 2012;73(6 suppl 

5):S388-S394.

9. Haut ER, Mann NC, Kotwal RS. Military Trauma 

Care’s Learning Health System: The Importance 

of Data Driven Decision Making. Washington, 

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Translation to the Civilian Sector; 2016. Available at: http://nationalacademies.org/hmd/~/me

dia/Files/Report%20Files/2016/Trauma-Care/

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pdf. Accessed June 27, 2017.

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JOINT TRAUMA SYSTEM PREHOSPITAL TRAUMA REGISTRY
October – December 2017 97

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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 

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airborne operations in Afghanistan and Iraq. Aviat 

Space Environ Med. 2004;75(10):833-840.

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DS, Meyer DE, Holcomb JB. A novel pain management strategy for combat casualty care. Ann Emerg 

Med. 2004;44(2):121-127.

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FK. Efficacy of point-of-injury combat antimicrobials. J Trauma. 2011;71(2 suppl 2):S307-S313.

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Analgesic Administration on the Contemporary 

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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 Houston, Texas.

MAJ Naylor is with the 28th Combat Support Hospital, 

Fort Bragg, North Carolina.

LTC Cunningham is with the US Army Institute of Surgical 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 Surgical Research and the DoD Joint Trauma System, Joint 

Base San Antonio-Fort Sam Houston, Texas.
98 http://www.cs.amedd.army.mil/amedd_journal.aspx

Endotracheal intubation is a critical skill for emergency 

physicians. While anesthesiologists have historically 

taken ownership of the procedure, emergency physicians are increasingly responsible for performing this 

intervention. Studies over the past 2 decades estimate 

the proportion of emergency department (ED) intubations performed by emergency physicians ranges from 

89% to 95%.1-3 This procedure is of particular importance to the military emergency physician as airway 

emergencies account for 9% of preventable deaths on 

the battlefield.4

 Adequate experience with this procedure in garrison will help to ensure physician readiness 

to execute this life-saving intervention in the deployed 

environment.

As the military’s largest hospital and only level 1 trauma 

center, Brooke Army Medical Center (BAMC) is an 

ideal training platform to offer physicians such experience 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 Realignment Commission decisions of 2005.5

 It is responsible 

for the care of active duty and retired military personnel 

and military beneficiaries, as well as sharing emergency 

medical care responsibilities with area civilian hospitals 

for nonmilitary trauma patients received from the surrounding communities.

In 2016, the BAMC ED initiated research-based surveillance 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 Study

MAJ 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

Abstract

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 collection 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 procedure. 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 intubation were related to trauma for 184 patients (71.0%) and medical conditions for 75 patients (29.0%). Overall, 

first-attempt success was 83.0%. Emergency medicine residents performed a majority of first attempts (95.0%). 

Most common devices chosen on first attempt were a video laryngoscope for 143 patients (55.2%) and a direct 

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 succinylcholine (18.9%; 95% CI, 14.3%-24.2%).

Conclusion: In the BAMC ED, emergency intubation most commonly occurred for trauma indications using 

video laryngoscopy with a high first-pass success.
October – December 2017 99

THE ARMY MEDICAL DEPARTMENT JOURNAL

Brigham and Women’s Hospital in Boston, Massachusetts.3,6 This article presents an overview of the data 

collected during the first 12-month period of study at 

BAMC. Our objective was to describe the intubation 

experiences, practices, and outcomes of the active duty 

physicians in this unique setting.

Materials and Methods

Study Design

We conducted a prospective observational study of intubations in the BAMC ED as part of the facility’s participation 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 Medical Research and Material Command approved the data 

sharing agreement with Brigham and Women’s Hospital 

for participation in NEAR.

Setting

Brooke 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 approximately 82,000 patients annually that includes active duty and retired military personnel, military beneficiaries, and nonmilitary trauma patients received from 

the surrounding communities. Brooke Army Medical 

Center is affiliated with the San Antonio Uniformed 

Services Health Education Consortium, the largest 

sponsoring institution for graduate medical education in 

the military and hence a major training platform for residents 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 Patients

This study includes all patients intubated during the 

first 12-month period of data collection at BAMC for 

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 Methodology

Intubating providers recorded data about each intubation using a data collection form. This form is standardized 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 

intubation was not successful with the first attempt we 

solicited data on additional attempts (up to 5 attempts 

total). All study variable definitions and data collection forms were in accordance with those established by 

NEAR.3

Providers recorded all such data as soon as possible. 

Providers then deposited completed forms in a secured 

file cabinet situated in the emergency department. Research 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 

identified by the daily nursing reports via e-mail, phone, 

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 upload, NEAR personnel based at Brigham and Women’s 

Hospital reviewed all data using quality assurance algorithms to minimize occurrence of data entry errors. We 

retrieved missing data whenever possible by interview 

of the intubating provider or manual chart review.

Analysis

For 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 

used, and patient outcomes. We calculated 95% confidence intervals (CI) for select outcomes. We did not perform 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 

all 259 intubations in the BAMC ED as confirmed by 

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%).

Physicians achieved first-attempt success in 215 patients 

(83.0%; 95% CI, 77.9%-87.4%). The detailed data is 
100 http://www.cs.amedd.army.mil/amedd_journal.aspx

presented in Table 3. One patient who sustained a gunshot wound to his face underwent a primary cricothyrotomy as the first method of endotracheal intubation. No 

patient required a cricothyrotomy as a result of a failed 

attempt at oral intubation. There were no significant differences in first-attempt intubation success percentages 

compared across alternative study variables.

Emergency medicine residents performed 246 of 259 

first attempts (95.0%). Forty-six of the residents were in 

postgraduate year (PGY) 1, 166 were PGY 2, and 34 

were PGY 3. Two hundred four (82.9%) first attempts 

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 attending physicians.

Direct laryngoscopy were used in first attempts for 

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 attempts. 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 laryngoscopy. Induction agents most commonly used during first 

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 succinylcholine for 49 patients (18.9%; 95% CI ,14.3%-24.2%).

Sixty-one of 259 (23.6%) patients intubated experienced 

80 peri-intubation adverse events during the first attempt (Table 4). The most commonly reported adverse 

event included was hypoxia (59%) defined as an oxygen 

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 

(n=7), fourth (n=4), and fifth attempts (n=1), making 

it difficult to assess the risk of adverse events for these 

subsequent efforts.

Comment

Endotracheal intubation is a critical skill for military healthcare providers as part of combat casualty care in the deployed environment.7-9 We report 

on 12 months of emergency airway management 

experiences at BAMC as part of its participation in the NEAR registry.3

 In total, we reported 

259 intubations, of which 83.0% were successful 

upon first attempt. Emergency physicians performed most intubations for trauma indications. 

These data provide an overview of the stateside 

emergency airway management experience at the 

military’s largest hospital and only level 1 trauma 

center.

The indications for a majority (71.0%) of intubations were related to trauma. This reflects the 

BAMC trauma program’s treatment of civilian 

trauma patients.10 Our results highlight the substantial 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 trauma 4 2.2 0.5%-4.3%

Burn/inhalation injury 16 8.7 4.9%-13.0%

Chest trauma 14 7.6 3.8%-12.0%

Combative/agitated 24 13.0 8.2%-17.9%

Facial trauma 8 4.3 1.6%-7.1%

Head injury without hemorrhage 14 7.6 4.3%-12.0%

Head injury with hemorrhage 36 19.6 14.1%-26.0%

Neck trauma 3 1.6 0%-3.8%

Polytrauma 41 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 arrest 18 9.8 5.9%-15.0%

Total 184 100.0

Table 2. Medical Indications for Intubation (n=75).

Indication Number of 

Patients

% n 95% CI

Airway obstruction* 2 2.7 0%-6.7%

Asthma 1 1.3 0%-4.0%

Cardiac arrest 14 18.7 9.4%-28.0%

Congestive heart failure 3 4.0 0%-9.3%

COPD 2 2.7 0%-6.7%

Gastrointestinal bleed 2 2.7 0%-6.7%

Intracranial hemorrhage 4 5.3 1.3%-12.0%

Myocardial infarction 2 2.7 0%-6.7%

Non-overdose mental status change 21 28.0 17.3%-38.7%

Overdose 6 8.0 2.7%-14.7%

Pneumonia 4 5.3 1.3%-10.7%

Seizure 5 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%

Stroke 1 1.3 0%-4.0%

Total 75 100.0

*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
October – December 2017 101

THE ARMY MEDICAL DEPARTMENT JOURNAL

of our participation in this program in maintaining the 

medical readiness of our force.

To this point, our first-pass success percentage of 83.0% 

is identical to that reported for ED centers nationwide as 

part of the NEAR registry during 2002-2012.3

 This suggests a comparable level of skill between the military 

practitioners in our hospital compared to civilian counterparts. This finding is noteworthy given recognition 

of the importance of experience and patient volume for 

procedural competence.11 Indeed, authors have voiced 

concerns regarding the potential lack of adequate exposure to sufficient procedure volume in domestic military 

treatment facilities for military healthcare providers to 

achieve and maintain clinical skills.12,13 Our findings 

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 substantial by the standards of a military treatment facility, it is a modest intubation volume by the standards of many civilian academic centers. Comparatively, a similar study observing all intubations performed 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 particular concern at smaller military healthcare facilities 

seeing much lower patient volumes.

Emergency medicine residents managed 95% of 

first attempts which is a testament to the educational 

mission of the BAMC ED. By way of comparison, 

previous iterations of NEAR reported the proportion of ED intubations managed by emergency medicine 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 emergency medicine residents prior to deployment as attending physicians. Our results highlight that this 

focus does not come at the expense of clinical outcomes or patient safety.

There are several notable differences in the intubation 

practices in our cohort as compared to nationwide statistics reported in the NEAR registry.3

 First, a larger 

proportion of intubations in our cohort used video laryngoscopy—55.2% at BAMC versus approximately 

10% in the NEAR registry. We suspect this largely reflects the different time periods examined; even within 

the earlier time period examined by the NEAR registry 

data (2002-2012), there was a clear trend towards increasing use of video laryngoscopy. We found a higher 

percentage of first-pass intubation success with video 

laryngoscopy (90.9%) as compared to direct laryngoscopy (73.0%). The literature reports conflicting findings regarding relative intubation success with direct 

versus video laryngoscopy.14-16 Our finding of higher 

first-pass success with video laryngoscopy may reflect 

less experience among our intubating providers with direct 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

Medical 75 58 77.3 68.0%-86.7%

Trauma 184 157 85.3 79.9%-90.2%

First Attempt Operator

EM1 46 34 73.9 60.9%-87.0%

EM2 166 141 84.9 79.5%-90.4%

EM3 34 29 85.3 73.5%-97.1%

EM attending 7 7 100.0 -

Anesthesia 6 4 66.7 -

First Attempt Device*

Direct laryngoscopy 115 84 73.0 64.0%-80.9%

Video laryngoscopy 143 130 90.9 85.0%-94.7%

First Attempt Method

Paralytic and sedative 211 184 87.2 82.5%-91.5%

Sedative only 5 4 80.0 -

Paralytic only 2 2 100.0 -

No medications 41 25 61.0 43.9%-75.6%

First Attempt Induction Agent

Etomidate 50 41 82.0 72.0%-92.0%

Ketamine 155 138 89.0 83.9%-93.5%

Midazolam 2 1 50.0 -

Propofol 9 8 88.9 -

None 43 27 62.8 48.8%-76.7%

First Attempt Paralytic Agent

Rocuronium 163 145 89.0 84.0%-93.3%

Succinylcholine 49 40 81.6 69.4%-91.8%

Vecuronium 1 1 100.0 -

None 46 29 63.0 47.8%-76.1%

*One patient underwent first-attempt cricothyrotomy.

EM indicates emergency medicine.
102 http://www.cs.amedd.army.mil/amedd_journal.aspx

broader NEAR registry will be of value to the military 

and emergency medicine communities. Should such research conclude superiority of video laryngoscopy, the 

literature would benefit from cost-effectiveness analyses of ensuring widespread availability of such devices 

for deployed personnel.18

Our study also reports a unique distribution of pharmacologic 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 reported by the historic NEAR registry (1.0%).3

 This finding 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 

reflect intubating culture at BAMC given the frequent 

use of this medication by military physicians in the deployed environment and its recommended use for analgesia by the Tactical Combat Casualty Care guidelines.21

Similarly, our finding that physicians used rocuronium 

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 succinylcholine. A growing literature suggests equivalent 

intubating conditions between these 2 agents when rocuronium is dosed at 1.0-1.2 mg/kg.23 This makes rocuronium an attractive option, particularly given that 

succinylcholine is contraindicated for use in patients 

with diseases upregulating skeletal muscle acetylcholine receptors. Examples of such disease processes include spinal cord injuries and burns 72 hours or more 

from the time of injury.24 Given that emergency medicine physicians may not necessarily be privy to the presence of these medical conditions when actively managing an airway emergency, it is understandable by the use 

of this agent is increasingly popular within the specialty 

of emergency medicine.25

This study has several limitations. As an observational 

study, we are unable to ascertain whether the apparent 

trends we observed (eg, higher first-pass success with 

video as compared to direct laryngoscopy) reflect correlation or causation. Moreover, given that it is a single 

center study, we have inadequate sample size to perform 

inferential analyses comparing first-pass success across 

alternative RSI regimens or intubation devices while 

controlling for potential confounders (eg, regression 

models, propensity matching). Moreover, given our reliance upon self-reported data, it is possible that biased responses skewed our results towards more favorable outcomes. 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 military’s largest academic hospital and an urban tertiary care center, our data may not 

reflect the emergency airway management experience at 

smaller military treatment facilities or in the deployed 

environment. Nevertheless, generalizability was not our 

intent. Rather, we sought to describe the garrison experience 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 military physicians practice and maintain readiness with regards to emergency airway management, a skill known 

to be critical for saving lives on the battlefield.4

It is our hope that these data related to endotracheal intubation will provide yet another building block to the 

growing literature exploring devices and training for the 

military related to airway management.26-28 Future research with the NEAR registry will be useful for clarifying whether some of the trends observed in our study 

are generalizable to other settings (eg, the superiority 

of video to direct laryngoscopy for first-pass success). 

Future military research will benefit from additional 

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 Occurring in Patients (n=61).

Adverse Events Number of

Patients

% n* 95% CI

Airway trauma 2 3.3 0.3%-11.9%

Cardiac arrest 10 16.4 9.0%-27.8%

Dysrhythmia 3 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%

Hypotension 13 21.3 12.8%-33.3%

Hypoxia 36 59.0 46.5%-70.5%

Main-stem intubation 5 8.2 3.2%-18.2%

Tachy-dysrhythmia 1 1.6 0.0%-9.6%

Vomiting 6 9.8 4.3%-20.2%

*Percentages do not total 100% as some patients experienced multiple adverse events.

A 12-MONTH DESCRIPTIVE ANALYSIS OF EMERGENCY INTUBATIONS AT

BROOKE ARMY MEDICAL CENTER: A NATIONAL EMERGENCY AIRWAY REGISTRY STUDY
October – December 2017 103

THE ARMY MEDICAL DEPARTMENT JOURNAL

In summary, this article reports the experience of emergency airway management at BAMC over a 12-month 

period. It highlights robust exposure to airway management opportunity for military healthcare providers at 

the military’s largest emergency medicine residency. It 

further reports comparable outcomes in terms of intubation 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, National Emergency Airway Registry I. Airway management 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, Investigators 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 

J, Tops T, Uribe P, et al. Death on the battlefield 

(2001-2011):implications for the future of combat 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, Investigators 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, Huberman 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, Rasmussen TE, Renz EM, et al. Prehospital interventions 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 management 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 year’s trauma mortality experience at Brooke 

Army Medical Center: is aeromedical transportation 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 Physicians: 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 Registry I. Improved glottic exposure with the Video 

Macintosh Laryngoscope in adult emergency department 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 Laryngoscopy vs Direct Laryngoscopy on Successful 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, Risavi B, Carlson JN. A pilot, prospective, randomized 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 meta-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 Etomidate and Ketamine for Induction During Rapid Sequence 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 propensity matched analysis. J Crit Care. 2017;38:209-214.

21. Butler FK, Kotwal RS, Buckenmaier CC, 3rd, Edgar EP, O’Connor 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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22. 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: etiologic factors and molecular mechanisms. Anesthesiology. 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 conventional 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, Kester N, April MD. Single rescuer ventilation using a 

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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 Department 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 Women’s Hospital, 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
October – December 2017 105

Military 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 shoulders.1

 What is more, executives are an important target 

group in occupational health promotion,2

 and many companies have launched health promotion projects.3

 Executives 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 

behavior is influenced by, among other things, educational level, with those attaining higher educational levels showing a more health-conscious lifestyle.5

 Another 

study revealed that work-related travel and commuting 

activity correlate with a lower level of physical fitness in 

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 

cardiopulmonary fitness can also cause the development 

of cardiovascular disease.8

 This can be verified with a 

lactate performance test.9

 The development of orthopaedic conditions, in particular back pain, is associated with 

insufficient trunk strength.10 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 factors affect physical fitness. The results of this retrospective observation 

study will lead to conclusions about how, as part of occupational health promotion, improvements can be made 

in the fields of physical fitness and disease prevention.

Material and Methods

Subjects

In total, 122 male subjects took part in the prevention 

program for executives during the study period. The average age was 54.6±4.2 years. The average BMI was 

26.6±2.8 kg/m2, and the average waist circumference 

was 95.9±8.2 cm. Prior to equipment-based testing, the 

subjects were given a standardised questionnaire on the 

following points: occupation, weekly working hours, alcohol consumption, smoking habits, commuting activity, exercise, mental stress, previous internal or orthopaedic disorders, and medications taken. This was followed by a nutritional analysis based on the Freiburger 

Ernährungsprotokoll (Freiburg Dietary Record). The 

subjects then provided a blood sample to determine 

the parameters glycated haemoglobin (HbA1c), blood 

count, alanine aminotransferase (ALAT), aspartate 

aminotransferase (ASAT), ɣ-GT, sodium, potassium, 

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

Abstract

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 

factors affect physical fitness. To collect their medical history, a total of 122 male subjects answered a questionnaire 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 

results showed that the presence of hypertension correlates with reduced fitness. While orthopaedic conditions 

had no negative influence on executives’ fitness, high body mass index and waist circumference, mental stress, 

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

creatinine, urea, blood glucose, total cholesterol, HDL 

cholesterol, and LDL cholesterol.

Lactate Performance Test

For the performance test, 86 patients used a stationary 

bicycle (Ergometrics 900; ErgoLine; Baden-Württemberg, 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, 

a stress profile was chosen that was started at an individual level, with the intensity increasing by 50 watts every 

3 minutes. For the treadmill ergometry, the stress profile 

was also started at an individual level and the speed increased 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 recovery phase. Blood samples were taken from the ear. The 

earlobe was pricked with a lancet (safety lancet, prick 

depth 1.8 mm; Saarstedt; Nürnbrecht, Germany) and a 

drop of blood was collected by means of manual compression. The first drop of blood was discarded, and the 

second was collected in a capillary tube (heparin-coated 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 Winlactat software (V 4.6.3.21; Mesics GmbH; Münster, 

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 analysis, the subjects received sports medical advice.

Statistical Evaluation

A descriptive data analysis was conducted for all groups 

(establishment of minimum, maximum, mean, and median). Group rank sum comparison was conducted by 

means of the Kruskal-Wallis test. This was followed 

by a significance analysis using a χ 2 test. The significance level was set at P>.05. The Mann-Whitney U test 

was used to conduct pairwise comparisons. The significance level was determined at P>.05. For the correlation analysis, the correlation coefficient was determined 

in accordance with Pearson’s r. The P>.05 value was 

specified as having a 2-tailed significance level. To determine the significance of individual factors affecting 

fitness, a multiple linear regression analysis was carried 

out. The coefficient of determination (R2), the standardized (ß) and nonstandardized (b) regression coefficients 

of the predictors together with the Pearson correlation 

coefficient (r) and squared semipartial correlation (sr 2) 

were reported. The statistical data analysis was carried 

out with IBM SPSS V 21.0 and the effect size was calculated with G*Power. According to Cohen, the effect 

size f 2

 was interpreted as follows: f 2=0.02 minor effect, 

f 2=0.15 moderate effect, f 2=0.35 major effect.12

Results

Effect of Individual Determinants on Fitness

Age

To determine the effect of age on performance, the subjects 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 

that Group 1 was fitter than Group 2. The treadmill ergometry also showed this trend. Younger subjects were 

fitter than older subjects.

Body Mass Index

After 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 ergometry revealed no significant difference in performance at 

the 4 mmol lactate threshold and at maximum performance (Table 2).

The treadmill ergometry revealed no significant difference either, but the group with a BMI≤25 kg/m2 tended to be fitter than the subjects with a BMI>25 kg/m2 

(Table 2). The physical fitness of executives decreased 

with increasing BMI, in particular on 

the treadmill.

Body mass index was identified in the 

regression analysis as a predictor for 

physical activity. The model was significant: F=2.473 (P=.038) and the model 

equation correlated to R= 0.338 with 

the criterion variable (R2=0.114; R2

 adjusted= 0.068; f 2=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 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=44/22)

Subjects aged ≤55 years

175.0 (±36.3) 243.8 (±46.5) 11 (±1.6) 13.5 (±1.6)

Group 2 (N=42/14)

Subjects aged >55 years

153.7 (±34.0) 200.7 (±44.6) 9.9 (±1.4) 12.3 (±1.1)

P.003.001.053.033
October – December 2017 107

THE ARMY MEDICAL DEPARTMENT JOURNAL

predicted to a significant extent by the variable BMI 

(ß= 0.624; b=39.559; SE=2.487; P=.003; r =0.294; 

sr 2= 0.294). Body mass index accounted for 7.8% of the 

variance in physical activity.

Waist Circumference

On the basis of the values measured, the subjects were divided 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.

The bicycle cardiac stress test revealed no significant 

difference between the groups at the 4 mmol lactate 

threshold (Table 3). However, a significant difference 

was established at maximum performance. Subjects 

with a small waist circumference were fitter (Table 3). 

Moreover, the subjects revealed a significantly lower 

heart rate at the individual anaerobic threshold (144/min 

(Group 1) vs 136/min (Groups 2 and 3); P=.026). The 

treadmill cardiac stress test also revealed a significant 

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 

physical fitness (r= -0.281; P=.015).

Nutrition

Subjects 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) hypercaloric (balanced) (n=12); (3) hypercaloric (imbalanced) (n=4); (4) hypocaloric (n=46).

Table 4 shows the average performance 

achieved. For the performance test, the 

statistical analysis showed no significant differences in the groups with the 

values for p4mmol-L or v4mmol-L. There was 

no proof that nutrition had a significant 

effect on the fitness level of executives.

Smoking Habits

Subjects 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 

had a significant influence on the physical fitness of executives (Table 5). It turned out, however, that the majority of the executives were nonsmokers.

Physical Activity Outside of Working Hours

Nineteen of the subjects specified that they never engaged in any sports/exercise activity outside of working hours. Six persons did not provide any information 

about their physical activity. Executives who exercised 

regularly outside of working hours were more physically 

fit than those who did not (Table 6).

Effect of Health Conditions on The Physical Fitness

of Executives

Diabetes Mellitus

Five of the 122 subjects in the study had diabetes mellitus. The study revealed no significant difference in 

physical fitness in comparison with the group that was 

not affected by the illness (data not shown).

Hypercholesterolemia

Fifty-eight of the 122 subjects had hypercholesterolemia. No significant difference in physical fitness was established between those affected and those 

not (data not shown).

Hyperuricemia

Of the 122 subjects, 17 had hyperuricemia. 14.4% of the senior officers (n=8) 

and 12.1% of the generals (n=8) were 

affected. No significant difference in 

Table 2. Overview of the performance of subjects by BMI group 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=20/16)

BMI<25 kg/m2 163.6 (±37.6) 237.7 (±52.9) 11 (±1.1) 13.1 (±1.3)

Group 2 (N=53/20)

BMI=25 to 30 kg/m2 163.8 (±37.0) 217.4 (±48.1) 10.2 (±1.8) 12.9 (±1.9)

Group 3 (N=13/0)

BMI>30 kg/m2 169.4 (±35.1) 221.7 (±53.9) - -

P.853.807.08.08

Table 3. Overview of the performance of subjects by waist circumference measurement 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 cm 167.8 (±40.9) 239.5 (±52.5) 11.1 (±1.3) 13.6 (±1.4)

Group 2 (N=27/9)

WC=94-102 cm 160.4 (±33.3) 214.3 (±46.2) 9.4 (±1.5) 11.5 (±0.9)

Group 3 (N=23/1)

WC>102 cm 160.2 (±28.8) 204.3 (±39.7) 8.0 10.0 

P.599.018.012.002
108 http://www.cs.amedd.army.mil/amedd_journal.aspx

physical fitness was established between those affected 

and those not (data not shown).

Hypertension

Of the 122 subjects, 38 had high blood pressure. A significant difference was established at maximum performance in the treadmill and the bicycle stress tests. Subjects without high blood pressure were significantly fitter 

than those with high blood pressure. At the 4 mmol lactate threshold, this could be observed as a trend (Table 7).

Orthopaedic Disorders

A total of 98.2% of the senior officers (n=54) and 84.8% 

of the generals (n=56) specified that they had orthopaedic disorders.

No significant difference was established at the 4 mmol 

lactate threshold or at maximum performance in the bicycle cardiac stress test (Table 8).

Performance levels differed significantly in the treadmill 

cardiac stress test. Subjects with orthopaedic disorders 

were significantly faster than those without (Table 8).

Mental Disorders

Only 2 subjects specified that they currently had a 

mental disorder. Physical fitness was only determined 

by means of a bicycle cardiac stress test. The p4mmol-L 

revealed no significant difference, but subjects with a 

mental disorder clearly tended to be less fit than subjects 

who had no mental disorder: 2 subjects with disorder,

p4mmol-L 120±22.6 W; 84 subjects with no disorder,

p4mmol-L 165.7±36.2 W; P=.057. At maximum performance, the effect rated previously as just a tendency 

proved to be a significant difference despite the small 

number of subjects: with disorder, pmax 139±43.8 W; no 

disorder: pmax 224.76±48.9 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 Advice

The 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 presenting 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 anaerobic 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 

first one. The BMI of the subjects who presented for the 

second examination had decreased from 27.3±3.3 kg/

m2

 to 26.9±3.4 kg/m2 (P=.116), which was insignificant. 

Waist circumference had decreased from 98.2±9.3 

cm to 97.3±10.5 cm, which was also insignificant 

(P=.575). On average, the performance test did not 

reveal any change in comparison with the previous values either. However, a lower heart rate (HR) 

was established at the individual anaerobic threshold (HRT0: 140.5±17.0/min, HRT1: 135.9±17.1/

min; P=.053).

Comment

Risk factors for cardiovascular diseases 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 

conventional limiting factors for fitness (age, BMI, waist circumference) 

were evident.6

 What is more, patients 

who had had an orthopaedic condition 

were fitter than those who had none. 

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 bicycle (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 (±48.2)

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 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

Nonexercisers (N=17/2) 138.76 (±23.1) 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
October – December 2017 109

THE ARMY MEDICAL DEPARTMENT JOURNAL

However, at this point it is important to understand that 

these conditions included sports injuries, and of course 

sports were identified as a performance-enhancing factor. The fact that there were many cases of sports injuries and injuries resulting from excessive strain as well 

as back pain is a significant basis for intervention as 

part of occupational health promotion. The fitness level 

of people with high blood pressure who were rated in 

our examination as not very fit, could, under controlled 

conditions, also be improved.16 Although no significant 

improvement was achieved in the body measurements 

and fitness of the subjects who returned for a second examination, the tendency was positive, and there was no 

deterioration in physical condition after receiving training advice. This comment, however, is limited to a large 

degree by the fact that less than a third of the initial subjects 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 

point is that although clear differences in fitness levels 

were sometimes detected, it was at times almost impossible to prove the statistical significance of these differences 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 

a well-known fact that physical fitness reduces susceptibility to psychological stress.17 Our study showed that 

subjects who were under psychological stress were not 

as physically fit as the other subjects. However, in 2 of 

the subjects who specified that they had psychological 

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 necessary as part of occupational health 

promotion to intervene in patients 

with a risk profile. Executives suffering from hypertonia, high BMI and 

waist circumference as well as executives with low physical activity level 

should be addressed by health promotion programs. These patients should 

perform regular weight and endurance training. In order to achieve optimum effects and avoid injuries as a 

result of excessive strain, this training 

should initially take place under guidance. 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, Hinder J, Lison A. An evaluation of the significance of 

work-related influence factors on fitness and the development of medical and orthopaedic conditions 

in military executives. ScientificWorldJournal. 

2016:3929104. doi:10.1155/2016/3929104.

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systematic review of factors influencing adoption 

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effects of smoking, alcohol, physical activity, and 

obesity on mortality? A prospective population 

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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 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

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/h

Orthopaedic 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
110 http://www.cs.amedd.army.mil/amedd_journal.aspx

6. 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.

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Shakerian M. Association between job strain (high 

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8. Laukkanen JA, Rauramaa R, Salonen JT, Kurl 

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9. Astrand PO. Measurement of maximal aerobic capacity. 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, Mücke S, Müller R, 

Hollmann W. Justification of the 4-mmol/l lactate threshold. Int J Sports Med. 1985;6(3):117-130. 

doi:10.1055/s-2008-1025824.

12. Cohen J. Statistical Power Analysis for the Behavioral Sciences. 2nd ed. Hillsdale, NJ: L. Erlbaum 

Associates; 1988.

13. Janhsen K, Strube H, Starker A. Hypertonie. Gesundheitsberichterstattung des Bundes 43. Berlin: 

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14. Lange C. Daten und Fakten:Ergebnisse der Studie 

Gesundheit in Deutschland aktuell 2010. Beiträge 

zur Gesundheitsberichterstattung des Bundes. Berlin: Robert-Koch-Inst; 2012.

15. Robert Koch-Institute, Federal Statistics Office. 

Health in Germany. Federal Health Reporting. 

Berlin; 2008.

16. McGonagle AK, Beatty JE, Joffe R. Coaching for 

workers with chronic illness: evaluating an intervention. J Occup Health Psychol. 2014;19(3):385-

398. doi:10.1037/a0036601.

17. Schwaberger G. Heart rate, metabolic and hormonal 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, Germany. He is also affiliated with the Bundeswehr Centre of 

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, Rostock 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 Medicine, 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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