January–March 2016

Correlation Between Femoral Neck Shaft Angle and Surgical Management 1

in Trainees With Femoral Neck Stress Fractures

CPT Robyn L. Chalupa; MAJ Jessica C. Rivera; CPT David J. Tennent; LTC (P) Anthony E. Johnson

Observed Rates of Lower Extremity Stress Fractures After Implementation of the Army 6

Physical Readiness Training Program At JBSA Fort Sam Houston

CPT Robyn L. Chalupa; Curtis Aberle, MSN; LTC (P) Anthony E. Johnson

What Soldiers Know and Want to Know about Preventing Injuries: 10

A Needs Survey Regarding a Key Threat to Readiness

Veronique Hauschild, MPH; Anna Schuh, PhD; Bruce Jones, MD, MPH

Rhabdomyolysis in a Sickle Cell Trait Positive Active Duty Male 20

CPT Pulkit Saxena; CPT Christopher Chavarria; MAJ John Thurlow

Hydration Status in US Military Officer Students 24

LTC (Ret) Reva Rogers; LTC Renee Cole

Muscle-related Disability Following Combat Injury Increases With Time 30

MAJ Jessica C. Rivera; Benjamin T. Corona, MD

War and Rehabilitation: Occupational Therapy’s Power to Transform Disability into Ability 35

1LT Catrinna Amorelli; 1LT Lindsay Sposato

Center for the Intrepid: Providing Patients POWER 39

1LT Catrinna Amorelli; 1LT Matthew L. Baumann; LTC Kathleen E. Yancosek; et al

Implementation of a Transition of Care Coordinator at a Military Treatment Facility 47

LTC Dana Nguyen; CPT Blake Busey; LTC Mark Stackle; et al

Influence of Individual Determinants on Physical Activity at Work and 53

During Leisure Time in Soldiers: A Prospective Surveillance Study

Maj Christoph Schulze, MD, German Air Force; Tobias Lindner, MD; et al

GEHS Neurophysiological Classification System for Patients with Carpal Tunnel Syndrome 60

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

Q Fever 68

CPT Akira A. Shishido; LCDR Andrew G. Letizia, USN; LTC Joshua D. Hartzell

Mobile Phone Health Applications for the Federal Sector 71

Capt Christin S. Burrows, USAF; MAJ Fred K. Weigel

A Primary Care Telehealth Experience in a US Army Correctional Facility in Germany 76

LTC Christian Swift; Steven M. Cain, MPAS, PA-C; CPT Michael Needham

Repair of a Gingival Fenestration Using an Acellular Dermal Matrix Allograft 81

COL Lawrence G. Breault; CPT Raquel C. Brentson; COL Edward B. Fowler; COL Frederick C. Bisch

Reasons for Non-third Molar Extractions in a Military Population 85

MAJ Hanane Jamghili; COL William J. Greenwood; COL Peter H. Guevara; Col William J. Dunn, USAF

Errata 80

JOURNAL

THE UNITED STATES ARMY

MEDICAL DEPARTMENT
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

January–March 2016 US Army Medical Department Center & School PB 8-16-1/2/3

The Army Medical Department Journal [ISSN 1524-0436] is published quarterly 

for The Surgeon General by the AMEDD Journal Office, USAMEDDC&S, AHS CDD

3630 Stanley RD STE B0204, JBSA Fort Sam Houston, TX 78234-6100.

Articles published in The Army Medical Department Journal are listed and 

indexed in MEDLINE, the National Library of Medicine’s premier bibliographic 

database of life sciences and biomedical information. As such, the Journal’s 

articles are readily accessible to researchers and scholars throughout the 

global scientific and academic communities.

CORRESPONDENCE: Manuscripts, photographs, official unit requests to 

receive copies, and unit address changes or deletions should be sent via 

email to usarmy.jbsa.medcom-ameddcs.list.amedd-journal@mail.mil, or by 

regular mail to the above address. Telephone: (210) 221-6301, DSN 471-6301

DISCLAIMER: The AMEDD Journal presents clinical and nonclinical 

professional information to expand knowledge of domestic & international 

military medical issues and technological advances; promote collaborative 

partnerships among Services, components, Corps, and specialties; convey 

clinical and health service support information; and provide a peer-reviewed, 

high quality, print medium to encourage dialogue concerning healthcare 

initiatives.

Appearance or use of a commercial product name in an article published 

in the AMEDD Journal does not imply endorsement by the US Government.

Views expressed are those of the author(s) and do not necessarily reflect 

official policies or positions of the Department of the Army, Department of 

the Navy, Department of the Air Force, Department of Defense, nor any other 

agency of the US Government. The content does not change or supersede 

information in other US Army Publications. The AMEDD Journal reserves the 

right to edit all material submitted for publication (see inside back cover).

CONTENT: Content of this publication is not copyright protected. Reprinted 

ma-terial must contain acknowledgement to the original author(s) and the 

AMEDD Journal.

OFFICIAL DISTRIBUTION: This publication is targeted to US Army Medical 

Department units and organizations, other US military medical organizations, 

and members of the worldwide professional medical community.

By Order of the Secretary of the Army:

Official:

GERALD B. O’KEEFE

Administrative Assistant to the 

Secretary of the Army

Mark A. Milley

General, United States Army

Chief of Staff

DISTRIBUTION: Special 1528705

LTG Nadja Y. West

The Surgeon General

Commander, US Army Medical Command

MG Steve Jones

Commanding General

US Army Medical Department Center and School

US Army Health Readiness Center of Excellence
January – March 2016 1

The most common overuse injury that leads to the discharge of new military recruits is a stress fracture.1

Stress fractures are associated with abrupt changes in 

physical activity level, such as the increase in activity 

some recruits are exposed to as part of military basic 

training.1 Stress fractures result from repetitive, submaximal loads on normal bone that cause bone formation to lag behind bone resorption, leaving bone prone 

to microtrauma.2 A subset of stress fractures, subject to 

high tensile forces and limited vascularity, are prone to 

delayed healing and are at risk for complete fracture, delayed, or nonunion, and require a more aggressive treatment approach.3

 One of the high-risk stress fractures is 

of the lateral femoral neck which risks osteonecrosis of 

the femoral head, the need for arthroplasty, and permanent disability.4,5 Early surgical intervention for these 

high risk stress fractures is recommended to prevent 

fracture progression.3-5 The cost of a recruit sustaining 

a femoral neck stress fracture that requires surgery is 

estimated to exceed $100,000 per injured recruit. At 

military treatment facilities (MTFs), surgical fixation is 

performed in about 25% of cases of femoral neck stress 

fractures.6

Femoral neck stress fractures make up less than 10% of 

all stress fractures.4,5,7-10 These injuries are most common in female military recruits.2,7 Overall, complications occur in 10% to 40% of all femoral neck stress 

fracture patients. Complication rates increase with displacement and varus surgical reduction.11

Both intrinsic and extrinsic factors have been associated 

with an increased risk of femoral neck stress fracture. 

Extrinsic factors may include the type of physical activity, prior training regimens, footwear, and environment.7

Intrinsic factors include sex, bone density and size, muscle size, foot shape, leg length, and hip geometry.5,7-9,12

Hip geometry is an important intrinsic risk for stress 

fractures. Clinically, loads in the average loading direction will not cause a fracture, but loads of extreme magnitude or extreme orientation may.13 In cases of altered 

femoral neck geometry, the joint load orientation becomes more vertical with coxa valga and more horizontal in coxa vara.13 Coxa vara is defined as a femoral neck 

shaft angle of less than 120°, coxa valga as an angle of 

greater than 140° average femoral neck shaft angle ranges from 125° to 131°.13 Femoral neck stress fractures are 

associated with coxa vara14 and compression side femoral neck stress fractures are more common.3

The treatment of femoral neck stress fractures should 

first focus on correcting predisposing intrinsic and extrinsic factors. Treatment of most compression side femoral neck stress fractures involves not bearing weight 

on the affected extremity for 6 weeks.3 Compression 

Correlation Between Femoral Neck Shaft

 Angle and Surgical Management in Trainees

 With Femoral Neck Stress Fractures

CPT Robyn L. Chalupa, SP, USA

MAJ Jessica C. Rivera, MC, USA

CPT David J. Tennent, MC, USA

LTC (P) Anthony E. Johnson, MC, USA

Abstract

The most common overuse injury leading to medical discharge of military recruits is a stress fracture. One of 

the high-risk stress fractures is of the lateral femoral neck which risks osteonecrosis of the femoral head, the 

need for arthroplasty and permanent disability. To prevent fracture progression early surgical intervention is 

recommended. Surgical repairs are performed in about 25% of cases of femoral neck stress fractures at military treatment facilities. Hip geometry is an important intrinsic risk for stress fractures. Loads in the average 

loading direction will not cause a fracture, but loads of extreme magnitude or extreme orientation may. The 

purpose of this study was to determine if, in the presence of femoral neck stress fracture, there is a correlation 

between femoral neck shaft angle, surgical treatment and outcomes. The results of this study suggest there is 

no correlation between return to full military duty rates, treatment, femoral neck shaft angle or fracture grade 

on MRI. Patients who underwent surgical fixation had greater fracture grade and pain than those that did not 

have surgery. Individuals who did not return to duty tended to have higher pain scores at initial evaluation.
2 http://www.cs.amedd.army.mil/amedd_journal.aspx

side stress fractures that show chronic changes such as 

cysts or intramedullary sclerosis involve more than 50% 

of the neck on MRI, and those that are complete may 

require surgical fixation.1,2 Sariyilmaz et al used coxa 

vara and the resulting mechanical abnormality as an additional indication for surgery.15 Tension side femoral 

neck stress fractures should be treated with increased 

vigilance to prevent progression to complete fracture.2,8

Nondisplaced stress fractures can be treated with cannulated screw fixation or Pauwel osteotomy; however, 

displaced fractures would require dynamic hip screw 

placement or arthroplasty.15

The purpose of this study is to determine if, in the presence of femoral neck stress fracture, there is a correlation between femoral neck shaft angle, surgical treatment, and outcomes.

Methods

After approval from the MTF Institutional Review 

Board, we performed a retrospective study. Patients that 

had been evaluated by orthopaedics, had imaging of the 

hip, and diagnosed with a femoral neck stress fracture 

at the MTF between June 1, 2012 and May 31, 2014 were 

included. We reviewed hospital and clinic records and 

available imaging data from surgical scheduling, electronic medical records, and the Picture Archive and 

Communication System (PACS) application.

A potential subject list, shown in Table 1, was compiled 

using an electronic medical record search of ICD-9 codes 

which correspond to stress fractures of the femur, hip, 

and pelvis. Imagery available in PACS was reviewed to 

ensure the potential subjects did, in fact, have a femoral 

neck stress fracture and the necessary imaging studies 

were available for analysis. We then screened the potential subject list for other inclusion and exclusion criteria, 

shown in Table 2.

Each subject’s femoral neck shaft angle was measured 

on the anteroposterior radiograph by calculating the 

angle formed by the intersection of a line bisecting the 

midpoint of the femoral neck and the midpoint of the 

femoral head, and the anatomic axis of the femur, illustrated in the Figure. Each subject’s MRI was then examined in order to grade the severity of the femoral neck 

stress reaction as indicated by bone edema and a frank 

fracture line (Table 3). Each subject’s electronic medical 

record was examined for details on the clinical course, 

provider recommended activity restrictions, and ability 

to perform full military duty. Each subject was searched 

on the surgical schedule to determine whether they underwent surgery for a femoral neck stress fracture.

Comparisons among groups were then made using unpaired student’s t test and Pearson’s correlation for continuous data, and 2-tailed Fisher’s exact test for categorical data. All analysis was performed using GraphPad 

Prism 6 (GraphPad Software, Inc, La Jolla, CA).

CORRELATION BETWEEN FEMORAL NECK SHAFT ANGLE AND SURGICAL MANAGEMENT

IN TRAINEES WITH FEMORAL NECK STRESS FRACTURES

Table 1. The potential subject list of codes corresponding to stress fractures of the femur, hip, and pelvis.

ICD-9 Description

733.90 Disorder of the bone and cartilage unspecified

733.95 Stress fracture of other bone

733.96 Stress fracture of the femoral neck

733.97 Stress fracture of the shaft of the femur

733.98 Stress fracture of the pelvis

736.31 Coxa valga (acquired)

736.32 Coxa vara (acquired)

736.39 Other acquired deformities of the hip

Table 2. Additional inclusion and exclusion criteria for subject screening.

Inclusion Criteria

Treated between June 1, 2012 and May 31, 2014

Diagnosis of a femoral neck stress fracture confirmed by MRI

Age: 18-45 years

Active duty

Treatment by orthopaedics

Available MRI and anteroposterior pelvis

Exclusion Criteria

Age <18 years

Age >45 years

Pathologic fracture

Electronic medical record not available

Imaging to evaluate stress fracture not available

Illustration of the parameters used to measure the femoral neck shaft angle determined from an anteroposterior 

radiograph image.

1⁄2

1⁄2

1⁄2 1⁄2

Neck Shaft Angle

Neck Midline

Shaft Midline
January – March 2016 3

THE ARMY MEDICAL DEPARTMENT JOURNAL

Results

Search of orthopaedic encounters within the electronic 

medical record found 205 uses of the queried ICD-9 

codes in 185 individuals. Of those, diagnosis of femoral 

neck stress fracture was found in 72 individuals. Nineteen individuals were excluded from the study because 

an MRI was not obtained as part of their workup, they 

had been treated at their previous duty station, had 

pathologic fractures, were not active duty, or had no 

fracture on MRI. This left 53 individuals as study participants, with 10 individuals having bilateral femoral 

neck stress fractures (63 total stress fractures).

Review of the 53 included individuals found that all of 

the affected individuals were initial trainees, and 12 

were male (23%). The average age of the included subjects was 22.9 years (range 18 to 39 years) and there was 

no difference in age between male and female subjects 

(P=.3820). Thirty of the 63 affected femurs were right 

side (48%). All of the evaluated femoral neck stress fractures were compression side. One male presented with a 

complete fracture. Women had a greater mean femoral 

neck shaft angle compared to men (132.2°±0.6° versus 

129.0°±0.8°, respectively; P=.0082). Normal is considered 125° to 131°. No correlation existed among femoral neck shaft angles, stress fracture grades, duration of 

symptoms, or pain scale results per hip.

Ten subjects (8 female, 2 male) had bilateral stress fractures. All bilateral stress fractures were noted on images 

obtained in a single encounter. In addition, the 7 patients who had surgical intervention for bilateral stress 

fractures had both sides fixed at one procedure. Having bilateral stress fractures did not affect surgery rates 

(P=.1563) or return to duty rates (P=.4639) compared to 

a unilateral stress fracture.

Twenty-four subjects (31 hips) underwent operative fixation. Percutaneous screw fixation was used in all 24 of the 

operative patients. One 19-year-old patient’s course was 

complicated by chondrolysis and went on to total joint 

arthroplasty. Femoral neck shaft angles were not different between subjects who were not treated with surgery 

(131.6°±0.8°) and those who underwent percutaneous 

screw fixation (131.4°±0.7°, P=.8759). However, subjects with operatively treated hips had higher stress fracture grades on MRI (3.4±0.1) versus subjects who did 

not undergo surgery (2.9±0.1, P=.0059). Subjects who 

underwent surgery also had higher mean pain scores on 

presentation to orthopaedics (4.8±0.5) versus subjects 

who did not undergo surgery (3.4±0.5, P=.0412).

Two-thirds of surgical patients did not return to full duty 

(16/24), and 48% of nonsurgical patients did not return 

to full duty (14/29, P=.2660). There was no difference 

between femoral neck shaft angles among subjects 

who were able to return to duty (132.0° ±1.1°) and subjects who were not able to return to duty (131.2°±0.6°, 

P=.5081). Stress fracture grade was also not different between those who returned to full military duty (3.1±0.1) 

and those who did not (3.2±0.1, P=.4701). There was a 

trend, though not significant, towards individuals who 

did not return to duty having higher mean pain scores 

on presentation to orthopaedics (4.6±0.4 not return to 

duty versus 3.3±0.6 return to duty, P=.0575).

Comment

The results of this study suggest there is no correlation 

between return to full military duty rates and treatment, femoral neck shaft angle, or fracture grade on 

MRI. There was a trend toward significance in higher 

pain level at presentation and lower return to duty rates. 

Patients who underwent surgical fixation had greater 

fracture grade and pain than those that did not have 

surgery. The femoral neck shaft angle was found to be 

more valgus in women. Additionally, the mean angle in 

this cohort was more valgus than the previously cited 

normal range of 125° to 131°.13 Bilateral stress fractures 

were found in 19% of study participants.

In this study, all of the patients who had stress fractures 

were trainees. This suggests initial training places added 

stress on the femoral neck that either does not continue 

after conditioning or results in the attrition of trainees 

prone to these fractures. Individual preconditioning and 

dietary variance would affect how the trainee reacts to 

the increase in physical activities unique to initial training. The programs that have shown to decrease training 

injuries, such as command awareness, provider training, 

and the Army Physical Readiness Training (PRT) program, should be continued.6

This study found no tension-sided femoral neck stress 

fractures. This is not surprising because compressionsided fractures are more common; however, the proportion of surgically-treated fractures was 49%. This 

percentage is greater than previously presented in the 

Table 3. Criteria table used to grade severity of the femoral 

neck stress reaction based on examination of the subject’s 

MRI imagery. Adapted from Arendt et al.16

Grade STIR* Signal

Change

T2 Signal 

Change

T1 Signal 

Change

Plain X-ray Film

1 Present None None Negative

2 Present Present None Negative

3 Present Present Present Periosteal reaction

4 Present Fracture 

line

Fracture 

line

Periosteal reaction 

or fracture line

*Short T1 inverse recovery imaging
4 http://www.cs.amedd.army.mil/amedd_journal.aspx

literature (25%).6 Although there was no statistically 

significant correlation between stress fracture grade and 

pain level, the stress fracture grade and pain level were 

higher for those operatively treated. While some literature supports treating compression side stress fractures 

with strict limitation of weight bearing,3 our high operative rate is evidence that surgeon and facility considerations play a role in management of this condition. For 

example, surgeons at this MTF must consider whether 

strict nonweightbearing is reasonable for individuals 

with training demands within the military environment.

Clinically, providers should continue to have a high 

index of suspicion for femoral neck stress fractures in 

trainees presenting with hip pain. An MRI should be 

obtained if history warrants. When obtaining MRIs, the 

contralateral hip should be imaged to exclude asymptomatic stress reaction in the contralateral hip.3,17 Care 

should also include identifying and treating any intrinsic factors that put the trainee at risk for stress fracture.3

Treatment may need to include supplementation with 

calcium and vitamin D, or treatment of women with 

low-dose estrogen.8 However, not all intrinsic factors 

are amenable to intervention and focus must remain on 

modification of extrinsic factors when possible.8 Initial military training fitness programs that assess and 

gradually progress fitness levels are necessary for injury 

prevention.8 These could include progressive resistance 

training and protective exercises such as the forward 

lunge, isokinetic hip extension, one-legged long jump, 

and isokinetic knee flexion.8,18,19

All retrospective studies have similar limitations including those imposed by querying records that differ in 

quality. Not all data that was desired was recorded in 

every medical record. Many lacked record of pain scale, 

duration of symptoms, and duration of restricted weight 

bearing. This study was unable to assess for female 

athlete triad due to the lack of records on the patient’s 

menstrual cycle and diet. In post-hoc power analysis using Stata 13.1, we found we were adequately powered at 

0.9519 for the comparison between return to full military duty and those that did not with regard to mean 

femoral neck shaft angle. A follow up study to obtain a 

power of 0.80 would require 424 subjects, with 212 subjects each in the surgical and nonsurgical groups, for the 

comparison between operatively treated hips and femoral neck shaft angles. So while we were adequately powered with this sample size to examine some dependent 

variables, we were not adequately powered to examine 

all of them. A study of such size would not be possible 

at this single medical facility.

Conclusion

Both intrinsic and extrinsic factors contribute to stress 

fracture. Extrinsic factors may include the type of physical activity, prior training regimens, footwear and environment.7

 Intrinsic factors include sex, bone density 

and size, muscle size, foot shape, leg length, and hip geometry.5,7-9,12 Those charged with training design should 

work to minimize the contribution of modifiable factors 

to prevent stress fractures. Future studies that prospectively gather information on female athlete triad, metabolic work-up results, pretraining fitness levels, and seasonal differences in rates would be useful. Studies that 

randomize surgical treatment may not be possible, but 

nonoperative treatment modalities involving treatment 

of modifiable intrinsic and extrinsic factors would be 

helpful in helping care providers choose the best treatment to avoid the patient’s separation. Stress modeling 

of the exercises preformed in initial training could also 

help tailor physical fitness program to prevent stress 

fractures. Future study is also necessary to limit the 

personal and financial effects of these costly fractures.

References

1. Shin AY, Gillingham BL. Fatigue fractures of the 

femoral neck in athletes. J Am Acad Orthop Surg. 

1997;5(6):293-302.

2. Boden BP, Osbahr DC, Jimenez C. Low-risk stress 

fractures. Am J Sports Med. 2001;29(1):100-111.

3. Boden BP, Osbahr DC. High-risk stress fractures: 

evaluation and treatment. J Am Acad Orthop Surg. 

2000;8(6):344-353.

4. Pihlajamaki HK, Ruohola JP, Kiuru MJ, Visuri TI. Displaced femoral neck fatigue fractures in military recruits. J Bone Joint Surg Am. 

2006;88(9):1989-1997.

5. Behrens SB, Deren ME, Matson A, Fadale PD, Monchik KO. Stress fractures of the pelvis and legs in 

athletes: a review. Sports Health. 2013;5(2):165-174.

6. Scott SJ, Feltwell DN, Knapik JJ, et al. A multiple 

intervention strategy for reducing femoral neck 

stress injuries and other serious overuse injuries 

in U.S. Army Basic Combat Training. Mil Med. 

2012;177(9):1081-1089.

7. Cosman F, Ruffing J, Zion M, et al. Determinants 

of stress fracture risk in United States Military 

Academy cadets. Bone. 2013;55(2):359-366.

8. Jacobs JM, Cameron KL, Bojescul JA. Lower extremity stress fractures in the military. Clin Sports 

Med. 2014;33(4):591-613.

9. Kupferer KR, Bush DM, Cornell JE, et al. Femoral 

neck stress fracture in Air Force basic trainees. Mil 

Med. 2014;179(1):56-61.

CORRELATION BETWEEN FEMORAL NECK SHAFT ANGLE AND SURGICAL MANAGEMENT

IN TRAINEES WITH FEMORAL NECK STRESS FRACTURES
January – March 2016 5

THE ARMY MEDICAL DEPARTMENT JOURNAL

10. Malhotra R, Meena S, Digge VK. Tensile type of 

stress fracture neck of femur: role of teriparatide in 

the process of healing in a high risk patient for impaired healing of fracture. Clin Cases Miner Bone 

Metab. 2013;10(3):210-212.

11. Lee CH, Huang GS, Chao KH, Jean JL, Wu 

SS. Surgical treatment of displaced stress fractures of the femoral neck in military recruits: a 

report of 42 cases. Arch Orthop Trauma Surg. 

2003;123(10):527-533.

12. Carey T, Key C, Oliver D, Biega T, Bojescul J. 

Prevalence of radiographic findings consistent with 

femoroacetabular impingement in military personnel with femoral neck stress fractures. J Surg Orthop Adv. 2013;22(1):54-58.

13. Fischer KJ, Eckstein, F.; Becker C. Density-based 

load estimation predicts altered femoral load directions for coxa vara and coxa valga. J Musculoskelet 

Res. 1999;3(2):83-92.

14. Carpintero P, Leon F, Zafra M, Serrano-Trenas 

JA, Roman M. Stress fractures of the femoral 

neck and coxa vara. Arch Orthop Trauma Surg. 

2003;123(6):273-277.

15. Sariyilmaz K, Ozkunt O, Sungur M, Dikici F, Yazicioglu O. Osteomalacia and coxa vara. An unusual 

co-existence for femoral neck stress fracture. Int J 

Surg Case Rep. 2015;16:137-140.

16. Arendt E, Agel J, Heikes C, Griffiths H. Stress injuries to bone in college athletes: a retrospective 

review of experience at a single institution. Am J 

Sports Med. 2003;31(6):959-968.

17. Moo IH, Lee YH, Lim KK, Mehta KV. Bilateral 

femoral neck stress fractures in military recruits 

with unilateral hip pain. J R Army Med Corps. June 

17, 2015 [epub ahead of print].

18. Martelli S, Kersh ME, Schache AG, Pandy MG. 

Strain energy in the femoral neck during exercise. 

J Biomech. 2014;47(8):1784-1791.

19. Qian JG, Li Z, Zhang H, Bian R, Zhang S. Effectiveness of selected fitness exercises on stress 

of femoral neck using musculoskeletal dynamics 

simulations and finite element model. J Hum Kinet. 

2014;41:59-70.

Authors

CPT Chalupa is a physician assistant with the Orthopaedic Surgery Service, Department of Orthopaedics and 

Rehabilitation, Brooke Army Medical Center, JBSA Fort 

Sam Houston, Texas.

MAJ Rivera is with the US Army Institute of Surgical 

Research, Joint Base San Antonio Fort Sam Houston, 

Texas.

CPT Tennent is with the Department of Orthopaedics 

and Rehabilitation, San Antonio Military Medical Center, Joint Base San Antonio-Fort Sam Houston, Texas.

LTC (P) Johnson is Chairman, Department of Orthopaedics and Rehabilitation, Brooke Army Medical Center, 

JBSA Fort Sam Houston, Texas.

Articles published in the Army Medical Department Journal are indexed 

in MEDLINE, the National Library of Medicine’s (NLM’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 NLM’s PubMed service.
6 http://www.cs.amedd.army.mil/amedd_journal.aspx

Millions of dollars are lost each year to the US military 

in medical discharges from injuries sustained in the initial training of recruits. According to the Government 

Accountability Office, the military loses an estimated 

$390 million annually in the recruitment and training 

of personnel who separate before completing the first 6 

months of service.1 Financial losses arise from the cost 

of initial recruitment; transport to the training location; 

uniforms and equipment; accommodation and rations; 

wages; instruction and supervision; administration; and 

medical, dental, and psychological care for recruits who 

are medically discharged.1,2 Each recruit who fails to 

complete training costs the military thousands of dollars.1,2 The loss of a single recruit costs between $7,000 

and $16,000 per recruit depending on branch of service 

and specialty.2-5

Additionally, medical discharge of recruits compromises military readiness by reducing force strength and 

depriving the military of critical skills.6 When overseas operations in Iraq and Afghanistan increased the 

demand for manpower, the attrition rate during initial 

military training became a serious and costly concern 

for all military services.

Medical discharge rates range between 16% and 53% 

of the total discharges of recruits.2-5 Although medical 

discharges can be attributed to many causes, approximately 40% of medical discharges were related to musculoskeletal injury, and half of those were overuse injuries, including stress fractures.2,7 Additionally, lower 

extremity overuse injuries account for more lost duty 

days and delays in completion of training than any other 

diagnosis.8 In fact, those sustaining a stress fracture are 

4 times more likely to be medically discharged. Sustaining a stress fracture during initial military training is 

the most powerful predictor of discharge.4

Given the association between medical discharge and 

lower extremity stress fractures, any strategies that 

can reduce injury rates are also likely to reduce rates 

of medical discharge during initial military training.2,4

The Army Physical Readiness Training (PRT) program, 

implemented in October 2010, was designed to establish a more comprehensive and standardized method of 

physical fitness training in order to reduce the number of 

preventable injuries. Injury prevention measures included reduced running miles, a greater variety of exercises, 

and enforced progressive training.9 The purpose of this 

Observed Rates of Lower Extremity Stress

 Fractures After Implementation of the

 Army Physical Readiness Training Program

 at JBSA Fort Sam Houston

CPT Robyn L. Chalupa, SP, USA

Curtis Aberle, MSN

LTC (P) Anthony E. Johnson, MC, USA

Abstract

Millions of dollars are lost each year to the US military in medical discharges from injuries sustained in the initial 

training of recruits. Most medical discharges in recruits are related to musculoskeletal overuse injuries, including 

stress fractures. Any strategies that can reduce injury rates are also likely to reduce rates of medical discharge. 

This study evaluated the Army Physical Readiness Training (PRT) program which was established to provide 

a method of physical fitness training that would reduce the number of preventable injuries. We conducted a 

retrospective study to evaluate the number of lower extremity stress fractures that were diagnosed in the 6 

months prior to and 6 months following the implementation of the PRT program. Electronic medical records were 

queried for specific diagnoses of stress fractures to the pelvis, femoral neck, femoral shaft, tibia, fibula, tarsals 

and metatarsals. The observed number of diagnoses in each time period were compared using the χ2 method. 

Decrease was shown not only in the overall occurrence of stress fractures, but specifically in the occurrence of 

stress fractures of the femoral neck, femoral shaft, and tarsals. Our study was able to show a correlation between 

the PRT program and a decrease in the observed occurrence of lower extremity stress fractures.
January – March 2016 7

THE ARMY MEDICAL DEPARTMENT JOURNAL

study is to evaluate the observed rates 

of lower extremity stress fractures 

diagnosed in recruits following the 

implementation of the PRT.

Methods

Our study was intended as a pilot study 

to evaluate the effect of implementing PRT on lower extremity stress 

fractures that could lead to discharge. 

Following Institutional Review Board 

approval, we queried the military 

electronic medical record (AHLTA) 

for ICD-9* codes corresponding to 

specific diagnoses of lower extremity stress fractures. We included 

diagnoses of stress fractures to 

the pelvis, femoral neck, femoral shaft, tibia, fibula, tarsals, and 

metatarsals, shown in Table 1. We 

limited our search to recruits seen 

at McWethy Troop Medical Clinic 

(TMC) at Joint Base San Antonio 

(JBSA) Fort Sam Houston, Texas. 

The TMC is the facility where recruits are initially evaluated for 

medical complaints. 

We divided our cohort into 2 

groups based upon the implementation date of the PRT program at 

JBSA Fort Sam Houston. Group 1 

was defined as lower extremity stress fractures that occurred during the 6-month period prior to implementation of the PRT program, from April to September 2010. 

Group 2 was defined as lower extremity stress fractures 

that occurred during the 6-month period following the 

implementation of the PRT program, from October 2010 

to March 2011. The total number of diagnoses, the number of each ICD-9 diagnoses, and groupings based on 

anatomic region (thigh, leg, and foot) were analyzed. 

Anatomic regions were used to determine if PRT changes affected one body region over the others. The thigh 

region was considered the femoral neck and shaft, the 

leg region was the tibia or fibula, and the foot region was 

the tarsals and metatarsals. There were 5000 recruits assigned to Fort Sam Houston during the period of our 

study. The groups were compared using the χ2 method 

of analysis with α=0.05 and β=0.8.

No protected health information and no patient demographic data were collected by investigators.

Results

There were a total of 408 lower extremity stress fractures diagnosed 

during our investigation. We observed 

that 234 lower extremity stress fractures were diagnosed during the 6- 

month period prior to the implementation of the PRT program (Group 1). 

We observed that 174 lower extremity 

stress fractures were diagnosed during the 6-month period following the 

implementation of the PRT program 

(Group 2). This represented 25.2% 

decrease in the overall occurrence of 

lower extremity stress fractures between the 2 groups (P=.002). Similarly, the occurrence of stress fractures of the tarsal bones decreased 

by 36.9% (P=.008), while femoral 

neck stress fractures decreased by 

47.0% (P=.003). Despite the fact 

that we observed a 60% decrease 

in the occurrence of femoral 

shaft fractures, the difference did 

not reach statistical significance 

(P=.109). There was also no statistical difference in the occurrence 

of tibial (P=.720) and metatarsal 

(P=.876) stress fractures. No pelvic stress fractures were observed 

during the examined period. The 

data is presented in Table 2. The 

Figure shows the distribution of the stress fractures 

through the study period.

Groupings based on anatomic region were also analyzed. 

We observed 49.3% decrease in stress fractures to the 

thigh region (P<.001) and 28.8% decrease in stress fractures to the foot region (P=.023). Statistical significance 

for the leg grouping was not achieved (P=.720). The data 

is presented in Table 3.

Comment

The PRT program was introduced to reduce the number of preventable injuries by establishing a more comprehensive and standardized method of physical fitness 

training.9 Our study demonstrated a decline in the diagnosis of lower extremity stress fractures under the 

PRT program. This decrease was shown not only in the 

overall rate of stress fractures occurrence, but also in 

stress fractures of the tarsal bones and the femoral neck. 

A significant reduction in femoral neck stress fractures 

is encouraging because these are a subset of highrisk stress fractures, prone to progression to complete *International Classification of Diseases, 9th Revision

Table 2. Data of observed lower extremity 

stress fractures displayed by location and 

group. Negative percentage change represents a decline in the number of lower extremity stress fractures observed. Positive 

percentage change represents an increase 

in the number of lower extremity stress fractures observed.

Group

1

Group

2

Change

%

P

Value

Pelvis 0 0 0% N/A

Femoral neck 59 31 -47.0% P=.003

Femoral shaft 10 4 -60.0% P=.109

Tibia/Fibula 61 65 6.6% P=.720

Tarsals 84 53 -36.9% P=.008

Metatarsals 20 21 5.0% P=.876

Total 234 174 -25.2% P=.002

Table 1. The ICD-9* codes used as 

search criteria.

ICD-9

Code

Description

733.93 Stress fractures of the tibia 

and/or fibula

733.94 Stress fractures of the 

metatarsals

733.95 Stress fractures of other 

bones (tarsals)

733.96 Stress fractures of the femoral 

neck

733.97 Stress fractures of the femoral 

shaft

733.98 Stress fractures of the pelvis

*International Classification of Diseases, 

9th Revision
8 http://www.cs.amedd.army.mil/amedd_journal.aspx

fracture and possibly requiring surgical intervention.10

While we found a meaningful decrease in the number of 

observed femoral shaft stress fractures, our study was 

likely underpowered, given the inability to show statistical significance. Our study was limited to one installation, JBSA Fort Sam Houston, and only extends to the 6 

months immediately prior to and after implementation 

of the PRT program. A larger cohort could be derived 

from including more installations or from examining a 

longer period around the time of implementation. 

In addition to an underpowered study, there are other 

limitations. The PRT program was only implemented 

for the Army recruits at JBSA Fort Sam Houston. As we 

collected no demographic information on the subjects, 

permanent party (nontrainee), Air Force, or Navy personnel that are also trained at JBSA Fort Sam Houston 

could be included despite not participating in the PRT 

program. Because the TMC is the entry point to the 

Military Health System for recruits, we are confident 

that we captured all recruits save those that presented 

primarily to the Emergency Department (ED). However, 

any post-ED follow up is performed at the TMC, regardless of subspecialty referral by the ED. All recruits are 

seen at this one TMC. We recognize that we could have 

missed stress fractures of individuals who chose not to 

seek treatment or delayed presentation until outside the 

study window. Furthermore, we would miss additional 

stress fracture diagnoses made following specialty care 

evaluation because initial evaluation by the primary care 

provider would have had a different ICD-9 code. Finally, 

given such as short study window, we could have missed 

potential seasonal variations similar 

to those seen in other injury patterns.

Conclusion

Our study demonstrated a decline in 

the diagnosis of lower extremity stress 

fractures in the 6 months following the implementation 

of the Army PRT program. This included a decrease in 

femoral neck stress fractures, which can be associated 

with worse outcomes. Continued investigation is warranted considering the high cost of training dollars lost 

to injury, treatment, and discharge of recruits early in 

their military training.

References

1. US Government Accountability Office. Military 

Attrition: DOD Could Save Millions by Better 

Screening Enlisted Personnel. Washington, DC: US 

Government Accountability Office; January 1997. 

GAO/NSIAD-97-39. Available at: http://www.gao.

gov/assets/160/155698.pdf. Accessed July 24, 2014.

2. Pope RP, Herbert R, Kirwan JD, Graham BJ. Predicting attrition in basic military training. Mil Med. 

1999;164(10):710-714.

3. Booth-Kewley S, Larson GE, Ryan MA. Predictors 

of Navy attrition. I. Analysis of 1-year attrition. Mil 

Med. 2002;167(9):760-769.

4. Reis JP, Trone DW, Macera CA, Rauh MJ. Factors 

associated with discharge during Marine Corps basic training. Mil Med. 2007;172(9):936-941.

5. Talcott GW, Haddock CK, Klesges RC, Lando H, 

Fiedler E. Prevalence and predictors of discharge 

in United States Air Force basic military training. 

Mil Med. 1999;164(4):269-274.

6. Knapik JJ, Canham-Chervak M, Hauret K, Hoedebecke E, Laurin MJ, Cuthie J. Discharges during 

U.S. Army basic training: injury rates and risk factors. Mil Med. 2001;166(7):641-647.

Table 3. Data of observed lower extremity stress fractures displayed by 

region and group. Negative percentage change represents a decline in 

the number of lower extremity stress 

fractures observed. Positive percentage change represents an increase in 

the number of lower extremity stress 

fractures observed.

Group

1

Group

2

Change

%

P

Value

Pelvis 0 0 0% N/A

Thigh 69 35 -49.3% P<.001

Leg 61 65 6.6% P=.720

Foot 104 74 -28.8% P=.023

Total 234 174 -25.2% P=.002

Distribution of diagnosed stress fractures by month for the study period April 2010

through March 2011.

Metatarsals

Tarsals

Tibia/Fibula

Femoral shaft

Femoral neck

20

0

40

50

30

60

10

Apr 10

May 10

Jun 10

Jul 10

Aug 10

Sep 10

Oct 10

Nov 10

Dec 10

Jan 11

Feb 11

Mar 11

Before PRT After PRT

OBSERVED RATES OF LOWER EXTREMITY STRESS FRACTURES AFTER IMPLEMENTATION OF THE

ARMY PHYSICAL READINESS TRAINING PROGRAM AT JBSA FORT SAM HOUSTON
January – March 2016 9

THE ARMY MEDICAL DEPARTMENT JOURNAL

7. Gemmell IM. Injuries among female army recruits: a conflict of legislation. J R Soc Med. 

2002;95(1):23-27.

8. Snoddy RO Jr, Henderson JM. Predictors 

of basic infantry training success. Mil Med. 

1994;159(9):616-622.

9. Knapik JJ, Rieger W, Palkoska F, Van Camp S, 

Darakjy S. United States Army physical readiness training: rationale and evaluation of the 

physical training doctrine. J Strength Cond Res. 

2009;23(4):1353-1362.

10. Boden BP, Osbahr DC. High-risk stress fractures: 

evaluation and treatment. J Am Acad Orthop Surg. 

Nov-Dec 2000;8(6):344-353.

Authors

CPT Chalupa is a physician assistant with the Orthopaedic Surgery Service, Department of Orthopaedics and 

Rehabilitation, Brooke Army Medical Center, JBSA Fort 

Sam Houston, Texas.

Mr Aberle is Chief, McWethy Troop Medical Clinic, 

JBSA Fort Sam Houston, Texas.

LTC (P) Johnson is Chairman, Department of Orthopaedics and Rehabilitation, Brooke Army Medical Center, 

JBSA Fort Sam Houston, Texas.
10 http://www.cs.amedd.army.mil/amedd_journal.aspx

Unintended injuries, in particular physical training-related injuries, continue to be one of the most significant 

threats to US military readiness.1 As many of these injuries are considered preventable, this study was undertaken to help determine what additional information might 

contribute to reducing these injuries in the US Army.

Historical Review

Common musculoskeletal and orthopedic injuries (ie, 

strains, sprains, joint derangements, and stress fractures) are the leading threat to the medical readiness of 

our troops.1 Almost 50% of all service members experience one or more injuries annually.2

 Each year, these injuries limit physical ability and cause disability among 

active duty service members, resulting in millions of 

medical encounters, lost or restricted duty days, and 

medical expenses.1,3-6 These injuries, predominantly of 

the back, knees, and lower extremities, are most often 

due to repetitive overuse, not from acute trauma.1,3-5,7-10

In fact, over half of these injuries result from unit or personal physical training activities like running or sports.2

Even during wartime operations, medical air evacuations are more often for nonbattle injuries such as those 

caused by sports and physical training than for injuries 

resulting from combat.11

This problem has persisted for decades.12,13 In 1992, an 

estimated 450,000 outpatient medical encounters resulted in several million days of restricted duty.13 In 

2012, 2.2 million Department of Defense (DoD) military medical encounters resulted from these same types 

of musculoskeletal injuries, resulting in an estimated 

25 million limited duty days.1 The Army accounts for 

about 40%—the largest portion—of these days of limited duty.1,4 It has been estimated that a 1% reduction 

in incidence of lower back pain could translate to the 

retention of thousands of trained Soldiers, avoidance of 

countless lost training hours, and significant cost savings through fewer disability payments and less consumption of medical care.13

The continued high incidence of these common injuries is, in part, because Soldiers must routinely conduct 

physical training. Physical training is the cornerstone 

to enhancing physical fitness and overall human performance. Yet physical training and optimizing human 

physical performance includes minimizing injury. Scientific study and injury surveillance data have helped 

to identify risk factors and evaluate the effectiveness of 

some tactics for reducing these injuries.14-19 Risks and 

interventions associated with running mileage, training 

programs, stretching, footwear, various braces (such as 

ankle, back, knee), gender, age, and medication use have 

been and continue to be investigated. In some cases, 

current evidence provides insights into training modifications that could reduce injuries. In other cases, scientific investigation has shown that evidence is inadequate 

to prove the benefits of some interventions. In fact, some 

scientific evidence shows that not all injury prevention 

(IP) tactics once believed to be effective are actually 

helpful. In reality, some may increase injury risks.3 Unfortunately, anecdotal information often drives risk prevention decisions.

Scope of this Effort

Investigators at the US Army Public Health Center (Provisional)* (USAPHC(P)) theorized that a lack of awareness and confusion about risk factors and effective 

physical training techniques may be contributing to this 

persistent injury problem. In order to guide the development of IP educational materials to increase awareness 

and correct misinformation, a voluntary survey tool was 

used to assess current awareness about IP topics and 

identify specific information needs and interests among 

Army audiences.

Methods

A group of health analysts, health educators, and statisticians experienced with survey tools developed a 

What Soldiers Know and Want to Know

 About Preventing Injuries: A Needs Survey

 Regarding a Key Threat to Readiness

Veronique D. Hauschild, MPH

Anna Schuh, PhD

Bruce H. Jones, MD, MPH

*Formerly the US Army Public Health Command.
January – March 2016 11

THE ARMY MEDICAL DEPARTMENT JOURNAL

29-question survey.20 The survey, 

designed to be anonymous, focused 

on unintentional musculoskeletal injuries, but also included some questions about heat and cold injuries. 

Data requirements were balanced 

with the desire to limit the time burden for respondents. Survey topics 

included demographics and job roles, 

personal injury history (past 12 

months), awareness of injury effects, 

risk factors, interventions, leadership perspectives (for nonsupervisor responders), and IP interests (ie, 

activities, injury types, and information sources and formats). Prior 

to disseminating the survey, documentation was submitted for review 

through the USAPHC(P) Human 

Protection Review Board. The collection of personally identifiable information was avoided through preestablished, broad categories provided in demographic 

questions.

The survey was delivered using the Vovici software 

application (Vovici is now Verint Enterprise Edition 

(Verint Systems Inc, Melville, NY)). The voluntary online survey was dispersed to Army audiences through 

several venues between July 9 and August 26, 2014 (61⁄2 

weeks). Venues included postings on Army medical and 

nonmedical social media sites, websites, and 

through mass Army (S-1 Net) and individual 

emails. Posting of the survey link was voluntary for the proponent organizations. All 

responses were received in a protected data 

archive only accessible by selected project 

investigators.

To assess general awareness of the problem, 

4 evidence-based statements regarding most 

common musculoskeletal injuries within the 

Army and leading causes of these injuries 

were provided for respondents to indicate 

their level of agreement (on a 5- point scale 

from Strongly Agree to Strongly Disagree). 

Respondents also scored the effects of various risk factors and prevention measures 

for musculoskeletal injuries by indicating 

whether they believed the measures decrease 

risk, neither increase/decrease risk, increase 

risk, or whether the respondent was not sure. 

The “correctness” of statements were evaluated based on previously published scientific 

evidence,1,5,11 including a systematic review 

of physical training injury intervention conducted by DoD experts.3

 In 

addition, respondents were asked to 

choose activities about which they 

were most interested in receiving 

IP information. Sixteen options (including “other”) were provided with 

the instruction to select all that apply. 

Responders who were not healthcare 

providers/educators were asked 4 

questions regarding their experiences or beliefs regarding their leadership’s support or interest in injury 

prevention. Other questions included 

asking respondents about preferred 

format and venue for obtaining additional IP information, and an open 

ended question for any additional 

comments.

Data analyses were conducted using IBM SPSS Statistics 21.0 and Microsoft Excel 2010. Only respondents 

who fully completed all questions were included in the 

final analysis. Quantified results were presented as frequencies and percentiles. Data cleaning of narrative 

free-text responses was completed by 2 investigators 

who separately reviewed all individual responses to determine whether responses could be grouped with preestablished response categories or into any newly created categories.

Table 1. Demographics of Respondents 

Completing Survey (N=685).

Total Military Civilian

Affiliation

Military 527 (77%)

Civilian 158 (23%)

Gender

Male 467 (68%) 377 90

Female 218 (32%) 150 68

Age (years)

<20 10 (1%) 9 1

21-30 131 (19%) 123 8

31-40 192 (28%) 179 13

41-50 205 (30%) 165 40

>50 147 (22%) 51 96

Job Field

Medical 265 (39%) 235 30

Nonmedical 420 (61%) 292 128

Figure 1. Percentage distribution of injury causes among respondents who 

reported injury (n=360) in response to the following question:

What was the cause of your most severe injury in the past 12 months? 

A B C D E F G H I J

10%

20%

0%

15%

5%

25%

35%

30%

A. Running F. Parachuting

B. Exercise other than running G. Combat training/obstacle course

C. Lift/push/pull H. Road marching

D. Sports I. Motor vehicle/motorcycle

E. Slip/trip/fall J. Other (variety of activities: general 

everyday tasks; pushing/pull/lifting 

items)
12 http://www.cs.amedd.army.mil/amedd_journal.aspx

Results

General and Demographics

The survey was initiated by 926 persons and fully completed by 685 respondents. The average time taken to 

complete the survey was 14 minutes. A comparison 

of the respondents who completed the survey (685) 

versus those who did not (241) revealed no significant 

differences.

Table 1 summarizes key demographic characteristics. 

Most respondents (77%) were Army personnel (62% 

officers, 38% enlisted). More men (68%) than women 

(32%) responded. Very few responders were under 20 

years of age, most falling between 21-50 years of age. 

Of the military respondents, almost half were of medical areas of concentration or military occupational specialties. Of these, the largest portions were physician 

assistants (32%), followed by physical therapists (18%). 

Nonmedical military personnel included chemical, biological, radiological and nuclear specialists, infantry, 

military intelligence, ordnance, and others.

Over half (53%) of respondents reported musculoskeletal injuries in the previous 12 months that affected 

their physical ability to do daily tasks or exercises. Of 

these, 61% were described as primarily associated with 

overuse. The most common cause reported was running 

(34%), as shown in Figure 1.

Knowledge and Awareness

The findings for musculoskeletal injuries are presented 

in Table 2. The responses of all medical respondents (ie, 

healthcare/educator providers) followed the same trends 

as the overall trends for all respondents, with slightly 

more accurate answers and slightly fewer unsure responses. Most respondents (62% to 78%) correctly 

chose “strong” or “very strong” agreement with each of 

the 4 evidence-based statements regarding the general 

magnitude and types of the injury problem. However, 

7% to 14% disagreed with each question, and 11% to 

23% neither agreed nor disagreed. Respondents were 

less likely to identify “correct” for responses pertaining 

to musculoskeletal injury risk factors and interventions 

than for those pertaining to heat and cold injury (data 

not shown). Responses for risk factors that were most 

incorrect included the increased risks that are associated 

with low body mass index (BMI), high flexibility, and 

smoking. For interventions, higher percentages of incorrect responses were found regarding the effectiveness of 

ankle braces and cotton socks, and the lack of IP effectiveness that has been shown with back braces, stretching, the use of anti-inflammatories prior to exercise, and 

wearing of minimalist running shoes.

Injury Prevention Interests

Figure 2 presents the types of activities about which 

respondents were most interested in receiving IP information. Respondents chose an average of 5 activities 

(mean 4.98, SD 2.84). Despite some minor variations, 

activity interests were very similar between medical 

and nonmedical responders.20 Write-in responses for 

“other” activities not listed included yoga, biking, and 

soccer. Sprains/strains/torn muscles and tendonitis/bursitis were most frequently selected as being of interest 

by both those personnel not in the health community 

(78% and 74%, respectively) and healthcare/educators 

(84% and 88%, respectively). Of next greatest interest 

to both groups were torn ligaments (56% for those not 

in the health community and 59% of those from health 

fields) and fractures (48% and 54%). Other types of injuries of interest identified in free-text responses included 

chronic conditions such as arthritis.

A common topic appearing in free-text comments concerned overtraining, along with requests for more detailed guidance regarding athletic form and technique. 

Some respondents noted that because physical training is integral to optimizing Army readiness, Soldiers 

should be treated more as athletes and coaching or professional guidance about injury prevention should be 

provided. Likewise, many free-text responses requested 

guidance concerning the prevention of re-injury. One 

suggestion made by a few respondents was to provide 

guidance or training specifically to unit leaders so they 

would not require injured or formerly injured personnel 

to participate in activities that are likely to result in reinjury. Of the 265 healthcare/health educator responders, 81% indicated that they would like products to help 

communicate information about risk factors and IP tactics to their patients/customers.

Perceptions of Leadership and Medical Roles

The experiences or beliefs those not in the health community (providers and/or educators) regarding their leadership’s support or interest in IP are shown in Figure 3. 

Only a slight majority (37% to 44%, depending on the 

statement) described positive leadership emphasis/support. Approximately a third (25% to 35%) had neutral 

perceptions and just under a third (22% to 32%) had negative views regarding their leadership’s emphasis on and 

support for IP. Responses for all 4 questions correlated 

strongly with one another (P<.01, correlation >0.74 to 

0.83; a strongly agree for one question correlated with a 

strongly agree for other questions). In addition, approximately one-third of respondents provided an additional 

written response to the last question of the survey, which 

was an open-ended request for any additional thoughts. 

WHAT SOLDIERS KNOW AND WANT TO KNOW ABOUT PREVENTING INJURIES:

A NEEDS SURVEY REGARDING A KEY THREAT TO READINESS
January – March 2016 13

THE ARMY MEDICAL DEPARTMENT JOURNAL

Figure 2. Percentage distribution of respondents’ choices of activities for which they were most interested in receiving 

information related to injury prevention. Note: Since each respondent was allowed to select all activities that apply, the 

sum of percentages displayed exceeds 100%.

10%

20%

0%

60%

50%

70%

80%

40%

30%

A B C D E F G H I J K L M N O P

A. Running I. Motor vehicle/motorcycle accidents

B. Weight training (free weights, weight machines) J. Basketball

C. Agility, calisthenics, stretching K. Snow Sports (skiing, snowboarding)

D. Extreme conditioning (CrossFit, P90Xm etc) L. Parachuting

E. Road marching M. Football

F. Heat N. Softball/baseball

G. Cold O. Other

H. Work related falling/tripping P. Racquet sports (racquetball, tennis)

Examples of comments written by respondents in the free-text area of the injury prevention survey.

“Changing the mentality of injury is a must within the military. Many of my patients report injuries weeks/

months/years after the initial injury and the damage has been exacerbated from continued use.... Teaching people that it’s okay to seek help because no one is Superman would do wonders for maintaining the fighting force 

as a whole.”

“Most of patients that I see are musculoskeletal due to overuse (overtraining). One of the biggest things I see 

is the leadership not taking care of their ‘Joes’ and allowing them to modify their training according to their 

injury.”

“Leaders need to be educated. They play a direct role in helping the junior Soldiers prevent and recover from 

injury. In many cases common sense is lacking....”

By far, the most frequently raised issue was concerns 

with leadership. Some examples of such responses are 

shown below. Despite awareness of the magnitude of 

the musculoskeletal injury problem, free-text responses 

suggested that many believe that such injuries are inherent to a Soldier’s job, and are even a way to “screen out 

the weak.” Specific concerns cited include the need for 

better unit leader IP training, specifically among Drill 

Sergeants and First Sergeants. Responders indicated 

that this was necessary to change what was described 

as a “suck it up” and “no pain is no gain” attitude and to 

improve awareness about the negative effect of trainingrelated injuries on Army readiness. Inadequate time and 

guidance for reconditioning and recovery, especially after a profile, was also described as exacerbating the injury problem. Leaders were described as being unaware 

of the magnitude of the adverse impacts that unintentional injuries have on the Army, and not recognizing 

what they can do to reduce these injuries. Suggestions 

included leader IP training, mentorship, and certification.
14 http://www.cs.amedd.army.mil/amedd_journal.aspx

Another major topic cited in free-text responses described a systemic lack of credibility in the Army Medical Profile system, particularly among unit leaders. Respondents indicated that although inconsistencies and 

misuse of the current Medical Profile system were due 

in part to individual Soldiers’ motivations, some respondents suggested problems within the medical community itself. Specifically, inadequately or inconsistently 

supported diagnoses, inconsistencies in work and physical training restrictions, and the lack of specific rehabilitation guidance were cited as areas that could be 

improved.

Comment

The size of the response to the voluntary survey was 

larger than expected and thus was considered a positive 

Table 2. Distribution by percentage of respondents’ beliefs on musculoskeletal injury risks and interventions.

Factors/interventions that: %N [685 total respondents]

%n [268 healthcare/educators]

Increase Risk Of Injury* Decrease Risk Neither

more nor less

Increase Risk* Not Sure

Increased running mileage 2%

2%

15%

10%

80%

86%

3%

2%

Dehydration 1%

1%

7%

8%

89%

90%

2%

2%

Prior injury 1%

1%

4%

2%

94%

97%

2%

0%

Cigarette smoking 1%

1%

16%

8%

75%

89%

9%

2%

High flexibility 71%

59%

16%

19%

10%

20%

3%

2%

Very thin body type 6%

5%

56%

53%

25%

33%

13%

9%

Does Not Decrease

Or May Increase Risk*

Decrease Risk Neither

more nor less* Increase Risk* Not Sure

Back brace/lift belt

(for job or weight training)

56%

44%

23%

33%

13%

18%

8%

4%

Over-the-counter anti-inflammatories

before workouts

19%

16%

39%

48%

26%

26%

16%

10%

Stretching before exercise 58%

41%

27%

38%

12%

19%

3%

2%

Reduce Risk* Decrease Risk* Neither

more nor less

Increase Risk Not Sure

Ankle brace (for basketball, parachuting) 61%

59%

22%

27%

9%

9%

8%

5%

Cotton socks 22%

20%

57%

62%

8%

9%

13%

8%

Does Not Either Decrease

Or Increase Risk*

Decrease Risk Neither

more nor less*

Increase Risk Not Sure

Minimalist running shoes 5%

5%

22%

25%

58%

58%

15%

12%

Effect On Risk Not Evident/Is Variable* Decrease Risk Neither

more nor less

Increase Risk Not Sure*

Fatigue/lack of sleep 1%

1%

5%

3%

91%

95%

2%

1%

Older age (>40 years) 1%

1%

16%

15%

80%

83%

2%

1%

Male 6%

9%

63%

58%

20%

26%

11%

7%

Energy or dietary supplements 3%

2%

27%

28%

56%

61%

13%

9%

Older running shoes 1%

0%

6%

7%

91%

92%

2%

0%

*Current assessment of scientific evidence per Bullock et al3

Key concerns

Topic for improved education given more than 10% incorrect responses

WHAT SOLDIERS KNOW AND WANT TO KNOW ABOUT PREVENTING INJURIES:

A NEEDS SURVEY REGARDING A KEY THREAT TO READINESS
January – March 2016 15

THE ARMY MEDICAL DEPARTMENT JOURNAL

indication of interest in this topic. Though the respondents included civilians, the large portion of military 

personnel provides an indication of the knowledge and 

interests of the overall active duty Soldier population. 

This is supported in part by the similarities in the injury experience of the respondents to prior studies of 

specific Army Soldier populations. These prior studies 

have shown that, like the survey respondents, about one 

half of personnel are injured each year, and that leading 

causes of these injuries include running, nonrunning exercise, and sports.2,17,18

While most respondents demonstrated a fairly accurate 

awareness regarding the general magnitude of this Army 

injury problem, approximately one third either disagree 

or are neutral to acknowledgement of the documented 

evidence. This suggests a majority are aware of the problem. In addition, respondents indicated through free-text 

responses that there remains a common belief that these 

injuries are inherently “part of the job” and thus cannot 

be prevented. They indicate that part of this problem is 

many unit leaders may be unaware of the adverse impacts that training-related overuse injuries have on Army 

readiness or how they can help reduce these injuries.

The current level of awareness is further exacerbated 

by confusion about certain risk factors and effective 

techniques to prevent common musculoskeletal injuries among both nonmedical and medical respondents. 

Awareness of risk factors and interventions was greater 

for heat and cold injuries (not addressed in this article), 

perhaps due to existing policies requiring annual heat 

and cold injury prevention training and strict accountability for such injuries.23,24 Though the overall magnitude of musculoskeletal injuries in the Army is much 

greater than that of heat and cold injuries, current policies do not require injury prevention training either annually or at any level of a Soldier’s basic, advanced, specialized or leadership development. Scientifically-supported educational products are needed to increase the 

broader Army community’s knowledge of injury causes, 

risk factors, and the effectiveness of interventions. 

These products must provide adequate details for medical personnel to educate patients, and be straightforward 

enough for their patients (Soldiers) to understand.

Key Activities of Interest

Injury prevention education and training needs can be 

framed in the context of specific activities that cause 

or contribute to common injuries. Key activities identified by respondents as top interests largely mirrored top 

causes of their own injuries (Figure 1) as well as top 

causes attributed to overall injuries to Army personnel2:

My leadership believes injuries can 

be prevented and 

makes it a priority.

22%

44%

34%

I am kept informed 

about the key types 

and risks of injuries 

in our unit/workforce.

32%

31%

37%

I am provided 

information to help 

reduce injuries (my 

own and/or others).

32%

25%

43%

My leadership 

models injury 

prevention efforts.

27%

35%

38%

Strongly disagree/Disagree

Strongly agree/Agree

Neither agree nor disagree

Figure 3. Percentage distribution of respondents’ perceptions 

of leadership interest in injury prevention.
16 http://www.cs.amedd.army.mil/amedd_journal.aspx

Running. Consistent with prior Army studies,8,11,17,19 running was the most common cause of injury cited by survey respondents and was the IP topic of greatest interest. 

Though numerous respondents specifically desired more 

information about how to run correctly, evidence does 

not support a single “one-size fits all” running style or 

technique that will reduce injury. However, information 

on risk factors and guidance about proper conditioning 

and avoidance of over-training problems can be provided through educational materials.

Weight-training and Extreme Conditioning. Respondents 

also desired information regarding proper form and 

technique to minimize injury associated with weight 

training and extreme conditioning. While some education products can be developed to advise against certain 

techniques, specifically trained and certified personnel 

trainers are recommended to give proper individualized 

instruction for these activities, especially for persons 

who have had prior injury.

Agility, Cross-training, and Stretching. Many respondents 

recognized the importance of a mixed exercise program 

and desired additional information about cross training 

and warm-up techniques. For example, information is 

desired to explain different types of stretching techniques (ie, static versus dynamic) with guidance as to 

when and how to incorporate them into a training program.

Road Marches. About half of the respondents desired additional IP guidance for minimizing injuries resulting 

from road marches. The scientific research on this military training activity topic25,26 may provide information 

for better educational products that describe key risk 

factors and injury types, with suggestions to minimize 

risks.

Risk factors and Interventions

Of the risk factors and interventions identified in this 

survey, the topics considered of greatest importance are 

those for which the majority of respondents exhibited 

lowest awareness as indicated by incorrect responses 

regarding the degree of risk associated with risk factors 

and interventions. While future study of effective interventions is still needed, increased awareness of current 

evidence is warranted for topics such as:

Body Type and Injury Risk. Many respondents (56%) were 

under the incorrect impression that a thin body type 

does not affect injury risk, and another 6% thought that 

it would even reduce risk. However, while poor fitness 

and high BMI have been shown by some to increase the 

risk of injury,9 current evidence shows that low BMI 

will also increase risk to injuries especially stress fractures.17-19 Products should be developed to help dispel 

myths that thinner means healthier.

Flexibility and Stretching. Though evidence has shown 

flexibility to be a bimodal risk factor (ie, those with low 

as well as those with high flexibility are at increased 

risk of injury),9,18,19 71% of respondents believed that 

having high flexibility decreases risk. In addition, while 

most respondents (58% total, 41% healthcare/educators) 

consider stretching prior to exercise to be a means of 

decreasing the risk of injury, the science is inadequate 

to support this.3 Current data is rather mixed. The complexity of variables include different types of stretching (eg, static versus dynamic), different body types and 

flexibility levels, and different exercise regimens.3,27-29

Given the unknowns, current expert guidance is to 

avoid static stretching prior to exercise and instead use 

dynamic and whole body warm-up techniques. Target 

audiences should be made aware of the variables and 

unknowns.

Footwear. Responses show confusion regarding risks resulting from use of cotton socks, minimalist shoes, and 

older running shoes. For example, the use of minimalist 

shoes (shoes with limited sole and “zero drop” heel to 

toe support) has been a popular trend in the past few 

years. While marketers have purported these shoes reduce injury risk, a majority of our survey respondents 

(58%) indicated they believe that minimalist shoes increase the risk of musculoskeletal injury. Evidence does 

not indicate they increase or decrease risk of injury 

compared to other shoe types.30,31 Products that clarify 

existing evidence and dispel myths on these topics are 

needed.

Braces. Many respondents (56% total, 44% health care/

educators) considered back braces/belts to be a means 

of decreasing injury risk. However, substantial evidence 

indicates that they do not reduce risk, and both military 

policy and national guidance advise against their use.3

This is especially important since concerns suggest 

a potential for increased risk due to use. On the other 

hand, the use of ankle braces to prevent injuries in basketball and parachuting has been strongly supported by 

scientific evidence.3,8,33-36 Products that clarify effectiveness of different types of personal equipment in risk reduction are needed.

Enhancing Unit Leadership Awareness

Essential elements of IP include leadership awareness, 

interest, and activity.3 Consistent with prior evaluation,13

the respondents in this survey pointed to leadership at the 

small unit level as frequently encouraging overtraining 

WHAT SOLDIERS KNOW AND WANT TO KNOW ABOUT PREVENTING INJURIES:

A NEEDS SURVEY REGARDING A KEY THREAT TO READINESS
January – March 2016 17

THE ARMY MEDICAL DEPARTMENT JOURNAL

(especially with running) and marginalizing those who 

are profiled or injured. Suggestions indicate that these 

leaders, who have direct oversight of physical training, 

would benefit from additional education, motivation, 

and/or policy requirements to prioritize IP objectives. 

As many unit leaders may not be reached without a direct mandate through their chain of command, respondent suggestions included requiring IP training or “IP 

certification” for leaders. A proponent agency with the 

authority to implement mandated training would help to 

effectively implement this recommendation.

Medical Profile Improvements

Based on responses from this survey and consistent with 

a prior study,13 the lack of consistent documentation of 

diagnoses and rehabilitation procedures in Army Medical Profiles are still a problem. This may be part of the 

reason that unit leaders ignore or marginalize those on a 

profile and may not allow adequate recovery. This lack 

of consistency may also encourage misuse of the Army 

Medical Profile system. While policies and guidance 

cannot address all Soldiers’ motivational differences, 

guidelines for documentation of profile determinations 

and inclusion of detailed rehabilitation and reconditioning procedures could improve the validity and credibility of medical profiles. This, in turn, could reduce the 

number of re-injuries and incidence of chronic injuries 

in what is a relatively young population.

Limitations

As it is not possible to determine the number of persons 

who were aware of the survey, response rates could not 

be estimated. A comparison of demographic data from 

this survey to that of the overall Army active duty population (eg, 86.4% male, 13.6% female; source: Armed 

Forces Health Surveillance data, 2013) shows the limited sample of respondents is not a cross-sectional representation of the Army. In addition, almost half of the 

respondents were from areas of concentration or military occupational specialties related to medicine, which 

is a much more substantial representation than that of 

the overall Army. However, the medical respondents 

referred to problems and interests on behalf of their 

patients, which at least indirectly represent the broader Army population. In addition, injury experiences of 

overall respondents reflected trends similar to that of the 

broader Army.2,15-17 In addition, medical professionals 

are more likely to influence the IP knowledge.

Conclusion

Considering the long-standing magnitude of a problem that has been documented for decades, awareness 

among Soldiers regarding physical training injuries and 

prevention could be improved. The findings of this survey indicate that many personnel desire additional information. Scientifically supported consumer-oriented 

educational materials can empower individuals to help 

reduce common musculoskeletal injuries in the Army. 

Products should address both knowledge gaps as well as 

topics of particular interest to the audience. To achieve 

a population-level reduction in injuries, improvements 

in leadership awareness and possibly even policy-level 

accountability are needed. Because lack of awareness 

among unit leaders may inhibit Army human performance optimization, they should be a key audience for 

future IP educational efforts. The Army medical community can also become better partners with its operational and Soldier training counterparts. This includes 

finding ways to improve the medical profile system to 

mitigate the occurrence of re-injuries and ensure the 

most effective rehabilitation, as well as assisting with 

future IP awareness and education.

Acknowledgments

We thank K. D. Deaver, MPH, E. J. Pfau, MPH, M. O. 

Stephen, MPH, M. Swantkowski-Hughes, MS, and S. 

Hall of the USAPHC(P) for their assistance with survey 

development.

References

1. Nindl BC, Williams TJ, Deuster PA, Butler NL, 

Jones BH. Strategies for optimizing military physical readiness and preventing musculoskeletal injuries in the 21st century. US Army Med Dep J. October-December 2013:7-23.

2. Loringer K, Bedno S, Hauret K, Jones B, Kao T, 

Mallon T. Injuries from Participation in Sports, 

Exercise, and Recreational Activities Among Active Duty Service Members. Aberdeen Proving 

Ground, MD: US Army Public Health Command; 

2011. Injury Prevention Report No. 12-HF-0DPT. 

Available at: http://www.dtic.mil/dtic/tr/fulltext/u2/

a560733.pdf. Accessed November 19, 2015.

3. Bullock S, Jones Bh, Gilchrist J, Marshall SW. 

Prevention of physical training-related injuries: 

recommendations for the military and other active 

populations based on expedited systematic reviews. 

Am J Prev Med. 2010;38(suppl 1):S156-S181.

4. Jones BH, Canham-Chervak M, Sleet DA. An evidence-based public health approach to injury priorities recommendations for the US military. Am J 

Prev Med. 2010;38(suppl 1):S1-S10.

5. Ruscio BA, Jones BH, Bullock SH, et al. A process 

to identify military injury prevention priorities 

based on injury type and limited duty days. Am J 

Prev Med. 2010;38(suppl 1):S19-S33.
18 http://www.cs.amedd.army.mil/amedd_journal.aspx

6. Cohen SP, Brown C, Kurihara C, Plunkett A, Nguyen C, Strassels SA. Diagnoses and factors associated 

with medical evacuation and return to duty for service members participating in Operation Iraqi Freedom or Operation Enduring Freedom: a prospective 

cohort study. Lancet. 2010;375(9711):301-309.

7. Bedno S, Hauret K, Loringer K, Kao TC, Mallon 

T, Jones B. Effects of personal and occupational 

stress on injuries in a young, physically active population: a survey of military personnel. Mil Med. 

2014;179(11):1311-1318.

8. Preventing US Military Injuries: The Process, Priorities, and Epidemiologic Evidence. Aberdeen 

Proving Ground, MD: US Army Center for Health 

Promotion and Preventive Medicine; 2008. Injury 

Prevention Report 12-HF-04MT-08. Available at: 

http://www.dtic.mil/dtic/tr/fulltext/u2/a496266.pdf. 

Accessed November 19, 2015.

9. National Research Council. Assessing Fitness for 

Military Enlistment: Physical, Medical, and Mental Health Standards. Washington, DC: National 

Academy Press; 2006:82-84.

10. Tiesman HM, Peek-Asa CL, Zwerling CS, Sprince 

NL, Amoroso PJ. Occupational and non-occupational injuries in the United States Army: focus on 

gender. Am J Prev Med. 2007;33(6):464-470.

11. Hauret KG, Taylor BJ, Clemmons NS, Block SR, 

Jones BH. Frequency and causes of nonbattle injuries air evacuated from Operations Iraqi Freedom 

and Enduring Freedom, U.S. Army, 2001-2006. Am 

J Prev Med. 2010;38(suppl 1):S94-S107.

12. Atlas of injuries in the United States Armed Forces. 

Mil Med. 1999;164 (suppl 8):1-633.

13. Walters TJ. Injury Prevention in the US Army, A 

Key Component of Transformation. Carlisle Barracks, PA: US Army War College; 2002. Document 

20020806 403. Available at: www.dtic.mil/cgi-bin/

GetTRDoc?AD=ADA404492. Accessed November 19, 2015.

14. Jones BH, Hauschild VD, Dada EO, Grier TL, 

Cowan DN. Regarding the Bulzachelli et al. article 

on injury during US Army Basic Combat Training. 

Am J Prev Med. 2015;49(1):e1-e3.

15. Anderson MK, Grier T, Canham-Chervak M, 

Bushman TT, Jones BH. Occupation and other risk 

factors for injury among enlisted U.S. Army Soldiers. Public Health. 2015;129:531-538.

16. Knapik JJ, Steelman R, Grier T, et al. Military 

parachuting injuries, associated events, and injury risk factors. Aviat Space Environ Med. 

2011;82(8):797-804.

17. Knapik J, Montain SJ, McGraw S, Grier T, Ely M, 

Jones BH. Stress fracture risk factors in basic combat training. Int J Sports Med. 2012;33(11):940-946.

18. Knapik JJ, Sharp MA, Canham-Chervak M, 

Hauret K, Patton JF, Jones BH. Risk factors for 

training-related injuries among men and women 

in basic combat training. Med Sci Sports Exerc. 

2001;33(6):946-954.

19. Jones BH, Cowan DN, Tomlinson JP, Robinson 

JR, Polly DW, Fryman PN. Epidemiology of injuries associated with physical training among 

young men in the Army. Med Sci Sports Exerc. 

1993;25(2):197-203.

20. Hauschild V, Schuh A. Injury Prevention Survey: 

Army Awareness Assessment and Needs Analysis, 

July 9 - August 26 2014. Aberdeen Proving Ground, 

MD: US Army Public Health Command; 2015. 

Public Health Report S.0023151.

21. Knapik JJ, et al. Injuries and physical fitness before 

and after deployment by the 10th Mountain Division to Afghanistan for Operation Enduring Freedom. Aberdeen Proving Ground, MD: US Army 

Public Health Command; 2007. USACHPPM Report No. 12-MA-05SD-07.

22. Knapik JJ, Jones SB, Darakjy S, et al. Injuries 

Among Army Light-Wheel Vehicle Mechanics. 

Aberdeen Proving Ground, MD: US Army Public Health Command. USACHPPM Report No. 

12-MA-7193A-06. Available at: http://handle.dtic.

mil/100.2/ADA444708. Accessed November 19, 

2015.

23. Memorandum: Heat Illness Prevention Program 

for the 2013 Heat Season. Fort Sam Houston, TX: 

US Army Medical Command: April 30, 2013.

24. Technical Bulletin (Medical) 508: Prevention and 

Management of Cold Weather Injuries. Washington DC: US Dept of the Army; 2005. Available at: 

http://armypubs.army.mil/med/DR_pubs/dr_a/pdf/

tbmed508.pdf. Accessed November 19, 2015.

25. Knapik JJ, Harman EA, Steelman RA, Graham BS. 

A systematic review of the effects of physical training on load carriage performance. J Strength Cond 

Res. 2012;26(2):585-597.

26. Knapik JJ. Prevention of blisters. J Spec Oper Med. 

2014;14(2):95-97.

27. Herbert RD, de Noronha M, Kamper SJ. Stretching to prevent or reduce muscle soreness after exercise. Cochrane Database Syst Rev [serial online]. 

2011;6(7).

28. Small K, McNaughton L, Matthews M. A systematic review into the efficacy of static stretching as 

part of a warm-up for the prevention of exerciserelated injury. Res Sports Med. 2008;16(3):213-231.

29. Thacker SB, Gilchrist J, Stroup DF, Kimsey CD Jr. 

The impact of stretching on sports injury risk: a 

systematic review of the literature. Med Sci Sports 

Exerc. 2004;36(3):371-378.

WHAT SOLDIERS KNOW AND WANT TO KNOW ABOUT PREVENTING INJURIES:

A NEEDS SURVEY REGARDING A KEY THREAT TO READINESS
January – March 2016 19

THE ARMY MEDICAL DEPARTMENT JOURNAL

30. Grier T, Canham-Chervak M, Bushman TT, Anderson M, North W, Jones BH. Injury risk and 

performance among soldiers wearing minimalist 

running shoes compared to traditional running 

shoes. Poster presented at: 60th Annual Meeting 

of the American College of Sports Medicine; May 

29, 2013; Indianapolis, IN. Available at: http://phc.

amedd.army.mil/PHC%20Resource%20Library/

MinimalistRunningShoes.pdf. Accessed November 20, 2015. [Abstract: Med Sci Sports Exerc. 

2013;45(5):S52]

31. Rixe JA, Gallo RA, Silvis ML. The barefoot debate: can minimalist shoes reduce running-related 

injuries?. Curr Sports Med Rep. 2012;11(3):160-165.

32. Luippold RS, Sulky SI, Amoroso PJ. Effectiveness 

of an external ankle brace in reducing parachutingrelated ankle injuries. Inj Prev. 2011;17(1):58-61.

33. Knapik JJ, Spiess S, Swedler DI, Grier TL, Darakjy SS, Jones BH. Systematic review of the parachute ankle brace: injury risk reduction and cost 

effectiveness. Am J Prev Med. 2010;38(suppl 1):

S182-S188.

34. Bricknell MC, Craig SC. Military parachuting 

injuries: a literature review. Occup Med (Lond). 

1999;49(1):17-26.

35. Burnham BR, Copley B, Shim MJ, Kemp PA. 

Mechanisms of basketball injuries reported to the 

HQ Air Force Safety Center: a 10-year descriptive 

study, 1993-2002. Am J Prev Med. 2010;38(suppl 

1):S134-S140.

36. McKay GD, Goldie PA, Payne WR, Oakes BW. 

Ankle injuries in basketball: injury rate and risk 

factors. Br J Sports Med. 2001;35(2):103-108.

Authors

Ms Hauschild, Dr Schuh, and Dr Jones are with the US 

Army Public Health Center (Provisional), Aberdeen 

Proving Ground, Maryland.
20 http://www.cs.amedd.army.mil/amedd_journal.aspx

In 1970, physicians at William Beaumont Army Medical Center in El Paso, Texas, noted a series of 4 cases 

of sudden death in Army cadets associated with sickle 

cell trait (SCT).1 Seven years later, Koppes et al 2 noted 

another 4 recruits, all with known sickle cell trait, were 

hospitalized for exertional rhabdomyolysis (ER) leading 

to myoglobinuric renal failure. These reports prompted 

further evaluation, leading to a military study which 

noted that among a total of 2 million recruits at army 

basic combat training, there was a higher incidence (40 

times) of unexplained sudden death in black recruits 

compared to the general military population. In addition to these findings, exercise-related death in black recruits with SCT was 30 times more common than black 

recruits without SCT.3 Even after prior identification of 

this risk factor, patients in the military and athletic settings with SCT continue to suffer injury and even death 

due to this underlying condition.4-8

We report the case of a young, active duty SCT positive 

African American male presenting with exertional rhabdomyolysis complicated by myoglobinuric renal failure 

requiring hemodialysis. The diagnosis was significantly 

delayed despite a typical clinical presentation and available SCT screening results. This case highlights the 

importance of the recognition of SCT as a risk factor 

for severe rhabdomyolysis, and suggests the need for a 

more robust and effective SCT screening program.

Case Report

In May 2015, a 26-year-old active duty African American male Army Soldier stationed in El Paso, Texas, 

experienced sudden severe leg and back pain while 

performing the Army Physical Fitness Test. Symptoms 

onset occurred after completing the pushup and sit-up 

portions. Cramping occurred while undergoing the 

2-mile run and quickly progressed to such intensity that 

he was unable to ambulate, requiring a wheelchair for 

transport. He subsequently presented to an acute care 

clinic the following day and received Ketorolac 60 mg 

intramuscularly for intense back spasms prior to being 

released to home.

Four days later, he presented to the emergency room 

for progressive cramping, nausea, and oral intolerance. 

Despite clinical evidence of rhabdomyolsis with classical urine dipstick finding (+3 blood with 5 red blood 

cells), he was given a prescription of sulfamethoxazole/

trimethoprim for suspected urinary tract infection and 

discharged from the emergency room.

The following day, he represented to the emergency 

room with worsening muscle pain, oral intolerance, and 

the new complaint of inability to urinate or defecate. On 

initial physical exam, the patient was found to have significant tension in his quadriceps bilaterally, as well as 

the lower back. No signs of altered mental status, asterixis, or paresthesia were noted on physical exam, and 

peripheral pulses were intact throughout. He denied any 

recent viral illness or prodrome. Initial laboratory evaluation in the emergency room was significant for serum 

CK of 37,069 U/L, serum urea nitrogen (SUN) 113 mg/

dL, serum Cr 13.6 mg/dL, AST of 704 U/L, ALT 424 

U/L, and serum potassium of 4.4 mg/dL (most recently 

4.2 mg/dL 2 years prior). Urinalysis again demonstrated 

classic findings of rhabdomyolysis. An abdominal and 

Rhabdomyolysis in a Sickle Cell Trait Positive

 Active Duty Male Soldier

CPT Pulkit Saxena, MC, USA

CPT Christopher Chavarria, MC, USA

MAJ John Thurlow, MC, USA

Abstract

Exertional rhabdomyolysis is a complication of sickle cell trait (SCT) likely first reported in the military 

population over 40 years ago. Although commonly a benign condition, numerous studies and case reports 

have identified SCT positive patients to be at increased risk for rhabdomyolysis, compartment syndrome and 

sudden cardiac death. We report a recent case of an SCT positive African American active duty male Soldier 

who suffered exertional rhabdomyolysis following an Army Physical Fitness Test. His course was complicated 

by acute renal failure requiring hemodialysis, and he eventually recovered renal function. The diagnosis was 

significantly delayed despite a typical clinical presentation and available SCT screening results. The case 

highlights the importance of the recognition of SCT as a risk factor for severe rhabdomyolysis, and suggests 

more must be done for an effective SCT screening program for the active duty military population.
January – March 2016 21

THE ARMY MEDICAL DEPARTMENT JOURNAL

pelvic CT-scan was performed showing mild right perinephric stranding with no hydronephrosis or hydroureter. The patient was subsequently admitted to the internal medicine service with a presumptive diagnosis of 

rhabdomyolysis-induced acute kidney injury. It was not 

until this time that the patient’s SCT positivity was documented while being evaluated for his acute complaints, 

despite positive screening history and family history of 

exertional rhabdomyolysis.

Upon arrival at the general medicine floor, the patient 

initially received aggressive intravenous hydration, but 

remained anuric in the first 24 hours with a continued 

uptrend in his serum urea nitrogen and creatinine levels. 

Hemodialysis was initiated on hospital day 2 for symptomatic uremia manifested by asterixis and nausea. The 

patient underwent 5 sessions of hemodialysis with improvement of his clinical function, as well as laboratory 

findings. His clinical course is presented in the Figure. 

At time of discharge, urine output was approximately 3 

liters of urine daily, and his labs had shown a significant 

improvement in SUN (42 mg/dL), serum creatinine (4.6 

mg/dL) and CK of (250 U/L). During admission, serum 

electrophoresis was ordered and would later be reported 

as 39.4% HgbS, 57.3% HgbA, and 3.3% HgbA2.

The patient was seen in follow-up a month after his initial insult and continued to show significant improvement with a SUN creatinine to 18 mg/dL and 1.6 mg/

dL respectively. He is currently in the medical evaluation board process for discharge in accordance with the 

provisions of Army Regulation 40-5019 regarding exertional rhabdomyolysis in the setting of known sickle cell 

trait requiring dialysis.

Comment

Sickle cell trait is an inherited, incompletely dominant 

hematologic disorder that causes red blood cell sickling during low oxygen states. It is present in 80,000 to 

100,000 Americans, with a presence in African Americans at a rate of 8% to 10%.10 The majority of individuals 

who are SCT positive experience no deleterious effect to 

their life span and often do not encounter medical complications during exertion. Many cases have been reported of sickle cell trait in athletes and military recruits 

for whom physical exertion results in severe medical 

morbidities such as rhabdomyolysis.4,5,8 The incidence 

of SCT associated ER is unknown, the incidence of ER 

in military trainees is 22.2 cases per 100,000 trainees.11

The precise mechanism of ER in SCT carriers is unclear. 

It has been speculated that the combination of severe 

hypoxemia, lactic acidosis, hyperthermia, and red cell 

dehydration that occur in muscles being exercised precipitates an environment in which red blood cells will 

sickle. Martin et al12 produced evidence of this by showing that exercise and physical exertion resulted in increased sickling in venous blood when testing military 

recruits performing arm exercises.

Another hypothesis is that increased sickling leads to 

vasooclusive crisis in the muscle that leads to muscle 

cell breakdown and injury. Injured muscle cells release 

cellular contents, including myoglobin into the blood 

stream. Myoglobin subsequently causes renal injury via 

renal vasoconstriction, formation of intratubular casts, 

and direct toxicity to the tubular cells of the kidney.13

Patient’s serum creatinine kinase and serum creatinine trend during hospitalization.

Hospital Day

Serum Creatinine

Kinase Level

(U/L)

Serum Creatinine

Level

(mg/dL)

4

10

0

8

6

2

16

12

14

1 2 3 4 5 6 7 8 9 10 11

20000

15000

10000

25000

5000

0

30000

35000

CK Level

Serum Cr
22 http://www.cs.amedd.army.mil/amedd_journal.aspx

In a recent study on the genetic polymorphisms associated with ER, Deuster et al14 corroborated the link 

between SCT and ER. However, they also noted that 

a causal pathogenic link remains unclear. The study 

indicates that, in contrast to an exertional sickling hypothesis, SCT may instead be a surrogate for some other 

genetically linked risk, or, alternatively, part of a 2-hit 

phenomenon. The uncertainty of the precise role SCT 

has in ER is the foundation of an ongoing debate concerning the premise of sickle cell screening.

The American Society of Hematology (ASH) guidelines 

oppose universal screening for SCT, stating that it does 

not properly address the issues at hand and places a stigmatization on SCT-positive individuals.15,16 The association instead supports administering universal precautions to reduce exercise induced injury and heat-related 

injury such as those implemented by the US Army. The 

ASH policy of universal precautions and the omission of 

a requirement for SCT testing has also been supported 

by clinicians and some professional medical organizations.16 Also of note, the ASH recommends increased 

research into the relationship of SCT with exertioninduced illness such as rhabdomyolysis before further 

policies are established.16

The opposing view supporting testing for SCT notes that 

universal precautions are ineffective and further intervention and screening is needed to properly identify this 

patient population. In 1996, the Department of Defense 

dropped its regulation requiring all military divisions 

to screen for SCT, leaving the decision to each military 

branch. The Army is the only branch that does not specifically test for SCT, but rather employs universal precautions with its recruits in an effort to reduce morbidity and mortality. In the past 5 years, numerous studies 

have noted significant medical complications in military 

recruits with SCT who suffered medical complications 

while undergoing strenuous exercise ranging from rhabdomyolysis, compartment syndrome, and even sudden 

cardiac death. In the civilian sector; following the death 

of a college football player in 2010, the National Collegiate Athletic Association adopted a policy* of mandatory testing for sickle cell trait in all athletes who seek 

to participate in Division I athletics15,17— a population 

similar to the active duty military population. Further, 

a recent (2012) study of approximately 2 million athlete 

years showed that the risk of exertional death of Division 

I football players with SCT was 37 times higher than 

those athletes without SCT.18 These studies all describe 

medical conditions for which timely diagnosis and treatment are imperative in improving medical outcomes.

Our case report illustrates that despite universal precautions for Army Soldiers, severe negative outcomes with 

exertion can occur in SCT-positive individuals. In fact, 

guidelines written by the Uniformed Services University Consortium for Health and Military Performance 

calls for referral of active duty military personnel with 

a concomitant diagnosis of ER and SCT to the medical 

evaluation board for review of their military status.19

Sickle cell trait status is an invaluable clinical determinant, which, when identified early, can prevent significant morbidity associated with ER. Improvement 

in SCT screening programs with emphasis on rapid 

identification of SCT status will dramatically decrease 

incidence of adverse outcomes and ultimately improve 

patient care. This could be aided with a policy by which 

SCT status is made more apparent on patient medical 

records and hospital electronic medical records, such 

as alerts in past medical history or allergies. Sickle cell 

trait positive patients should not be given nonsteriodal 

anti-inflamatory drugs for exertional muscle pain or 

cramping until after a workup for ER, including renal 

function assessment. Also, SCT screening tests should 

be easily accessible. Finally, all clinicians, including 

physician extenders, must be aware of the association 

of SCT and ER. Prompt recognition and proper treatment of exertional rhabdomyolysis is essential to avoid 

significant complications.

References

1. Jones SR, Binder RA, Donowho EM Jr. Sudden death in sickle-cell trait. N Engl J Med. 

1970;282(6):323-325.

2. Koppes GM, Daly JJ, Coltman CA Jr, Butkus DE. 

Exertion-induced rhabdomyolysis with acute renal 

failure and disseminated intravascular coagulation 

in sickle cell trait. Am J Med. 1977;63(2):313-317.

3. Kark JA, Posey DM, Schumacher HR, Ruehle CJ. Sickle-cell trait as a risk factor for sudden death in physical training. N Engl J Med. 

1987;317(13):781-787.

4. Fajardo KA, Tchandja J. Exercise-induced cardiac 

arrest in a sickle cell trait-positive Air Force recruit: 

a case report. Mil Med. 2015;180(3):e372-e374.

5. Ferster K, Eichner ER. Exertional sickling deaths 

in Army recruits with sickle cell trait. Mil Med. 

2012;177(1):56-59.

6. Anzalone ML, Green VS, Buja M, Sanchez LA, 

Harrykissoon RI, Eichner ER. Sickle cell trait and 

fatal rhabdomyolysis in football training: a case 

study. Med Sci Sports Exerc. 2010;42(1):3-7.

*http://www.ncaa.org/health-and-safety/medical-conditions/sickle-cell-trait
January – March 2016 23

THE ARMY MEDICAL DEPARTMENT JOURNAL

7. Shelmadine BD, Baltensperger A, Wilson RL, 

Bowden RG. Rhabdomyolysis and acute renal failure in a sickle cell trait athlete: a case study. Clin J 

Sport Med. 2013;23(3):235-237.

8. Ridha A, Khan A, Al-Abayechi S, Puthenveetil V. 

Acute compartment syndrome secondary to rhabdomyolysis in a sickle cell trait patient. Lancet. 

2014;384(9960):2172.

9. Army Regulation 40-51: Standards of Medical Fitness. Washington, DC: US Dept of the Army; August 2011:35. Available at: http://www.apd.army.

mil/pdffiles/r40_501.pdf. Accessed December 31, 

2015.

10. Motulsky AG. Frequency of sickling disorders in 

U.S. blacks. N Engl J Med. 1973;288(1):31-33.

11. Alpers JP, Jones LK Jr. Natural history of exertional rhabdomyolysis: a population-based analysis. 

Muscle Nerve. 2010;42(4):487-491.

12. Martin TW, Weisman IM, Zeballos RJ, Stephenson 

SR. Exercise and hypoxia increase sickling in venous blood from an exercising limb in individuals 

with sickle cell trait. Am J Med. 1989;87(1):48-56.

13. Bosch X, Poch E, Grau JM. Rhabdomyolysis and acute kidney injury. N Engl J Med. 

2009;361(1):62-72.

14. Deuster PA, Contreras-Sesvold CL, O’Connor 

FG, et al. Genetic polymorphisms associated with 

exertional rhabdomyolysis. Eur J Appl Physiol. 

2013;113(8):1997-2004.

15. Thompson AA. Sickle cell trait testing and athletic participation: a solution in search of a problem? Hematology Am Soc Hematol Educ Program. 

2013;2013:632-637.

16. American Society of Hematology. Statement on 

Screening for Sickle Cell Trait and Athletic Participation [internet]. January 26, 2012. Available 

at: http://www.hematology.org/Advocacy/State

ments/2650.aspx. Accessed July 16, 2015.

17. Anderson SA, Doperak J, Chimes GP. Recommendations for routine sickle cell trait screening for 

NCAA division I athletes. PM R. 2011;3(2):168-174.

18. Harmon KG, Drezner JA, Klossner D, Asif IM. 

Sickle cell trait associated with a RR of death of 

37 times in National Collegiate Athletic Association football athletes: a database with 2 million 

athlete-years as the denominator. Br J Sports Med. 

2012;46(5):325-330.

19. O’Connor FG, Campbell WW, Heled Y, et al. Clinical Practice Guideline for the Management of Exertional Rhabdomyolysis in Warfighters. Bethesda, 

MD: Uniformed Services University of the Health 

Sciences. Available at: https://qmo.amedd.army.

mil/general_documents/ExertionalRhabdomyoly

sis.pdf. Accessed December 31, 2015.

Authors

CPT Saxena and CPT Chavarria are Internal Medicine 

Residents, Department of Medicine, William Beaumont 

Army Medical Center, El Paso, Texas.

MAJ Thurlow is Chief, Department of Nephrology, William Beaumont Army Medical Center, El Paso, Texas.

RHABDOMYOLYSIS IN A SICKLE CELL TRAIT POSITIVE ACTIVE DUTY MALE SOLDIER
24 http://www.cs.amedd.army.mil/amedd_journal.aspx

Relocation from northern to southern climates is a routine occurrence for US military service members. It is 

also common for newly relocated individuals to participate in physical and/or field training almost immediately 

after reporting to a new unit. Acclimatization to a hot 

and humid environment typically requires 7 to 14 days of 

exposure to the new climate.1 During this period of time, 

unacclimatized individuals exercising in a hot environment frequently fail to consume adequate fluids.2 Individuals who commence exercise in a hypohydrated state 

can quickly become dehydrated once activity begins.

Dehydration is a contributing factor in the onset of heatrelated illness. Dehydration reduces skin blood flow and 

sweating responses during exercise, increasing core 

temperature and cardiovascular strain; any hindrance 

to thermoregulatory mechanisms increases the potential risk for heat injuries.3

 Dehydration levels as small 

as a 2% loss in body mass can negatively affect physical 

performance, increasing perceived exertion levels and 

impairing mental functioning.4,5

Although each of the armed services have heat injury 

mitigation programs, heat illness and injury continue 

to affect US military service members and pose a significant threat to mission readiness.6

 There were 2,025 

documented incidences of heat stroke and/or heat injury 

in active service members in 2013.7 Service members in 

healthcare related fields were not immune to heat stroke 

and illness, with 128 documented cases reported in 2013.7

The US Army Medical Department’s basic (Basic Officer Leaders Course (BOLC)) and advanced (Captains’ 

Career Course (CCC)) officer training is conducted at 

Joint Base San Antonio (JBSA) Fort Sam Houston, Texas, where the average summer month temperature range 

is 86°F to 90°F.8 Officers attending these courses typically take an Army Physical Fitness Test (APFT) within 

one week of arrival. Soldiers relocating from cooler climates are known to be at greater risk for developing heat 

illnesses,9 thus hypohydration may also be an exacerbating concern for those in that category.

The purpose of this study was to determine if Soldiers 

relocating from northern climates were at greater risk 

for being hypohydrated prior to the APFT. This paper 

presents study results along with recommendations to 

reduce Soldiers’ risk for heat injury and illness when 

relocating to a hot training environment.

Methods

The study was a cross-sectional descriptive design. Recruitment briefings were given to all BOLC and CCC 

students in July 2012. Inclusion criteria for participation: active duty military officers, aged 18 years and 

older, attending BOLC or CCC at JBSA in July 2012. 

Hydration Status in US Military

 Officer Students

LTC (Ret) Reva Rogers, SP, USA

LTC Renee Cole, SP, USA

Abstract

Relocation from a cool to a hot climate is a frequent occurrence in military service. Acclimatization requires 

time and exposure to heat. Nonacclimatized individuals frequently consume inadequate fluid leading to 

hypohydration, which can quickly result in dehydration with increased risk of heat illness/injury. This descriptive 

cross-sectional study assessed the hydration status of 196 officers attending the US Army Medical Department’s 

Officer Basic Course (67%) or Captain’s Career Course (33%) in San Antonio, Texas, prior to taking the Army 

Physical Fitness Test (APFT). Consenting Soldiers provided a first morning void urine sample and demographic 

survey (age, rank, sex, previous geographic location, etc) prior to the APFT. Height, weight, and APFT event 

scores were collected from a subject-coded, APFT scorecard without personal information data. Binary logistic 

regression was performed to identify variables that contribute to predicting hypohydration status. The sample 

population was 54% male, a mean age of 30 years, 5.2 years of military service, and a mean body mass index 

of 25 kg/m2. Nearly one-third met the criteria for hypohydration (≥1.02 urine specific gravity). Soldiers who 

relocated from a cool environment within 9 days of taking the APFT had 2.1 higher odds of being hypohydrated 

compared with individuals who had resided in a hot environment for more than 9 days. Women had a 0.5 lower 

odds of being hypohydrated as compared to males. Significantly more Soldiers were hypohydrated on Monday 

compared to those tested on Tuesday (33% vs 16%, P=.004). Given these findings, the authors provided 5 

recommendations to reduce the number of Soldiers exercising in a hypohydrated state.
January – March 2016 25

THE ARMY MEDICAL DEPARTMENT JOURNAL

Pregnant women and those not completing all 3 APFT 

events (2 minutes of pushups, 2 minutes of sit ups, and 

a 2-mile run) were excluded from the study. Volunteers 

were provided with a survey, urine specimen cup, hydration status card (Figure 1), identification sticker for their 

APFT card, an informed consent information paper, and 

data collection instructions. Flyers were placed at student lodging locations the night prior to data collection 

reminding the participants to bring their surveys and 

urine samples. On the morning of testing, participants 

provided their first morning void urine sample and provided a completed survey to the research team prior to 

undergoing physical testing. The urine sample was assessed using a handheld refractometer (Atago USA Inc, 

Bellevue, WA) to ascertain hydrations status, the primary outcome variable, via urine specific gravity (USG) 

levels. The urine sample was then discarded. Urine specific gravity of first morning void is a field expedient 

yet valid method to determine hydration status.10 Specific gravity values were categorized as euhydration 

(USG<1.02) or hypohydration (USG≥1.02).11-14

The survey collected secondary outcome variables including the following demographics: age, rank, sex, 

previous geographic location (categorized as northern 

or southern region), commissioning source, time in 

military service, and current length of stay at JBSA. 

Height and weight, used to calculate body mass index 

(BMI), and APFT event scores were collected from a 

subject-coded, APFT scorecard (DA Form 705) without 

personal identification information. The study followed 

a protocol approved by the Army Medical Department 

Center and School and reviewed by the Brooke Army 

Medical Center Institutional Review Board.

Statistical Analysis

Data were analyzed using SPSS version 21.0 (SPSS Inc., 

Chicago, Illinois). Descriptive statistics were completed for demographic data and reported as frequencies 

for categorical data and mean plus/minus standard deviation for continuous data. The data were categorized 

and analyzed by military course (BOLC vs CCC), sex 

(male vs female), and hydration status (hypohydrated 

vs hydrated). Independent t test evaluated differences 

between groups for descriptive demographic and APFT 

results. Binary logistic regression was performed to 

identify if significant independent variables contributed 

to predicting hypohydration status. Nonparametric correlational analysis was performed using Spearman’s ρ or 

Kendall’s τ to assess associations with hydration status, 

APFT day of the week, sex, prior climate, and other demographic characteristics. Power was set at 80%, α=.05.

Results

Subject Descriptive Data

Of the 552 Soldiers attending training (BOLC, n=360; 

CCC, n=192) in July 2012, 297 (58% of BOLC; 45% of 

CCC) students volunteered to participate; however, 196 

participants (132 BOLC; 64 CCC) completed data collection (34% attrition). Table 1 presents the demographic 

descriptive results by course, sex, and hydration status. 

Approximately half of BOLC (53%) and CCC students 

(56%) were male. As expected, CCC students were older (mean: 34 vs 28 years; P<.001), had more years in 

military service (mean: 8.8 vs 3.5 years; P<.001), and 

were higher ranking than BOLC students (CPT vs 2LT; 

P<.001). Significantly more BOLC students had resided 

for a minimum of 9 days in the San Antonio area prior 

to the APFT compared to CCC students (89% vs 16%; 

Figure 1. US Army Public Health Command Urine Color Hydration Chart.
26 http://www.cs.amedd.army.mil/amedd_journal.aspx

P<.001), but a higher percentage of BOLC students relocated from a cool geographical location (50%) than CCC 

students (41%). There was no difference in commissioning source between groups.

Body mass index significantly differed between male 

(mean, 26.1±3.1 kg/m2) and female (mean, 24.0±2.8 

kg/m2) participants (P<.001). Additionally, older participants were associated with a higher BMI (r=0.283; 

P<.001), lower APFT score (r=-0.236, P<.02), and 

exceeding weight (r=0.231; P=.002) and body fat 

(r=0.248; P=.001) standards according to the 

Army Body Composition program.

Minimum temperatures in San Antonio on the 

testing days (July 9, July 16, July 17, 2012) ranged 

from 74°F to 77°F.15 Rain persisted throughout the 

APFT on the CCC test day, with a precipitation accumulation of 0.26 inch for the day.

Hydration Status

Thirty-one percent of Soldiers met the criteria for 

hypohydration prior to the APFT, with significantly more participants hypohydrated on Monday 

(33%) compared to those testing on Tuesday (16%)

(P=.004). More students residing in Texas for 9 

days or less were hypohydrated at the time of the 

APFT than those who resided longer in Texas (42% vs 25%; P=.015). 

More men were hypohydrated than 

women (62% vs 38%; P=.03). More 

CCC participants relocating from 

a cool climate were hypohydrated 

compared to those from a hot climate (56% vs 22%; P=.007); while 

no such observance was found in 

BOLC participants (23% cool vs 

36% hot climate; P=.096).

A logistic regression analysis was 

conducted to predict hydration status as either hydrated (USG<1.02) 

or hypohydration (USG≥1.02) using statistically significant demographic variables as predictors. 

Table 2 details the 2 independent 

variables meeting the Wald criterion as predictors of hydration status: days in Texas (P=.021) and sex 

(P=.040). Despite the significant 

model, Nagelkerke’s R2 of 0.071 

indicated a small relationship between prediction and hydration 

grouping. The Exp(B) odds ratio 

value indicates that women had a 0.5 lower odds of being hypohydrated, and Soldiers who had less than 9 days 

to acclimate to the Texas environment had a 2.1 higher 

odds of being hypohydrated.

APFT Performance

The relationship between hydration status and APFT 

performance was not significant (P=.063). There was 

also no difference in APFT run, sit-up, or push-up 

scores between BOLC and CCC participants; higher 

BMI was associated with lower APFT scores (r=-0.299, 

Table 1. BOLC and CCC Student Demographic Descriptive Results.

BOLC

(N=132)

CCC

(N=64)

Male

(N=106)

Female

(N=90)

Hydrated

(N=135)

Hypohydrated

(N=61)

Mean±SD

Age (yr) 28.3±5.0* 34.3±6.2 31.0±6.4 29.4±5.6 30.0±6.2 30.8±5.7

BMI (kg/m2) 24.8±3.0 25.6±3.2 26.1±3.1* 24.0±2.8 24.9±3.1 25.5±3.2

Time in service (yr) 3.5±4.8* 8.8±5.6 5.7±6.0 4.7±5.1 5.2±5.5 5.3±6.0

n (%N)

Male* 70 (53%) 36 (56%) 66 (49%) 40 (66%)

Female* 62 (47%) 28 (44%) 69 (51%) 21 (34%)

Rank

2LT 73 (55%)* 0 (0%) 35 (33%) 38 (42%) 53 (39%) 20 (33%)

1LT 8 (6%) 1 (2%) 5 (5%) 4 (5%) 6 (4%) 3 (5%)

CPT 49 (37%)* 58 (90%) 60 (56%) 47 (52%) 71 (53%) 36 (59%)

MAJ 2 (2%) 4 (6%) 5 (5%) 1 (1%) 4 (3%) 2 (3%)

LTC 0 (0) 1 (2%) 1 (1%) 0 (0) 1 (1%) 0 (0)

Commission Source

ROTC/academy 51 (39%) 28 (44%) 47 (44%) 32 (35%) 58 (43%) 21 (34%)

Direct

(from civilian)

44 (33%) 15 (23%) 32 (30%) 27 (30%) 37 (27%) 22 (36%)

Prior enlisted 37 (28%) 21 (33%) 27 (26%) 31 (34%) 40 (30%) 18 (30%)

Cool climate origin 65 (50%) 25 (41%) 51 (49%) 39 (44%) 61 (47%) 29 (48%)

In Texas 9 days

or more

117 (89%)* 10 (16%) 66 (62%) 61 (68%) 95 (70%) 32 (53%)

*P<.05

Table 2. Logistic Regression of Variables Predicting Significant Hypohydration.

Independent

Variable

B (SE) Wald Sig Exp(B)

Odds

Ratio

95% CI

for Exp(B)

Lower Upper

Days in Texas (1) 0.745 (0.322) 5.349 0.021 2.106 1.120 3.958

Sex (1) -0.665 (0.324) 4.210 0.04 0.514 0.272 0.971

Model χ2=10.118

Pseudo R2=0.071 (Nagelkerke)

Goodness-of-Fit χ2=0.998, dƒ=2, P=.607 (Hosmer-Lemeshow test) 

Notes:

The dependent variable is hydration status, coded:

0=Well hydrated or mild hypohydrated (USG<1.02)

1=Significant or severe hypohydration (USG≥1.02)

The independent variables used in the model:

Sex, coded 1=female; 2=Male

Days in Texas, coded 0=<9 days; 1=≥9 days

HYDRATION STATUS IN US MILITARY OFFICER STUDENTS
January – March 2016 27

THE ARMY MEDICAL DEPARTMENT JOURNAL

P<.001). More participants who failed the Army Body 

Composition Program body fat test also failed the APFT 

(P=.027) with more failing the APFT on Monday compared to Tuesday (P=.014).

Comment

This study examined hydration status of Army officers 

newly relocated for basic and advanced officer training. 

Students were classified by course type, sex, and hydration status. Students who had less than 9 days to acclimate to the Texas environment had a 2.1 higher odds 

of being hypohydrated. Only the CCC group exhibited 

a relationship between previous location and hydration 

status. This association may be attributed to the shorter 

period of time (less than 9 days) in San Antonio for the 

majority of CCC students (84%) compared to only 11% 

of BOLC students. Acclimatization occurs within 7 to 

9 days when individuals are physically active in the hot 

environment (active acclimatization), while passive acclimatization (no physical activity conducted) requires 

additional time.1 The USG data from CCC students relocating from a cool environment suggest that they did 

not have adequate time to acclimatize.

First morning void USG is an accepted method to evaluate hydration status, however, there is a fair amount of 

individual variance in USG levels that equate to a 2% 

dehydration level. There is some evidence that a large 

amount of muscle mass is associated with higher USG 

readings regardless of hydration status due to an increase in urine protein metabolites.11 However, the exact 

amount of muscle mass needed to cause increased urine 

protein metabolites is unknown at this time. In this 

study, women had a 0.5 lower odds of being hypohydrated; a higher percentage of men (62%) were hypohydrated compared to women (38%) (P=.03). It is unclear 

if this observed effect on urine specific gravity is truly 

related to gender differences or some other factor.

We are not able to explain why this study found a difference in the prevalence of hypohydration between 

Monday and Tuesday. There are a myriad of factors 

that could impact hydration status including weekend 

activities that increase fluid losses or weekday activities 

that increase consumption of nondiuretic fluids. Activities that increase fluid loss could include participation 

in outdoor activities leading to high sweat losses, or 

consumption of alcoholic beverages. Copious amounts 

of nondiuretic fluids consumed to aid in staying alert 

during classes and briefings the previous day could also 

contribute to the lower prevalence of hypohydration 

seen on Tuesday morning. Additional investigations are 

required to determine why differences are seen in the 

prevalence of hypohydration on Monday mornings and 

to determine if there is a specific day of the week when 

the percentage of hypohydrated Soldiers is lowest.

As expected, hydration status was not found to have an 

effect on APFT performance due to the short duration, 

moderate temperatures, and precipitation during the testing. A common military practice on the day of the APFT 

is to obtain Soldier height and weight measurements, either immediately before or after the APFT, in conjunction with the Army Body Composition Program.16 Unlike many units, Soldiers in this study completed body 

composition assessment several days prior to their APFT, 

most likely eliminating intentional dehydration as a 

method to comply with weight standards. Future topics 

to investigate include prevalence of intentional dehydration and severity of dehydration levels in this population.

Several study limitations exist, including descriptive 

study design, a high attrition rate, no assessment of body 

weight and/or body composition change pre- to posttest, 

or a method to collect data to understand the dissonance 

between sexes and APFT days of the week. The high attrition rate was possibly attributed to a week’s delay between the briefing and data collection. Although flyers 

were posted at student lodging locations the night prior 

to data collection, many participants may have forgotten 

or simply changed their minds.

Despite the study limitations, our research provided an 

opportunity to highlight several recommendations for 

units to consider regarding the physical requirements 

placed on Soldiers newly assigned to hot environments 

and reduce the number of Soldiers exercising in a hypohydrated state. Leadership should consider 5 simple 

recommendations for inclusion in their heat-injury mitigation program:

1. Inform Soldiers prior to reporting to their new 

duty station that conducting high intensity interval training in the cooler northern climate 

may help them prepare to exercise in a hot 

environment.1,17

2. Wait 10 days to conduct an APFT or to require Soldiers to participate in long-duration 

or multiple bouts of physical activity in a hot 

environment.

3. Implement an active acclimatization plan. This 

plan should include 2 hours of heat exposure (at 

one-bout or as 2 one-hour exposures) per day.17

Along with heat exposure, include endurance 

exercise beginning at 50% VO2max intensity 

(such as marching), and gradually increase intensity and duration.1,17
28 http://www.cs.amedd.army.mil/amedd_journal.aspx

4. Encourage Soldiers to monitor the color of their 

first morning void and increase daily fluid intake if urine appears darker than a golden honey 

color. As the first void is an indicator of their 

prior 24-hour hydration status, this can inform 

Soldiers if their daily intake of fluid is adequate. 

Training aids such as pocket urine color assessment cards (Figure 1) or posters are available 

free of charge from the Public Health Command 

(https://usaphcapps.amedd.army.mil). Using 

photographs of actual urine samples comparing euhydrated and hypohydrated alongside of 

a urine hydration color charts may further assist 

visualization (Figure 2).18

5. Conduct APFTs on Tuesday morning rather than 

Monday mornings, immediately following a 

holiday, day of unscheduled activities, or temporary duty.

Conclusion

Hypohydration was identified in AMEDD officers attending BOLC or CCC courses within 9 days of relocating from a northern climate. Waiting ten days to administer the APFT after Soldiers report to JBSA will give 

those relocating from a cooler climates time to acclimatize and may reduce the number of Soldiers starting the 

event in a hypohydrated state. Additionally conducting 

APFTs on Monday mornings may result in more Soldiers testing in a hypohydrated state. Unit leaders can 

use these finding and recommendations to refine their 

heat mitigate programs.

Acknowledgements

The authors recognize several entities for their contribution: the US Military Graduate Program in Nutrition 

students (Class of 2013) for their assistance with data 

collection; the BOLC and CCC leadership for allowing 

access to their student population; LTC (Ret) Lori Sigrist 

for research mentorship and protocol development; and 

Dr Sam Cheuvront, Thermal and Mountain Medicine 

Division, US Army Research Institute of Environment 

Medicine, for editorial services.

References

1. Armstrong LE, Maresh CM. The induction and 

decay of heat acclimatisation in trained athletes. 

Sports Med. 1991;12(5):302-312.

2. Greenleaf JE. Problem: thirst, drinking behavior, 

and involuntary dehydration. Med Sci Sports Exerc. 

1992;24(6):645-656.

3. Armstrong LE, Maresh CM, Gabaree CV, et al. 

Thermal and circulatory responses during exercise: 

effects of hypohydration, dehydration, and water 

intake. J Appl Physiol (1985). 1997;82(6):2028-2035.

4. Wendt D, van Loon LJ, Lichtenbelt WD. Thermoregulation during exercise in the heat: strategies for 

maintaining health and performance. Sports Med. 

2007;37(8):669-682.

5. Maughan RJ. Impact of mild dehydration on wellness and on exercise performance. Eur J Clin Nutr. 

2003;57(suppl 2):S19-S23.

6. Goldman R. Introduction to heat-related problems 

in the military operations. In: Pandolf KB, Burr 

RE, eds. Medical Aspects of Harsh Environments. 

Vol 1. Fort Sam Houston, TX: Borden Institute; 

2001:3-49.

7. Armed Forces Health Surveillance Center. Update: 

Heat injuries, active component, U.S. Armed Forces, 2013. MSMR. 2014;21(3):10-13.

8. National Oceanic and Atmospheric Administration. 

Climatological Rankings [internet]. Available at: 

http://www.ncdc.noaa.gov/temp-and-precip/clima

tological-rankings/. Accessed March 5, 2015.

9. Carter R III, Cheuvront SN, Williams JO, et al. 

Epidemiology of hospitalizations and deaths from 

heat illness in Soldiers. Med Sci Sports Exerc. 

2005;37(8):1338-1344.

10. Cheuvront SN, Kenefick RW. Dehydration: physiology, assessment, and performance effects. Compr Physiol. Jan 2014;4(1):257-285.

11. Hamouti N, Del Coso J, Avila A, Mora-Rodriguez 

R. Effects of athletes’ muscle mass on urinary 

markers of hydration status. Eur J Appl Physiol. 

2010;109(2):213-219.

12. Bartok C, Schoeller DA, Sullivan JC, Clark RR, 

Landry GL. Hydration testing in collegiate wrestlers undergoing hypertonic dehydration. Med Sci 

Sports Exerc. 2004;36(3):510-517.

Euhydration

USG 1.016

Osmolality 522

Color 4

Hypohydration

USG 1.035

Osmolality 1252

Color 7

Figure 2. Samples comparing USG and color of urine 

from subjects in euhydrated and hypohydrated hydration status respectively.

HYDRATION STATUS IN US MILITARY OFFICER STUDENTS
January – March 2016 29

THE ARMY MEDICAL DEPARTMENT JOURNAL

13. Cheuvront SN, Ely BR, Kenefick RW, Sawka MN. 

Biological variation and diagnostic accuracy of 

dehydration assessment markers. Am J Clin Nutr. 

2010;92(3):565-573.

14. Sawka MN, Burke LM, Eichner ER, Maughan 

RJ, Montain SJ, Stachenfeld NS. American College of Sports Medicine position stand. Exercise 

and fluid replacement. Med Sci Sports Exerc. 

2007;39(2):377-390.

15. Wunderground. Weather History for KSAT [San Antonio, TX][internet]. Available at: http://www.wun

derground.com/history/airport/KSAT/2012/7/9/

DailyHistory.html?req_city=&req_state=&req_

statename=&reqdb.zip=&reqdb.magic=&reqdb.

wmo=. Accessed April 5, 2015.

16. Army Regulation 600-9: The Army Body Composition Program. Washington DC: US Dept of the 

Army; 2013.

17. Sawka MN, Kolka MA, Montain SJ. Ranger & Airborne School Students Heat Acclimatization Guide. 

Aberdeen Proving Ground, MD: US Army Center 

for Health Promotion and Preventive Medicine; 

2003. Available at: http://www.benning.army.mil/

infantry/rtb/1-507th/airborne/content/pdf/HeatAc

climatizationGuide.pdf. Accessed September 25, 

2015.

18. Kenefick RW, Cheuvront SN, Leon LR, O’Brien 

KK. Dehydration and rehydration. In: Auerbach 

PS, ed. Wilderness Medicine. Philadelphia: Mosby 

Elsevier; 2012:1393-1405.

Authors

LTC (Ret) Rogers, a retired Army dietician, resides in 

Reno, Nevada.

LTC Cole is a Researcher and the Acting Safety Director, 

Military Nutrition Division, US Army Research Institute 

of Environmental Medicine, Natick, Massachusetts.
30 http://www.cs.amedd.army.mil/amedd_journal.aspx

Combat extremity injuries frequently result in lasting disability. Recent publications from our Institution 

have helped delineate the nature of war wound sequalea, 

highlighting the prevalence of specific types of orthopaedic-related disability.1,2 Among those is the irrecoverable loss of skeletal muscle, or volumetric muscle loss 

(VML), which clinically can result in loss of motor power, fatigability, and cosmetic aberrations.3

 Animal models of VML indicate that strength loss after small VMLs 

(10%-20% loss of total muscle volume) is disproportionately high (30%-90% deficit).4,5 Furthermore, loss of 

overlying muscle can adversely affect fracture healing 

because of multifactorial contributions skeletal muscle 

supplies to the fracture biology.6-9 That VML is clinical significant entity is further supported by our recent 

findings that muscle-related disability is present in 24% 

of wounded service members with Type III open tibia 

fractures who are medically retired from the military.10

Currently, the loss of skeletal muscle is not a clinical 

target due to the lack of available therapies to address 

the volumetric defect and due to the clinical emphasis on bone healing rather than the overlying muscle 

injury. However, VML may present ramifications for 

the remaining skeletal muscle and limit the ability for 

the muscle group to optimally rehabilitate. This supposition is supported by limited clinical observations 

of patients with VML that present chronic functional 

deficits, which are unresponsive to traditional physical 

therapy.3,11,12 A preclinical rodent study demonstrated 

that VML-injured muscle strength can increase in response to physical therapy (ie, wheel running). But no 

evidence of muscle fiber hypertrophy or hyperplasia 

was observed, raising questions regarding the maintenance of plasticity of the traumatized musculature.13

Lastly, of significant concern is a protracted repair and 

remodeling response after VML injury that may eventually exhaust the regenerative potential of the remaining 

portion of the injured musculature and lead to a progressive further loss of function. Preclinical animal studies 

have documented some evidence of this potential condition, such as the prolonged presence of centrally located 

nuclei within the remaining muscle fibers, increased 

intramuscular fibrosis, and prolonged TGF-ß1* expression.3,4,14 All told, growing evidence suggests that VML 

injury may present a progressive degenerative condition.

Muscle-related Disability Following

 Combat Injury Increases With Time

MAJ Jessica C Rivera, MC, USA

Benjamin T. Corona, PhD

Abstract

Background: Combat injuries are most often to the extremities, resulting in a majority of long term disabilities being of orthopaedic nature. Some injuries are expected to improve with time. The Army Physical Evaluation Board 

(PEB) gives consideration for conditions that may improve with further care by placing eligible patients on a temporary retirement list. While this may be appropriate for some conditions, injuries such as those to skeletal muscle 

can be irrecoverable. We aimed to examine combat injured subjects with known muscle injuries who were placed in 

temporary retirement status to determine if their muscle conditions improved. We hypothesized that muscle-related 

disability would not improve despite additional time for recovery.

Methods: The PEB results of 33 combat wounded service members were reviewed to determine what individuals 

were placed in temporary retirement status. We compared what muscle conditions were present at each PEB examination including the initial review, internal temporary retirement reexaminations, and the final adjudication. We 

also compared if the disability rating assigned to the muscle condition changed with time.

Findings: Eighteen of the 33 subjects were placed in temporary retirement status prior to their final retirement. None 

of the subjects experienced improvement in their muscle condition as measured by disability ratings. Seven subjects 

worsened while 9 subjects had muscle conditions recognized at their final disposition that were not recognized at 

initial exam. Two subjects have muscle disability ratings that were unchanged.

Conclusions: While temporary retirement status provided opportunities for injured service members to experience 

additional improvement prior to permanent retirement, not all conditions can be expected to improve. This study 

demonstrates that the Army PEB ratings for muscle conditions did not improve despite additional recovery time 

being granted to the subjects on temporary retirement status.

* Transforming growth factor beta 1
January – March 2016 31

THE ARMY MEDICAL DEPARTMENT JOURNAL

Unfortunately, the natural history of an injured limb’s 

function after VML injury is unknown. We aim to explore preliminary evidence on the natural history of 

VML injury by examining disability outcomes over 

time in a cohort of wounded service members with muscle-related disability. We hypothesize that VML injuries 

result in deterioration of muscle function with time.

Methods

This study was conducted in accordance with an Institutional Review Board approved protocol. We examined 

the Army Physical Evaluation Board (PEB) results of 

previously published cohorts of medically retired service members to determine how disability designations 

for muscle injury change with time for service members 

who underwent more than one examination by the PEB. 

In brief, a 450 service member cohort’s overall disability 

characteristics were published by Cross et al1 and disability related directly to muscle conditions is described 

by Corona et al10 for 36 service members (8%). Of the 36 

individuals with muscle-related disability, 33 had documentation in their medical records describing the volumetric loss and persistent weakness, allowing us to confirm that for these 33 service members, VML was the 

cause of their muscle-related disability. The disability 

designation itself is assigned by the PEB as any condition that detracts from an injured service member’s ability to perform his or her military occupational specialty 

on active duty, therefore rendering the individual “unfit” 

for duty. Each unfitting disabling condition is also assigned a percentage rating which, on a spectrum from 

0%-100%, reflects the degree to which the condition detracts from the service member’s fitness. A high rating 

indicates a significant degree of disability.

Once the PEB determines an injured service member 

is unfit for return to duty and his or her unfitting conditions are enumerated and rated, the service member 

may be medically retired or separated from active duty. 

The PEB can also determine that the service member’s 

injury is not stabilized enough to determine to what 

degree the injury will affect permanent fitness for duty. 

In this case, the PEB expects that the illness or injury 

will improve with additional care and that the service 

member has not yet met “maximal medical benefit.” The 

assumption is that the condition will improve and the 

service member should not be separated or medically 

retired from active duty prematurely. In this case, the 

PEB places the service member on Temporary Disability Retirement List (TDRL). The service member continues to get care for the conditions and is reevaluated 

periodically by the PEB to determine if the condition is 

stable enough for final adjudication. At each evaluation 

leading up to either return to duty (if sufficient recovery 

is reached) or medical retirement/separation, the PEB 

still enumerates potentially unfitting conditions and assigns each a disability rating.

We examined the PEB database outcomes for the 33 

subjects with confirmed VML as their disabling muscle condition to identify which subjects were placed 

on TDRL for any period of time prior to being medical 

retired. Because the assumption for TDRL placement 

is that the conditions in question may improve, we examined the changes in disability ratings for the muscle 

conditions between the initial PEB evaluations, iterative 

TDRL evaluations if applicable, and the final PEB disposition at the time of each service member’s medical 

retirement. This allowed us to determine if, from the 

PEB evaluation standpoint, disabling muscle conditions 

improved, deteriorated, or stayed the same as reflected 

by the assigned disability rating. The time between the 

evaluations was noted in an attempt to describe how 

VML injuries change with time in terms of increments 

of disability ratings. Comparisons between subjects 

with different PEB outcomes were made using student’s 

2-tailed t test. Linear regression analysis was performed 

to determine if disability rating increased as a function 

of time postinjury. To perform regression analysis, patients who did not have a VML disability rating upon 

initial TDRL were given a disability of 0%. Statistical 

significance was achieved at an alpha of 0.05.

Results

Of the 33 subjects with confirmed VML, 15 (45%) subjects were medically retired at their first PEB evaluation. Their average age was 28.2±1.7 years (range 22-44 

years) and median rank was E6 (range E4-O6). Combining each of their unfitting conditions, their average overall disability rating was 64% (range 20%-100%) and average individual disability rating for just the VML was 

29% (range 0%-60%). The average time between their 

dates of injury and respective medical retirement was 

681 days (range 246-995 days).

Eighteen (55%) subjects were placed on TDRL during 

at least one of their PEB evaluations prior to final medical retirement. Their average age was 24.5±1.2 years 

(range 19-35 years) and median rank was E4 (range E4-

E6). Age was not different compared to service members who were medically retired at their first PEB evaluation (P=.0784) but service members placed on TDRL 

prior to retirement were of significantly lower rank 

(P=.0140). Their average overall disability rating combining each of their unfitting conditions was 48% (range 

20%-70%) and average individual disability rating for 

just the VML was 25% (range 10%-60%). The overall 

rating for service members who were medically retired 
32 http://www.cs.amedd.army.mil/amedd_journal.aspx

at their first PEB evaluation compared to service 

members placed on TDRL prior to retirement was 

significantly higher (P=.0463) but the disability 

rating assigned to the VML alone was not different (P=.5140). The average time between their 

dates of injury and respective medical retirement 

was 1,293 days (range 630-1,986 days). Because of 

the additional time allowed for maximal medical 

benefit to be reached, service members placed on 

TDRL at any point had a significantly longer duration between date of injury and date of medical 

retirement (P<.0001).

Of the 18 service members that were placed on 

TDRL, 7 subjects with an initial muscle condition 

rating were granted a higher (more disabling) rating at their final retirement evaluation compared 

to their initial evaluations (35% final rating [range 

20%-60%] versus 20% initial rating [range 10%-

40%], P=.0313). The charts in the Figure demonstrate the increase in the disability ratings for each 

service member. Nine additional service members 

were not assigned a muscle-related disabling condition at their initial PEB evaluation but went on 

to have a VML disability at their final evaluation. 

All of these service members had a pain or loss 

of motion rating initially which was recognized 

as a muscle condition at their follow up evaluation as shown in the Table. The remaining 2 service members had VML disability ratings which 

did not increase or decrease between their initial 

TDRL evaluations and their final medical retirement dispositions, one with a 20% VML disability 

rating and one with a 30% VML disability rating.

Comment

These results indicate that, for a portion of service 

members with VML related disability following 

combat injuries, some are medically retired at 

their first PEB evaluation and some are placed 

on TDRL for a period of time prior to medical 

retirement. Despite the intent of TDRL which is 

to allow for improvement until maximal medical 

benefit has been reached, subsequent PEB evaluations for service members placed on TDRL result 

in worsening VML disability. Sixteen of the 18 

(89%) service members placed on TDRL either had an 

increase in their VML disability rating at their final dispositions or were recognized to have a VML related disability at their final dispositions which was not assigned 

at interval evaluations.

Some differences existed between the service members 

that were medically retired at their first PEB evaluation 

and those who were placed on TDRL. First evaluation 

retirees were of higher rank, tended to be older but 

not significantly so, and had higher overall disability 

ratings. This could reflect a perception that the older, 

more senior service member would not improve given 

additional time. However, the “first pass” medical retirement was probably due to the cumulative amount of 

injury and disability for these individuals as reflected by 

Disability rating due to VML injury of patients on TDRL. Disability ratings due specifically to VML are plotted as a function of time postinjury 

(chart A), and per subject evaluation (chart B). Ratings are stratified 

by TDRL review (initial and final) and by whether the patient had a 

muscle rating upon initial TDRL review. Regression analysis indicates 

a significant increase in disability rating as a function of time (R2=0.24, 

P=.0032).

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18

0 365 730 1095 1460 1825 2190

20

0

30

40

50

60

70

10

% Disability

20

0

30

40

50

60

70

10

% Disability

A

B

TPI (days)

Subject

Initial Final (with initial rating)

Initial Final (with no initial rating)

MUSCLE-RELATED DISABILITY FOLLOWING COMBAT INJURY INCREASES WITH TIME
January – March 2016 33

THE ARMY MEDICAL DEPARTMENT JOURNAL

their higher overall disability rating. The 

contribution of VML to the overall rating was not different between the groups, 

suggesting that other injuries contributed 

in part to their medical retirement at their 

first PEB evaluation.

The VML disabling conditions of service members placed on TDRL did not 

improve but rather deteriorated. This is 

anticipated for a number of potential reasons. Volumetric muscle loss is not addressed during acute stages of care and, 

therefore, the remaining muscle mass is 

left to undergo continued degeneration 

and prolonged remodeling.3,4 During this 

time, VML injury propagates extensive 

compartmental fibrosis, which progressively restricts range of motion. It is likely 

under this condition that the injured musculature exhibits reduced or disuse atrophy. Coupled with the clinical 

observations that physical rehabilitation of VML injuries does not significantly restore limb function or muscle strength of the injured musculature, it is predictable 

that VML presents a deteriorating condition. Prospective investigation is needed and warranted to define the 

pathophysiology of VML injured muscle.

Limitations to our study include the use of the PEB disability designations as surrogates for true disability and 

our small sample size. The PEB ratings are assigned in 

accordance with the Veterans Affairs System for Rating Disabilities (VASRD), which at minimum provides 

a uniform guidance to how the PEB designations should 

be assigned. While every grading system contains some 

level of subjectivity, the VASRD guidance is enforced 

to attempt to minimize interrater differences. The PEB 

ratings may also fail to reflect increments of true loss of 

function or other true deterioration in clinical status. We 

used the PEB disability rating as a surrogate for worsening muscle condition, however, because the ratings 

are intended to reflect what percentage each condition 

detracts from a service member’s ability to perform on 

active duty job. As such, we feel that the increased disability rating between time points for any given service 

member provides some measure of decreased functional 

status attributable to the VML. Finally, our small sample size may not allow us to make accurate statistical 

inferences. This is a limitation imparted by the availability of retrospective data. However, when taken in 

total with the overall description of the larger published 

cohort, this data adds to the granular detail of the longterm sequelae of extremity injury not found in a vast 

majority of descriptive studies on war injury.

In conclusion, these data are consistent with growing 

body of preclinical literature demonstrating whole muscle unit deterioration following VML injury. The natural history of VML in human subjects has not been described. This is foundational preliminary evidence that 

the natural history of combat sustained VML injury is 

also one of deterioration.

References

1. Cross JD, Ficke JR, Hsu JR, Masini BD, Wenke JC. 

Battlefield orthopaedic injuries cause the majority 

of long-term disabilities. J Am Acad Orthop Surg. 

2011;19(suppl 1):S1-S7.

2. Cross JD, Stinner DJ, Burns TC, Wenke JC, Hsu 

JR, Skeletal Trauma Research C. Return to duty 

after type III open tibia fracture. J Orthop Trauma. 

2012;26(1):43-47.

3. Garg K, Ward CL, Hurtgen BJ, Wilken JM, Stinner 

DJ, Wenke JC, Owens JG, Corona BT. Volumetric 

muscle loss: persistent functional deficits beyond 

frank loss of tissue. J Orthop Res. 2015;33(1):40-46.

4. Corona BT, Garg K, Ward CL, McDaniel JS, Walters TJ, Rathbone CR. Autologous minced muscle 

grafts: a tissue engineering therapy for the volumetric loss of skeletal muscle. Am J Physiol Cell 

Physiol. 2013;305(7):C761-C775.

5. Li MT, Willett NJ, Uhrig BA, Guldberg RE, 

Warren GL. Functional analysis of limb recovery following autograft treatment of volumetric 

muscle loss in the quadriceps femoris. J Biomech. 

2014;47(9):2013-2021.

6. Abou-Khalil R, Yang F, Lieu S, Julien A, Perry J, 

Pereira C, Relaix F, Miclau T, Marcucio R, Colnot 

C. Role of muscle stem cells during skeletal regeneration. Stem Cells. 2015;33(5):1501-1511.

Nine subjects were given disability rating for nonmuscle conditions at their 

initial evaluation only to have recognized muscle-related disability at their final 

evaluation.

Subject Initial Rated Clinical Condition, Rating Final Muscle

Rating of VML

Site of 

VML

1 Limited range of motion of the ankle, 20% 20% Posterior 

Leg

2 Pain and decreased range of motion in the 

ankle, 20% 20% Posterior Leg

3 Decreased range of motion of the shoulder 

along with sensory deficits in the hand, 30% 10% Deltoid

4 Chronic thigh pain, 0% 10% Quadriceps

5 Shoulder pain, 20% 30% Deltoid

6 Healing tibia fracture, 30% 50% Posterior 

Leg

7 Hand weakness and chronic pain, 10% 10% Volar 

forearm

8 Chronic Pain, 0% 10% Posterior 

Leg

9 Neuralgia, 10% 10% Quadriceps
34 http://www.cs.amedd.army.mil/amedd_journal.aspx

7. Utvag SE, Grundnes O, Rindal DB, Reikeras O. Influence of extensive muscle injury on 

fracture healing in rat tibia. J Orthop Trauma. 

2003;17(6):430-435.

8. Utvag SE, Iversen KB, Grundnes O, Reikeras O. 

Poor muscle coverage delays fracture healing in 

rats. Acta Orthop Scand. 2002;73(4):471-474.

9. Richards RR, McKee MD, Paitich CB, Anderson 

GI, Bertoia JT. A comparison of the effects of skin 

coverage and muscle flap coverage on the early 

strength of union at the site of osteotomy after devascularization of a segment of canine tibia. J Bone 

Joint Surg Am. 1991;73(9):1323-1330.

10. Corona BT, Rivera JC, Owens JG, Wenke JC, Rathbone CR. Volumetric muscle loss leads to permanent disability following extremity trauma. J Rehabil Res Dev. In press.

11. Gentile NE, Stearns KM, Brown EH, Rubin JP, 

Boninger ML, Dearth CL, Ambrosio F, Badylak 

SF. Targeted rehabilitation after extracellular matrix scaffold transplantation for the treatment of 

volumetric muscle loss. Am J Phys Med Rehabil. 

2014;93(11 suppl 3):S79-S87.

12. Mase VJ, Jr., Hsu JR, Wolf SE, Wenke JC, Baer 

DG, Owens J, Badylak SF, Walters TJ. Clinical application of an acellular biologic scaffold for surgical repair of a large, traumatic quadriceps femoris 

muscle defect. Orthopedics. 2010;33(7):511.

13. Aurora A, Garg K, Corona BT, Walters TJ. Physical 

rehabilitation improves muscle function following 

volumetric muscle loss injury. BMC Sports Sci Med 

Rehabil. 2014;6(1):41.

14. Corona BT, Wu X, Ward CL, McDaniel JS, Rathbone CR, Walters TJ. The promotion of a functional 

fibrosis in skeletal muscle with volumetric muscle 

loss injury following the transplantation of muscleECM. Biomaterials. 2013;34(13):3324-3335.

Authors

MAJ Rivera and Dr Corona are with the US Army Institute of Surgical Research, Joint Base San Antonio Fort 

Sam Houston, Texas.

MUSCLE-RELATED DISABILITY FOLLOWING COMBAT INJURY INCREASES WITH TIME
January – March 2016 35

The Global War on Terror has left an indelible mark on 

Americans, particularly on US military personnel who 

have served on multiple overseas deployments. The media has highlighted stories of Soldiers with amputations, 

traumatic brain injuries, and posttraumatic stress disorder. The Army’s response to ensure provision of total 

care for wounded Soldiers following serious injuries is 

the Warrior Transition Unit (WTU), a comprehensive 

program designed to house, rehabilitate, and return 

Soldiers to duty or foster a transition from military to 

civilian life. Occupational therapists have historically 

been agents of social change related to disability, and 

occupational therapy practitioners provide care at the 

WTU as part of an interdisciplinary team. An examination of the WTU provides insight into disability, and 

knowledge gained from an analysis of the benefits and 

considerations of the WTU helps inform future practice.

Establishment of the Warrior Transition Unit

In response to the recognition in 2007 of the extent of 

substandard care for wounded military personnel,1 the 

Army established 35 WTUs at major bases in the continental United States and overseas to ensure the availability of professional services for those Wounded Warriors.2

The mission of the WTU is to “heal and prepare [the 

Soldier] for transition,” and it aims to accomplish this 

by providing each Soldier with a Comprehensive Transition Plan (CTP).3

 While working through the CTP, the 

Soldier has access to a system called the Triad of Care. 

This Triad includes a squad leader, a nurse care manager, 

and a primary care manager who is either a physician or 

physician’s assistant.3 The Triad is supplemented by an 

interdisciplinary team of occupational therapists, physical therapists, social workers, transition coordinators, 

and career counselors, among others.2

The command structure of the WTU provides oversight 

and accountability. While assigned to the WTU, the 

Soldier maintains his or her military benefits, receiving 

housing, normal pay and allowances, and healthcare services. The Soldier’s daily responsibilities are to attend 

medical appointments, engage in therapy to learn new 

life skills, and seek career counseling to transition out of 

the military or to a new military occupational specialty, 

as appropriate for the Soldier’s future plans.

Active Duty, National Guard, and Reserve Soldiers who 

have sustained physical and/or mental health injuries 

while serving and who require at least 6 months of intensive medical care are accepted into the WTU. A fact 

sheet published by the Warrior Transition Command4

states that as of February 2, 2015, the majority (84%) 

of the 4,001 Soldiers remaining in the WTU have been 

deployed at some point, but only 167 were injured in 

combat. Currently, the WTU success rate of returning 

Soldiers to duty is approximately 45%. The WTU recognizes that work is important to the Soldier’s mental and 

physical well-being, therefore, returning the Soldier to 

a purposeful worker role is emphasized within occupational therapy treatment.

Evolution and Adaptation

Fulfillment of meaningful roles and participation in occupations to restore mental and physical health are foundational tenets of occupational therapy. One fundamental example of this is the “moral treatment movement” 

in Europe in the 18th and 19th centuries. That movement marked a critical paradigm shift when individuals 

with mental illness began to participate in work tasks, 

or meaningful occupations, rather than being restrained. 

Adolph Meyer, the psychiatrist recognized as the “father of occupational therapy,” acknowledged the link 

between meaningful occupations and overall health, an 

idea ahead of its time.5 Since its creation and throughout 

its growth, occupational therapy has long been rooted 

in social justice, fostering cultural change related to disability. Presently, occupational therapy and healthcare 

provision continue to evolve within the WTU.

As of 2015, the WTU has downsized from 35 to 25 units 

in operation with 11 Community Care Units, smaller 

units for Soldiers with less complex care needs which 

allow them to heal closer to home.2,4 Fewer service 

War and Rehabilitation: Occupational

 Therapy’s Power to Transform

 Disability Into Ability

1LT Catrinna Amorelli, SP, USA

1LT Lindsay Sposato, SP, USA
36 http://www.cs.amedd.army.mil/amedd_journal.aspx

members are deploying and returning with injuries as 

the military’s current presence and involvement in overseas conflicts subsides. As a result, the Army has initiated the closure of select WTUs while “ensuring no degradation to the care and services provided to Soldiers 

and their families.”* The WTUs at 5 regional medical 

commands have been designated for inactivation by August 2016. Consequently, Soldiers within those WTUs 

will be transferred to other units.* As the WTU structure continues to evolve and downsize, there is an opportunity to critically evaluate it.

Lessons Learned

The benefits of the WTU structure and function are 

noteworthy. Three key benefits are the maintenance 

of the military unit structure which fosters unit camaraderie among Soldiers, the interdisciplinary team of 

healthcare providers, and the inclusion of the Soldier’s 

family members in the plan of care. Despite the benefits, criticisms of the WTU are worth consideration as 

well. As shown in the inset, these include the potential 

that receiving a medical disability rating may incentivize “sick role” behavior, financial compensation for disability may foster symptom exaggeration, and the multilayer administrative and clinical processes may cause 

extended lengths of stay, perhaps beyond the ideal time 

required for rehabilitation goals to be reached.

The criticism that the WTU may create a climate that 

fosters identification with the sick role is counterintuitive, since the language was purposefully written so the 

Soldiers would identify themselves as “Warriors in transition.” Regardless of intentions, Soldiers learn about 

the medical disability rating system and the fact that additional diagnoses in their medical record can result in 

greater financial gain. Insights into the system processes 

during the transition and recovery stage may influence 

susceptible Soldiers to identify with their diagnoses, 

and even seek additional diagnoses to add to their medical disability claim. Occupational therapy practitioners 

who work closely with Soldiers vulnerable to identifying with the sick role must be proactive. As creators of 

change, therapists can facilitate an incentive to recover 

and identify with ability rather than disability.

Appeal to Action

It is necessary to create a shift relating to the Soldier 

mindset that surrounds the disability rating system. Disability ratings by Veteran’s Affairs are assigned to Soldiers who have sustained injuries or diseases that are 

service-related, such as qualifying Soldiers receiving 

care within the WTU.6 A disability rating is a percentage 

(0%-100%) assigned to a Soldier based on injury or illness severity. The higher the rating, the greater amount 

of compensation provided from the government.6 Instead of promoting health, the system may inadvertently 

endorse disability, providing financial benefit for dysfunction. Reliance on a disability rating may provide a 

predictable, continuous income, but may also inadvertently decrease overall quality of life. Modifications 

to the system including the possibility of a lump sum 

disability payment (rather than a continuous payment), 

coupled with a release for all future disability claims, 

could effectively deter system misuse. After acceptance 

of a lump sum with a release, there may be less incentive 

for discharged Soldiers to revisit their disability claims 

and continue the cycle of dependence.

As rehabilitation professionals within the WTU, occupational therapists must hold themselves accountable for 

services rendered, as well as services withheld. Soldiers 

deserve compensation for injuries, but allowing Soldiers 

to advance towards a higher rating than warranted is 

a disservice not only to the Soldier, but to the ethical 

standards of the profession. The Army values and the 

occupational therapy code of ethics should be revisited 

frequently to regain focus for both Soldier and therapist.

Occupational therapists can steer the rehabilitation paradigm from the medical model to the social integrative 

model of disability. The medical model views disability 

as a negative occurrence, which can leave an individual 

dependent on supports and unmotivated to reintegrate 

into previous roles and responsibilities. In this model, 

the individual may assume the sick role and attempt to 

incentivize his or her disability. In contrast, the social 

integrative model views disability as a naturally-occurring phenomenon. Through full participation in occupations and roles, the individual will become more resilient, therefore regaining health and wellness.7

 Therapists 

WAR AND REHABILITATION: OCCUPATIONAL THERAPY’S POWER

TO TRANSFORM DISABILITY INTO ABILITY

*US Army Medical Command OPORD 15-31, February 2015. Internal 

military document not readily accessible by the general public.

Benefits and Considerations/Concerns Involved With the Care 

and Services Provided by the Warrior Transition Unit.

Benefits

Interdisciplinary communication and teamwork

Individualized goal-setting and attainment with professional 

assistance

Availability and access to services

Assistance for family and caregivers

Sense of camaraderie among Soldiers in a military unit setting/

structure

Considerations/Concerns

Potential for extended care/recovery times

Receiving a medical disability rating may incentivize sick role 

behavior

Financial incentive of disability may create risk of secondary gain 

and symptom magnification
January – March 2016 37

THE ARMY MEDICAL DEPARTMENT JOURNAL

must be cautious in labeling clients as disabled. Instead, 

care must be taken to assist the Soldier in creating a new 

identity, one that promotes ability.

Finally, as with any system of multilayer administrative 

and clinical processes, there may be unexpected delays 

or breakdowns in coordination in regards to delivery of 

care. In-processing, out-processing, and any executive 

requests may be lengthy and not as efficient as one might 

find within a smaller system of care. The sheer size of the 

healthcare system may expose the Soldier to getting “lost 

in the shuffle,” unnecessarily lengthening the amount of 

time the Soldier is receiving services. Specifically, the 

process of the Integrated Disability Evaluation System, 

which determines whether a Soldier can return to duty or 

separate from military service with a disability payment, 

is recognized as slow-moving.8 Occupational therapists 

should strive to educate Soldiers on the functions of the 

WTU, while simultaneously keeping the Soldier motivated, goal-focused, and proactive towards discharge. Assisting Soldiers to take an active role in managing their 

own care provides accountability and a sense of purpose. 

Overall, lessons cultivated go far beyond the WTU, and 

identified considerations for renovation can be applied 

within the civilian sector of support systems.

Application Within the Civilian Sector

Civilian social supports provide similar opportunities 

to incentivize disability. With the implementation of the 

Affordable Care Act in 2010, Medicaid coverage was expanded, adding millions of individuals to this system of 

care.9 Supporters stated the expansion provided assistance for individuals who, prior to the initiative, did not 

qualify. However, challengers of this expansion argue 

that it may promote dependence on the government’s assistance. Social Security Disability Insurance is a highly 

criticized program which cycles around an individual’s 

impairment(s) and inability to provide for oneself, possibly incentivizing disability and encouraging exaggeration of symptoms.10 These systems of support are only 

a few of the civilian programs which are criticized for 

potential encouragement to remain in the system, accepting a dysfunctional disability role as part of one’s 

personal identity.

The roots of occupational therapy and history have 

shown that individuals need meaningful roles and engagement in occupations to restore or maintain overall 

health. Occupation has been recognized as a means 

of treatment for mental and physical illness since the 

18th century, long before the term “occupational therapy” was first used to label the method in the 1920s.5

In 1915, Hall and Buck11 discussed the importance of 

engagement, or “occupation” in occupational therapy 

lingo, as a means of recuperation, stating:

For the well-to-do, work with the hands may be a potent 

remedy against the harmful effects of idleness.

As a profession, occupational therapists have known for 

nearly a century that participation in occupations is a 

way to restore health. Whether in the WTU or in the civilian sector, occupational therapists do well to remind 

clients that it is in their best interest to be engaged and 

fully participate in occupations. Furthermore, in pursuit 

of health for clients, occupational therapists may simultaneously discourage unnecessary reliance on social 

support and subsequent idleness.

Conclusion

In any social support system, loopholes will be found 

and resources may be unjustly over-utilized. As this is 

never the purpose of these programs, health professionals should transform unhealthy mindsets and behaviors 

toward independence. As the past has demonstrated, 

occupational therapy practitioners can be instrumental 

in analyzing and altering the future of such services. 

Through war and rehabilitation, Army occupational 

therapists have the unique opportunity to be actively 

involved in a large, evolving healthcare system. The 

WTU is simply one example of a support system developed when a vital need was identified. Whether in the 

military or civilian sector, it is the duty of occupational 

therapists to motivate clients to accomplish the mission 

of return to function, independence, health, and participation in meaningful occupations. In this way the focus 

is empowerment, not entitlement.

References

1. Priest D, Hull A. Soldiers face neglect, frustration at Army’s top medical facility. The Washington Post. February 18, 2007. Available at: http://

www.washingtonpost.com/wp-dyn/content/arti

cle/2007/02/17/AR2007021701172.html. Accessed 

July 20, 2015.

2. Erickson MW, Secrest DS, Gray AL. Army occupational therapy in the warrior transition. OT Practice. 2008;13(13):10-14.

3. US Army Warrior Transition Command. Warrior 

Transition Units [internet]. December 2014. Available at: http://www.wtc.army.mil/documents/fact

sheets/WTU_FACT_SHEET.pdf. Accessed July 

20, 2015.

4. US Army Warrior Transition Command. Warrior 

Transition Command [internet]. February 2015. 

Available at: http://www.wtc.army.mil/documents/

factsheets/WTC_Overview_FactSheet_FINAL.

pdf. Accessed July 20, 2015.
38 http://www.cs.amedd.army.mil/amedd_journal.aspx

5. Reed K, Hocking C, Smythe L. The meaning of 

occupation: historical and contemporary connections between health and occupation. N Z J Occup 

Ther. 2013;60(1):38-44. Available at: https://www.

questia.com/library/journal/1G1-328657463/themeaning-of-occupation-historical-and-contempo

rary. Accessed October 5, 2015.

6. US Department of Veteran’s Affairs. Compensation [internet]. August 2015. Available at: http://

www.benefits.va.gov/compensation/index.asp. Accessed July 20, 2015.

7. Cooper RA, Pasquina PF, Drach R eds. Warrior 

Transition Leader: Medical Rehabilitation Handbook. Fort Sam Houston, Texas: Borden Institute; 

2009.

8. US Army Warrior Transition Command. Integrated Disability Evaluation System (IDES) [internet]. 

Available at: http://www.wtc.army.mil/modules/

Soldier/s6-ides.html. Updated June 22, 2015. Accessed July 20, 2015.

9. Centers for Medicare and Medicaid Services. Eligibility [internet]. Available at: http://www.med

icaid.gov/medicaid-chip-program-information/bytopics/eligibility/eligibility.html. Accessed July 20, 

2015.

10. Burke TF, Barnes J. Republicans want to reform 

disability insurance. Here’s why that’s hard. The 

Washington Post. February 17, 2015. Available at: 

http://www.washingtonpost.com/blogs/monkeycage/wp/2015/02/17/republicans-want-to-reformdisability-insurance-heres-why-thats-hard. Accessed July 20, 2015.

11. Hall HJ, Buck MM. The Work of Our Hands: A 

Study of Occupations for Invalids. New York, NY: 

Moffat, Yard & Company; 1915.

Authors

1LT Amorelli and 1LT Sposato are Senior Fellows in the 

Army-Baylor University Doctor of Science in Occupational Therapy Program, Fort Sam Houston, Texas.

WAR AND REHABILITATION: OCCUPATIONAL THERAPY’S POWER

TO TRANSFORM DISABILITY INTO ABILITY
January – March 2016 39

Never underestimate your POWER to change yourself...

H. Jackson Brown, Jr

The Center for the Intrepid (CFI) at Fort Sam Houston, 

San Antonio, Texas, officially opened in January 2007. 

The 4-story, 65,000 square foot facility is one of the 

premier outpatient rehabilitation centers for the Department of Defense. The CFI provides advanced prosthetic 

and rehabilitative care for individuals following amputation, burn, and/or functional limb loss.1

 The CFI staff 

uses an interdisciplinary approach to provide holistic 

care with the goal of positively impacting the physical, 

psychological, and behavioral functioning of injured 

military service members and veterans. Over the past 

8 years, a variety of clinical challenges have shaped the 

progress of rehabilitative care. Advancements in surgery have prevented limb amputation; however, limb 

salvage procedures can result in unique complications 

and disadvantages that challenge providers and patients. 

Because service members and military veterans are accustomed to (and often drawn to) high intensity, physically demanding pursuits, the request was made to address the gap between the actual versus desired level of 

function after limb salvage. Healthcare professionals at 

the CFI met this request with a custom orthosis, the Intrepid Dynamic Exoskeletal Orthosis (IDEO).

Intrepid Dynamic Exoskeletal Orthosis

The IDEO is a carbon fiber, energy storing ankle-footorthosis which enhances plantarflexion power, ankle 

stability, and agility.2,3 To maximize the rehabilitation 

and training outcomes of patients wearing the IDEO 

after limb salvage, physical therapy, orthotics/prosthetics, and orthopedic surgery worked to develop a “Return to Run” program at the CFI. The program is based 

on sports-medicine principles and embodies a traditional rehabilitation mindset of improving strength and 

conditioning.3

During the initial successful implementation of the 

IDEO and Return to Run program, deficits and issues 

that went beyond traditional physical rehabilitation were 

identified and a health psychologist Fellow at San Antonio Military Medical Center was engaged to augment 

the existing program. Through creativity and collaboration, complementary components of health and wellness 

were incorporated into the Return to Run program. This 

professional collaboration transformed initial concepts 

into a comprehensive, performance-focused program 

titled POWER: Performance-Optimization Warrior Enhanced Rehabilitation.

Performance-Optimization Warrior Enhanced

Rehabilitation

The POWER program is a play on words, built on the 

foundational belief that every individual has the personal power to act, achieve goals, make decisions, and 

triumph over life’s obstacles. While it focuses on human 

optimization through cognitive, nutritional, and fitness 

enhancements comparable to other programs (eg, the 

Army’s Tactical Human Optimization, Rapid Rehabilitation and Reconditioning program), the POWER program is unique in several ways:

3⁄4 Focuses on improving self-efficacy

3⁄4 Customized to the patient

3⁄4 Injured service members and veterans are the target 

population

3⁄4 Direct instruction from professionals across various disciplines is incorporated

The POWER program uses a practice-based evidence 

model to influence patients, seeking to apply the best 

available evidence-based research within clinical practice to achieve desired therapeutic milestones.4

Although the POWER program grew out of a desire to 

better meet the needs of patients with limb salvage, patients referred to the CFI with any diagnosis are eligible 

for enrollment. Patients are screened for POWER program eligibility during initial in-clinic treatment sessions; patient needs are then discussed weekly during 

interdisciplinary team meetings thereafter. The POWER 

program is recommended for patients with issues that 

may potentially interfere with recovery (eg, medication 

dependency, behavioral health issues, poor coping, low 

resiliency, or low self-efficacy). The timeframe for the 

program is dependent upon the patient and their individual needs.

Center for the Intrepid:

 Providing Patients POWER

1LT Catrinna R. Amorelli, SP, USA Benjamin M. Keizer, PhD

1LT Matthew L. Baumann, SP, USA MAJ Daniel J. Stinner, MC, USA

LTC Kathleen E. Yancosek, SP, USA Jason M. Wilken, PhD, MPT
40 http://www.cs.amedd.army.mil/amedd_journal.aspx

Implementation of the POWER Program

The POWER program is executed through professional collaboration. This interdisciplinary strategy 

inspires CFI staff to motivate, challenge, and support patients as they strive to regain prior levels of 

function and return to duty. At the CFI, the following disciplines contribute skills, knowledge, and expertise to create a team-oriented rehabilitation approach as illustrated in Figure 1:

Case Management Physiatry

Dietetics Physical Therapy

Health Psychology Recreational Therapy

Occupational Therapy Research

Orthotics/Prosthetics

The interdisciplinary team is headed by 2 physicians: 

a physiatrist and an orthopaedic surgeon (the Medical Director of the CFI). They lead weekly interdisciplinary team meetings to discuss patients with CFI 

staff. The rehabilitation team monitors the progress 

of each patient with respect to his or her treatment 

plan, and decides whether or not the POWER program may enhance recovery. Open communication 

is encouraged at the weekly meetings, including effective consultation with other services at any time 

during the patient’s rehabilitation process. Due to 

widely differing injury patterns and patient requirements, engagement in the POWER program may 

span anywhere from 4 to 52 weeks. The POWER 

program’s lessons are systematically divided into 3 

distinct modules—health psychology, nutrition, activity—with corresponding submodules as shown in 

Figure 2.

Power Program Modules

Health Psychology

Beyond the physical trauma of the injury itself, 

combat injuries often have profoundly negative 

consequences including loss of health and military 

achievement potential. Specifically, combat injuries 

have the potential to create numerous psychological 

disturbances, including increased anxiety, depression, insomnia, anger, tension, and diminished quality 

of life.5

Significant advances in physical medicine and rehabilitation have created situations in which an individual 

service member may be physically ready to return to 

duty, but not yet psychologically recovered. Successful 

rehabilitation programs have increasingly recognized 

this trend and have integrated psychological interventions (ie, relaxation, mindfulness-imagery, goal setting, 

stress management) into their programs.6 

The Optimal Performance Program (OPP) is integrated 

psychological skills training to reduce the negative psychological consequences of injury and teach new techniques that improve performance. Regardless of diagnosis, OPP, as a component of the POWER program, aims 

to produce autonomous, highly functioning military service members with improved coping skills, decreased 

reinjury anxiety, and improved psychological flexibility.

Incorporating techniques from sports psychology, rehabilitation psychology, and health psychology, OPP 

CENTER FOR THE INTREPID: PROVIDING PATIENTS POWER

Figure 1. An interdisciplinary approach provides specialized, 

holistic, practice-based patient care.

OCCUPATIONAL

THERAPY

ORTHOTICS &

PROSTHETICS

PHYSICAL

THERAPY

CASE

MANAGEMENT

RECREATIONAL

THERAPY

HEALTH

PSYCHOLOGY

PHYSIATRY

RESEARCH DIETETICS

Professions Integral to the POWER Program

Case

Management

Management of cases by coordination of all services and facilities transitions surrounding patient 

discharge.

Dietetics One on one and group sessions to promote healthy 

eating, dietary modifications, and illness prevention 

through proper nutrition.

Health

Psychology

One on one and group therapy sessions with a focus 

on education of behavioral health techniques to imrove outcomes.

Occupational

Therapy

Engages the patient in meaningful thearpeutic activities to return to their highest level of function and 

quality of life.

Orthotics &

Prosthetics

Custom fabrication of prosthetic and orthotic devices.

Physiatry Thorough and ongoing evaluation and holistic management of patients. Serves as the lead provider for the 

rehabilitation care of each patient.

Physical

Therapy

Evaluation and treatment of neuromusculoskeletal 

conditions. Provides therapeutic exercises, modalities, and gait training.

Recreational

Therapy

Facilitates emotional and physical health through leisure pursuits and community reintegration. Lead service for biofeedback training.

Research Contributes to the objective assessment of outcomes 

to ensure/develop best practice.
January – March 2016 41

THE ARMY MEDICAL DEPARTMENT JOURNAL

consists of 8 distinct, 2-hour treatment modules that are 

administered over a 4-week period at a rate of 2 treatment sessions per week. Each 2-hour treatment group 

ends with a 15-minute group clinical hypnosis session. 

Before receiving a fabricated IDEO brace and entering 

the program, patients receive a 60-minute intake and 

program introduction that prepares them for the group 

treatment modules. During this initial group, patients 

complete baseline assessment forms and receive basic 

information about hypnosis, heart-rate variability biofeedback, physical self-regulation, the physiology of 

stress, and chronic pain management. All treatment 

modules are led by the CFI’s health psychologist.

Concurrently, patients are issued a personal biofeedback 

device that measures heart rate variability, a key indicator of physiological resiliency and behavioral flexibility.7

A trained biofeedback provider supervised by a health 

psychologist works with the patients both individually 

and collectively. Additionally, patients practice biofeedback training and the results are tracked digitally 

through the biofeedback device and logged by the biofeedback provider. Patients also attend individual appointments to address each patient’s progress in the program, reinforce previous treatment interventions, and 

make goals for future progress.

Group treatments of OPP are divided into 2 distinct, primary subject areas: performance education and skill acquisition. Performance education specifically focuses on 

teaching preventive strategies to manage illness/disease 

in the midst of practicing and maintaining healthy behaviors. In an efficient and structured manner, patients 

are active contributors to their recovery. Performance 

education contains standalone submodules on 4 separate topics: stress management, sleep, pain I, and pain II.

Figure 2. The main modules and corresponding submodules of the POWER Program.

Nutrition

1. Nutritional Survey

2. Laboratory Evaluation

a. CBC, iron-panel, sTfr

b. Chem 7

c. Lipid panel

d. 25-OH d

3. The 5 Rs

a. Rehydrate

b. Repair

c. Rest

d. Revitalize

e. Reload

4. Individual Classes

a. Review Labs

b. Body composition

c. Review supplements

d. Goal setting

e. Follow-up as needed

Health Psychology

1. Performance Education

a. Stress management

b. Sleep

c. Pain I

d. Pain II

2. Skill Acquisition

a. Attention and self-talk

b. Critical thinking and self-analysis

c. Anger management

d. Learned optimism

Activity

1. Evaluation and Screening Tools

a. History and physical exam

b. Biodex

c. Biofeedback

d. FCE-M

e. Military performance lab

2. Restoration

a. Strength training

b. BFR

c. Motion

d. AlterG

e. Edema recovery

f. Flowrider

3. Return to Run

a. Sprinting

b. Plyometrics

c. Cut dynamics

d. Landing mechanics

e. Power development

f. Acceleration/deceleration

4. Return to Duty

a. FCE-M

b.	 MOS specific training

c. FATS

d. WFSC Freedom Park

e. CAREN

f. Community outings

Glossary

BFR - blood flow restricted training	 FCE-M - Functional Capacity Evaluation-Military

CAREN - Computer Assisted Rehabilitation ENvironment MOS - military occupational specialty

CBC - complete blood count sTfr - soluble transferrin receptor

Chem 7 - basic metabolic panel WFSC - Warrior and Family Support Center

FATS - Firearms Training Simulator 25-OH d - 25 hydroxyvitamin D
42 http://www.cs.amedd.army.mil/amedd_journal.aspx

Stress management is the first module addressed under 

performance education. During the stress management 

module, the physiology of stress response is discussed, 

including the role of cortisol and oxytocin, culturalunique military stressors, the stress diathesis theory of 

disease/illness, and stress resilience. Patients learn energy conservation techniques and power posing, in addition to various practice strategies to apply and promote 

energy management including inducing the relaxation 

response through physical self-regulation.

Because poor sleep can impair quality of life, decrease 

the progression of the recovery process, and increase 

one’s risk for other diseases,8,9 patients in the POWER 

program learn the physiology of sleep, including the 

management of circadian rhythms, social and biological zeitgebers, and the connection between sleep and 

memory. The importance of maintaining healthy sleeping patterns along with the causes and types of insomnia 

and the effects of drugs on the sleep cycle are discussed. 

Recommendations for proper sleep hygiene are shared 

(eg, creating a relaxing routine before bed, developing 

a regular sleep-wake cycle) and strategies for how to 

manage intrusive, negative, anxiety-producing thoughts 

at nighttime are taught. At the completion of the treatment module, patients develop a sleep performance plan.

The first pain module explains pain as a subjective, multifaceted experience. Physiology of the pain response is 

reviewed, the biopsychosocial model of pain is introduced, and the differences between acute versus chronic 

pain are distinguished. Patients learn the biological purpose of pain, the role of emotions/thoughts in the pain 

experience, while also recognizing methods for better 

management of pain (eg, biofeedback, relaxation training, distraction, pacing, cranial electrical stimulation/

Alpha-Stim).

The second pain module focuses on the neuroscience of 

pain and managing fear and avoidance following an injury. Patients learn about how pain is often a disconnect 

between the real body and the virtual body, the role of 

mechanoreceptors in a pain experience, introduction to 

the concept of proprioception, body maps, pain neurotags, mirror neurons, and the physiology of inflammation and stiffness.

Alongside performance education, skill acquisition is 

the second portion of the health psychology module. 

Skill acquisition uses a comprehensive, multimodal approach to teach patients how to consciously attend to 

and regulate individual thoughts, emotions, and behaviors. Patients are taught to be mindful of their circumstances, and are empowered with the ability to employ 

well-known psychological strategies to overcome environmental stressors. Skill acquisition contains submodules on 4 separate topics:

 Attention and self-talk

 Critical thinking and self-analysis

 Anger management

 Learned optimism

In the attention and self-talk module, the physiology of 

the brain in improving attention is discussed, and the 

sequence of information-processing within the human 

body is highlighted. Additionally, patients are lead 

through sports psychology grid training drills to improve their selective attention. The POWER program 

teaches patients how to better guide, regulate, and evaluate thought processes through the implementation of 

learned metacognitive skills, including monitoring and 

changing self-talk to improve performance.

The module on critical thinking and self-analysis asks 

each patient to thoughtfully consider his or her own 

self-concept (or the collection of beliefs a person holds 

about him or herself). This process includes evaluating 

past, present, and future self-identity, as well as the effects of the injury on the new self-identity. Therapists 

work with patients through this process to help detect 

thoughts, cognitive errors, and realistic versus idealistic 

thinking. Self-concept constructs are individually analyzed as they may function as reinforcement for certain 

undesirable behavior(s).

The mood and anger management training module challenges patients to critically analyze several adaptive and 

maladaptive responses to anger. Patients are educated 

on the physiology of anger, distinguishing between 

adaptive and maladaptive anger, consequences of those 

who demonstrate hostility/aggression towards self and 

others, and managing both anger directed at self and/or 

others. Problem solving, cognitive restructuring, relaxation activities, and interpersonal communication strategies are all discussed.

The learned optimism and performance module focuses 

on the science of optimism and performance. Optimism 

(dispositional versus situational) is defined, patients 

learn how to apply optimism in improving physical 

and emotional performance, how to use defensive pessimism to manage anxiety, fear, and worry, and how to 

use positive psychology techniques to enhance dispositional optimism.

Nutrition

The second component of the POWER program encompasses nutritional health and wellness. A dietician 

CENTER FOR THE INTREPID: PROVIDING PATIENTS POWER
January – March 2016 43

THE ARMY MEDICAL DEPARTMENT JOURNAL

conducts a nutritional survey to gather baseline information regarding the patient’s diet. Also, blood is analyzed in the lab to provide information on vitamin deficiencies, cholesterol levels, and body system functions. 

The baseline survey and lab values are essential aspects 

of the program as they can be key identifiers of factors 

contributing to fatigue, weight gain, depression, and 

poor healing after injury. Furthermore, the information 

can assist the dietician in identifying nutritional needs 

and addressing deficiencies.

Education is delivered on the “5 Rs” of recovery nutrition (rehydrate, repair, rest, revitalize, and reload). 

Rehydration focuses on individual fluid needs before, 

during, and after rehabilitation. This component should 

always be individualized, establishing rehydration requirements on the physical exertion demands of each patient.10 Repair emphasizes to patients the importance of 

consuming high quality protein, both prior to and after 

rehabilitation. Rest highlights sleep as a major factor in 

the recovery process; it is crucial to obtain 7 to 9 hours 

of sleep daily to maximize rest of exhausted muscles 

and minimize mental fatigue in preparation for the following day’s training. Revitalize emphasizes the need to 

extract vitamins and minerals from whole grains, fruits, 

and vegetables to energize the body’s systems. Similar to 

repair, patients are taught methods to reload their muscles with carbohydrates and protein for muscle recovery, 

growth, and heightened performance.11 In addition to 

the 5 Rs, education is continually provided to ensure 

knowledge of healthy food choices, effective shopping 

habits, and importance of fueling the body with clean, 

nutritional food. Throughout the POWER program, patients routinely meet with a dietician to discuss the 5 

Rs, identify areas for improvement, devise strategies to 

regain health, establish attainable goals, and follow-up 

with a provider as necessary.

Activity

Physical activity is necessary to optimize health and 

performance of desired activities. The mission of the 

POWER program is to restore an injured service member or veteran, regardless of injury, to duty and/or highest level of independence. To accomplish this aim, focus 

is placed on achieving adequate endurance, strength, 

flexibility, and mobility necessary to perform daily activities.12 Without these key components, the likelihood 

of reinjury may increase. The activity module consists 

of 4 distinct categories—comprehensive evaluation and 

screening, restoration, Return to Run, and return to 

duty—each of which includes 6 subdivisions of select 

treatment options for patient care.

The first module involves a comprehensive evaluation 

with additional screening tools (as deemed necessary) to 

obtain a holistic view of the patient’s areas of movement 

dysfunction. A thorough medical history and physical 

examination is conducted. Supplementary measures 

may also be requested, such as biofeedback, Biodex 

(Biodex Medical Systems, Inc, Shirley, NY), functional 

movement screen, gait lab analysis, and/or a functional 

capacity evaluation-military (FCE-M).

The second module focuses on restoration and advancing the patient towards his or her prior level of function. 

Strength, endurance, joint range of motion, dynamic 

balance, and edema are addressed through means of 

blood flow restriction therapy, AlterG (AlterG, Inc, Fremont, CA), and Flowrider (Flowrider, Inc, San Diego, 

CA). One unfortunate reality of rehabilitating trauma 

patients is that they need strength training, but are often 

not able to withstand the high loads required to build 

strength in the typical fashion. Blood flow restricted 

training is a technique used to address this significant 

clinical challenge. It is important because it allows a patient to obtain muscle hypertrophy at 20% of his or her 

one rep maximum, thus allowing the individual to reap 

the benefits while performing significantly less work.13

The AlterG Anti-Gravity Treadmill is an additional tool 

which requires less physical demand, decreasing the 

forces generated through the lower extremities while 

exercising and possibly enhancing recovery time.14 Furthermore, the Flowrider incorporates excitement and entertainment alongside functional (dynamic) balance and 

core strengthening.

Return to Run is the third module under the scope of 

activity. Pairing the IDEO with a structured Return to 

Run clinical pathway addresses the need to return to basic activities of daily living as well as the high-level rehabilitation goals of limb salvage patients who aspire to 

attain or exceed the functional mobility of patients with 

transtibial amputations. While this module is implemented by a physical therapist and physical therapy assistant, 

orthopaedic and orthotic/prosthetic staff serve as interdisciplinary partners. The physical therapy practitioners 

engage and educate the patients in plyometric exercises, proper landing mechanics, sprinting, cut dynamics, 

power development, and acceleration/deceleration techniques. Objective data15 and patient reports suggest that 

without the assistance of the IDEO, mobility and ambulation remain limited. The IDEO and Return to Run module allow patients to maximize use of their salvaged limb.

To complete the physical activity module, return to duty 

is addressed through 6 submodules of evaluation and 
44 http://www.cs.amedd.army.mil/amedd_journal.aspx

training, with each submodule systematically assessing 

patients’ capabilities, both physically and mentally. In 

this part of the POWER program, a patient’s military 

occupational specialty is scrutinized to identify the primary skills, roles, duties, and job tasks that are essential 

to perform within the identified military profession. A 

FCE-M, specifically designed for service members, may 

be completed for personnel who wish to return to duty. 

While wearing a Kevlar tactical vest, helmet, 35-pound 

rucksack, and carrying an M-4 carbine, patients are 

timed and graded on their ability to perform tasks such 

as dragging a 160-pound sled (to simulate a casualty), 

climbing walls, clearing stairs, and running a one-mile 

ruck. The components within the FCE-M are specifically designed to simulate the realistic demands of active 

duty service. Physical abilities are also tested and assessed through the Warrior and Family Support Center 

Freedom Park trail. The park contains fitness stations 

of varying difficulty and a trail that can be utilized for 

training and assessment.

The Firearms Training Simulator and Computer Assisted Rehabilitation ENvironment (CAREN) are used 

to assist with FCE-M evaluations. Firearms training in 

a simulated environment allows patients who wish to 

return to duty the opportunity for skill acquisition, remediation, and refinement through simple and complex 

scenarios.1 In addition, the CAREN offers a multisensory virtual reality simulation where service members 

feel safe while being immersed in highly demanding 

scenarios that are comparable to those encountered in 

combat.16 Finally, recreational therapy opportunities for 

outings are used to engage patients in leisure pursuits, 

reinforcing comradery, unity, and reintegration into the 

community.

Enhancing functional independence both physically, 

psychologically, and behaviorally requires a multimodal 

form of rehabilitation. Establishment and implementation of the POWER program encourages a holistic 

view of a patient through an interdisciplinary approach, 

building relationships between healthcare professionals 

and demonstrating to patients a model system of care.

Evaluation of the Power Program

Researchers in the CFI’s Military Performance Laboratory are well into a multiyear effort to establish robust 

and clinically relevant assessments and outcome measures that allow objective determination of patient ability, support the prediction of outcomes trajectories, and 

allow validation of the various modules of the POWER 

program. Although assessments can include technologically sophisticated tools,17 an emphasis is placed on 

assessments that are time-efficient, easy to implement, 

reliable, valid, and capture the effects of the clinical interventions in the POWER modules. As stated earlier, 

the POWER program is an extension of the Return to 

Run program, a specialized training program which has 

robust scientific evidence demonstrating its ability to return limb salvage patients to a higher level of functional 

independence.15 For example, a retrospective analysis of 

limb salvage patients who had participated in the Return 

to Run program was conducted from October 2009 to 

June 2010. Researchers discovered 10 patients who met 

the inclusion criteria. Results reported that all 10 patients 

had resumed a weight-lifting program, eight returned to 

running (one completed a full and half marathon while 

two completed a minitriathlon), and three were redeployed with elite units.3

 It is the desire to equally demonstrate the effectiveness of the POWER program and 

its interdisciplinary approach to rehabilitation in returning individuals to their highest level of functional 

independence.

In addition to a range of objective measures of physical function, measures that characterize an individual’s 

psychosocial makeup are also being actively pursued. 

Due to the interdisciplinary approach to care within 

the POWER program, and a growing body of literature 

supporting the importance of nonphysical factors on resulting recovery, areas such as self-efficacy, resilience, 

anger, and depression are being evaluated. By better 

understanding service member’s nonphysical makeup, 

such as an individual’s readiness to engage in the various components of the POWER program, intervention 

type and timing can be optimized to ensure maximal 

benefit in an individualized manner.

Value to The Military

In 2013, Army Surgeon General LTG Patricia Horoho, 

spearheaded a campaign to advance Army Medicine 

from a healthcare system to a “System for Health.” LTG 

Horoho described the transition thusly:

This means shifting the focus to prevention of disease, 

injury, and disability. More importantly, it means advocating a cultural shift to Soldiers and beneficiaries by encouraging them to develop a mindset that drives them to 

optimize their own health.18

LTG Horoho asked Soldiers and beneficiaries to take 

active roles in maintaining their own physical health 

through fitness and injury/illness prevention strategies.

Also during 2013, the Army introduced the Performance 

Triad to support Army Medicine’s transition to a System 

for Health. Focusing on sleep, activity, and nutrition, the 

Performance Triad provides a comprehensive plan for 

CENTER FOR THE INTREPID: PROVIDING PATIENTS POWER
January – March 2016 45

THE ARMY MEDICAL DEPARTMENT JOURNAL

healthy, sustainable life roles and routines. The aims of 

the Performance Triad are for individuals to engage in 

daily physical activities, improve personal nutrition, and 

increase quality sleep.19

The CFI POWER program is congruent with the Performance Triad and resonates with Army Medicine’s System of Health. The POWER program seeks to empower 

patients with a “skill toolbox” to positively affect their 

life space.* Various components of health psychology, 

nutrition, and activity are taught for patients to improve 

individual functioning levels while reducing negative 

psychological, emotional, and physical consequences 

often associated with injury. As the POWER program 

is individualized, each plan of care is tailored to fit the 

patient’s needs.

Conclusion

The CFI implemented POWER as an innovative, comprehensive, interdisciplinary rehabilitation program to 

leverage clinician and patient assets to optimize individual functional performance. Although POWER is in the 

early implementation phase, researchers integral to the 

CFI continue to identify, evaluate, and implement measures to assess the program’s effect on patient outcomes. 

Although it is the CFI’s desire to demonstrate the program’s unique contribution to patient healing, research 

is necessary to demonstrate the clinical effectiveness of 

POWER.

References

1. Yancosek K, Daugherty SE, Cancio L. Treatment 

for the service member: A description of innovative interventions. J Hand Ther. 2008;21(2):189-195.

2. Patzkowski JC, Blanck RV, Owens JG, Wilken 

JM, Blair JA, Hsu JR. Can an ankle-foot orthosis change hearts and minds?. J Surg Orth Adv.

2010;20(1):8-18.

3. Owens JG, Blair JA, Patzkowski JC, Blanck RV, 

Hsu JR, and the Skeletal Trauma Research Consortium. Return to running and sports participation 

after limb salvage. J Trauma. 2011;71(1):120-124.

4. McKeon PO, McKeon JM. Evidence-based practice or practice-based evidence: what’s in a name? 

Int J Athl Ther Train. 2015;20(4):1-4. 

5. Hoge CW, Castro CA, Messer SC, McGurk D, Cotting DI, Koffman RL. Combat duty in Iraq and Afghanistan, mental health problems, and barriers to 

care. N Engl J Med. 2004;351(1):13-22.

6. Schwab-Reese L, Pittsinger R,Yang J. Effectiveness of psychological intervention following sport 

injury. J Sport Health Sci. 2012;1(2):71-79.

7. Thayer JF, Ahs F, Fredrikson M, Sollers JJ, Wager 

TD. A meta-analysis of heart rate variability and 

neuroimaging studies: implications for heart rate 

variability as a marker of stress and health. Neurosci Biobehav Rev. 2012;36(2):747-756.

8. Chen X, Gelaye B, Williams MA. Sleep characteristics and health-related quality of life among a 

national sample of American young adults: assessment of possible health disparities. Qual Life Res. 

2014;23(2):613-625.

9. Young JS, Bourgeois JA, Hilty DM, Hardin KA. 

Sleep in hospitalized medical patients, part 1: factors affecting sleep. J Hosp Med. 2008;3(6):473-482.

10. Lopez RM. Exercise and hydration: individualizing fluid replacement guidelines. Strength Cond J. 

2012;34(4):1-6. 

11. Moore DR. Nutrition to support recovery from 

endurance exercise: optimal carbohydrate and 

protein replacement. Curr Sports Med Rep. 

2015;14(4):294-300.

12. Roy TC, Springer BA, McNulty V, Butler NL. 

Physical fitness. Mil Med. 2010;175(8):14-20.

13. Pope ZK, Willardson J, Schoenfeld BJ. Exercise 

and blood flow restriction. J Strength Cond Res. 

2013;27(10):2914-2926.

14. Patil S, Steklov N, Bugbee WD, Goldberg T, Colwell CW, D’Lima DD. Anti-gravity treadmills are 

effective in reducing knee forces. J Orthop Res.

2013;31(5):672-679.

15. Patzkowski JC, Blanck RV, Owens JG, et al, and the 

Skeletal Trauma Research Consortium. Comparative effect of orthosis design on functional performance. J Bone Joint Surg AM. 2012;94(6):507-515.

16. Gates DH, Darter BJ, Dingwell JB, Wilken JM. 

Comparison of walking overground and in a Computer Assisted Rehabilitation Environment (CAREN) in individuals with and without transtibial amputation. J Neuroeng Rehabil. 2012;9:81.

17. Wilken JM, Rodriguez KM, Brawner M, Darter BJ. 

Reliability and minimal detectable change values 

for gait kinematics and kinetics in healthy adults. 

Gait Posture. 2012;35(2):301-307.

18. Horoho PD. A system for health: essential element 

of national security. US Army Med Dep J. OctoberDecember 2013:4.

19. US Army Medical Department. Performance Triad 

[internet]. 2015. Available at: http://armymedicine.

mil/Pages/performance-triad.aspx.. Accessed August 10, 2015.

*Life space is defined as the physical and psychological environment of an individual or group. Source: Merriam–Webster Medical Dictionary.
46 http://www.cs.amedd.army.mil/amedd_journal.aspx

Authors

1LT Amorelli and 1LT Baumann are Senior Fellows in the Army-Baylor University Doctor of Science in Occupational 

Therapy Program, Joint Base San Antonio Fort Sam Houston, Texas.

LTC Yancosek is the Director of the Center for the Intrepid, Joint Base San Antonio Fort Sam Houston, Texas.

Dr Keizer is a Clinical Psychologist at the Brooke Army Medical Center, Joint Base San Antonio Fort Sam Houston, 

Texas.

MAJ Stinner is the Medical Director of the Center for the Intrepid, Joint Base San Antonio Fort Sam Houston, Texas.

Dr Wilken is the Director of the Military Performance Laboratory, Joint Base San Antonio Fort Sam Houston, Texas.

CENTER FOR THE INTREPID: PROVIDING PATIENTS POWER
January – March 2016 47

Safety, quality, and the cost of healthcare are currently 

at the forefront of healthcare discussions in the United 

States. One of the most vulnerable periods for a hospitalized patient occurs during transfer of that patient’s care 

among providers or between healthcare settings. This 

risk is particularly significant for ill or elderly patients, 

since these transitions of care are prone to confusion, 

miscommunication, and medical errors.1,2

Within hospital systems, discharge planning services 

aim to ease the patient transition from the hospital. 

Many studies suggest that these services decrease cost 

and utilization rates. A 2013 Cochrane review evaluated the value of hospital discharge planning and determined that individualized hospital discharge plans lead 

to reductions in hospital length of stay and readmission 

rates.3 Additional evidence in the Cochrane review was 

inconsistent regarding the impact of discharge planning 

on cost, mortality, or other health outcomes.

When compared to the availability of hospital-based 

discharge planning services, fewer systems exist to assist patients after discharge from the hospital. Often, 

patients experience problems which arise after their 

hospital discharge, but prior to a follow-up appointment. 

During this time, hospital discharge planners are not always available, and the patient’s primary care medical 

home may be unaware of the hospitalization. Specific 

problems that may arise during the transition of care 

from the hospital include inaccurately reconciled medication lists, inadequate access to appropriate social support or transportation to appointments, poorly coordinated postdischarge home medical services, or lack of 

access to a physician for follow-up outpatient care. Each 

of these issues can contribute to medical errors, patient 

morbidity, and rehospitalization rates.4,5 As these problems have become more apparent, they have become increasingly studied in an attempt to decrease costs while 

improving patient safety and the quality of care delivered during the transition periods.

One of the strongest bodies of evidence supporting 

a deliberate approach to facilitating care transitions 

is described in Boston University’s Project RED (ReEngineered Discharge) research group (https://www.

bu.edu/fammed/projectred/). Project RED researchers 

executed and evaluated strategies for successful patient 

transition from the inpatient to the outpatient care settings. Through the development and implementation of 

their first discharge protocol, Project RED significantly 

reduced both hospital readmissions and postdischarge 

visits to the ED.6 As an additional part of their project, 

they published a tool kit for other health teams to employ 

when discharging patients.7 Other studies demonstrated 

Implementation of a Transition of Care

 Coordinator at a Military Treatment Facility

LTC Dana Nguyen, MC, USA CPT Sarah Strickland, MC, USA

CPT Blake Busey, MC, USA CPT Ashley Roselle, MC, USA

LTC Mark Stackle, MC, USA CPT Scott Hahn, MC, USA

Tammy Donoway, DO CPT Nick Bennett, MC, USA

Abstract

A patient’s transition from the inpatient to the outpatient setting is complex and prone to medical errors. This 

subsequently increases patient morbidity and cost to the healthcare system.

Methods: Our quality improvement initiative used a licensed clinical social worker from within a Family Medicine residency clinic to serve as a Transitions of Care Coordinator (TOCC) with the goal of decreasing patient 

morbidity and system cost.

Results: The number of documented patient contacts by our primary care office in the postdischarge period 

increased significantly after implementation of the TOCC (3.1% vs 40.2%, P=.01). Pearson correlation during 

our postimplementation period suggested an inverse relationship between contact by a TOCC and emergency 

department (ED) and hospital utilization rates (r=-0.68, P=.05 and r=0.062, P=.005, respectively). However, 

the percentage of ED visits (11.9% vs 20.8%, P=.02) and hospital readmissions (5.6% vs 13.7%, P=.01) significantly increased overall between the pre-and postimplementation periods.

Conclusions: The implementation of a TOCC within a military Family Medicine residency clinic significantly 

increased the frequency of ED visits and readmissions to the inpatient service for patients discharged from the 

Family Medicine inpatient service.
48 http://www.cs.amedd.army.mil/amedd_journal.aspx

similar evidence with regard to the effect of discharge 

planning protocols on ED utilization and hospital readmission rates.8-11

Studies such as these have led to campaigns throughout 

the United States designed to improve the quality of patient care delivered during this transition period. One of 

the largest such campaigns is the 2010 Partnership for 

Patients Campaign led by the Department of Health and 

Human Services. As part of this campaign, over 3,700 

hospitals have collaborated in order to make hospitals 

safer, less costly, and more reliable. One of the 2 cornerstone goals of the Partnership for Patients campaign is to 

reduce hospital readmissions by 20%.12 The Department 

of Defense and the Military Healthcare System (MHS) 

joined other federal agencies to support the Partnership 

for Patients campaign.13 As part of its campaign, the 

MHS recommended adoption of the Project RED toolkit 

within its healthcare facilities.

Based on this MHS recommendation and other local 

mandates to improve the quality of healthcare within 

our institution, the leadership of the Womack Army 

Medical Center established a Project RED team to facilitate transitions of care throughout its health system. 

As part of this effort, the Family Medicine residency 

clinic implemented the use of a licensed clinical social 

worker to serve as the transitions of care coordinator 

(TOCC) for patients enrolled in the residency clinic and 

cared for by the Family Medicine inpatient team. The 

TOCC’s primary role was to enable effective and safe 

transitions of care from the inpatient ward to the followup outpatient appointment. With the implementation of 

the TOCC, our objectives were to increase the number 

of patients that had follow-up appointments with their 

primary care manager (PCM) shortly after hospital discharge, identify and assist with patient problems posthospitalization, decrease the frequency of emergency 

department (ED) visits posthospitalization, decrease 

hospital readmissions to the Family Medicine inpatient 

team, and improve the overall quality of care for our 

high acuity patients. Overall, we aimed to study the 

relative quality metrics associated with implementation 

of a transitions of care coordinator within an academic 

clinic in the MHS.

Methods

This study was conducted as a local quality improvement initiative. Within our Family Medicine residency 

clinic at a large Army military treatment facility, we 

implemented a TOCC to facilitate a smoother transition 

to outpatient healthcare for patients recently discharged 

from the hospital. We chose a licensed clinical social 

worker to assume this role.

The initial step in our transition of care protocol was 

for the TOCC to contact all patients discharged from 

the Family Medicine inpatient team within 48 hours of 

discharge. The TOCC used a structured interview script 

based on Project RED guidelines which reviewed the patient’s diagnosis, discharge medications, follow-up appointments, consultations, and overall plan of care. The 

TOCC was also responsible for confirming that each of 

the patients had a follow-up visit in our clinic (preferably with the primary care manager), answering patients’ 

questions about their hospitalization, ensuring patients 

received any indicated postdischarge services, bringing 

medication reconciliation questions to the attention of 

the inpatient team and the PCM, and addressing any additional patient concerns. The TOCC conducted these 

encounters telephonically and documented the results 

within the electronic medical record.

All adult admissions to the Family Medicine inpatient 

team from February 2013 through March 2014 were 

evaluated monthly for primary outcomes data. Chart reviews were conducted with the following primary outcome variables recorded:

1. Number of patients contacted by the TOCC 

within 48 business hours.

2. Number of patients who completed a follow-up 

visit within 7 days of discharge in our practice.

3. Number of patients who completed a follow-up 

visit within 7 days of discharge with their PCM.

4. Number of patients who completed a follow-up 

visit within 14 days of discharge in our practice.

5. Number of patients who completed a follow-up 

visit within 14 days of discharge with their PCM.

6. Number of ED visits within 30 days of admission.

7. Number of readmissions to our facility within 

30 days of discharge.

A run chart was constructed from this data to identify 

any emerging trends. At 6 months following the TOCC 

implementation, the data was analyzed by run charts as 

well as via SPSS Statistics 20.0 (IBM Corp, Armonk, 

New York) analysis. 

Results

Table 1 shows the demographic characteristics of the patient groups admitted to the Family Medicine inpatient 

adult medicine service during the preimplementation 

and the postimplementation periods. Outcome variables 

were assessed comparing the preimplementation and the 

postimplementation periods for the TOCC. During this 

analysis, we did not consider whether the TOCC actually contacted the patient during the postimplementation 

IMPLEMENTATION OF A TRANSITION OF CARE COORDINATOR

AT A MILITARY TREATMENT FACILITY
January – March 2016 49

THE ARMY MEDICAL DEPARTMENT JOURNAL

period, as this happened within 48 hours in only 40% 

of cases. Table 1 also compares outcome variables for 

these periods regardless of TOCC contact. As expected, 

the number of documented patient contacts by our primary care office in the postdischarge period increased 

significantly after implementation of the TOCC (3.1% vs 

40.2%, P=.01). Additionally, the percentage of ED visits (11.9% vs 20.8%, P=.02) and hospital readmissions 

(5.6% vs 13.7%, P=.01) increased during the postimplementation period.

Figure 1 shows the run chart of primary outcome measures after we implemented the TOCC. Over the course 

of 6 months, the number of patients from our practice 

contacted within 48 business hours after hospital discharge rose from approximately 20% to 70%. During 

this time period, the percentage of patients completing 

a follow-up appointment within 14 days of discharge 

also increased. This increase also included the number of patients that were able to see their PCM. The 

percentage of ED visits as well as the percentage of 

patients readmitted within 30 days appeared to have 

a declining trend after our implementation. No trends 

were identified for patients following-up within 7 days 

of discharge.

The postimplementation data was analyzed for correlations using Pearson product moment correlation. The 

Pearson coefficients between variables is presented in 

Table 2. In the post implementation period, receiving 

a phone call within 48 hours postdischarge from our 

TOCC correlated inversely with 30-day readmissions, 

as well as ED visits following hospital discharge (r=

-0.68, P=.05 and r=0.062, P=.005, respectively). The 

14-day PCM follow-up visit also correlated, though less 

strongly, with decreased ED visits and 30-day readmissions following discharge (r=-0.13, P=.017 and r=

-0.31, P=.006, respectively).

The postimplementation period was also analyzed to 

determine if an actual contact within 48 hours by the 

TOCC or within 14 days by the PCM made differences 

in patient outcomes among this group. Tables 3 and 4 

show this data. Contact by the TOCC within 48 hours 

did not significantly change the frequency of posthospitalization ED utilization or hospital readmission rates. 

Patient follow-up within 14 days of hospitalization with 

the PCM led to an increase in ED visits (14.9% vs 27.3%, 

P=.02), but did not lead to significant differences in readmission rates.

Finally, data from February and March of 2013 was 

compared to data from February and March of 2014 to 

identify possible seasonal variation. In 2014, there was 

a slight reduction in ED visits following implementation 

of the TOCC (Figures 2 and 3). Between 2013 and 2014, 

there was an absolute rate reduction of 3.2% and 2.4% for 

ED visits in February and March, respectively. Between 

2013 and 2014, there was an absolute rate increase of 

3.8% in February 2014 and reduction of 4.9% in March 

2014 for 30 day hospital readmissions, respectively.

Comment

As part of our study design, we theorized that the implementation of a TOCC would decrease health care utilization within our system, specifically with ED visits 

and hospital readmissions within 30 days. However, 

Table 1. Comparison of patient outcome variables for 

preimplementation vs postimplementation of a TOCC. 

PreimplementationPostimplementationP

value

Demographics

Patients (N) 160 256

Men (%N) 82 (51.2%) 125 (48.8%)

Average Age (years) 57 61

Outcome Results [n(%N)]

48-hour Call 5 (3.1%) 103 (40.2%) .01

7-day Appt 77 (48.1%) 128 (50.0%) .71

7-day PCM Appt 47 (29.4%) 84 (32.8%) .46

14-day Appt 106 (66.3%) 171 (66.8%) .91

14-day PCM Appt 68 (42.5%) 121 (47.3%) .34

ED Visits 19 (11.9%) 53 (20.8%) .02

30-day Readmission 9 (5.6%) 35 (13.7%) .01

Figure 1. Trend lines for monthly reports of primary outcome 

measures following implementation of TOCC 48-hour call back.

ED Visits per Admission

14-day Follow-up

30-day Readmission

48-Hour Call 

14-day PCM

Notes:

(a) Standardized script

(b) ED electronic medical

record implementation

(c) Direct counseling

Sep

2013

(a)

Oct

2013

(b)

Nov

2013

(c)

Dec

2013

Jan

2014

Feb

2014

Mar

2014

40%

50%

0%

30%

60%

20%

70%

10%

80%

90%
50 http://www.cs.amedd.army.mil/amedd_journal.aspx

review of the overall preimplementation and postimplementation data suggests that our population’s ED visits 

and readmissions actually increased after our TOCC 

initiative. Similarly, when considering the possible benefits of provider continuity in the postdischarge period, 

we theorized that higher rates of PCM visits would decrease utilization rates. This was not the case, however, 

as patients seeing their PCM within 14 days during our 

postimplementation period had significantly higher ED 

utilization and hospital readmission rates.

The cause of these seemingly paradoxical results is 

unclear. Patients typically have increased morbidity 

rates in the posthospitalization period. Increased contact by our outpatient practice may be simply identifying problems or complications at an earlier time period. 

Although this may negatively affect utilization rates, it 

may be providing improved quality of care in regard to 

long-term patient outcomes. This was not evaluated in 

our study. Also, examining data from across our entire 

medical center would generate stronger statistical power 

to assess the increased utilization rates.

In our postimplementation period, higher rates of timely 

contact by the TOCC was inversely correlated with the 

ED and hospital utilization rates, as evaluated by a Pearson correlation. However, χ2 analysis of these measures 

in the same period did not show significantly decreased 

rates of utilization for those same patients. These trends 

still suggest promise of utilization and cost savings benefit to our hospital as the program continues to mature.

IMPLEMENTATION OF A TRANSITION OF CARE COORDINATOR

AT A MILITARY TREATMENT FACILITY

Table 2. Pearson Correlation Coefficients between primary outcome variables post-TOCC implementation.

Pearson Correlation Coefficients

r P value

48-hour Call

14-day Follow-up 0.23 .016

14-day PCM follow-up 0.63 .936

ED visits per admission -0.68 .050

30-day Readmission -0.62 .005

14-day PCM

Follow-up

48-hour Call 0.63 .936

ED Visits per admission -0.13 .017

30-day Readmission -0.32 .001

Table 3. Comparison of emergency department and 

readmission outcomes between patients (N=256) 

who were contacted by the TOCC vs those who were 

not contacted.

48-hour Call No

n(%N)

Yes

n(%N)

P

value

Patients 153 (59.8%) 103 (40.2%)

ED Visits 30 (19.7%) 23 (22.3%) .62

30-day Readmission 22 (14.5%) 13 (12.6%) .67

Table 4. Comparison of emergency department and 

readmission outcomes between patients (N=256) 

that completed a follow-up appointment within 14

days and those that specifically saw their PCM).

14-day Follow-Up No

n(%N)

Yes

n(%N)

P

value

Patients 85 (33.2%) 171 (66.8%)

ED Visits 16 (19.0%) 37 (21.6%) .63

30-day Readmission 13 (15.5%) 22 (12.9%) .57

14-day PCM

Follow-Up

No

n(%N)

Yes

n(%N)

P

value

Patients 135 (52.7%) 121 (47.3%)

ED Visits 20 (14.9%) 33 (27.3%) .02

30-day Readmission 18 (13.4%) 17 (14.0%) .89

Figure 2. Comparison of outcome data between a preimplementation month (February 2013) and a postimplementation 

month (February 2014).

48-hour Call ED Visits per

Admission

30-day

Readmission

40%

50%

0%

30%

60%

20%

10%

Feb 2014

Feb 2013

0%

5.0%

52.9%

8.8%

15.0%

11.8%

Figure 3. Comparison of outcome data between March 2013 

(preimplementation) and March 2014 (postimplementation).

20.0%

10.0%

3.3% 5.1%

17.6%

71.8%

48-hour Call ED Visits per

Admission

30-day

Readmission

40%

50%

0%

30%

60%

20%

70%

10%

80%

Mar 2014

Mar 2013
January – March 2016 51

THE ARMY MEDICAL DEPARTMENT JOURNAL

The implementation of a TOCC led to a significant portion of our practice patients being contacted within 48 

hours of a hospitalization. The goal of 100% patients 

contacted with 48 hours of discharge was not met due 

to transfers to other facilities, deaths, and a myriad of 

administrative challenges.

Timely patient contact was hampered by incorrect phone 

numbers, patients who did not return phone calls, and 

the lack of an alternate TOCC when the primary TOCC 

was on vacation or ill. Despite these limitations, most 

patients not contacted within the first 48 hours following 

discharge were contacted by our practice within a week.

The use of a licensed clinical social worker as our TOCC 

is unique since most facilities use nurses for this function. The potential drawbacks of using a social worker 

in the role include unfamiliarity with the medications 

reviewed as part of the 48-hour telephone encounter. To 

mitigate this issue, when our TOCC identified a medicine reconciliation issue, he relayed the concern to both 

the discharging inpatient team as well as to the PCM. 

The advantages of using a social worker as a TOCC include an understanding of how to navigate a complex 

medical system, experience in the coordination of outpatient specialty referrals and appointments, and an appreciation of the influence of family dynamics on a patient. Additional benefits of employing a social worker 

in this role include professional training and experience 

with counseling patients and clear communication and 

emotional support.

There are several limitations to our study. We did not 

consider variables other than those described above. 

During the period that the TOCC was established, additional changes within our health system occurred which 

may have influenced our results. The Family Medicine 

inpatient team standardized the written discharge summary and instructions given to all patients. Additionally, 

the ED transitioned from a paper health record to an 

electronic medical record. Each of these changes may 

have independently affected our study’s outcomes or the 

ability to capture data accurately. The standardized discharge summary was part of an overall quality improvement measure for the Family Medicine inpatient team 

and was designed in accordance with Project RED and 

Medicare documentation requirements with their emphasis on improved readability. Additionally, we only 

studied patients within our military medical system. 

Our practice patients who were admitted to hospitals 

other than our facility were not included in the analysis.

Despite the unanticipated outcomes involving ED utilization and hospital readmission rates after our intervention, the strategies used by our team within this quality 

improvement initiative subjectively enhanced communication and coordination of care within our practice. 

These benefits included clear communication of the 

study’s objectives, a standardized script for the TOCC, a 

standardized discharge summary format for the Family 

Medicine inpatient team, and the establishment of common, obtainable goals. We believe that the value we derived from these strategies can be replicated, and should 

be used throughout the MHS.

Conclusion

The implementation of a TOCC within an academic 

clinic at a large MTF has significantly increased our patient population’s frequency of ED visits and hospital readmissions after discharge. However, trends during our 

postimplementation period suggest possible future benefit of a TOCC if assessed over a longer period of time. 

The broader medical literature still largely supports an 

overall cost, quality, and utilization benefit by improving transitions in care. Therefore, the MHS should investigate the utility of this effort on a larger scale.

References

1. Forster AJ, Murff HJ, Peterson JF, Gandhi TK, 

Bates DW. The incidence and severity of adverse 

events affecting patients after discharge from the 

hospital. Ann Intern Med. 2003;138(3):161-167.

2. Forster AJ, Clark HD, Menard A, et al. Adverse 

events among medical patients after discharge 

from hospital. CMAJ. 2004;170(3):345-349.

3. Shepperd S, Lannin NA, Clemson LM, McCluskey 

A, Cameron ID, Barras SL. Discharge planning 

from hospital to home. Cochrane Database Syst 

Rev. [serial online]. 2013;1.

4. Davis MM, Devoe M, Kansagara D, Nicolaidis 

C, Englander H. “Did I Do as Best as the System 

Would Let Me?” Healthcare professional views on 

hospital to home care transitions. J Gen Intern Med. 

2012;27(12):1649-1656.

5. Balaban RB, Weissman JS, Samuel PA, et al. Redefining and redesigning hospital discharge to enhance patient care: a randomized controlled study. 

J Gen Intern Med. 2008;23:1228-1233.

6. Jack BW, Chetty VK, Anthony D, et al. A re-engineered hospital discharge program to decrease rehospitalization: a randomized trial. Ann Intern Med. 

2009;150(3):179-197.
52 http://www.cs.amedd.army.mil/amedd_journal.aspx

7. Jack B, Greenwald J, Forsythe S, et al. Developing 

the tools to administer a comprehensive hospital 

discharge program: the ReEngineered Discharge 

(RED) Program. In: Henriksen K, Battles JB, 

Keyes MA, et al, eds. Advances in Patient Safety: New Directions and Alternative Approaches 

(Vol 3:Performance and Tools). Rockville, MD: 

Agency for Healthcare Research and Quality. 2008. 

Available at: http://www.ncbi.nlm.nih.gov/books/

NBK43688/. Accessed December 24, 2015.

8. Coleman EA, Parry C, Chalmers S, Min SJ. The 

care transitions intervention: results of a randomized controlled trial. Arch of Intern Med. 

2006;166:1822-1828.

9. Allen J, Hutchinson AM, Brown R, Livingston 

PM. Quality care outcomes following transitional 

care interventions for older people from hospital to 

home: a systematic review. BMC Health Serv Res. 

2014;14:346.

10. Cauwels JM, Jensen BJ, Winterton TL. Giving readmission numbers a BOOST. S D Med. 

2013;66(12):505-509.

11. Constantino ME, Frey B, Hall B, Painter P. The 

influence of a postdischarge intervention on reducing hospital readmissions in a medicare population. 

Popul Health Manag. 2013;16(5):310-316.

12. Department of Health and Human Services. Partnership for Patients Campaign Website. Available 

at: http://partnershipforpatients.cms.gov/. Accessed 

January 10, 2015.

13. Military Health System. Implementation Guide 

for Readmissions. Washington, DC: US Dept of 

Defense; February 13, 2014. Available at: http://

www.health.mil/Reference-Center/Technical-Doc

uments/2014/02/13/Implementation-Guide-for-Re

admissions. Accessed January 10, 2015.

Authors

LTC Nguyen is Clerkship Director, Department of Family Medicine, Uniformed Services University of the 

Health Sciences, Bethesda, Maryland.

CPT Busey is a Staff Physician, Soldier Family Medical 

Clinic, Fort Bliss, Texas.

LTC Stackle is Deputy Commander for Clinical Services, BG Crawford Sams US Army Health Clinic, Camp 

Zama, Japan.

Dr Donoway and CPT Roselle are Staff Physicians, Department of Family Medicine, Womack Army Medical 

Center, Fort Bragg, North Carolina.

CPT Strickland is a Staff Physician, Reynolds Army 

Community Hospital, Fort Sill, Oklahoma.

CPT Hahn is a Staff Physician, Darnall Army Community Medical Center, Fort Hood, Texas.

CPT Bennett is a Staff Physician, Farrelly Health Clinic, 

Fort Riley, Kansas.

IMPLEMENTATION OF A TRANSITION OF CARE COORDINATOR

AT A MILITARY TREATMENT FACILITY
January – March 2016 53

Individual body dimensions and derived characteristics 

are reflected in the physical activity level (PAL). For 

example, it has been shown that the body mass index 

(BMI) and body fat percentage of children correlate 

negatively with their physical activity.1 If the PAL is 

changed by a daily target number of steps being set and 

the use of pedometers, parameters like BMI, body fat 

percentage, and weight can be influenced.2 Data have 

been collected on the classification of physical activity 

and its importance for a healthy lifestyle.3 It has been 

postulated that adults over 30 years of age should take 

an average of more than 10,000 steps a day to reduce 

their risk of developing disorders associated with inactivity.3

 Various disorders, eg, the risk of cardiovascular 

diseases, can be influenced positively by an adequate 

activity level.4 Woolf et al have shown that, in addition 

to physical activity, age and diet have a significant influence on body dimensions and that there is a specific 

interdependence among these factors.5

Recommendations regarding exercise should be adjusted to specific factors. For example, it is recommended 

that children take up to 12,000-15,000 steps a day in order to be rated as active and to have a positive effect on 

their state of health.6 Appropriate guidelines have also 

been published for older people.7 Moreover, evidence 

suggests that the positive effects of exercise on body 

dimensions and health risks also differ between office 

workers and workers who do physical work.8 Irrespective of this, it was shown that exercise during leisure 

time correlates with the level of training. Workers who 

do physical work and craftsmen exercise less during 

their leisure time than office workers.9 Attitudes towards 

physical activity differ with gender. They are particularly associated with sociocultural influences. For example, 

men in southeast Asia show a higher level of physical 

activity, while no standard gender differences have been 

observed in Western industrial nations due to different 

factors influencing working and private lives.9,10 In addition, office workers and executive personnel usually 

have a lower level of physical activity during working 

hours, and this entails health risks.11 Soldiers need high 

PAL in their physical training to be prepared for deployment.12 Studies from the US Army showed that physical 

activity is also dependent on the specific type of training the Soldier is conducting.13 During deployment, Soldiers showed decreased physical activity compared to 

that experienced during predeployment preparation.14

Influence of Individual Determinants on

 Physical Activity at Work and During

 Leisure Time in Soldiers: A Prospective

 Surveillance Study

Maj Christoph Schulze, MD, German Air Force Lt Marie Müller, German Army

Tobias Lindner, PhD Wolfram Mittelmeier, MD

Capt Pauline Goethel, MD, German Navy Rainer Bader, MD

Abstract

Quantified physical activity is an important parameter for evaluating the risk of the incidence of internal and 

musculoskeletal disorders. The objective of this study was to evaluate the physical activity of German Soldiers 

on duty and during leisure time with regard to individual determinants and to evaluate if factors associated 

with the risk of the incidence of internal or musculoskeletal disorders are of relevance for physical activity.

For this purpose, we conducted activity measurements on 169 subjects. The accelerometer-based activity sensor was worn for 7 consecutive days. The number of steps taken was evaluated as an activity marker.

We observed that a high body mass index and a large waist circumference were associated with a low activity level. Women were found to be more active than men, particularly during leisure time. Personnel under 25 

years of age were more physically active than those between 25 and 50 years of age. Subjects with underlying 

musculoskeletal disorders were less active than those who had internal disorders or were healthy. Men and 

overweight people run a higher risk of developing musculoskeletal and internal disorders.

Health promotion should focus on raising the physical activity level with the aim of exerting a positive influence on the associated risk factors.
54 http://www.cs.amedd.army.mil/amedd_journal.aspx

The extent to which physical activity of Soldiers is influenced by factors such as age, BMI, waist circumference, 

gender, and job is not yet fully clear. For this reason, we 

conducted this study to evaluate the physical activity of 

a personnel cohort on duty and during leisure time with 

regard to individual physical determinants. Our study 

was also intended to evaluate how far above mentioned 

risk factors known to influence the incidence of musculoskeletal disorders, injuries, and internal disorders are 

of relevance in the case of Soldiers.

Methods

The study was conducted with 169 subjects (142 male, 

27 female). Twenty-five subjects were officers, 89 were 

noncommissioned officers (NCO), and 55 were junior 

enlisted personnel. Ninety-seven subjects mainly did office work, while 72 mainly did physical work. The mean 

age of the subjects was 27.5±8.3 years, their mean weight 

was 84.3±16.4 kg, their mean BMI was 26.6±4.3 kg/m2, 

and their mean waist circumference was 90.2±13.3 cm. 

The subjects underwent a medical examination. Only 

Soldiers who did not show any acute limiting disorder 

that prevents him or her from doing regular service were 

included. Health records of each participant were evaluated with regard to musculoskeletal disorders, injuries, 

internal disorders, and regular use of medication.

To be as precise as possible, an activity profile was produced which distinguishes for time spent walking, standing, or lying/sitting covering the duty hours and leisure 

time of the subjects 24 hours a day over a period of 7 

consecutive days.15 Physical activity was measured by 

using the wearable sensor activPAL (PAL Technologies, 

Glasgow, UK). The activPAL is an accelerometric sensor that can detect a person’s body position, any changes 

in this position, the steps taken, and the step frequencies 

(measuring frequency: 10 Hz), as well as calculate the 

energy the person consumed on the basis of these data. 

Reliability of this sensor was tested by Dahlgren et al.16

Following the manufacturer’s instruction, after activation, the sensor was taped onto the midline of the right 

anterior thigh of the subjects. The participants were also 

asked to keep a daily activity log, which was correlated 

with the readings. These results were assigned to distinct 

measuring points in the activity log, eg, start of duty, 

end of duty, breaks, night rest, and exercise. The study 

was approved by the ethical committee of the University 

of Rostock (Reference No. A 2009 36) and we obtained 

a written informed consent from each participant.

Statistical Analysis

Descriptive statistics were determined (mean, standard 

deviation, minimum, and maximum). The statistical 

significance test between the groups was based on an 

analysis of variance (ANOVA and post hoc least significant difference test). Paired comparisons were checked 

using an independent sample t test. The level of significance was established at P≤.05. F-statistic and eta2

 were 

reported. All the data were computed using the SPSS 

statistical program version 21.0 (SPSS Inc, Chicago, IL, 

USA).

Additionally, a bipartite analysis was conducted. First, 

the categorisation of the study cohort examined according to the various parameters (waist circumference, BMI, 

age, state of health, gender, and job) was conducted as 

a basis for assessing whether there was a difference in 

activity between built up groups. In a second statistical 

analysis, the relationships between the above-mentioned 

parameters and significant predictors of physical activity were determined in subsequent correlation and regression analyses. Therefore, the individual parameters 

were correlated with one another or whether there were 

specific predictors of physical activity. For this purpose, 

a correlation analysis was conducted, ie, the calculation 

of Pearson’s correlation coefficient (r) for metric readings and Spearman’s correlation coefficient for category readings (CS). A multiple linear regression analysis 

was conducted. The coefficient of determination (R2), 

the standardized regression coefficient (ß), and the nonstandardized regression coefficient (b) of the predictors 

together with the Pearson correlation coefficient and 

semipartial correlation squared (sr 2) were reported. 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.17

Results

The mean awake time for the 169 participants was 16.5 

(±1) hours per day. As a mean, they passed 8,500 steps 

during that time. They were sitting or lying 65.6% 

(±7.5%) of that time. Only 10.2% (±2.91%) of the time 

awake was spent walking. and 24.2% (±5.6%) of the time 

awake was spent standing. Only 41 Soldiers reached the 

recommended step count of 10,000 steps/day.

Influence of Individual Physical Determinants

Age

Subjects were divided into 5 groups by age in years: <25, 

25 to 30, 31 to 40, 41 to 50, >50. This classification was 

used to produce a distribution of participants such that 

there were enough participants in every group. Considering the subjects’ ages, participants under 25 years of 

age were significantly more active than those between 

25 and 50 years of age as shown in Figure 1 and Table 

1. There were no significant differences among the subjects aged 25 years or more in the various age groups. 

INFLUENCE OF INDIVIDUAL DETERMINANTS ON PHYSICAL ACTIVITY AT WORK AND

DURING LEISURE TIME IN SOLDIERS: A PROSPECTIVE SURVEILLANCE STUDY
January – March 2016 55

THE ARMY MEDICAL DEPARTMENT JOURNAL

Table 1 and Figure 1 shown that 

subjects over 50 years of age were 

just as active as those under 25 

years of age. Increased activity 

during duty hours correlated positively with subjects of a young 

age (r=0.24; P=.002). A negative correlation was observed 

between a high PAL, particularly 

during leisure time, and older age 

(r≤-0.177; P≤.021). Older age 

correlated with a higher weight 

(r=0.314; P<.001), a larger waist 

circumference (r=0.444; P<.001), 

and a higher BMI (r=0.361; 

P<.001).

Job Position at Work

The number of steps taken per 

hour during work time decreased 

among subjects who had a higher 

or senior job position, shown in 

Table 2. During leisure time, officers were more active than NCOs, 

and junior enlisted personnel 

tended to be more active than 

NCOs (Table 1). Mean BMI of the 

NCOs was 26.7 kg/m2, and thus 

tendentially higher than that of officers (BMI 25.5 kg/m2, 

P=.071) and significantly higher than that of junior enlisted personnel (BMI 25.3 kg/m2, P=.011). This trend is 

also evident with regard to waist circumference (officer 

and junior enlisted, 87 cm; NCO, 92.5 cm; P=.015 and 

P=.004, respectively).

Low-level positions at work correlated negatively with 

the incidence of internal disorders (CS=-0.339; P<.001) 

and disorders of the locomotor system (CS=-0.302, 

P<.001) and positively with high activity levels on duty 

(CS=0.278; P<.00

Gender

Altogether, women showed a higher activity level than 

men (F=3.91; P=.007) as shown in Figure 2. No relevant 

difference was observed during duty hours (F=1.834; 

P=.607). However, during leisure time the number of 

steps taken was significantly higher among the women 

than in the male comparison group (F=13.459; P<.001) 

(Figure 2). Female gender correlated with an increase 

in leisure activity (CS=0.205; P=.001). Furthermore, 

a high BMI correlated negatively with female gender 

(CS=-0.306; P<.001).

BMI

As shown in Figure 3, there was 

a significant difference in activity between Soldiers of normal 

weight (BMI<25 kg/m2) and overweight Soldiers (BMI between 25 

and 30 kg/m2). Subjects of normal weight achieved a higher step 

count than overweight subjects 

(F=2.131; e2=170760.611; P=.04). 

Participants of normal weight got 

up to 42 minutes more sleep a day 

than obese subjects (P=.048) and 

24 minutes more than overweight 

subjects (P=.012).

Waist Circumference

Soldiers with a large waist circumference were less physically 

active. Additionally, as shown 

in Figure 4 and Table 3, significant differences in the number 

of steps taken during duty hours 

and leisure time were observed 

between the groups studied. The 

difference in leisure time activity was particularly clear. Soldiers 

with a waist circumference below 

90 cm were markedly more active 

Table 1. P-values of the comparison of activity 

levels in relation to age groups for whole day, leisure time period, and on duty period as shown 

in Figure 1.*

Whole Day

Age

Group (y)

25-30 31-40 41-50 >50

<25 .001 .07 .014 .0648

25-30 .0331 .0783 .0292

31-40 .0333 .063

41-50 .0268

Leisure Time

Age

Group (y)

25-30 31-40 41-50 >50

<25 .015 .0453 .051 .0739

25-30 .024 .0694 .0167

31-40 .022 .0493

41-50 .0141

On Duty

Age

Group (y)

25-30 31-40 41-50 >50

<25 .009 .009 .023 .0239

25-30 .0676 .0547 .0992

31-40 .0798 .0826

41-50 .0706

*Note: Whole day: F=3.901; e2=397645.31; P=.005

Leisure time: F=2.212; e2=334402989; P=.07

On duty: F=3.346; e2=762120.334; P=.012

0

100

200

300

400

500

600

700

800

900

1000

<25

(n=81)

25-30

(n=43)

31-40

(n=26)

41-50

(n=13)

>50

(n=6)

Steps/h Whole Day Steps/h Leisure Time Steps/h on Duty

Age (years)

Steps per Hour

Figure 1. Influence of age on physical activity levels. Plotted 

steps per hour (steps/h) is the mean (±SE) of the detected steps 

of participants by age group over each daily measuring period 

category. Note: N=169 total participants.
56 http://www.cs.amedd.army.mil/amedd_journal.aspx

during their leisure time than those with a larger 

waist circumference. No significant differences 

in physical activity were observed among subjects with a waist circumference above 90 cm. A 

large waist circumference correlated negatively 

with female gender (CS=-0.412; P<.001) and 

fixed-term employment contracts (CS=-0.292; 

P<.001). A larger waist circumference correlated positively with a higher BMI (CS=0.744; 

P<.001), older age (CS=0.45; P<.001), the incidence of internal disorders (CS=0.327; P<.001) 

or orthopedic disorders (CS=0.302, P<.001), and 

use of medication (CS=0.241; P<.002). A negative correlation was observed between a high PAL, particularly 

during leisure time, and older age (r≤-0.177; P≤.021), 

waist circumference (r≤-0.253; P≤.001), and BMI (r≤-

0.158; P≤.04).

State of Health

The analysis showed that the activity levels of subjects 

with preexisting chronic internal disorders (hypertension, hyperuricemia (n=22)) did not differ significantly 

from those of healthy subjects. Subjects with chronic 

orthopedic (n=24) or chronic internal and orthopedic disorders (n=15) took approximately 100 steps per 

hour less than healthy subjects (F=2.981; e2=155.091; 

P=.017) or subjects who only had preexisting internal 

disorders (P=.03).

Subjects with a history of acute injury to the locomotor system (distortion of the upper ankle joint, muscle 

injuries) were less physically active. Subjects without a 

history of injury (n=135) were physically active (time 

spent waking) for 12.5% of their duty hours, while this 

figure was 10.5% for subjects with a history of injury 

(n=34) (F=0.597; P=.01). Regarding leisure activity, 

there were no significant differences between subjects 

with and without a history of injury. Short-term employment contracts (12 to 24 months) correlated negatively with internal disorders (CS=-0.459; P<.001), 

injuries suffered due to exercise (CS=-0.447, P<.001), 

use of medication (CS=-0.302; P<.001), and BMI (CS=

-0.299; P<.001). There was no significant correlation between an increase in body dimensions (BMI and waist 

circumference) or low levels of physical activity and the 

number of visits to a doctor. The amount of exercise the 

subjects performed also did not correlate with the number of visits to a doctor. However, increased physical activity on duty correlated negatively with the incidence of 

injuries (CS=-0.152; P<.049).

Correlation and Regression Analysis of the 

Determinants-Predictors of Activity

In the following sections we describe the results of the 

correlation and regression analysis of the influence of 

known risk factors of internal and orthopaedic diseases 

on physical activity. We investigated the effect of the risk 

factors on step count per day as well as on step count per 

hour in mean, leisure time and on duty. In order of appearance, we identified waist circumference, BMI, age, 

and gender to be the main predictors of physical activity.

Step Count Per Hour (Mean)

The statistic model was significant at F=4.645 (P=.001), 

and the model equation correlated to R=0.321 with 

the criterion variable (R2=0.103; R2adjusted=0.081; 

f 2=0.115; power=0.99). The variance in the mean step 

count per hour was predicted to a significant extent by 

the variable waist circumference (ß=-0.511; b=-6.374; 

SE=2.059; P=.002; r=-0.283; sr 2=0.06). Waist circumference accounted for 10.3% of the variance in the mean 

step count per hour.

INFLUENCE OF INDIVIDUAL DETERMINANTS ON PHYSICAL ACTIVITY AT WORK AND

DURING LEISURE TIME IN SOLDIERS: A PROSPECTIVE SURVEILLANCE STUDY

Table 2. Mean (±SE) step counts per hour of participants by military 

rank status over each daily measuring period category, with P-values of 

comparison among rank groups.

Military

Rank

Status

Steps per Hour P-values of

Comparison 

With NCO Count

P-values of

Comparison With 

Officer Count

On Duty Leisure

Time

On Duty Leisure

Time

On Duty Leisure

Time

Junior

Enlisted

725 (±245) 411 (±130) <.001 .057 <.001 .009

NCO 579 (±202) 434 (±208) <.001 .008

Officer 541 (±219) 537 (±247) <.001 .008

Figure 2. Influence of gender on physical activity levels. Plotted 

steps per hour (steps/h) is the mean (±SE) of the detected steps 

of participants by gender over each daily measuring period category. Note: N=169 total participants.

Steps/h Whole Day Steps/h Leisure Time Steps/h on Duty

Steps per Hour

0

100

200

300

400

500

600

700

800

900

1000

Male

(n=142)

Female

(n=27)
January – March 2016 57

THE ARMY MEDICAL DEPARTMENT JOURNAL

Step Count per Hour (During Duty Hours)

The statistic model was significant at F=3.051 (P=.019), 

and the model equation correlated to R=0.265 with 

the criterion variable (R2=0.07; R2adjusted=0.047; 

f 2=0.075; power=0.944). The variance in the step count 

per hour during work time was predicted to a significant extent by the variable age (ß=-0.215; b=-6.351; 

SE=2.517; P=.013; r=-0.153). Age accounted for 7% 

of the variance in the step count per hour during duty 

hours.

Step Count per Hour (During Leisure Time)

The statistic model was significant at F=3.431 (P=.01), 

and the model equation correlated to R=0.279 with 

the criterion variable (R2=0.078; R2adjusted=0.055; 

f 2=0.085; power=0.96). The variance in the step 

count per hour during leisure time was predicted to a 

significant extent by the variable waist circumference 

(ß=-0.469; b=-6.972; SE=2.487; P=.006; r=-0.284; 

sr 2=0.033). Waist circumference accounted for 7.8% of 

the variance in the step count per hour during leisure 

time.

Step Count per Day (Mean)

The statistic model was significant at F=2.653 (P=.007), 

and the model equation correlated to R=0.362 with 

the criterion variable (R2=0.131; R2adjusted=0.082; 

f 2=0.151; power=0.999). The variance in the mean 

step count was predicted to a significant extent by the 

variables waist circumference (group) (ß=-0.417; b=

-6020.038; SE=1827.427; P=.001; r=-0.298; sr 2=0.06) 

and BMI (group) (ß=0.242; b =5609.392; SE=2687.715; 

P=.038; r=-0.128; sr 2=0.024). Waist circumference 

(group) and BMI (group) accounted for 13.1% (41.7%: 

24.2%) of the variance in the mean step count.

Step Count per Day (During Leisure Time)

The statistic model was significant at F=4.298 (P<.001), 

and the model equation correlated to R=0.443 with 

the criterion variable (R2=0.197; R2 adjusted=0.151; 

f 2=0.245; power=0.99). The variance in the step count 

during leisure time was predicted to a significant extent by the variables waist circumference (group) 

(ß=-0.352; b =-4196.461; SE=1451.402; P=.004; r=

-0.296; sr 2=0.009), BMI (group) (ß=0.221; b=4221.637; 

SE=2134.67; P=.05; r=-0.127; sr 2=0.02), and gender 

(ß=0.271; b=11369.217; SE=3394.708; P=.001; r=0.326; 

sr 2=0.057). Waist circumference (group), BMI (group), 

and gender accounted for 19.7% (35.2%: 22.1%: 27.1%: 

19.7%) of the variance in the step count during leisure 

time.

Comment

This study shows that some individual determinants correlate with physical activity. Analogous to the study conducted by Woolf et al, it has been shown that a large waist 

circumference correlates negatively with physical activity.5

 Our study has also shown that the leisure time PAL 

was particularly dependent on the waist circumference.

Waist Circumference in Centimeters

Steps per Hour

91-100

(n=35)

71-80

(n=34)

101-110

(n=24)

81-90

(n=55)

>110

(n=11)

<70

(n=10)

Steps/h Leisure Time

Steps/h on Duty

0

200

400

600

800

1000

1200

Figure 4. Influence of waist circumference on physical activity 

levels. Plotted steps per hour (steps/h) is the mean (±SE) of the 

detected steps of participants by BMI score grouping over each 

Figure 3. Influence of BMI on physical activity levels. Plotted daily measuring period category. Note: N=169 total participants.

steps per hour (steps/h) is the mean (±SE) of the detected steps 

of participants by BMI score grouping over each daily measuring 

period category. Note: N=169 total participants.

BMI in kg/m2

Steps per Hour

0

100

200

300

400

500

600

700

800

25-29

(n=63)

<25

(n=83)

30-34

(n=17)

≥35

(n=6)
58 http://www.cs.amedd.army.mil/amedd_journal.aspx

With regard to age, subjects under 25 years of age and 

over 50 years of age in particular showed a comparably 

high level of physical activity. The subjects in the age 

groups in between were less active, particularly during 

their leisure time. Subjects who had a history of injury 

to the locomotor system or suffered from a musculoskeletal disorder were less active than those who had only 

internal disorders or were healthy. Physical activity is 

thus limited by musculoskeletal disorders, which was 

specifically demonstrated for spondyloarthropathy.18

As a consequence of these factors, attention should be 

paid to the fact that the BMI and waist circumference increase in relation to the level of physical inactivity, particularly during leisure time, and constitute risk factors 

for the development of orthopedic and internal disorders. 

For example, a high body weight is a significant risk factor for the incidence of gonarthrosis.19,20

Regarding the influence of gender on physical activity, 

our survey is unlike the findings of Cheah et al10 in that 

we found women are more active than men, particularly during their leisure time. This also correlated with 

our finding that the female subjects had smaller waist 

circumferences and lower BMIs than the male subjects. 

All recruited women had fixed-term employment contracts. Irrespective of gender, it was revealed that people 

with fixed-term employment contracts were more likely 

to have normal values (BMI and waist circumference) 

than employees with contracts of indefinite duration.11

Other working group studies have shown that social status is an especially important predictor and that a low 

status correlates with poor health behavior.21 In our study, 

employment contracts of indefinite duration are associated with higher earnings and status within the cohort. 

Age is a key factor here. Some permanent employees 

had a lower status than some temporary employees who 

held executive positions. In an earlier study, we showed 

that noncommissioned officers, who are comparable to 

intermediate service employees, had a significantly unhealthier lifestyle than officers.11 The current study has 

also shown that officers are less physically active during 

duty hours than other comparison groups, but they compensate for this deficiency by increased leisure activity. 

Beenackers et al observed a greater health awareness in 

higher social classes.22 Our study has confirmed that in 

addition to affiliation to a specific job position group; 

age, waist circumference, BMI, and gender in particular 

constitute predictors of physical activity.

This study has some limitations. Environmental factors, 

which also affect physical activity, such as the area in 

which the subjects live, public transport, and the route 

they take to work or shopping facilities, have not been 

analyzed.23 The fact that the subjects were recruited 

from a single occupational group (Soldiers), the limited 

number of participants, and the resulting imbalance in 

their age and gender structure must also be acknowledged as limitations.

In summary, the present study identified waist circumference, BMI, age, and gender as essential predictors of 

physical activity. A large waist circumference, a high 

BMI, and the male gender correlate with low PALs, particularly during leisure time. The subjects under 25 years 

of age and between 50 and 60 years of age were more 

active than subjects between those age groups. 

Subjects with musculoskeletal disorders were less 

active than healthy subjects or those with internal 

disorders. Health promotion should focus on raising the physical activity level, particularly during 

leisure time, with the aim of exerting a positive 

influence on the associated risk factors.

References

1. Abbott RA, Davies PSW. Habitual physical 

activity and physical activity intensity: their 

relation to body composition in 50-105-y-old 

children. Eur J Clin Nutr. 2004;58:285-291.

2. Staudter M, Dramiga S, Webb L, Hernandez D, 

Cole R. Effectiveness of pedometer use in motivating active duty and other military healthcare beneficiaries to walk more. US Army Med 

Dep J. July-September 2011:108-119.

3. Tudor-Locke C, Bassett DR Jr. How many 

steps/day are enough? Preliminary pedometer 

indices for public health. Sports Med Auckl 

NZ. 2004;34:1-8.

INFLUENCE OF INDIVIDUAL DETERMINANTS ON PHYSICAL ACTIVITY AT WORK AND

DURING LEISURE TIME IN SOLDIERS: A PROSPECTIVE SURVEILLANCE STUDY

Table 3. P-values of the comparison of activity levels in relation to waist 

circumference for leisure time period and on duty period.*

Leisure Time

Waist

Circumference

71-80 cm 81-90 cm 91-100 cm 101-110 cm >110 cm

<70 cm .0023 <.0001 <.0001 <.0001 <.0001

71-80 cm .0018 .002 .0052 .001

81-90 cm .0836 .0994 .0246

91-100 cm .0871 .0328

101-110 cm .0295

On Duty

Waist

Circumference

71-80 cm 81-90 cm 91-100 cm 101-110 cm >110 cm

<70 cm .0195 .0579 .0878 .094 .065

71-80 cm .0189 .0076 .0088 .0048

81-90 cm .051 .0487 .0223

91-100 cm .0916 .045

101-110 cm .0521

*Note: Leisure time: F=3.604; e2=650258.13; P=.004

On duty: F=1.24; e2=370349.64; P=.293
January – March 2016 59

THE ARMY MEDICAL DEPARTMENT JOURNAL

4. Schmidt MD, Cleland VJ, Shaw K, Dwyer T, Venn 

AJ. Cardiometabolic risk in younger and older 

adults across an index of ambulatory activity. Am J 

Prev Med. 2009;37:278-284.

5. Woolf K, Reese CE, Mason MP, Beaird LC, Tudor-Locke C, Vaughan LA. Physical activity is 

associated with risk factors for chronic disease 

across adult women’s life cycle. J Am Diet Assoc. 

2008;108(6):948-959.

6. Tudor-Locke C, Pangrazi RP, Corbin CB, et al. 

BMI-referenced standards for recommended pedometer-determined steps/day in children. Prev 

Med. 2004;38(6):857-864.

7. Chodzko-Zajko WJ, Proctor DN, Fiatarone Singh 

MA, et al, and the American College of Sports Medicine. American College of Sports Medicine position stand. Exercise and physical activity for older 

adults. Med Sci Sports Exerc. 2009;41(7):1510-1530.

8. Asztalos M, Wijndaele K, De Bourdeaudhuij I, et al. 

Specific associations between types of physical activity and components of mental health. J Sci Med 

Sport. 2009;12(4):468-474.

9. Burton NW, Turrell G. Occupation, hours worked, 

and leisure-time physical activity. Prev Med. 

2000;31:673-681.

10. Cheah WL, Helmy H, Chang CT. Factors associated with physical inactivity among female and male 

rural adolescents in Borneo - a cross-sectional 

study. Int J Adolesc Med Health. 2014;26:447-453.

11. Schulze C, Lindner T, Goethel P, et al. Evaluation 

of the physical activity of German Soldiers depending on rank, term of enlistment, and task area. Mil 

Med. 2015;180(5):518-523.

12. Wyss T, Scheffler J, Mäder U. Ambulatory physical 

activity in Swiss Army recruits. Int J Sports Med. 

2012;33:716-722.

13. Simpson K, Redmond JE, Cohen S, et al. Quantification of physical activity performed during US 

Army Basic Combat Training. US Army Med Dep J. 

October-December 2013:55-65.

14. Carlson AR, Smith MA, McCarthy MS. Diet, physical activity, and bone density in Soldiers before 

and after deployment. US Army Med Dep J. AprilJune 2013:25-30.

15. Herrmann SD, Barreira TV, Kang M, Ainsworth 

BE. How many hours are enough? Accelerometer 

wear time may provide bias in daily activity estimates. J Phys Act Health. 2013;10:742-749.

16. Dahlgren G, Carlsson D, Moorhead A, Häger-Ross 

C, McDonough SM. Test-retest reliability of step 

counts with the ActivPAL device in common daily 

activities. Gait Posture. 2010;32(3):386-390.

17. Cohen J. Statistical Power Analysis for the Behavioral Sciences. 2nd ed. Mahwah, NJ: Lawrence Erlbaum Associates; 1988.

18. Swinnen TW, Scheers T, Lefevre J, et al. Physical 

activity assessment in patients with axial spondyloarthritis compared to healthy controls: a technology-based approach. PLoS One. 2014;9(2):e85309.

19. Trofa D, Smith EL, Shah V, Shikora S. Total weight 

loss associated with increased physical activity after bariatric surgery may increase the need 

for total joint arthroplasty. Surg Obes Relat Dis. 

2014;10:335-339.

20. Lee R, Kean WF. Obesity and knee osteoarthritis. 

Inflammopharmacology. 2012;20:53-58.

21. Schnohr C, et al Does educational level influence 

the effects of smoking, alcohol, physical activity, 

and obesity on mortality? A prospective population study. Scand J Public Health. 2004;32:250-256.

22. Beenackers MA, Kamphuis CB, Giskes K, et al. 

Socioeconomic inequalities in occupational, leisure-time, and transport related physical activity 

among European adults: a systematic review. Int J 

Behav Nutr Phys Act. 2012;9:116.

23. Van Holle V, Deforche B, Van Cauwenberg J, et 

al. Relationship between the physical environment 

and different domains of physical activity in European adults: a systematic review. BMC Public 

Health. 2012;12:807.

Authors

Major Schulze is with the Department of Orthopaedics, 

Rostock University Medical Center, Rostock, Germany. 

His military assignment is the Armed Forces Hospital, 

Westerstede, Westerstede, Germany.

Dr Lindner is scientifically affiliated with the Department of Orthopaedics, Rostock University Medical Center, Rostock, Germany.

Captain Goethel is scientifically affiliated with the Department of Orthopaedics, Rostock University Medical 

Center, Rostock, Germany. Her military assignment is 

the Rostock Military Medical Center, Rostock, Germany.

Lieutenant Müller is scientifically affiliated with the Department of Orthopaedics, Rostock University Medical 

Center, Rostock, Germany. Her military assignment is 

the Rostock Military Medical Center, Rostock, Germany.

Dr Mittelmeier is a Professor and head of the Department of Orthopaedics, Rostock University Medical Center, Rostock, Germany.

Dr Bader is a Professor at the Department of Orthopaedics, 

Rostock University Medical Center, Rostock, Germany.
60 http://www.cs.amedd.army.mil/amedd_journal.aspx

Median mononeuropathy at or distal to the wrist, or carpal tunnel syndrome, is the most common peripheral 

nerve compression disorder in the upper extremity.1-4

Carpal tunnel syndrome (CTS) is one of a number of 

muscle, tendon, and nerve-related disorders that affect 

people performing intensive work with their hands.5-7

Carpal tunnel syndrome is defined by the American 

Academy of Orthopaedic Surgeons as a symptomatic 

compression neuropathy of the median nerve at the level 

of the wrist, characterized physiologically by evidence 

of increased pressure within the carpal tunnel and decreased function of the nerve at that level.8

A thorough history and physical examination are considered essential screening tools for detecting signs and 

symptoms of peripheral neuropathy.9-12 Nerve conduction 

measurement is often performed on the median nerve to 

determine whether certain entrapment neuropathies are 

present, and nerve conduction studies are considered the 

gold standard or has criterion-related validation when 

assessing the electrophysiological status of the peripheral nerve.3,9-15 The electrophysiological examination 

including both nerve conduction and electromyography 

studies should identify the peripheral nerve, specific location in the nerve pathway, involvement of sensory and/

or motor axons, and the presence of myelinopathy and/

or axonopathy neuropathic process.10-12

Neurophysiological Classification Systems for

Patients With CTS

Different ways of expressing the severity of carpal tunnel syndrome are found in the existing literature and in 

clinical records. In 2000, Bland16 documented the distribution of patients with CTS on a scale based upon nerve 

conduction study findings. Bland created this CTS 

classification system largely independent of the exact 

GEHS Neurophysiological Classification

 System for Patients with Carpal Tunnel

 Syndrome

David G. Greathouse, PT, PhD

Greg Ernst, PT, PhD

John S. Halle, PT, PhD

COL Scott W. Shaffer, SP, USA

Abstract

Background: Median neuropathy at or distal to the wrist or carpal tunnel syndrome (CTS) is one of a number of 

muscle, tendon, and nerve-related disorders that affect people performing intensive work with their hands. Following 

a thorough history and physical examination, electrophysiological examination including both nerve conduction 

studies (NCS) and electromyography (EMG) testing may be performed and currently serve as the reference standard 

for the diagnosis of CTS. The EMG and NCS exams should identify the peripheral nerve, specific location in the 

nerve pathway, involvement of sensory and/or motor axons, and the presence of myelinopathy and/or axonopathy 

neuropathic process.

Neurophysiological Classification Systems for Patients with CTS: Clinical electrophysiologists now have 2 

neurophysiological classification systems for patients with CTS from which to choose when preparing their 

electrophysiological testing reports. The Bland (2000) and GEHS (2012) neurophysiological classification systems 

for patients with CTS are discussed.

Case Studies: Two case studies of patients with electrophysiological evidence of CTS are presented. Application and 

comparison of categorizations by the Bland and GEHS neurophysiological classification systems are incorporated 

into the presentation and discussion of these case studies.

Summary and Clinical Relevance: This article describes 2 neurophysiological classification systems for patients with 

CTS. The Bland system documents the distribution of patients with CTS on a scale based upon nerve conduction study 

findings, but it does not include any EMG findings in its grading scale. The GEHS neurophysiological classification 

system includes findings for both the NCS and EMG components of the electrophysiological examination. The 

GEHS classification system provides electrophysiological evidence of myelinopathy and/or axonopathy for patients 

with CTS. Additional research comparing the psychometric properties and prognostic utility of the Bland and GEHS 

neurophysiologic classifications is warranted.
January – March 2016 61

THE ARMY MEDICAL DEPARTMENT JOURNAL

normal values used in any given electrodiagnostic 

laboratory. This classification scale demonstrates a 

highly significant linear relationship between the 

neurophysiological grading and a numerical score 

derived from the clinical history.16,17 Bland’s neurophysiological grading scale for patients with CTS is 

shown in Table 1.

Nerve conduction studies (NCS) and electromyography (EMG) testing will provide electrophysiological evidence of pathological conditions of the median nerve to include demyelination (myelinopathy) 

and axon loss (axonopathy).9-12 The Bland classification system for patients with carpal tunnel syndrome is based on nerve conduction findings but 

does not include any reference to the EMG portion 

of the electrophysiological evaluation.16

A new neurophysiological classification system for 

patients with CTS was introduced in 2012.18 The 

GEHS (Greathouse, Ernst, Halle, and Shaffer) neurophysiological classification system for patients 

with CTS includes findings for both the NCS and 

EMG components of the electrophysiological examination. The GEHS classification system provides electrophysiological evidence of myelinopathy and/or axonopathy for patients with CTS. The 

GEHS neurophysiological classification system for 

patients with CTS is shown in Table 2.

The GEHS neurophysiological classification system 

for patients with CTS is comprised of data from 

both the NCS and EMG components of the electrophysiological examination.18 Furthermore, this new 

system provides information including specific abnormal findings of sensory and/or motor axons and 

myelinopathy and/or axonopathy. The GEHS neurophysiological classification system for patients 

with CTS is presently being used by clinical electrophysiologists and has been cited in numerous research manuscripts.19-23

The purpose of developing and implementing the 

new GEHS neurophysiological classification system for 

patients with CTS is to provide health care providers 

an enhanced system of electrophysiological evaluation 

and grading scale so that they may evaluate and treat 

their patients with CTS with the most complete electrophysiological data that includes both NCS and EMG 

testing. This article describes the GEHS neurophysiological classification system for patients with CTS and 

presents 2 case studies of patients with electrophysiological evidence of CTS. The Bland and GEHS neurophysiological classification system for patients with CTS 

is incorporated into the presentation and discussion of 

these case studies.

Case 1

A 49-year-old right-hand dominant woman was referred 

by an orthopaedic surgeon for electrophysiological evaluation of suspected bilateral CTS. She is employed as 

a unit coordinator at a local school district. In January 

2013, the patient noted numbness and tingling (N/T) in 

the palmar surface of both hands. She has no past medical history of bilateral upper extremity problems and 

Table 1. Bland’s Neurophysiological Grading Scale for Patients with 

carpal tunnel syndrome.17

Grade Nerve Conduction Findings

0 Normal Normal motor and sensory conduction studies

1 Very mild CTS demonstrable only with most sensitive tests

2 Mild

Sensory nerve conduction velocity slow on

finger/wrist measurement

Normal terminal motor latency

3 Moderate Sensory potential preserved

Motor slowing; DML to ABP <6.5 ms

4 Severe Sensory potentials absent

Motor potential preserved; DML to APB <6.5 ms

5 Very

Severe

Sensory potentials absent

DML to APB >6.5 ms

6 Ext Severe Sensory and motor potentials effectively unrecordable

Surface motor potential from ABP <0.2 mV amplitude

DSL indicates distal sensory latency; DML, distal motor latency; APB, abductor 

pollicis brevis; and Ext, extremely.

Table 2. GEHS Neurophysiological Classification System for Patients 

with carpal tunnel syndrome.19

Grade Nerve Conduction and EMG Findings

Very Mild

Abnormal comparison study; eg, prolonged comparison study between D4 median/ulnar DSLs

Normal EMG of the APB

Mild

(sensory only)

Prolonged palmar and/or D2 DSLs

Normal DML to APB

Normal EMG of the APB

Mild

(sensory and 

motor)

Prolonged palmar and/or D2 DSLs

Prolonged DML to APB <5.0 ms

Normal EMG of the APB

Moderate

Prolonged or absent DSLs

Prolonged DML to APB <6.0 ms

Normal EMG of the APB

Moderate/Severe

Prolonged or absent DSLs

Prolonged DML to APB >6.0 ms

EMG – presence of abnormal spontaneous electrical activity in the APB; no decrease in interference 

pattern or abnormal MUP duration and amplitude 

of the APB

Severe Prolonged or absent DSLs

Prolonged DML to APB >7.0 ms

EMG – presence of abnormal spontaneous electrical 

activity in the APB; decreased interference pattern 

of APB, may have abnormal duration and amplitude 

of motor unit potentials in the APB

DSL indicates distal sensory latency; DML, distal motor latency; EMG, 

electromyography APB, abductor pollicis brevis; APB, abductor pollicis brevis; 

and D2, digit 2 (index finger).
62 http://www.cs.amedd.army.mil/amedd_journal.aspx

denies recent trauma to the neck or both upper extremities (BUE). In the right upper extremity (RUE) she has 

N/T in the palmar surfaces of all digits (D1-D5), but 

otherwise denies N/T in the RUE proximal to the wrist. 

She denies pain or weakness in the RUE. The left upper extremity (LUE) symptoms are identical to the RUE 

but less severe in the left hand. No proximal N/T, pain, 

or weakness in the LUE. She has chronic neck pain but 

denies radicular symptoms in BUE. The patient denies 

history of headaches, or visual or cranial nerve problems. 

She was evaluated and treated by a chiropractic provider 

without relief of symptoms. She wears bilateral wrist 

splints with some relief of symptoms from this intervention. The patient is being treated for anxiety but otherwise, the review of systems is noncontributory for cardiovascular, pulmonary, gastrointestinal, genitourinary, 

or endocrine problems. She denies 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 2014. On physical examination, the patient displayed mild decreased motion 

of active cervical mobility in all planes with mild neck 

pain or right side bend and rotation. The Spurling’s test 

to the right produced neck pain, but no neck pain was 

produced on the left maneuver. Neither the left nor right 

Spurling’s test produced radicular pain in BUE. She 

had normal active mobility of bilateral shoulder, elbow, 

forearm, wrist, and hand motions. There was normal 

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

forearm, wrist, and hand motions and 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 

and pain (pin prick) in the palmar surfaces of the right 

thenar eminence and right D2. Otherwise, sensory testing was normal for light touch and pain in BUE, including all peripheral nerves and dermatomes (C4-T1). The 

Tinel’s and Phalen’s tests were negative for bilateral median nerve involvement at the wrists. There were normal 

radial pulses bilaterally for thoracic outlet syndrome in 

the scalene, costoclavicular, and pectoralis minor/clavipectoral fasica humeral maneuvers.

Results of the nerve conduction and electromyography 

studies are provided in Tables 3 and 4, respectively. Clinically noteworthy NCS abnormal findings are indicated 

by the shaded cells in Table 3. Electromyography of selected muscles in BUE (C5-T1 innervation) and bilateral 

cervical paravertebral muscles were normal (Table 4).

In conclusion of case study 1: this was an abnormal NCS 

study of BUE and a normal EMG study of BUE and the 

bilateral low cervical paravertebral muscles. There was 

electrophysiologic evidence on this exam of a mild, bilateral (right = left) median mononeuropathy at or distal 

to the wrist; demyelinating neuropathic process; affecting both motor and sensory fibers; EMG of the left and 

right abductor pollicis brevis (APB) was normal. There 

was no electrophysiologic evidence on this exam of (1) 

bilateral median mononeuropathy in the forearms; (2) 

bilateral ulnar or superficial radial mononeuropathy; or 

(3) bilateral C5-T1 radiculopathy in BUE and the bilateral cervical paravertebral muscles.

Based on the case study 1 results, the GEHS neurophysiological classification system category was a mild 

(sensory and motor fiber involvement) bilateral (left and 

right median nerves) CTS with prolonged palmar and 

D2 distal sensory latencies (DSLs) and a prolonged distal motor latency (DML) to APB of less than 5.0 milliseconds. EMG of the bilateral APBs was normal. In 

contrast, the Bland neurophysiological classification 

system would grade these findings as a bilateral moderate CTS with sensory potential preserved and motor 

slowing, DML to APB less than 6.5 milliseconds. The 

Bland system does not include EMG evaluation of the 

APBs. Both CTS classification systems identified bilateral median motor and sensory involvement with a 

demyelinating neuropathic process, but only the GEHS 

classification system demonstrated electrophysiological 

evidence of the absence of motor fiber axonopathy.

Case 2

A 53-year-old right-hand dominant woman was referred 

by her primary care provider for electrophysiological evaluation of suspected CTS. The patient is a bus 

driver. In 2000, the patient was evaluated with NCS 

and diagnosed with CTS, resulting with treatment of 

bilateral wrist splints. She had decreased pain and N/T 

in both hands after using the wrist splints. In the summer of 2014, she noted increased pain and N/T in both 

hands. After the onset of these new symptoms, she used 

her wrist splints, but the splints only exacerbated her 

symptoms. The hand pain and N/T increased with driving and at night. She reported right shoulder pain but 

otherwise no pain in the RUE other than the hand pain. 

She denied N/T or weakness in the BUE proximal to the 

wrist. She had N/T in the palmar surfaces of both hands 

D1-D5, right more than left. She denied neck pain or radicular pain in BUE. She had low back pain and some 

occasional N/T in the dorsum and toes of both feet. Otherwise, she denied pain, N/T, or weakness in BLE. The 

patient is being treated for congestive heart failure and 

is not on blood anticoagulants. Otherwise, the review 

of systems was noncontributory for cardiovascular, pulmonary, gastrointestinal, genitourinary, or endocrine 

GEHS NEUROPHYSIOLOGICAL CLASSIFICATION SYSTEM

FOR PATIENTS WITH CARPAL TUNNEL SYNDROME
January – March 2016 63

THE ARMY MEDICAL DEPARTMENT JOURNAL

problems. She denied diabetes, heavy metal exposure, 

thyroid disease, renal disease, or alcohol abuse. Her maternal aunt has multiple sclerosis, but otherwise there is 

no family history of neuromuscular disease.

The patient was evaluated in March 2015. On physical 

examination, the patient had normal active cervical 

motion in all planes without neck or BUE pain. Both the 

left and right Spurling maneuvers were normal without 

pain in the neck or BUE. She had normal active mobility of bilateral shoulder, elbow, forearm, wrist, and hand 

motions. There was 3+/5 motor strength of the bilateral 

APB and opponens pollicis, but otherwise there was 

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

Table 3. Case 1: Nerve Conduction Study Results. Note: clinically noteworthy values are indicated by shaded cells.

Anti Sensory Summary

Site NR Peak

(ms)

Normal

Peak

(ms)

P-T

Amplitude

(μV)

Normal

P-T

Amplitude

(μV)

Site 1 Site 2 ∆P

(ms)

Distance

(cm)

Velocity

(m/s)

Normal

Velocity

(m/s)

Left Superficial Radial Anti Sensory (Base 1st Digit)

D1 2.3 <2.7 21.4 D1 Base 1st Digit 2.3 10.0 43

Right Superficial Radial Anti Sensory (Base 1st Digit)

D1 2.5 <2.7 28.4 D1 Base 1st Digit 2.5 10.0 40

Ortho Sensory Summary

Site NR Peak

(ms)

Normal

Peak

(ms)

P-T

Amplitude

(μV)

Normal

P-T

Amplitude

(μV)

Site 1 Site 2 ∆P

(ms)

Distance

(cm)

Velocity

(m/s)

Normal

Velocity

(m/s)

Left Median Ortho Sensory (Wrist)

Palm 2.8 <2.2 46.3 >15 Palm Wrist 2.8 8.0 29

D2 4.0 <3.6 21.9 >15 D2 Wrist 4.0 14.0 35

Right Median Ortho Sensory (Wrist)

Palm 2.8 <2.2 26.8 >15 Palm Wrist 2.8 8.0 29

D2 4.3 <3.6 13.8 >15 D2 Wrist 4.3 14.0 33

Left Ulnar Ortho Sensory (Wrist)

Palm 1.7 <2.2 60.8 >10 Palm Wrist 1.7 8.0 47

D5 2.9 <3.5 23.8 >10 D5 Wrist 2.9 14.0 48

Right Ulnar Ortho Sensory (Wrist)

Palm 1.8 <2.2 48.2 >10 Palm Wrist 1.8 8.0 44

D5 2.9 <3.5 27.0 >10 D5 Wrist 2.9 14.0 48

Motor Summary

Site NR Onset 

(ms)

Normal

Onset

(ms)

O-P

Amplitude

(mV)

Normal

O-P

Amplitude

(mV)

Site 1 Site 2 ∆O

(ms)

Distance

(cm)

Velocity

(m/s)

Normal

Velocity

(m/s)

Left Median Motor (Abd Poll Brev)

Wrist 4.8 <4.2 4.8 >5 Elbow Wrist 3.6 23.0 64 >50

Elbow 8.4 6.7

Right Median Motor (Abd Poll Brev)

Wrist 4.9 <4.2 3.1 >5 Elbow Wrist 4.4 25.0 57 >50

Elbow 9.3 3.3

Left Ulnar Motor (Abd Dig Minimi)

Wrist 2.9 <3.6 7.2 >5 B Elbow Wrist 3.2 20.0 63 >50

B Elbow 6.1 5.1 A Elbow B Elbow 1.6 12.0 75 >50

A Elbow 7.7 5.5

Right Ulnar Motor (Abd Dig Minimi)

Wrist 2.8 <3.6 8.6 >5 B Elbow Wrist 3.3 21.0 64 >50

B Elbow 6.1 8.5 A Elbow B Elbow 1.6 12.0 75 >50

A Elbow 7.7 8.2

NR indicates no response; P-T, peak to trough; and O-P, onset to peak.
64 http://www.cs.amedd.army.mil/amedd_journal.aspx

elbow, forearm, wrist, and hand motions, and 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 palmar surface of 

the right thenar eminence and right D1, and increased 

sensation to LT and PP in the palmar surface of the left 

D1. Otherwise, sensory testing was normal for LT and 

pain in BUE to include all peripheral nerves and dermatomes (C4-T1). The Tinel’s and Phalen’s tests were negative for bilateral median nerve involvement at the wrists. 

There were normal radial pulses bilaterally for thoracic 

outlet syndrome in the scalene, costoclavicular, and pectoralis minor/clavipectoral fasica humeral maneuvers.

Results of the nerve conduction study are presented in 

Table 5. Electromyography of selected muscles in BUE 

(C5-T1 innervation) is presented in Table 6. Clinically 

noteworthy NCS and EMG abnormal findings are indicated by the shaded cells in Tables 5 and 6. There was 

abnormal spontaneous electrical activity including increased insertional activity and the presence of fibrillation potentials and positive waves in both the right and 

left APBs. In the right APB, there was a 50% decreased 

interference pattern on maximum voluntary contraction 

but normal configuration (shape, duration and amplitude) of the motor unit potentials (MUPs). There was 

normal MUP configuration and interference pattern in 

the left APB. Otherwise, EMG testing of selected muscles in BUE was normal.

In conclusion of case study 2: this was an abnormal NCS 

and EMG study of BUE. There was electrophysiological 

evidence on this exam of a severe, bilateral (right more 

than left) median mononeuropathy at or distal to the 

wrist; demyelinating and axonal loss neuropathic process affecting both motor and sensory fibers. Chronic 

denervation was present in both the left and right APB. 

There was no electrophysiological evidence on this 

exam of: (1) bilateral median mononeuropathy in the 

forearms; (2) bilateral ulnar or superficial radial mononeuropathy; (3) bilateral brachial plexopathy; or (4) bilateral C5-T1 radiculopathy in BUE.

Based on the case study 2 results, the GEHS neurophysiological classification system was a severe (sensory and 

motor fiber involvement), bilateral (right more than left 

median nerves) CTS with absent palmar and D2 DSLs 

on the right; prolonged palmar and D2 DSLs on the left; 

and prolonged DMLs to the right APB (8.9 milliseconds) 

and left APB (9.1 milliseconds). There was electrophysiological evidence of chronic denervation in both the left 

and right APB, with decreased interference pattern in 

the right APB. In contrast, the Bland neurophysiological 

classification system would grade these findings as a bilateral, very severe CTS with sensory potentials absent 

and motor slowing; DML to APB more than 6.5milliseconds. The Bland system does not include EMG evaluation of the bilateral APBs. Both CTS classification 

systems identified bilateral median motor and sensory 

involvement with a demyelinating neuropathic process, 

but only the GEHS classification system demonstrated 

Table 4. Case 1: Electromyography Results. 

Side Muscle Nerve Root Ins

Act

Fibs Psw Amp Dur Poly Recrt Int 

Pat

Comment

Right 1stDorInt Ulnar C8-T1 Nml Nml Nml Nml Nml 0 Nml Nml

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 ExtCarRadLong Radial C6-7 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 Cervical Parasp Low Rami C7-8 Nml Nml Nml

Left 1stDorInt Ulnar C8-T1 Nml Nml Nml Nml Nml 0 Nml Nml

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 ExtCarRadLong Radial C6-7 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 Cervical Parasp Low Rami C7-8 Nml Nml Nml

Abbreviations

Nml: normal Psw: positive sharp waves Poly: polyphasic

Ins Act: insertional activity Amp: amplitude Recrt: recruitment

Fibs: fibrillation potentials Dur: duration Int Pat: interference pattern

GEHS NEUROPHYSIOLOGICAL CLASSIFICATION SYSTEM

FOR PATIENTS WITH CARPAL TUNNEL SYNDROME
January – March 2016 65

THE ARMY MEDICAL DEPARTMENT JOURNAL

electrophysiological evidence of motor fiber axonopathy 

in the bilateral APBs by EMG examination.

Comment

The advantage of having this additional information 

regarding EMG changes (axonopathy) for patients with 

CTS, is that it provides the health care team and the 

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

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. The EMG examination 

specifically provides information regarding motor fiber 

Table 5. Case 2: Nerve Conduction Study Results. Note: clinically noteworthy values are indicated by shaded cells.

Anti Sensory Summary

Site NR Peak

(ms)

Normal

Peak

(ms)

P-T

Amplitude

(μV)

Normal

P-T

Amplitude

(μV)

Site 1 Site 2 ∆P

(ms)

Distance

(cm)

Velocity

(m/s)

Normal

Velocity

(m/s)

Left Superficial Radial Anti Sensory (Base 1st Digit)

D1 2.3 <2.7 38.8 D1 Base 1st Digit 2.3 10.0 43

Right Superficial Radial Anti Sensory (Base 1st Digit)

D1 2.3 <2.7 33.1 D1 Base 1st Digit 2.5 10.0 43

Ortho Sensory Summary

Site NR Peak

(ms)

Normal

Peak

(ms)

P-T

Amplitude

(μV)

Normal

P-T

Amplitude

(μV)

Site 1 Site 2 ∆P

(ms)

Distance

(cm)

Velocity

(m/s)

Normal

Velocity

(m/s)

Left Median Ortho Sensory (Wrist)

Palm 4.2 <2.2 15.7 >15 Palm Wrist 4.2 8.0 19

D2 5.1 <3.6 16.3 >15 D2 Wrist 5.1 14.0 27

Right Median Ortho Sensory (Wrist)

Palm NR <2.2 >15 Palm Wrist 8.0

D2 NR <3.6 >15 D2 Wrist 14.0

Left Ulnar Ortho Sensory (Wrist)

Palm 1.9 <2.2 36.6 >10 Palm Wrist 1.9 8.0 42

D5 3.3 <3.5 15.5 >10 D5 Wrist 3.3 14.0 42

Right Ulnar Ortho Sensory (Wrist)

Palm 1.9 <2.2 30.1 >10 Palm Wrist 1.9 8.0 42

D5 3.3 <3.5 17.3 >10 D5 Wrist 3.3 14.0 42

Motor Summary

Site NR Onset 

(ms)

Normal

Onset

(ms)

O-P

Amplitude

(mV)

Normal

O-P

Amplitude

(mV)

Site 1 Site 2 ∆O

(ms)

Distance

(cm)

Velocity

(m/s)

Normal

Velocity

(m/s)

Left Median Motor (Abd Poll Brev)

Wrist 9.1 <4.2 4.6 >5 Elbow Wrist 4.8 25.0 52 >50

Elbow 13.9 4.8

Right Median Motor (Abd Poll Brev)

Wrist 8.9 <4.2 2.0 >5 Elbow Wrist 4.8 26.0 54 >50

Elbow 13.7 1.5

Left Ulnar Motor (Abd Dig Minimi)

Wrist 3.4 <3.6 5.7 >5 B Elbow Wrist 3.6 22.0 61 >50

B Elbow 7.0 7.4 A Elbow B Elbow 1.6 11.0 69 >50

A Elbow 8.6 6.6

Right Ulnar Motor (Abd Dig Minimi)

Wrist 3.2 <3.6 10.9 >5 B Elbow Wrist 3.6 20.0 56 >50

B Elbow 6.8 9.8 A Elbow B Elbow 1.6 11.0 69 >50

A Elbow 8.4 7.6

NR indicates no response; P-T, peak to trough; and O-P, onset to peak.
66 http://www.cs.amedd.army.mil/amedd_journal.aspx

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. Collectively, the EMG examination affords critical motor fiber neurophysiologic information 

that allows the healthcare team, in concert with the patient, to carefully consider interventions.9-12,24,26

Although the Bland and GEHS classification schemes 

provide a framework for reporting and categorizing 

carpal tunnel syndrome based on neurophysiologic 

findings, further research regarding the predictive and 

prognostic value of the classification schemes is needed. Currently research is limited to previous work by 

Bland et al who surveyed 1,268 patients who had undergone carpal tunnel decompression. Multiregression 

identified preoperative nerve conduction study findings, 

greater age, lower symptom scores, longer disease duration, and male gender as significant (P<.05) predictors of poor surgical outcome. Nerve conduction studies 

had the strongest effect of predictors, with patients with 

middle-grade nerve conduction abnormalities having 

better results than those with normal results or severe 

abnormalities.17 These findings are promising, but additional longitudinal studies examining the predictive 

and prognostic value of the Bland and GEHS classification schemes regarding various interventions (duty limitations, splinting, mobilization, injection, and surgical 

release) are 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 the classification schemes.

Summary and Clinical Relevance

Clinical electrophysiologists now have 2 neurophysiological classification systems for patients with CTS 

from which to choose when preparing their electrophysiological testing reports. The Bland classification system was formulated based on nerve conduction study 

findings only. It was created largely independent of the 

exact normal values used in any given electrodiagnostic 

laboratory, and does not include any EMG findings in 

the grading scale. The GEHS neurophysiological classification system includes findings for both the NCS 

and EMG components of the electrophysiological examination in its grading scale. The GEHS classification system provides electrophysiological evidence of 

myelinopathy and/or axonopathy for patients with CTS. 

Future research comparing the psychometric properties 

and prognostic utility of the Bland and GEHS neurophysiologic classifications is warranted.

References

1. Bickel K. Carpal tunnel syndrome. J Hand Surg 

Am. 2010;35:147-152.

2. Moscony AMB. Common peripheral nerve problems. In: Cooper C, ed. Fundamentals of Hand 

Therapy: Clinical Reasoning and Treatment Guidelines for Common Diagnoses of the Upper Extremity. Philadelphia, PA: Mosby; 2007:201-250.

3. MacDermid JC, Doherty T. Clinical and electrodiagnostic testing of carpal tunnel syndrome: 

a narrative review. J Orthop Sports Phys Ther. 

2004;34:565-588.

Table 6. 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 Nml Nml Nml Nml Nml 0 Nml Nml

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

Right Abd Poll Brev Radial C8-T1 Incr 3+ 3+ Nml Nml 0 Reduced 50% fib amp<100

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

Left 1stDorInt Ulnar C8-T1 Nml Nml Nml Nml Nml 0 Nml Nml

Left Abd Poll Brev Median C8-T1 Incr 2+ 2+ Nml Nml 0 Nml Nml fib amp<100

Left PronatorTeres Median C6-7 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

Abbreviations

Nml: normal Psw: positive sharp waves Poly: polyphasic Incr: increased

Ins Act: insertional activity Amp: amplitude Recrt: recruitment fib amp: fibrillation potential amplitude

Fibs: fibrillation potentials Dur: duration Int Pat: interference pattern

GEHS NEUROPHYSIOLOGICAL CLASSIFICATION SYSTEM

FOR PATIENTS WITH CARPAL TUNNEL SYNDROME
January – March 2016 67

THE ARMY MEDICAL DEPARTMENT JOURNAL

4. American Association of Electrodiagnostic Medicine: Practice parameter for electrodiagnostic studies in carpal tunnel syndrome: Summary statement. 

Muscle Nerve. 1993;16:1390-1391.

5. Franklin GM, Haug J, Heyer N, Checkoway H, 

Peck N. Occupational carpal tunnel syndrome in 

Washington State, 1984-1988. Am J Public Health. 

1991;81(6):741-746.

6. Hanrahan LP, Higgins D, Anderson H, Haskins L, 

Tai S. Project SENSOR: Wisconsin surveillance of 

occupational carpal tunnel syndrome. Wis Med J. 

1991;90(2):80, 82-83.

7. Stockstill JW, Harn SD, Strickland D, Hruska R. 

Prevalence of upper extremity neuropathy in a clinical dentist population. JADA 1993;124(8):67-72.

8. American Academy of Orthopaedic Surgeons. 

Clinical Guidelines on Diagnosis of Carpal Tunnel Syndrome. May 2007. Available at: http://www.

aaos.org/research/guidelines/CTS_guideline.pdf.

9. American Association of Electrodiagnostic Medicine: Practice parameter for electrodiagnostic studies in carpal tunnel syndrome: summary statement. 

Muscle Nerve. 1993;16:1390-1391.

10. Dumitru D, Amato A, Zwarts M. Electrodiagnostic Medicine. 2nd ed. St. Louis, MO: Hanley & 

Belfus: 2002.

11. Kimura J. Electrodiagnosis in Diseases of Nerve 

and Muscle: Principles and Practice. 3rd ed. New 

York, NY: Oxford University Press; 2001.

12. Oh SJ. Clinical Electromyography in Nerve Conduction Studies. Baltimore, MD: Williams & 

Wilkins; 1993.

13. van Dijk JG. Multiple tests and diagnostic validity. 

Muscle Nerve. 1995;18:353-355.

14. Graham B. The value added by electrodiagnostic 

testing in the diagnosis of carpal tunnel syndrome. 

J Bone Joint Surg Am. 2008;90:2587-2593.

15. Jablecki CK, Andary MT, So YT, et al. Literature 

review of the usefulness of nerve conduction studies and electromyography for the evaluation of patients with carpal tunnel syndrome. Muscle Nerve. 

1993;16:1392-1414.

16. Bland JD. A neurophysiological grading scale 

for carpal tunnel syndrome. Muscle Nerve. 2000; 

23(8):1280-1283.

17. Bland JD. Do nerve conduction studies predict the 

outcome of carpal tunnel decompression?. Muscle 

Nerve. 2001;24(7):935-940.

18. Greathouse DG. A new classification system for patients with carpal tunnel syndrome. Electroneuromyographic Symposium Proceedings. Provo, Utah: 

Rocky Mountain University of Health Professions; 

September 14, 2012:22-24.

19. 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.

20. 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.

21. 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.

22. 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.

23. Galloway K, Greathouse DG. Carpal tunnel syndrome in an obese adolescent: a case report. Pediatr Phys Ther. In press.

24. Watson JC. The electrodiagnostic approach to carpal 

tunnel syndrome. Neurol Clin. 2012;30(2):457-477.

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

Q fever is a zoonotic infection caused by the obligate intracellular gram negative bacteria Coxiella burnetti.

1

 First 

identified in Queensland, Australia, in 1933 and dubbed 

“Query Fever,” it often presents as a self-limited flu-like 

illness that occasionally causes more severe disease or a 

chronic form of illness. Q fever has been reported worldwide with recent studies suggesting a high prevalence 

in Iraq and Iran.1-4 Estimates from recent studies in the 

United States suggest that Q fever is significantly more 

prominent than previously thought, and that US military personnel are at increased risk.2-6 C burnetti infects 

many animal species, though cattle, sheep, and goats are 

thought to be the primary reservoirs.1-7 Human infection 

usually occurs through inhalation of dust or aerosols 

from infected animals; however sexual contact, unpasteurized milk, transplacental transmission, and tick bites, 

though rare, are also known modes of transmission.1-4,7

Clinical Presentation

Q fever can present in acute and chronic forms. In acute 

Q fever, symptoms generally begin 2-3 weeks after infection. Patients present with a constellation of flu-like 

symptoms that include fever, headache, malaise, myalgias, and gastrointestinal symptoms.3,7 Severe infection 

is uncommon but can present as pneumonia, meningitis, 

and granulomatous hepatitis with inoculum size being 

proportional to severity.3,7 The mortality rate varies but 

is generally estimated to be about 2%.1-7 Sixty percent of 

patients infected with C burnetti will develop the acute 

form of infection, however, 1% to 5% of those patients 

will eventually develop chronic Q fever.2,3,5-7 Pregnant 

patients, immunosuppressed patients and those with 

valvulopathies and prosthetic heart valves are at highest 

risk of developing chronic Q fever.3,7 The most common 

form of chronic Q fever is endocarditis, though vascular, bone, and testicular infections, have been reported.3

Patients typically develop chronic Q fever 3 months after initial infection.

Diagnosis

Q fever is an inherently difficult infection to diagnose. It 

requires a high level of suspicion and is often a clinical 

diagnosis with serologic confirmation. In the deployed 

environment, Q fever infection should be suspected in 

patients with a flu-like febrile illness with recent exposure to livestock.7

 However, absence of animal exposure 

should not exclude the diagnosis as a recent study suggested only one third of cases of Q fever had a known 

exposure.4-6 Additional clues to infection include prolonged fever, thrombocytopenia, and hepatitis.3,7 A 

clinical diagnosis should be confirmed with serology.3

Providers should collect serum samples at initial presentation and subsequently after 4 to 6 weeks.3

 Of note, empiric therapy of suspected Q fever should not be withheld waiting for laboratory results. Presently, the USAF 

School of Aerospace Medicine (USAFSAM) is the only 

Department of Defense (DoD) laboratory approved to 

perform Q fever serologic testing; ideally all specimens should be sent to USAFSAM to minimize laboratory variation.3

 Serologies can also be performed at 

the Centers for Disease Control and Prevention (CDC). 

Commercial laboratories should be avoided as results 

are often unreliable. Interpretation of these serologies 

requires understanding of the antigenic phases of C burnetii and is beyond the scope of this review.3

 A rapid 

PCR test is available at some DoD laboratories and may 

aid in diagnosis. The sensitivity for the rapid PCR test is 

highest in the first week of infection.3

Additional studies should include a complete blood 

count with differential, a basic metabolic panel, liverassociated enzymes test, erythrocyte sedimentation rate, 

Q Fever

CPT Akira A. Shishido, MC, USA

LCDR Andrew G. Letiaia, MC, USN

LTC Joshua D. Hartzell, MC, USA

Abstract

Q fever is a significant infectious disease threat to US military personnel deployed in the Middle East. Its environmental 

stability, aerosol transmission, and animal reservoir make it a considerable risk for deployed troops due to its potential 

for weaponization and risk of natural infection. It presents as a flu-like illness that responds promptly to antimicrobial 

therapy. Q fever should be suspected in patients presenting with a compatible febrile illness in an endemic area and especially if the individual has been exposed to livestock. Diagnosis is confirmed with serologic blood tests, but empiric 

therapy should be initiated when Q fever is considered. If left untreated, patients with acute Q fever can develop severe 

complications as well as chronic disease manifesting several months after the initial infection.
October – December 2015 69

THE ARMY MEDICAL DEPARTMENT JOURNAL

and C-reactive protein.3 Patients with acute fever should 

have follow-up to ensure resolution of the acute infection. This is best done under the guidance of an infectious diseases physician.3

Chronic Q fever should be suspected in patients with a 

history of acute Q fever and symptoms of chronic infection (fevers, elevated inflammatory markers, heart 

murmur).3 Chronic Q fever diagnosis requires the presence of elevated antibody titers, clinical symptoms, and 

an identifiable source of infection (such as vegetation 

on a heart valve suggestive of endocarditis).3 Consideration of chronic Q fever should prompt consultation 

of an infectious diseases specialist.3 The Armed Forces 

Infectious Disease Society and the CDC have provided 

thorough guidelines, illustrated in the Figure, providing 

further instruction and guidance on the diagnosis and 

management of Q fever.3,7

Treatment

Patients with suspected acute Q fever should receive 

empiric doxycycline 100 mg every 12 hours for 14 days.3

Pregnant patients should be treated with trimethoprim/

sulfamethoxazole (160 mg/800 mg) DS twice daily until delivery.3,7 Patients treated within the first 3 days of 

illness typically improve within 72 hours.7 Treatment for 

chronic Q fever should consist of doxycycline 100 mg 

every 12 hours and hydroxychloroquine 200 mg every 8 

hours for 18 months and should be coordinated closely 

with an infectious disease specialist.3 An effective vaccine for Q fever has been developed in Australia, but is 

not available in the United States and requires serologic 

testing prior to administration due to severe inoculationsite reactions related to previous exposures.7

 Prevention 

efforts should focus on minimizing exposure to livestock and ticks.

Importance in a Deployed Setting

C burnetii is exceptionally infectious (with only a single 

organism being able to cause infection), easily aerosolized, and can remain stable in the environment for 

months, making it an attractive agent for bioterrorism, 

currently category B.1,3,7 Prior to the Biological Weapons Convention which banned use of biological agents 

in war, it was studied in offensive weapon programs 

for this purpose.1 Additionally, Q fever is endemic to 

numerous countries where US troops are located, and 

more than 150 cases among active duty service members deployed in Iraq have been confirmed.3,4 The risk 

for natural infection in the deployed setting is presumably due to the primary reservoirs of the disease (cattle, 

sheep, and goats) being the most common livestock in 

much of the Middle East.2

References

1. Ruiz S, Wolfe DN. Vaccination against Q fever for 

biodefense and public health indications. Front Microbiol. 2014;5:726. eCollection 2014.

2. Anderson AD, Smoak B, Shuping E, Ockenhouse C, 

Petruccelli B. Q Fever and the US military. Emerg 

Infect Dis. 2005;11(8):1320-1322.

3. Hartzell JD, Gleeson T, Scoville S, Massung RF, 

Wortmann G, Martin GJ. Practice guidelines for 

the diagnosis and management of patients with Q 

fever by the Armed Forces Infectious Diseases Society. Mil Med. 2012;177(5):484-494.

4. Hartzell JD. Q fever reporting: tip of the iceberg? 

Am J Trop Med Hyg. 2015;92(2):217-218.

5. Dahlgren FS, McQuiston JH, Massung RF, Anderson AD. Q fever in the United States: summary of 

case reports from two national surveillance systems, 2000–2012. Am J Trop Med Hyg. 2015;92: 

247-255.

6. Dahlgren FS, Haberling DL, McQuiston JH. Q 

fever is underestimated in the United States: a 

comparison of fatal Q fever cases from two national reporting systems. Am J Trop Med Hyg. 

2015;92:244-246.

Q fever management algorithm. Adapted from Armed 

Forces Infectious Diseases Society guidelines.3

*Serology should be performed at the same reference lab 

to minimize interlaboratory variability.

†Report confirmed cases to public health/preventive 

medicine office.

Acute Q fever suspected

Positive† Negative

Infectious diseases

consultation

No further 

testing or 

treatment

Repeat clinical assessment and serology at 6, 

12, 18, and 24 months.

Empirically treat with doxycycline 100 mg po bid for 14 days 

while serologic workup or PCR 

is pending.

Obtain acute serology* at initial presentation and convalescent serology at 2-6 weeks.
70 http://www.cs.amedd.army.mil/amedd_journal.aspx

7. Anderson A, Bijlmer H, Fournier PE, et al. Diagnosis and management of Q fever–United States, 2013: recommendations from CDC and the Q Fever Working Group. MMWR Recomm Rep. 2013;62(RR-03):1-30.

Authors

CPT Shishido is a 3rd year resident in the Department of Internal Medicine, Walter Reed National Military Medical 

Center, Bethesda, Maryland.

LCDR Letizia is a Fellow in the Department of Infectious Diseases, Walter Reed National Military Medical Center, 

Bethesda, Maryland.

LTC Hartzell is the Assistant Program Director of Internal Medicine, Department of Internal Medicine, Walter Reed 

National Military Medical Center, Bethesda, Maryland.
January – March 2016 71

Although 90% of American adults now own a mobile 

phone and 64% own some form of smartphone,1,2 the 

opportunities for using them in healthcare delivery have 

remained largely unexplored. Mobile phones are portable, accessible, and ideal for transmitting individualized 

information; thus, they have the potential to provide 

means to streamline healthcare at relatively small cost 

outlays.3 For now, however, applying mobile phone use 

toward improving healthcare remains mainly confined 

to that found in academic studies; despite the evidence 

indicating the prospective value of employing mobile 

technology in healthcare, we found no indication that 

federal healthcare leaders have exercised the capacity on 

a scale of any magnitude. We recognize the substantial 

potential for using mobile phones in the areas of primary, 

preventive, and population health, and a need for federal 

healthcare to improve its use of this technology to stay 

competitive in the areas of access, costs, and satisfaction. 

To seize that potential and answer that need, we propose 

a 5-year federal implementation plan to integrate mobile 

phone capabilities into federal healthcare delivery.

Methods

We began our analysis with a comprehensive review of 

the literature. Using Google Scholar, the Association 

for Computing Machinery Database, and PubMed, we 

queried the extant recent literature (2009 to the present) 

using the following criteria: mobile phone health applications and cell phone text message health. From the 

result of our query, we included articles and studies specifically relating to the application of mobile phones in 

healthcare. We excluded those articles that did not have 

a focus on the use of mobile phones toward improving 

healthcare such as articles concerning the medical side 

effects of prolonged cell phone use.

From our review and analysis of the initial set of articles, 

a pattern emerged. We identified 3 predominant themes 

in mobile application use in healthcare: primary, preventive, and population health applications. These themes 

motivated us to further refine our literature search to 

include search query terms such as mobile phones primary care and cell phone preventive health. Synthesizing our search results, we identified a final sample of 55 

articles for subsequent analysis. Our review of the studies formed our recommendation.

Findings

Primary Care

Primary care can be defined as the “continual basic and 

routine care” that is provided as the first point of care 

for the patient.4 The first of our major themes in using 

Mobile Phone Health Applications

 for the Federal Sector

Capt Christin S. Burrows, MS, USAF

MAJ Fred K. Weigel, MS, USA

Abstract

Purpose: As the US healthcare system moves toward a mobile care model, mobile phones will play a significant 

role in the future of healthcare delivery. Today, 90% of American adults own a mobile phone and 64% own a 

smartphone, yet many healthcare organizations are only beginning to explore the opportunities in which mobile phones can improve and streamline care.

Method: After searching Google Scholar, the Association for Computing Machinery Database, and PubMed 

for articles related to mobile phone health applications and cell phone text message health, we selected articles 

and studies related to the application of mobile phones in healthcare. From our initial review, we identified the 

potential application areas and continued to refine our search, identifying a total of 55 articles for additional 

review and analysis.

Findings: From the literature, we identified 3 main themes for mobile phone implementation in improving 

healthcare: primary, preventive, and population health. We recommend federal health leaders pursue the value 

and potential in these areas; not only because 90% of Americans already own mobile phones, but also because 

mobile phone integration can provide substantial access and potential cost savings.

Conclusion: From the positive findings of multiple studies in primary, preventive, and population health, we 

propose a 5-year federal implementation plan to integrate mobile phone capabilities into federal healthcare 

delivery. Our proposal has the potential to improve access, reduce costs, and increase patient satisfaction, therefore changing the way the federal sector delivers healthcare by 2021.
72 http://www.cs.amedd.army.mil/amedd_journal.aspx

mobile phone technology in healthcare delivery is found 

in primary care. Both the civilian and federal sectors 

face a primary care shortage, and the lack of access creates overcrowded emergency rooms and rising costs.4

 In 

the United States, primary care access is one of healthcare’s biggest challenges,5

 and recent studies show that 

various mobile phone applications can help to improve 

that access.

First, messaging capabilities between primary care 

managers and patients can reduce the number of routine 

visits that do not require face-to-face interaction, such 

as for prescription renewals. Military treatment facility 

administrators have started to explore secure messaging 

in primary care delivery. Secure messaging provides a 

method to communicate health information electronically while protecting the health information from unauthorized viewing. Available on mobile phones, a goal 

of secure messaging is to ease communication between 

primary care managers and patients, allowing patients 

to ask routine questions without an appointment. Implemented correctly, the secure messaging system can improve access for those who need a physical visit, recapturing care that the military might otherwise send to the 

civilian sector.

Second, studies show that using text messaging for appointment reminders significantly reduces missed appointments, resulting in up to 40% improved attendance 

rates.6,7 These attendance rates receive great attention 

and are highly visible in the federal system, because of 

the negative effect that missed appointments have on access and costs. Most efforts to improve missed appointment rates in the military are based on enforcing punitive measures, but these recent studies suggest that a 

proactive text messaging approach can be very effective 

and a viable alternative.6,7 Although the US Army has 

started to use text messages as appointment reminders, 

the method has been employed only on a limited scale.8

Finally, mobile phones have the potential to improve access by enabling providers and disease managers to effectively monitor chronic conditions. Most relevant studies focus on diabetes, hypertension, and asthma management.9

 Many studies show that text messaging and 

phone interventions have positively influenced patient 

behaviors and outcomes, such as by significantly improving blood sugar measures in diabetes patients who 

received continual text messages to monitor and control their levels.9

 These encouraging text messages spur 

patients to be involved with their own care, which can 

help keep them from further complications. Therefore, 

effective disease management via mobile phones provides a viable option to preserve valuable primary care 

appointment availability through inspiring a high level 

of patient engagement in personal health maintenance.

Preventive Health

The second major field for mobile phone use in healthcare is prevention, including smoking cessation, fitness, 

and immunization reminders, among others. Researchers often focus on smoking cessation, in part because 

smoking is so prevalent—it is the leading cause of premature deaths in the United States and responsible for 

1 in 5 deaths nationwide10—and because mobile phone 

intervention results are so dramatic, increasing cessation rates by up to 70%.11 Most experiments include 

interactive text messages that send smokers positive 

reminders about the benefits of quitting, and replies 

to messages when the smokers need extra encouragement. These studies have been among those indicating 

the most effective mobile phone use interventions; the 

majority of findings show significantly increased cessation rates both in the short- and long-term.11,12 However, 

there is limited published literature about mobile phone 

use as a smoking cessation tool, and that lack of literature may be a contributing factor to Whittaker and colleagues’ lack of a significant finding of mobile phones 

providing a long-term effect on smoking cessation.11

Another potential preventive health application is the use 

of location services to send notifications when a mobile 

phone is at a specific place. Researchers are beginning 

to explore this technology as a possibility for just-intime interventions.13 People could program their phone 

with “trigger” locations, like workplace smoking area

and favorite fast food restaurant. A visit to these locations would generate a reminder to avoid unhealthy behaviors, intervening in moments of weakened willpower.

The main goal for any preventive health intervention is 

to change poor behaviors while encouraging good behaviors, so incentives have a large role in mobile phone 

integration with preventive care. Most mobile phone 

prevention studies to date focus on intrinsic rewards 

like self-efficacy—one’s ability to plan and proceed toward a goal.14,15 However, there may be an opportunity 

to study prevention with other reward systems, especially in the social networking setting. Ultimately, prevention, with or without mobile phones, is about positively 

influencing patient behaviors to take more individual 

responsibility for healthcare.

Population Health

Mobile phones have several applications in population health. Healthcare leaders could adopt the model 

of other data-gathering industries and collect individual health information via mobile phones, analyzing 

MOBILE PHONE HEALTH APPLICATIONS FOR THE FEDERAL SECTOR
January – March 2016 73

THE ARMY MEDICAL DEPARTMENT JOURNAL

the data to determine current and localized trends in 

population health. There are already applications testing this capability, gathering and filtering through large 

amounts of user-input data to determine where outbreaks happen.16 For example, Chunara and colleagues16

outline their own Outbreaks Near Me, an application for 

Android and iPhone smartphones, with which users can 

provide real-time disease outbreak reports. They further 

describe other applications for disease and disaster reporting as well as the ability to integrate the reporting 

with internet-based outbreak monitoring systems, such 

as HealthMap.org (http://www.healthmap.org/en/).

These types of applications are especially helpful with 

cold and flu viruses; people may choose not to visit their 

primary care managers when they have a virus that only 

requires symptom management, so the primary care 

facility may not have an accurate picture of the virus’ 

prevalence without self-reporting. Once trends materialize, mobile phones can be used to disseminate population health messages back to the people. Patients can 

receive messages that warn of a high flu incidence in 

their area and provide helpful reminders such as to wash 

their hands or get vaccinated. This infrastructure would 

be particularly helpful for population protection; if public health officials suspected a serious epidemic, mass 

messaging could disseminate that information to many 

people simultaneously.

Although the Army has started to explore mobile phone 

integration into traumatic brain injury management,8

many federal administrators have not been quick to 

adopt mobile phone technology, perhaps due to the associated challenges. We propose the implementation of a 

5-year plan that depends on the federal sector’s ability to 

mitigate the difficulties of privacy and reimbursement. 

Integrated into our proposal, federal health leaders will 

have to implement security measures to protect patient 

information as well as decide how to best capture virtual workload and collect reimbursement from insurers. 

Without good reimbursement methods, detailed costsavings of mobile phone use is almost impossible. We 

provide greater detail of our proposal in the next section.

Comment

After researching effective methods for incorporating mobile phones into health delivery, we propose a 

3-phase, 5-year plan for the federal sector to improve 

access, costs, and patient satisfaction by 2021, allowing 

federal health to compete in today’s health environment.

The first phase will require one year and focuses on 

perfecting the new secure messaging systems in military health. For example, the Air Force is currently 

introducing its secure messaging system, MiCare, which 

advertises a 72-hour response time from a primary care 

managers.17 It is critical that Air Force leadership focuses 

on this response time and adjusts provider schedules accordingly; if this response window is broken early and 

often in MiCare’s debut, patients will view secure messaging as a burden instead of an improvement to their 

health delivery, making them very hesitant to participate 

in future efforts. Secure messaging is a pilot program for 

the federal sector, and military treatment facility leaders 

should take great care to ensure a smooth implementation.

The second phase in our proposal, lasting approximately 

2 years, includes implementing high-visibility programs 

of interactive appointment and smoking cessation reminders. First, federal health will focus on interactive 

appointment messages, giving patients the option to 

reply and immediately reschedule. This is a relatively 

simple way to improve access and gain patient support 

for future mobile phone integration. Second, the federal 

sector will implement an interactive messaging system 

to assist with smoking cessation in its health and wellness centers. Encouraging smokers to quit is important 

for both individual health and rising healthcare costs, 

and this effort will again garner further support for future mobile health applications. Gaining the patients’ 

trust and confidence during this phase will be crucial 

for the third phase.

The final and most advanced stage, which we also 

project to have a 2-year duration, includes integrating 

mobile phones into the federal health sector’s disease 

management and population health programs. This 

phase depends on the success of patient engagement 

in the first 2 phases; if disseminating information via 

mobile phones receives the appropriate public support 

response, federal health providers can next start collecting information from the patients. Patients can input 

disease management measures into applications or text 

messages, which can give the provider better oversight 

and identify complications before they become severe. 

Potentially, the disease management information could 

be integrated into currently available internet-based outbreak monitoring platforms. Similarly, public health officials can pull information from the general population 

to analyze localized illness trends.

Limitations and Additional Research

As with other approaches that focus on the archival analysis, the sampling procedure is a limitation.18 Despite 

our confidences that we chose appropriate and sufficient 

search criteria for this study, the potential search criteria 

options are vast. It is possible, perhaps likely, that had 

we included additional search terms, our search would 
74 http://www.cs.amedd.army.mil/amedd_journal.aspx

have revealed additional articles that would inform this 

study. Likewise, had we searched in additional databases, we may have unearthed other literature. Future researchers may benefit their analyses by broadening their 

scope and database selections.

Through this research, we exposed several areas for further inquiry. Although there are numerous studies on 

appointment reminders, most that we found are limited 

to one-way messaging: caregivers to patients. Future 

studies should consider investigating interactive messaging with rescheduling capability, as well as its effect 

on access. We found that the literature on cost-savings 

for mobile phones in healthcare is also lacking. Exploring reimbursement models for provider messaging and 

the effect on costs would contribute insights into reducing costs in healthcare mobile phone use that would be 

of interest to both researchers and practitioners.

An additional limitation for this study is the sheer pace 

of innovation; because technology changes at a rapid 

pace, arguably, some of our suggested applications for 

mobile phone use may be obsolete and supplanted by 

newer technology by 2021. Future researchers should 

note that because of the pace of technology innovation 

and development, the 5-year plan we propose is suitable 

for longitudinal study.

Conclusion

The federal health system should employ the 5-year integration plan now to fully use mobile phones in the areas 

of primary, preventive, and population health. Employing these programs quickly and accurately can help the 

federal healthcare sector stay competitive in today’s environment by improving access, controlling purchasedcare costs, and increasing patient satisfaction, all of 

which will change the way that federal administrators 

deliver healthcare as we head into the 2020s.

References

1. Pew Research Internet Project: Mobile technology 

fact sheet. 2014. Available at: http://www.pewinternet.org/fact-sheets/mobile-technology-fact-sheet/. 

Accessed August 10, 2015.

2. Smith A. US Smartphone Use in 2015 [internet]. 

Pew Research Center. 2015. Available at: http://

www.pewinternet.org/2015/04/01/us-smartphoneuse-in-2015/. Accessed December 21, 2015.

3. Klasnja P, Pratt W. Healthcare in the pocket: mapping the space of mobile-phone health interventions. J Biomed Inform. 2012;45(1):184-198.

4. Shi L, Singh DA. Delivering Healthcare In America: A Systems Approach. 6th ed. Burlington, MA: 

Jones and Bartlett Learning; 2014.

5. Bodenheimer T, Pham HH. Primary care: current problems and proposed solutions. Health Aff. 

2010;29(5):799-805.

6. Hocking GR, Wand J, Stott S, Ali H, Kaldor 

J. How effective are short message service reminders at increasing clinic attendance? A metaanalysis and systematic review. Health Serv Res. 

2012;47(2):614-632.

7. Perron NJ, Dao MD, Kossovsky MP, et al. Reduction of missed appointments at an urban primary 

care clinic: a randomized control study. BMC Fam 

Pract. 2010;11(1):79.

8. Poropatich R, Pavliscsak HH, Rasche J, Barrigan 

C, Vigersky RA, Fonda SJ, Bell A. Mobile healthcare in the US Army. Proc Wirel Health 2010. 

2010:184-187. Available at: http://dl.acm.org/cita

tion.cfm?id=1921103. Accessed December 21, 2015.

9. Fjeldsoe BS, Marshall AL, Miller YD. Behavior 

change interventions delivered by mobile telephone short-message service. Am J Prev Med. 

2009;36(2):165-173.

10. American Lung Association, Research and Program Services, Epidemiology and Statistics Unit. 

Trends in Tobacco Use [internet]. July 2011. Available at: http://www.lung.org/finding-cures/ourresearch/trend-reports/Tobacco-Trend-Report.pdf. 

Accessed January 2014.

11. Whittaker R, McRobbie H, Bullen C, Borland R, 

Rodgers A, Gu Y. Mobile phone-based interventions for smoking cessation. Cochrane Database 

Syst Rev [serial online]. 2012;(11).

12. Free C, Knight R, Robertson S, et al. Smoking cessation support delivered via mobile phone text messaging (txt2stop): a single-blind, randomised trial. 

Lancet. 2011;378(9785):49-55.

13. Patrick K, Griswold WG, Raab F, Intille SS. 

Health and the mobile phone. Am J Prev Med. 

2008;35(2):177-181.

14. Riley WT, Rivera DE, Atienza AA, Nilsen W, Allison SM, Mermelstein R. Health behavior models 

in the age of mobile interventions: are our theories 

up to the task?. Transl Behav Med. 2011;1(1):53-71.

15. Bandura A. Self-efficacy: toward a unifying theory of behavioral change. Psychol Rev. 

1977;84(2):191-215.

16. Chunara R, Mekaru SR, Chan EH, Kass-Hout T, 

Iacucci AA, Brownstein JS. Participatory epidemiology: use of mobile phones for community-based 

health reporting. PLoS Med. 2010;7(12).

17. Davis K. Sign on to MiCare to connect with your 

doctor online. Air Force Times. April 6, 2014. 

Available at: http://archive.airforcetimes.com/article/20140406/BENEFITS06/304060021/SignMiCare-connect-your-doctor-online. Accessed December 21, 2015.

MOBILE PHONE HEALTH APPLICATIONS FOR THE FEDERAL SECTOR
January – March 2016 75

THE ARMY MEDICAL DEPARTMENT JOURNAL

18. Weigel FK, Rainer Jr RK, Hazen BT, Cegielski CG, Ford FN. Uncovering research opportunities in the medical informatics field: a quantitative content analysis. Comm Assoc Inform Syst. 2013;33(1):15-32. Available at: http://aisel.

aisnet.org/cais/vol33/iss1/2/. Accessed December 21, 2015.

Authors

Capt Burrows is a Resident at Massachusetts General Hospital, Boston Massachusetts, as part of the Masters of Health 

Administration/Masters of Business Administration Joint Degree Program, Army-Baylor University Graduate Program 

in Health and Business Administration, AMEDDC&S/Health Readiness Center of Excellence, Joint Base San AntonioFort Sam Houston, Texas.

MAJ Weigel is the Chair, Research & Faculty Development Committee, and Associate Professor, Army-Baylor University Graduate Program in Health and Business Administration, AMEDDC&S/Health Readiness Center of Excellence, 

Joint Base San Antonio-Fort Sam Houston, Texas.
76 http://www.cs.amedd.army.mil/amedd_journal.aspx

Care of prisoners or inmates of correctional facilities 

poses unique challenges. These include considerations 

of security threats, challenge of transportation under 

secure conditions, a varying and highly transient population, and often the remote locations of correctional facilities must all be taken into account when developing 

a strategy for medical care of this population.

In Europe, the US Army Correctional Facility (CORFAC) was previously located at Mannheim, Germany, 

45 geographical miles from the nearest military medical treatment facility (MTF). It moved in 2015 and is 

now located in Sembach, Germany. The location is 30 

to 60 minutes from provider locations at various clinics. The CORFAC census generally ranges from 13-15 

inmates who are young (aged 18-40 years) and generally 

healthy. The inmates in this CORFAC are confined for 

less than 120 days. Longer confinements are transported 

to a stateside correctional facility. This mission requires 

medical support but due to the size would not be efficient use of a full time privileged medical provider. Additionally, the requirement for a provider to commute 

to and from the CORFAC daily put an unacceptable 

burden on the productivity of that provider’s assigned 

clinic. Therefore, a solution was proposed in the form of 

establishing a telehealth protocol.

Telehealth, the practice of interviewing and examining 

a patient from a remote location using the assistance of 

trained technicians and high quality video and sound 

equipment, has been studied for many years in various 

settings, including prison facilities.1-5 While TH has 

been found to have significant potential for increasing 

productivity, the benefits from a business standpoint 

have been inconsistent.6 One concept that seems to be 

clear is that despite initial resistance from providers and 

patients, the effectiveness, and satisfaction (for both providers and patients) tends to increase with time and exposure to TH medicine.1,7,8

The Department of Defense and Landstuhl Regional 

Medical Center (LRMC) have invested in the expansion 

and development of a TH program which has potential 

for significant benefit in Europe, as downsizing results 

in communities that are not large enough to justify a 

dedicated provider.

A Primary Care Telehealth Experience in a

 US Army Correctional Facility in Germany

LTC Christian Swift, AN, USA

Steven M. Cain, MPAS, PA-C

CPT Michael Needham, MC, USA

Abstract

Objective: To assess the feasibility of using telehealth (TH) equipment and infrastructure within the US Army’s 

European Theater to evaluate and treat inmates with general medical complaints, and perform physicals and 

medical safety checks in a US Army Correctional Facility (CORFAC).

Methods and Materials: Synchronous TH encounters were performed using Polycom RealPresence software 

on providers’ computers with high definition cameras on monitors at distant sites and PolyCom HDX9000 

Practitioner Cart along with AMD Global Telemedicine devices at the originating site within the CORFAC. 

These devices included an AMD-2500 General Exam Camera, AMD Fiber optic Otoscope, and AMD Telephonic 

Stethoscope. Patient consent for TH was obtained, and they were seen in the Medical Dispensary with Army 

Medics presenting the patients to the providers via TH.

Results: From May 22, 2014, to January 12, 2015, a physician assistant, nurse practitioner, and 4 physicians 

completed 177 synchronous TH encounters primarily at a CORFAC in Mannheim, Germany. Of these 177 

encounters, 114 were Special Housing Unit (SHU) safety checks and 63 encounters were for physicals, 

medication management, and a variety of medical complaints including acute infections, abdominal pain, and 

musculoskeletal and dermatological complaints.

Conclusion: Synchronous TH was an effective option for the delivery of high quality routine medical care for 

minor illnesses, injuries, and other nonurgent conditions, as well as for general physicals and SHU checks in 

a correctional facility. Acceptance by providers and clinic staff was found to be high. Inmates were generally 

satisfied with their TH encounters. However, some inmates reported a preference to see providers in-person, 

highlighting one of the challenges with acceptance of telehealth programs.
January – March 2016 77

THE ARMY MEDICAL DEPARTMENT JOURNAL

This article reviews the implementation 

of a TH program specifically for the European CORFAC. The support of this 

type of unit can be accomplished by any 

TH trained provider from any location 

where video conferencing equipment 

was available. Any provider connected 

to the Europe Regional Medical Command (ERMC) intranet can perform 

medical video teleconferencing from 

their office desktop. The goal of project 

was to assess the feasibility of medical 

visits via TH while meeting the medical mission needs of the CORFAC. The 

result envisioned was high quality care 

while decreasing the time and costs 

spent in provider transportation to and 

from his/her assigned location.

Materials and Methods

Program Organization

Implementation of this TH effort required a rethinking of the delivery of 

medical care at the CORFAC by the 

dispensary technician staff, the primary care providers, and ultimately the 

patients themselves. Initially, potential 

barriers identified included possible resistance from medical personnel, lack 

of staff technical expertise, and difficulties coordinating services. In March 

2014, the Landstuhl TH Program Office 

(THPO) and the CORFAC Dispensary 

Team began meeting to work through 

barriers and technical and clinical issues. A standard operating procedure 

was written with guidelines outlining 

tasks and roles. Inquiries were made to the American 

Correctional Association regarding the feasibility and 

legality of TH in prison systems. Many institutions in 

the United States were using some form of TH, even 

if only simple telephonic connections. A 2004 survey 

of institutions in all 50 states revealed that slightly over 

half of state correctional institutions and 39% of federal institutions use some type of TH or telemedicine 

applications.1 Armed with some existing experience delivering specialty care via synchronous TH in Europe, 

THPO began training providers and dispensary medical 

technicians in the use of TH equipment. Per Army Telehealth Policy Memo 08-053,* written informed consent 

is required prior to participating in synchronous TH. 

This is obtained from inmates during CORFAC initial 

processing. Only one inmate chose not 

to consent to being seen for his medical issues via TH. Telehealth Clinic was 

performed Monday through Friday, except Wednesdays when a provider was 

present at the CORFAC. Inmates would 

register for sick call the night prior and 

at an agreed upon time the next morning, the TH Clinic would commence 

in which both patient and the provider 

would meet in the Virtual Exam Room. 

The medics assisted providers with 

physical exam elements during the 

TH encounter. Special Housing Unit 

checks were also performed via TH 

during weekdays.

The Special Housing Unit (SHU) is a 

location within the correctional facility where inmates are in cells in what 

is normally called solitary confinement. 

Special Housing Unit checks are a daily 

medical safety check which must be 

performed by a credentialed medical 

provider assessing both the inmate’s 

cell condition and the general health 

of the inmate. Special Housing Unit 

checks consist of a brief presentation 

by the guard staff as to the condition of 

the cell and a brief interview with the 

inmate regarding any overnight health 

issues or concerns. A review of American Correctional Association Guidelines revealed that solitary confinement 

checks via TH met the duty of the facility to provide face-to-face credentialed 

provider daily medical safety checks.2

A small group of internists at LRMC were trained to 

perform these checks via TH on weekends.

Sick call presenting complaints were mostly minor involving medication issues, acute illnesses, and injuries 

as shown in the Table. Physical exams were performed 

via TH using mostly the TH general exam camera, 

stethoscope, and otoscope. Emergency procedures were 

in place for the occasion that an inmate presents to the 

TH sick call with a problem requiring evaluation at the 

Emergency Department.

Telehealth Equipment at CORFAC Originating Site

In 2009, the Europe Regional Medical Command THPO 

purchased PolyCom HDX9000 Practitioner Carts (Polycom, Inc, San Jose, CA) along with telehealth devices 

such as the AMD-2500 General Exam Camera, AMD *Internal military document not readily accessible by the general 

public.

Correctional Facility Telehealth Patient Encounters.

Reason For Encounter Number of

Encounters

Confinement physical 8

Periodic Health

Assessment

8

Medication visit 8

Abdominal pain 6*

Transfer physical 5

Musculoskeletal pain/

injury (other)

5

Intake medical 

screening

3

Back pain 2

Rash 2

Onychomycosis 2

URI (cold symptoms) 2

Knee pain 1

Lower extremity 

contusion

1

Toe pain 1

Ankle injury 1

Wrist injury 1

Dry scalp 1

Pharyngitis 1

Chest pain 1

Difficulty sleeping 1

ER F/U syncope 1

Generalized weakness 1

Diarrhea 1

Total sick call 

encounters

63

Special Housing Unit 

(solitary confinement) 

checks

114

Total TH encounters 177

*One abdominal pain patient transferred 

to emergency department for evaluation.
78 http://www.cs.amedd.army.mil/amedd_journal.aspx

Fiberoptic Otoscope, and AMD Telephonic Stethoscope 

(AMD Global Telemedicine, Chelmsford MA) (Figures 

1, 2). By 2010, nearly all Army clinics in Europe had robust TH capabilities. Although not originally slated for 

the equipment, these items were installed at the CORFAC from a clinic in Germany which was not using them 

at the time. Smaller, desktop PolyCom HDX4000 units 

were installed in all behavioral health clinics including 

the CORFAC in 2010. The PolyCom HDX9000 Practitioner Cart and the telehealth general exam camera, otoscope and stethoscope provided sufficient quality tools 

to perform comprehensive assessments of patients at the 

CORFAC for most primary care/sick call complaints 

presented by this patient group.

Telehealth Equipment at Distant Site

Technicians from the LRMC Video Network Center 

(VNC) installed PolyCom RealPresence software on 

providers’ laptops at Kleber Army Health Clinic and 

LRMC. Additionally, high definition web cameras were 

installed on monitors on the provider desks or in a video 

teleconference (VTC) room.

LRMC Video Network Center

The LRMC VNC manages the VTC servers for both 

nonmedical and medical conferencing using PolyCom 

CMA Gatekeeper. At the initiation of every medical 

VTC encounter, the VNC technicians would assign the 

encounter a unique identification number to secure the 

connection for patient privacy. The VNC also checked 

the audio and video quality of each encounter and were 

available anytime there were connection problems. 

Rarely were there any audio/video issues and there were 

no technical issues that prompted cessation of TH services. Bandwidth within the ERMC Network was sufficiently high to ensure good audio/video quality with 

near negligible network delay.

Electronic Medical Record Data and Peer Review

Encounters and provider notes were documented in the 

patient’s outpatient military electronic medical record 

(AHLTA). Physician peer review was performed and no 

standard of care issues were identified.

Data

Patient encounter data for physicals and sick call visits 

were culled from a variety of sources, including a password-protected ERMC TH cart reservation calendar for 

which all TH Encounters in ERMC are documented, 

and daily printed AHLTA clinic lists from the COREFAC dispensary. Special Housing Unit checks were all 

documented on a CORFAC blotter report and each individual solitary confinement check is documented on 

an electronic Standard Form 600 signed by the provider 

assigned that day.

Results

Providers participating in the care of inmates via TH 

consisted of a physician assistant, nurse practitioner, 

family practitioner, and a group of 3 internists who 

saw inmates on the weekend for SHU checks. These 

Figure 1. (A) PolyCom HDX9000 Practitioner Cart at originating/patient location; (B) provider laptop with PolyCom RealPresence software at healthcare provider location.

B

A

Figure 2. AMD Global Telemedicine instruments which are 

on the Practitioner Cart for use in assessing the patient.

Stethoscope

Fiberoptic Cable

General Exam Camera

Otoscope

Illumination System

A PRIMARY CARE TELEHEALTH EXPERIENCE IN A US ARMY CORRECTIONAL FACILITY IN GERMANY
January – March 2016 79

THE ARMY MEDICAL DEPARTMENT JOURNAL

providers completed 177 synchronous TH encounters, 

primarily at the Mannheim and Sembach CORFACs. 

Patients were seen weekly from May 22, 2014, to January 12, 2015. Of these 177 TH encounters, 114 were SHU 

safety checks and 63 were for physicals, medication visits, and a variety of other typical acute care complaints. 

During this time, only one patient required transfer to a 

higher level of care during a TH encounter. The inmate 

complained of severe epigastric pain which necessitated 

transfer to the LRMC Emergency Department for evaluation due to the limitation of ancillary services of lab 

and x-ray at the US Army Correctional Facility-Europe.

Primary Care Encounters

The routine physical and sick call types of encounters 

comprised 63 of the encounters as shown in the Table. 

About one-third (24) of those encounters were for physicals and medication visits. All newly incarcerated inmates require an initial medical screening to assess any 

urgent needs, followed by a confinement physical within 

48 hours of arrival. Intake medical screenings and physicals were accomplished using synchronous TH equipment. The remainder of the encounters addressed a variety of complaints which were easily assessed using TH.

Special Housing Unit Checks

The SHU encounters consisted of a brief presentation 

by the CORFAC medic or guard staff relaying the appearance and condition of the inmate’s cell and any 

overnight events affecting the inmate’s health. The encounters were brief and did not require use of telehealth 

examination devices. The encounters were very easily 

accomplished via TH. A SHU check could turn into a 

medical encounter if the inmate had a medical complaint, but this did not occur during the pilot study.

Provider, Staff and Inmate Satisfaction

Although not formally surveyed, there was a generally 

good acceptance by the providers involved in the program and appreciation for the high quality of the network connections and TH medical devices used. The 

clear advantage for providers was being able to manage minor sick-call type complaints and physicals via 

TH from their own offices, saving many hours a day of 

driving. There was general acceptance of the idea of 

using TH, and a provider’s confidence was further bolstered knowing that every Wednesday a provider would 

be “in-house” to see inmates and perform follow-ups. 

There was also recognition that contingency plans and 

access to local emergency service was also available if 

required. Providers noted satisfaction with the capabilities of the TH equipment to include general exam camera, and fiber optic otoscope. Some difficulty was noted 

with the telephonic stethoscope. It seemed to perform 

well for heart sounds when the distant provider wore 

headphones. For breath sounds however, it seemed less 

useful, possibly due to cord or connection interference 

noise. The idea of seeing patients from a distance via 

TH is new to many medical care providers and although 

acceptance is not immediate, providers recognize that 

high quality encounters can be achieved and acceptance 

improves over time.

Inmates were generally satisfied with their TH experience. Many inmates did express a preference to see a 

provider in person. Solitary confinement checks and 

many of the initial intake medical screenings of the inmates are performed while the patients are handcuffed. 

Despite some reported dissatisfaction, nearly all inmates 

freely consented to the encounters and many came back 

multiple times for TH services, even though they could 

have waited to be seen in person on Wednesdays. Generally, medical visits via TH seemed to meet inmate expectations for high quality health care.

Comment

The Landstuhl THPO and CORFAC partnership started 

in March 2014 and has developed into an enduring line 

of service which continues to assist in the performance 

of daily sick call, physicals, and solitary confinement 

checks using synchronous TH. There is somewhat of a 

learning curve in both performing TH encounters as a 

provider and receiving care via TH as a patient. It is the 

view of the authors that not all types of care can be successfully accomplished via TH. This particular group of 

inmates in this smaller correctional facility represented 

a generally young, healthy, and male cohort confined 

for short periods. However, in a larger institution with 

a more diverse inmate population, carefully considered screening criteria should be incorporated into developing TH programs. That is particularly important 

for screening to determine which patients may require 

a carefully nuanced or specialized physical exam or 

may have more urgent or emergent conditions that require treatment. Telehealth encounters may be used as 

a screening tool; an information-gathering encounter 

to assess whether a patient may need a face-to-face encounter or higher level of care facility. Telehealth may 

also be used for medical education classes such as diabetes education.

Conclusions

Synchronous TH was shown to be a feasible and effective option for the delivery of high quality, routine 

medical care for minor illnesses, injuries, and other 

nonurgent and nonemergent conditions, as well as for 

general physicals and checks in a population aged 18 

to 30 years. Synchronous TH provided a platform for 
80 http://www.cs.amedd.army.mil/amedd_journal.aspx

safe and effective health care delivery to this population over a 7- month period. Overall, the TH encounters 

appeared to be accepted by providers and clinic staff. 

A conservative estimate is that 660 hours of unproductive provider time traveling to and from the facility was 

saved. Inmates were generally satisfied with their TH 

encounters. Some inmates did report a preference to see 

providers in person. This highlights one of the challenges with TH programs and their acceptance by both providers and patients. The authors believe that acceptance 

should improve over time as with most new technological advances.

Acknowledgments

Special thanks to LRMC Commander COL Judith Lee 

for her critical advocacy and support of LRMC telehealth 

initiatives. Thanks as well to the physician staff who 

participated by seeing TH patient encounters, including MAJ Daniel Hatcher, CPT Stephanie Ng, CPT Erica 

Murray, and CPT Michael Needham. A special thanks 

to all of the dedicated CORFAC Army Medic staff and 

the LRMC THPO staff whose support and hard work 

made this cooperative effort possible: SGT Matthew Belot, SGT Brianna Lambert, SGT Brian Curtis, SFC Todd 

Hall, and Mr Anthonia Clark.

References

1. Magaletta, PR, Fagan, TJ, Peyrot, MF. Telehealth 

in the Federal Bureau of Prisons: inmates’ perceptions. Prof Psychol Res Pr. 2000;31(5):497-

502. Available at: http://dx.doi.org/10.1037/0735-

7028.31.5.497. Accessed September 29, 2015.

2. Anogianakis G, Ilonidis G, Milliaras S, Anogeianaki A, Vlachakis-Milliaras E. Developing prison telemedicine systems: the Greek experience. J 

Telemed Telecare. 2003; 9(suppl 2):S4-S7.

3. Ajami S, Arzani-Birgani A. The use of telemedicine to treat prisoners. J Inform Tech Soft Eng. 

2013;S7.

4. Darkins A, Ryan P, Kobb R, et al. Care coordination/home telehealth: The systematic implementation of health informatics, home telehealth, and disease management to support the care of veteran patients with chronic conditions. Telemed J E Health. 

2008;14(10):1118-1126.

5. Ellis DG, Mayrose J, Jehle DJ, Moscat RM, Pierluisi GJ. A telemedicine model for emergency care 

in a short-term correctional facility. Telemed J E 

Health. 2001;7(2):87-92.

6. LeRouge C, Tulu B, Forducey P. The business of 

telemedicine: strategy primer. Telemed J E Health. 

2010;16(8):898-909.

7. Weinstein RS, Lopez AM, Krupinski EA. Telemedicine: news from the front lines. Am J Med. 

2014;127(3):172-173.

8. Glaser M, Winchell T, Plant P, et al. Provider satisfaction and patient outcomes associated with a 

statewide prison telemedicine program in Louisiana. Telemed J E Health. 2010;16(4):472-479.

9. Larsen D, Stamm BH, Davis K, Magaletta PR Prison telemedicine and telehealth utilization in the 

United States: state and federal perceptions of benefits and barriers. Telemed J E Health. 2004;10(suppl 2):S-81-S-89.

10. American Correctional Association. Performance 

of solitary confinement checks. Core Jail Standards. Alexandria, VA: American Correctional 

Association; 2010.

Authors

LTC Swift is Officer-in-Charge, Kleber Army Health 

Clinic, Kaiserslautern, Germany.

Mr Cain is a surgical physician assistant and Landstuhl 

Telehealth Program clinical advisor, Landstuhl Regional 

Medical Center, Landstuhl Germany.

CPT Needham is a family practice physician at the Kleber Army Health Clinic, Kaiserslautern, Germany.

Erratum

In the book review article “A New Monograph From the Borden Institute” on pages 99-100 of 

the October-December 2015 issue of the AMEDD Journal, the title of the book reviewed was 

incorrectly stated as:

Long-Term Health Consequences of Exposures to Burn Pits in Iraq and Afghanistan

The correct title is:

Airborne Hazards Related to Deployment

A PRIMARY CARE TELEHEALTH EXPERIENCE IN A US ARMY CORRECTIONAL FACILITY IN GERMANY
January – March 2016 81

Repair of a Gingival Fenestration Using an

 Acellular Dermal Matrix Allograft

COL Lawrence G. Breault, DC, USA

CPT Raquel C. Brentson, DC, USA

COL Edward B. Fowler, DC, USA

COL Frederick C. Bisch, DC, USA

Abstract

A case report illustrating the successful treatment of a gingival fenestration with an acellular dermal matrix 

(ADM) allograft. After 21⁄2 months of healing, the ADM was completely integrated into the soft tissues of the 

mandibular anterior gingiva with complete resolution of the gingival fenestration, resulting in excellent gingival esthetics.

Marginal tissue recession is of 2 types; one due to periodontitis and the other primarily related to mechanical 

factors like tooth brushing. Recession from periodontitis can involve all tooth surfaces, while recession from 

mechanical factors typically involves only one surface. 

Periodontitis is associated with plaque and calculus 

whereas facial recession is associated with high levels 

of personal oral hygiene and professional care. Predisposing factors to gingival recession include frenal pull, 

underlying bone dehiscence, subgingival restorations, 

tooth malposition, orthodontic appliances, and thin gingival biotype.1-5

While a wide array of various gingival defects may be 

diagnosed in patients, only those anomalies that also 

present with associated symptoms, esthetic concerns, 

or the potential for exacerbated sequelae may require 

treatment.

Two commonly discussed localized gingival defects 

include the gingival dehiscence and fenestration. The 

more common of the two, the gingival dehiscence, is described as an isolated area in which the root is denuded 

of bone.6 The defect combines 3 characteristic qualities 

including gingival recession, bone loss through the margin of the bone, and root exposure (Figure 1).7

In contrast, the gingival fenestration is a rarer phenomenon.1,7,8 The word fenestration is derived from the Latin 

word fenestra, meaning window, which describes how 

the defect clinically presents.7 A fenestration may be 

distinguished by the loss of overlying alveolar bone and 

gingiva, which results in an exposed root surface, but 

the marginal bone and gingiva remain intact (Figure 2).7

Gingival fenestration defects are of uncertain etiology.1,2,7 Some authors have suggested the etiology of gingival fenestration as subgingival calculus and the use of 

Gutka (a mixture of powdered tobacco, areca nut [fruit 

of Arecacatechu] and slaked lime [aqueous calcium hydroxide]).1

 Other reports of gingival fenestrations have 

listed etiologies as extreme buccal inclination of root 

tips with thin or nonexistent cortical plates combined 

with chronic periapical inflammation.9,10 Additionally, 

two of the authors (LGB and EBF) have clinically attributed gingival fenestrations to possible trauma leading to 

Figure 1. Gingival dehiscence.

Figure 2. Gingival fenestration.
82 http://www.cs.amedd.army.mil/amedd_journal.aspx

bony sequestration (Figure 2) and to past use of smokeless tobacco with subsequent healing over previously 

exposed root calculus.

Localized gingival defects are routinely corrected with 

autogenous grafts from either the palatal mucosa or buccal gingiva. However, many patients may not desire a 

palatal graft due to the additional morbidity of the procedure, or due to a history of significant postsurgical 

bleeding from the palatal donor site.4,11

The surgical correction of gingival defects have evolved 

from the early use of pedicle grafts originally described 

by Grupe and Warren in 1956.12 Presently, with the advent of the autogenous subepithelial connective tissue 

graft (SCTG), as described by Langer and Langer with 

modification by others, predictable root cover has increased to more than 90%.13-17

An alternative to the autogenous graft is the acellular 

dermal matrix (ADM*) allograft. The material is human 

dermis which has been decellularized and treated to 

prevent disease transmission, leaving only a scaffold of 

Type I collagen.18 The benefit of ADM is the elimination 

of the morbidity associated with graft removal from an 

oral site. Several authors have reported on the success of 

ADM allograft .4,18-21

Repair of gingival fenestrations has been reported in the 

literature.1,22-25 Previous case reports all used the SCTG 

for repair of the defects. This article reports a case of 

repair of a gingival fenestration using an ADM allograft.

Case Report

A male, 28-year-old Soldier was referred to the Department of Periodontics for evaluation of his mandibular 

anterior gingiva associated with tooth #24, a mandibular 

central incisor (Figure 3). The patient reported a history 

of daily smokeless tobacco use in the area of the mandibular anterior but reported complete cessation of this 

product approximately 2 years prior.

Subsequent to the cessation of smokeless tobacco use, 

the patient noticed an irregularity of his gingiva, which 

upon clinical examination was determined to be a gingival fenestration (Figure 3). 

A review of the medical history revealed that the patient 

was taking no medications and no contraindications to 

treatment were noted. All surgical options were presented and discussed. The patient selected ADM as the 

material for the procedure.

Following a presurgical rinse with 0.12% chlorhexidine 

and administration of local anesthesia (2% lidocaine 

with 1:100,000 epinephrine), the gingival fenestration 

was excised to expose new connective tissue margins 

REPAIR OF A GINGIVAL FENESTRATION USING AN ACELLULAR DERMAL MATRIX ALLOGRAFT

*Perio Derm: Dentsply International, Inc; York, PA.

Figure 5. Hydrated ADM allograft.

Figure 4. Site preparation.

Figure 3. Presurgery: gingival fenestration, tooth #24.
January – March 2016 83

THE ARMY MEDICAL DEPARTMENT JOURNAL

(Figure 4). The labial tissue was elevated to create a 

“pouch.” The tissue preparation was intentionally designed to avoid the marginal gingiva, thereby decreasing the chance of postsurgical recession. Following the 

removal of calculus with ultrasonic instrumentation, 

root planing was completed with hand instruments.

The ADM was hydrated according to the manufacturer’s 

instructions (Figure 5), and placed under the elevated 

labial tissue as shown in Figure 6. The allograft was secured with 5.0 Chromic Sutures* (Figure 7). The labial 

tissue was then closed over the ADM using 5.0 Vicryl 

Sutures* (Figure 8). Hemostasis was obtained with direct pressure for 2 minutes. Home instruction included 

daily chlorhexidine oral rinsing every 12 hours as well 

as the administration of pain medications: acetaminophen (500 mg) with codeine (30 mg) (1 to 2 tabs every 4 

to 6 hours as needed for severe pain and naproxen (500 

mg) (1 tab every 12 hours as needed for moderate pain).

The patient was followed at one, 2, 4, and 10 weeks (21⁄2 

months) when a final follow up revealed good healing of 

the soft tissues with complete integration of the ADM 

allograft (Figure 9).

Comment

Although gingival fenestration is a relatively rare occurrence, as this case report demonstrates, one of the etiologies of this condition can be resolution of a smokeless 

tobacco lesion over previously exposed calculus. The 

predictable repair of this clinical entity has been earlier 

demonstrated with the autogenous subgingival connective tissue graft.1,22-25

This report demonstrates the success of surgical treatment utilizing ADM. The advantage of this technique 

is the elimination of the need for autogenous donor tissue. Additionally, the surgical design in this case did not 

incorporate the free gingival margin, thus reducing the 

risk of postsurgical recession or dehiscence formation.

Summary

This case illustrates the successful treatment of a gingival fenestration with an ADM allograft. After 21⁄2 

months of healing, the allograft was completely integrated into the soft tissues of the mandibular anterior *Ethicon US, LLC; Neenah, WI.

Figure 6. Initial ADM placement.

Figure 7. ADM secured with Chromic Sutures.

Figure 8. Labial tissue sutured with Vicryl Suture.

Figure 9. Photo taken at 21⁄2 month postsurgical visit 

(complete correction of fenestration).
84 http://www.cs.amedd.army.mil/amedd_journal.aspx

gingiva with complete resolution of the gingival fenestration. ADM allograft is easy to use and resulted in excellent gingival esthetics.

References

1. Pendor S, Baliga V, Muthukumaraswarmy A, 

Dhadse PV, Ganji KK, Thakare K. Coverage of 

gingival fenestration using modified pouch and 

tunnel technique: a novel approach. Case Rep Dent. 

2013: 902585. Epub Jul 7.

2. Maynard JG, Ochesenbein C. Mucogingival problems, prevalence and therapy in children. J Periodontol. 1975;46(9):543-552.

3. Bohannan HM. Studies in the alteration of vestibular depth III. Vestibular incision. J Periodontol. 

1963;34(3):209-215.

4. Fowler EB, Breault LG. Root coverage with an 

acellular dermal allograft: a three-month case report. J Contemp Dent Pract. 2000;1(3):47-59.

5. Greenwell H, Fiorellini J, Giannobile W, et 

al. Oral reconstructive and corrective considerations in periodontal therapy. J Periodontol. 

2005;76(9):1588-1600.

6. Singh S, Panwar M, Amora V. Management of mucosal fenestration by multidisciplinary approach: 

a rare case report. Med J Armed Forces India. 

2013;69(1):86-89.

7. Lane J. Gingival fenestration. J Periodontol. 

1977;48(4):225-227. 

8. Patel PV, Kumar N, Durrani F. Microsurgical aesthetic treatment of gingival fenestration by a coronally repositioned partial thickness graft: a case 

report. J Clin Diagn Res. 2013;7(11):2649-2650.

9. Ju Y, Tsai AH, Wu Y, et al. Surgical intervention of 

mucosal fenestration in the maxillary premolar: a 

case report. Quintessence Int. 2004;35(2):125-128.

10. Chen G, Fang CT, Tong C. The management of mucosal fenestration: a case report of two cases. Int 

Endo J. 2009;42(2):156-164.

11. Druckman, RF, Fowler EB, Breault LG. Post-surgical hemorrhage: formation of a “liver clot” secondary to periodontal plastic surgery. J Contemp Dent 

Pract. 2001;2(2):62-71.

12. Grupe HE, Warren RF. Repair of the gingival 

defects by a sliding flap operation. J Periodontol. 

1956;27(2):92-95.

13. 12.Nelson SW. The subpedicle connective tissue 

graft. A bilaminar reconstructive procedure for the 

coverage of denuded root surfaces. J Periodontol. 

1987; 58(2):95-102.

14. Cordioli G, Mortarino C, Chierico A, et al. Comparison of 2 techniques of subepithelial connective 

tissue graft in the treatment of gingival recessions. 

J Periodontol. 2001;72(11):1470-1476.

15. Hirsch A, Attsal U, Chai E, et al. Root coverage 

and pocket reduction as combined surgical procedures. J Periodontol. 2001;72(11):1572-1579.

16. Harris RJ. Connective tissue grafts combined with 

either double pedicle grafts or coronally positioned 

pedicle grafts: results of 266 consecutively treated 

defects in 200 patients. Int J Peridodontics Restorative Dent. 2002;22(5):463-471.

17. Tozum TF, Dini FM. Treatment of adjacent gingival recessions with subepithelial connective tissue 

grafts and the modified tunnel technique. Quintessence Int. 2003;34(10):7-13.

18. Sedon CL, Breault LG, Covington LL, Bishop BG. 

The subepithelial connective tissue graft: part 1. 

patient selection and surgical techniques. J Contemp Dent Pract. 2005;6(1):146-162.

19. Harris RJ. A comparison of two techniques for 

obtaining a connective tissue graft from the 

palate. Int J Peridodontics Restorative Dent. 

1997;17(3):260-271.

20. Aichelmann-Reidy ME, Yukna RA, Evans GH, 

Nasr HF, Mayer ET. Clinical evaluation of acellular 

allograft dermis for the treatment of human gingival recession. J Periodontol. 2001;72(8):998-1005.

21. Henderson RD, Greenwell H, Drisco C, et al. 

Predictable multiple site root coverage using an 

acellular dermal matrix allograft. J Periodontol. 

2001;72:571-582.

22. Yang ZP. Treatment of labial fenestration of maxillary central incisor. Endod Dent Traumatol. 

1996;12(2):104-108.

23. Sawes WL, Barnes IE. The surgical treatment of 

fenestrated buccal roots of an upper molar- a case 

report. Int Endod J. 1983;16(2):82-86.

24. Rawlinson A. Treatment of a labial fenestration of a lower incisor tooth apex. Br Dent J. 

1984;156(12):448-449.

25. Peacock ME, Mott DA, Cuenin MF, Hokett SD, 

Fowler EB. Periodental plastic surgical technique for gingival fenestration closure. Gen Dent. 

2001;49(4):393-395.

Authors

COL Breault is a Periodontal Mentor, Advanced Education in General Dentistry – 1 Year Training Program, US 

Army Dental Activity, Fort Carson, CO.

CPT Brentson is a former Advanced Education in General Dentistry – 1 Year Resident, US Army Dental Activity, 

Fort Carson, CO, and is now a staff Dental Officer, Schofield Barracks Dental Clinic, US Army Dental Activity, HI.

COL Fowler is Chief of Periodontics, US Army Dental 

Activity, Fort Bliss, TX.

COL Bisch is Chief of Periodontics, Birmingham Veterans Administration Medical Center, Birmingham, AL, 

and past Director of the US Army Periodontic Training 

Program, US Army Dental Activity, Fort Gordon, GA.

REPAIR OF A GINGIVAL FENESTRATION USING AN ACELLULAR DERMAL MATRIX ALLOGRAFT
January – March 2016 85

The mission of the US Army Dental Command is to 

provide responsive and reliable oral health services and 

influence health to improve readiness and advance wellness in support of the force, their military families, and 

all those entrusted to our care. That mission is directly 

supportive of the Dental Command’s vision of strengthening the health of our nation by improving the oral 

health of our Army.1

Based on the fact that dental care is an essential and required component for readiness and is a cost-free benefit, 

one could assume that the number of non-third molar extracted teeth in the active-duty military population is low. 

That perception may be why the reasons for non-third 

molar extractions in a high-tempo Army population have 

not been extensively studied. The objective of this study 

was to examine the relationship between the frequency 

of non-third molar tooth extraction and the factors that 

contributed to extraction in a military population.

The reasons for and pattern of tooth loss in nonmilitary 

populations are well-documented.2-18 The main reasons 

for permanent tooth loss varies among different countries. Dental caries predominates as the most common 

reason for tooth extraction in most countries.2-7,12-14,17,18

In Germany and Canada, however, periodontal disease 

has been cited as the primary reason for tooth extraction.10,11 In Italy and Singapore, caries and periodontal 

disease appear to affect the extraction rate equally.8,9

The damage caused by dental caries is the main reason 

for tooth loss in younger populations, but periodontal disease is the primary factor for tooth loss in older 

populations.2,3,6-13

Methods

This retrospective study was reviewed by the Tripler 

Army Medical Center Regional Institutional Review 

Board (IRB) and was determined to be no greater than 

minimal risk. This project used existing data/records 

and collected information that was recorded in charts 

from January 1, 2000 to January 1, 2014. Individually 

identifying data elements were not recorded. The researcher did not keep a linking list of any sort. The IRB 

granted a waiver of consent process after it made the following determinations: the research involved no more 

than minimal risk to the subjects; the waiver did not 

adversely affect the rights and welfare of the subjects; 

the research could not be practicably carried out without the waiver; and, whenever appropriate, the subjects 

were provided with additional pertinent information after their participation. No personal identifiers were used 

and records were locked in the records room.

Power analysis determined that a sample size of 400 

records was sufficient to detect significant differences 

between the different reasons for extraction. Inclusion 

criteria for records required that at least one non-third 

molar tooth was extracted. Four hundred dental records 

were selected (using online random number generators) from over 12,000 available records. To ensure that 

no records were duplicated, a stratified randomization 

scheme was used; 40 records were selected from each 

of the 10 color jackets used to sort records in the clinic. 

This process continued until the sample size of 400 nonthird molar extraction cases was reached. Color jackets 

indicated differences in the second to last number of the 

patients’ social security number. At no time was personally identifiable information recorded and social security numbers were not recorded. Data (without any identifiers) were recorded directly on an Excel spreadsheet. 

Patient records were not removed from the dental clinic. 

Research records were maintained on a secured (common access card) computer in the dental clinic; access 

to research records was restricted to authorized research 

personnel only.

The records were reviewed with the Corporate Dental 

Application and Digital Enterprise Viewing and Acquisition Application databases for information relating to 

the location of the tooth extracted, previous treatment 

performed, reason for extraction, gender and age of the 

patient. With a sample size of 400 subjects, the study 

was able to estimate the reasons for non-third molar 

extraction with 95% confidence at α=0.05. The study 

had 80% power to detect a difference of 14% between 

rates for older and younger patients. Rates and reasons 

Reasons for Non-third Molar Extractions

 in a Military Population

MAJ Hanane Jamghili, DC, USA

COL William J. Greenwood, DC, USA

COL Peter H. Guevara, DC, USA

Col William J. Dunn, DC, USAF
86 http://www.cs.amedd.army.mil/amedd_journal.aspx

for extraction and location of tooth extracted were estimated at 95% confidence intervals. Rates were estimated separately for number of patients and for the total 

number of extractions. A 2-sided Fisher’s exact test was 

used to compare reasons for extraction by age category, 

gender, caries risk and tooth location. A significance 

level of 0.05 was used for all analyses.

Results

Chart selection was random but stratified so that an equal 

distribution of charts was reviewed using the next to last 

digit scheme. For patients who had multiple reasons for 

extractions, all of the reasons were recorded. Therefore, 

the totals for some categories exceeded 100%. The reasons for extraction of non-third molar teeth, categorized 

by gender, age, inclusion or exclusion in the High Caries Risk (HCR) program,* and tooth location are presented in Tables 1, 2, 3, and 4, respectively. Based on 

the collected data, caries was the primary reason for 

extraction of 73% of non-third molar teeth followed 

by failed endodontic treatment (21%) and extraction 

of teeth which were originally planned for prosthodontic treatment (14%). Loss of teeth due to trauma 

was also 14%, while loss due to periodontal disease 

was 10%, followed by extractions for orthodontic reasons (3%) and extractions due to hyperocclusion (2%). 

A diagnosis was not recorded in 80 of the 400 records. 

Because of this, the sample size was adjusted to 320 

records for all subsequent analyses.

The distribution of caries as the reason for extraction 

among gender reveals no statistical difference (69% female, 74% male). When comparing the reasons for extraction based on age groups, caries remain the leading 

cause at 80% for the group aged 19-29 years, 73% for the 

group aged 30-39 years, and 57% for the group aged 40-

60 years. Extraction due to caries across all age groups 

was significant (P=.003). Ninety-seven percent of the 

extractions due to caries were performed on patients 

who were identified as HCR according to the American Dental Association Caries Risk Criteria, shown on 

the following page. Posterior teeth were extracted more 

frequently than anterior teeth. Based on tooth location, 

significant differences were found for teeth extracted 

due to caries and for trauma. Posterior teeth were more 

likely to be extracted due to caries than anterior teeth, 

and anterior teeth were more likely to be extracted if 

trauma was involved.

The second most common reason for non-third molar 

tooth extraction was failed endodontic treatment. Based 

on gender, 23% of female Soldiers and 20% of male 

Soldiers required extraction due to failed endodontic 

REASONS FOR NON-THIRD MOLAR EXTRACTIONS IN A MILITARY POPULATION

*The High Caries Risk Program is designed to improve overall oral 

health by customizing dental treatment for the individual Soldier 

to meet his or her needs. It seeks to create a partnership between 

the Soldier and the dental professional and help break the decayrepair-decay cycle. The program helps the Soldier identify risk factors and receive nutritional counseling, oral hygiene instructions, 

intensive treatment to help prevent future decay, and treatment 

for any cavities. The program follows Soldiers as they are assigned 

to various locations throughout their Army careers.

Table 3. Reasons for extraction, displayed by qualification 

for High Caries Risk (HCR) category (yes or no). Percentages may sum to greater than 100% because an extracted tooth may match more than one category. Note: study 

sample=320.

Reason for

Extraction

Category P value

HCR No

N=143

[45% sample]

n (%N)

HCR Yes

N=177

[55% sample]

n (%N)

Caries 62 (43%) 171 (97%)

<.001

Failed Endo 45 (31%) 21 (12%)

Preprosthetic 33 (23%) 11 (6%)

Trauma 37 (26%) 8 (5%)

Periodontal 25 (17%) 6 (3%)

Orthodontics 11 (8%) 0 (0%)

Hyperocclusion 7 (5%) 0 (0%) .003

Table 2. Reasons for extraction by age group. Percentages may 

sum to greater than 100% because an extracted tooth may 

match more than one category. Note: study sample=320.

Reason for

Extraction

Age Group P value

19-29 Years

N=128

[45% sample]

n (%N)

30-39 Years

N=131

[41% sample]

n (%N)

40-60 Years

N=61

[19% sample]

n (%N)

Caries 103 (80%) 96 (73%) 34 (57%) .003

Failed Endo 25 (20%) 30 (23%) 10 (17%) .583

Preprosthetic 17 (13%) 19 (15%) 7 (12%) .865

Trauma 15 (12%) 17 (13%) 12 (20%) .289

Periodontal 5 (4%) 11 (8%) 15 (25%) <.001

Orthodontics 3 (2%) 6 (5%) 2 (3%) .614

Hyperocclusion 4 (3%) 2 (2%) 1 (2%) .648

Table 1. Reasons for extraction by gender. Percentages may 

sum to greater than 100% because an extracted tooth may 

match more than one category. Note: study sample=320.

Reason for

Extraction

Total

(% sample)

Gender P value

Male

N=268

[84% sample]

n (%N)

Female

N=52

[16% sample]

n (%N)

Caries 233 (73%) 197 (74%) 36 (69%) .610

Failed Endo 66 (21%) 54 (20%) 12 (23%) .708

Preprosthetic 14 (14%) 34 (13%) 10 (19%) .269

Trauma 45 (14%) 37 (14%) 8 (15%) .827

Periodontal 31 (10%) 24 (9%) 7 (13%) .310

Orthodontics 11 (3%) 10 (4%) 1 (2%) 1.000

Hyperocclusion 7 (2%) 6 (2%) 1 (2%) 1.000

No Diagnosis 80 (20%)
January – March 2016 87

THE ARMY MEDICAL DEPARTMENT JOURNAL

Table 4. Reasons for extraction by tooth location. Percentages may sum to greater than 100% because an extracted 

tooth may match more than one category. Note: study sample=320.

Reason for

Extraction

Tooth Location P value

Anterior

N=23

[7% sample]

n (%N)

Posterior

N=297

[93% sample]

n (%N)

Caries 2 (26%) 227 (76%) <.001

Failed Endo 5 (22%) 61 (21%) .796

Preprosthetic 2 (9%) 42 (14%) .753

Trauma 11 (48%) 34 (11%) <.001

Periodontal 3 (13%) 28 (9%) .477

Orthodontics 2 (19%) 9 (3%) .183

Hyperocclusion 0 (0%) 7 (2%) 1.000

treatment which was not appropriate for retreatment. 

All age groups showed similar percentages for the number of teeth extracted due to failed endodontic treatment with age groups 19-29 years (20%), 30-39 years 

(23%), and 40-60 years (17%). Thirty-one percent of the 

patients who were treated with extraction due to failed 

endodontic treatment were not in the HCR category, 

while 12% of those patients were in HCR category. This 

difference was significant (P<.001).

The next most common reason for extractions in the 

military population was divided equally between extractions on teeth which were originally planned for 

prosthodontic treatment and trauma. For the preprosthodontic and trauma categories, there was no difference 

based on gender or age group.

Based on HCR, 23% of preprosthodontic treatment extractions were performed on patients who did not qualify for HCR, while 6% of the extractions were performed 

on patients who qualify for the HCR program with a 

statistical significance of P<.001 (Table 3).

Analysis of the number of teeth extracted due to trauma 

revealed no apparent difference based on gender or age 

group. Twenty-six percent of patients treated with extraction due to trauma did not qualify for the HCR program, while 5% did qualify (P<.001). Also, 48% of the 

teeth extracted due to trauma were anterior teeth, while 

11% were posterior teeth (P<.001) as shown in Table 4.

Caries Risk Criteria

Low Risk Criteria

No incipient or cavitated primary or secondary carious lesions during current exam and no factors 

that may increase caries risk.*

Moderate Risk Criteria (any of the following)

One or two incipient or cavitated primary or secondary carious lesions during current exam.

No incipient or cavitated primary or secondary carious lesions during current exam but presence of 

at least one factor that may increase caries risk.*

High Risk Criteria (any of the following)

Three or more incipient or cavitated primary or secondary carious lesions diagnosed during current 

exam.

Presence of multiple factors that may increase caries risk.

Xerostomia (medication, radiation, or disease induced).

Suboptimal fluoride exposure (inadequate/no systemic fluoride, inadequate topical fluoride exposure).

Poor oral hygiene.

Irregular dental visits.

Incipient lesions are noncavitated localized or generalized white spots and/or interproximal radiolucencies.

*Risk Factors: factors that increase the risk of developing caries include, but are not limited to:

Deep pits and fissures. Many multisurface restorations.

Exposed root surfaces. Eating disorders.

Frequent sugar intake (>5 times per day). Restoration overhangs and open margins.

Active orthodontic treatment. Chemotherapy or radiation therapy.

Developmental or acquired enamel defects. Physical disability that impedes oral hygiene.

Inadequate salivary flow, as determined from PMH

or unstimulated salivary flow testing (<0.2 mL/min).

Source: American Dental Association
88 http://www.cs.amedd.army.mil/amedd_journal.aspx

Periodontal disease was the reason for extraction of 31 

of 320 teeth (10%). There was no statistical difference 

based on gender or tooth location. The majority of the 

patients who had extractions due to periodontal disease 

(17%) did not qualify for the HCR program, while 3% 

did qualify. Also, patients in the 40-60 year age group 

had 25% tooth loss due to periodontal disease versus 4% 

of patients in group aged 19-29 years and 8% in 30-39 

year age group. This difference was significant (P<.001).

Comment

Many advances have been made in the etiology of dental 

caries and the importance of prevention. Awareness of 

the risks of high sugar diets and the importance of regular dental exams and daily brushing is well known.19-21

However, the data collected from the current study indicate that the main reason for non-third molar extraction 

in our military patient population is still caries. In fact, 

73% of non-third molar extractions in our study were 

due to caries. This supports other research findings that 

identified caries as the primary reason for tooth extraction in many other populations.2-7,12-14,17,18 Caries was 

identified as the primary reason for emergency visits for 

deployed military members as well.22,23 In their study, 

Richards et al14 identified caries as the reason for 59% of 

the 558 tooth extractions in 417 visits. The distribution 

of extractions among age groups in the current study 

revealed that of the 233 extractions due to caries, 80% 

were in the 19-29 year age group, 73% were in the 30-

39 year group and 57% in the 40-60 year group. This 

finding was statistically significant (P=.003). This distribution could be explained by the fact that most Army 

recruits are in the 19-29 year age group. The majority of 

these Soldiers had not received dental treatment prior to 

enlistment in the Army, so some teeth were inevitably 

deemed nonrestorable during their dental examination.

The Soldiers in the group aged 30-39 years had the same 

dental problems observed in the younger age group. 

One observation is that the average age of enlistment 

has increased over the past decade, perhaps reflecting 

the continuous operational nature of the military mission. Another important factor is multiple deployments 

lasting between 12 and 18 months (or longer) over the 

last 14 years with the increased deployment tempo from 

military operations. It was often difficult for some Soldiers to be seen at a dental clinic for routine care during 

deployment. The probability of a Soldier with an asymptomatic carious lesion receiving dental treatment during 

deployment was small as emergency care was often the 

only type of care available.

The extraction rate due to caries dropped in the 40-60 

year age group. At this point in their military careers, 

Soldiers have been seen multiple times for annual exams and have most likely eliminated the active component of caries.

Soldiers are dentally categorized based on their risk of 

developing a significant dental problem over the next 

year. This type of categorization is common across the 

uniformed services. In 2006, the Department of Defense (DoD) published the latest policy letter on oral 

health and readiness.24 Health Affairs Policy 06-011 

set the guidelines for the updated Individual Medical 

Readiness requirements outlined in DoD Instruction 

6025.19.

25 Military departments perform annual dental 

readiness assessments to determine a service member’s 

Dental Readiness Classification (DRC):

 Service members designated Class 1 (DRC 1) are 

those with a current dental examination who do not 

require dental treatment or reevaluation. As such, 

from a dental health standpoint, those personnel are 

deployable worldwide.

 Dental Class 2 (DRC 2) service members have a 

current dental examination and require nonurgent 

dental treatment or reevaluation for oral conditions 

that are unlikely to result in dental emergencies 

within 12 months. They are deployable worldwide.

 Dental Class 3 (DRC 3) service members require 

urgent or emergent dental treatment. They normally 

are not considered to be deployable worldwide.

 Dental Class 4 (DRC 4) are service members whose 

dental readiness classification is undetermined by 

virtue of being overdue for their annual dental 

examination.

Despite the efforts to ensure dental readiness in the 

Army, DRC 2 patients may progress to DRC 3 if no restorative intervention occurs in a reasonable amount of 

time. Another possible reason for the high percentage 

of Soldiers suffering from extensive caries is lifestyle. 

Many Soldiers resort to high caffeine, high sugar energy 

drinks to stay alert. This could help explain why caries 

remain a concern in the 40-60 year age group.

The second most common reason for non-third molar 

extraction, regardless of gender or age group, was failed 

endodontic treatment. The lack of a well-sealed restoration can lead to bacterial leakage into the root canal 

system, necessitating retreatment or extraction. The 

most common reasons for endodontic failure are missed 

canals, incompletely treated canals, and fractured 

roots.26 From the data, it was difficult to accurately discern between true failed endodontic therapy and failed 

endodontic therapy due to a faulty restoration. The two 

are often inextricably linked. The success rate for root 

canal therapy is often cited as greater than 80%.26 It is 

REASONS FOR NON-THIRD MOLAR EXTRACTIONS IN A MILITARY POPULATION
January – March 2016 89

THE ARMY MEDICAL DEPARTMENT JOURNAL

not uncommon that the lack of a quality restoration to 

cover the cusps of endodontically treated posterior teeth 

will lead to fracture of the tooth/restoration and subsequent exposure of the obturation material to oral fluids. 

Sorensen and Martinoff 27 determined that among 1,273 

endodontically treated teeth, those treated with coronal 

coverage restorations (onlays, partial, or complete metal crowns; and metal ceramic crowns) survived much 

longer than endodontically treated teeth with no coronal coverage restorations. Coronal coverage did not significantly improve the success of endodontically treated 

anterior teeth. This finding supports the placement of 

crowns on posterior teeth that cover sufficient coronal 

tooth structure to prevent fracture when occlusal forces 

attempt to separate the cusp tips. Zadic et al28 found that 

57% of extracted teeth in their sample population did not 

have a permanent coronal restoration.

Based on data from the current study, it appears that 31% 

of the extractions due to endodontic failure were performed on patients who did not qualify for HCR program, 

while 12% were performed on patients who did qualify 

(P<.001). This supports the idea that the clinical failure 

of most endodontically treated posterior teeth is not an 

active caries issue, but rather a mechanical issue where 

immediate cuspal coverage is necessary to support teeth 

that have lost a considerable amount of supporting dentin. Vire29 found that prosthetic failure of teeth restored 

with a crown occurred after an average of 87 months. 

Without a crown, the average prosthetic failure occurred 

at 50 months. Fourteen percent of the non-third molar 

extractions occurred prior to prosthodontic treatment. 

These teeth received endodontic treatment but fractured 

before receiving prosthodontic restoration. The data collected showed no association with gender, age, or tooth 

location. Most patients treated with tooth extraction prior to prosthodontic treatment did not qualify for the HCR 

program (23%), while 6% qualified for the program. Full 

cuspal coverage following endodontic treatment is a 

practice guideline for posterior teeth. However, some 

long wait times can be experienced before the patient is 

seen. We suspect that some of the extracted teeth were 

from patients waiting to be seen for cuspal coverage.

Trauma was the cause for extracting 14% of non-third 

molar teeth. There was no association between extraction due to trauma and gender and age. Based on tooth 

location, most teeth extracted due to trauma were anterior teeth in patients who did not qualify for the HCR 

program. Some reported reasons for trauma included 

falling due to seizures, vehicle accidents, sports-related 

trauma, or fights. Anterior teeth were involved in trauma much more than posterior teeth. This difference was 

statistically significant (P<.001).

The percentage of periodontally involved teeth that were 

treated by extraction ranged from 4% in the group aged 

19-29 years to 25% in the 40-60 year group (P<.001). 

This is consistent with results of other research that indicate that periodontal disease is the main reason for extraction in older age groups.10,11,30-33 Albandar et al34 conducted a study to estimate the prevalence and extent of 

periodontal disease in the United States using data from 

the third National Health and Nutrition Examination 

Survey (http://www.cdc.gov/nchs/nhanes/nh3data.htm). 

In their study, they used the data from a sample size of 

9,689 dentate persons aged 30 to 90 years who received 

a periodontal examination. The data collected included 

periodontal attachment loss, probing depth, and furcation involvement in 2 randomly selected quadrants per 

person. Based on the analysis of the results, Albandar 

et al reported that the overall number of teeth lost increased with age from 1.49 teeth in the group aged 30-34 

years to 11.29 teeth in the group aged 85-90 years.34

Based on caries management by risk assessment,35 the 

criteria for which is shown on page XX, patients who 

qualify for the HCR program were more likely to have 

extractions due to caries as shown in Table 3. Ninetyseven percent of the patients who were treated by extraction due to caries qualifed for the HCR program. On the 

other hand, caries was responsible for 43% of extractions among those not qualified for HCR (P<.001). These 

results emphasize the importance of the HCR program 

in the prevention of tooth extraction due to caries. The 

findings from the extractions categorized by HCR are 

interesting in that every factor (reasons for extraction) 

was statistically significant. Unfortunately, the statistical tests can only show that there was a difference but 

cannot explain why those differences occurred. Some 

reasons are intuitive—patients with teeth extracted due 

to caries were much more likely to be enrolled in the 

HCR program. There were significant differences for 

all other reasons for extraction, based on whether the 

patient was enrolled in HCR, but it is difficult to speculate why these differences occurred. Patients were much 

more likely to have teeth extracted for failed endodontics, preprosthetic reasons, trauma, periodontal issues, 

orthodontics, and hyperocclusion if they were not enrolled in the HCR program. More than half of the study 

population was enrolled in the HCR program, but patients in the HCR category were less likely to have teeth 

extracted for reasons other than caries.

An incidental finding was that 80 extractions were performed without recording the reason for the extraction. 

Because the treatment was tooth extraction, it was necessary to record a diagnosis, communicate treatment options with the patient, and also have the patient sign and 
90 http://www.cs.amedd.army.mil/amedd_journal.aspx

authorize consent to show that the patient understood 

and agreed with the provider about the treatment plan. 

From a legal standpoint, the dental record is a medicolegal document that should be comprehensive, easy to use, 

clear, legible, and retrievable. The dental record should 

contain a record of diagnoses and findings, record of 

treatment, and prescriptions including all diagnostic 

aids, recommendations, and patient responses. The lack 

of a recorded diagnosis is a serious breach of proper record keeping. It is difficult to believe that 20% of the 

providers did not have a diagnosis prior to extracting 

the teeth. It is reasonable to assume that the error was 

administrative, caused by inadequate attention to the 

details of accurate record keeping. However, such does 

not diminish the seriousness of the error.

Based on collected data, caries was the major cause of 

non-third molar extraction in this military population. 

Even though Soldiers are entitled to dental care at no 

monetary cost and must make mandatory annual dental visits, dental caries remains the primary reason for 

non-third molar tooth extraction. This trend could be 

related to the fact that many Soldiers are from lower socioeconomic families. It has been established that low 

socioeconomic status is a risk factor for caries.36-38 Many 

Soldiers enter the military with little dental information 

and are unaware of the causes of dental caries and the 

importance of prevention. Many Soldiers have never 

seen a dental care provider prior to joining the military 

and subsequently never received oral hygiene instruction. Explaining the importance of oral hygiene and 

demonstrating the proper brushing and flossing technique to Soldiers are important steps toward improved 

oral health. Additionally, when diagnosed with caries, 

some Soldiers lack the motivation to follow up with the 

necessary appointments in order to receive treatment. 

If enough time lapses, Soldiers may wait until the only 

treatment option is extraction. Further study is needed 

to address the high caries rate in active duty military 

populations and to investigate why so many providers 

apparently do not enter a diagnosis for tooth extractions.

Conclusions

The results of this retrospective study of a high-tempo 

Army unit show that the primary reason non-third molar 

teeth were extracted was due to caries, followed by endodontically treated teeth failures, failures of teeth prior 

to definitive prosthodontic care, trauma and periodontal 

disease. Loss of teeth due to caries was not related to 

gender, but was significant for Soldiers aged less than 40 

years, for location of the teeth (posterior more common 

than anterior), and highly significant for those persons 

enrolled in a High Caries Risk program. Loss of teeth 

due to periodontal disease accounts for approximately 

10% of non-third molar tooth loss and is highly correlated with advancing age. Based on tooth location, posterior teeth are more likely to be extracted rather than 

anterior teeth due to caries, and anterior teeth are more 

likely to be extracted due to trauma.

References

1. US Army Dental Command [internet]. Washington, 

DC: US Army Medical Dept. Available at: http://

armymedicine.mil/Pages/home.aspx. Accessed 

July 14, 2015

2. Trovik TA, Klock KS, Haugejorden O. Trends in 

reasons for tooth extractions in Norway from 1968 

to 1998. Acta Odontol Scand. 2000;58:89-96.

3. McCaul LK, Jenkins WM, Kay EJ. The reasons 

for extraction of permanent teeth in Scotland: a 15-

year follow-up study. Br Dent J. 2001;190:658-662.

4. Cahen PM, Frank RM, Turlot JC. A survey of the 

reasons for dental extractions in France. J Dent Res. 

1985;64:1087-1093.

5. Klock KS, Haugejordan O. Primary reasons for 

extraction of permanent teeth in Norway: changes 

from 1968 to 1988. Community Dent Oral Epidemiol. 1991;19:336-341.

6. Chestnutt IG, Binnie VI, Taylor MM. Reasons for tooth extraction in Scotland. J Dent. 

2000;28:295-297.

7. Agerholm D. Reasons for extraction by dental 

practitioners in England and Wales: a comparison 

with 1986 and variations between regions. J Dent. 

2001;29:237-241.

8. Angelillo IF, Nobile CG, Pavia M. Survey of reasons for extraction of permanent teeth in Italy. 

Community Dent Oral Epidemiol. 1996;24:336-340.

9. Ong G, Yeo JF, Bhole S. A survey of reasons for 

extraction of permanent teeth in Singapore. Community Dent Oral Epidemiol. 1996;24:124-127.

10. Reich E, Hiller KA. Reasons for tooth extraction 

in the western states of Germany. Community Dent 

Oral Epidemiol. 1993;21:379-383.

11. Murray H, Locker D, Kay EJ. Patterns and reasons 

for tooth extractions in general practice in Ontario, Canada. Community Dent Oral Epidemiol. 

1996;24:196-200.

12. Morita M, Kimura T, Kanegae M, Ishikawa A, 

Watanabe T. Reasons for extraction of permanent 

teeth in Japan. Community Dent Oral Epidemiol. 

1994;22:303-306.

13. Chauncey HH, Glass RL, Alman JE. Dental Caries. 

Principal cause of tooth extraction in a sample of 

US male adults. Caries Res. 1989;23:200-205.

14. Richards W, Ameen J, Coll AM, Higgs G. Reasons 

for tooth extraction in four general dental practices 

in South Wales. Br Dent J. 2005;198(5):275-278.

REASONS FOR NON-THIRD MOLAR EXTRACTIONS IN A MILITARY POPULATION
January – March 2016 91

THE ARMY MEDICAL DEPARTMENT JOURNAL

15. Sayegh A, Hilow H, Bedi R. Pattern of tooth loss 

in recipients of free dental treatment at the University Hospital of Amman, Jordan. J Oral Rehabil. 

2004;31(2):124-130.

16. Chrysanthakopoulos NA. Reasons for extraction of 

permanent teeth in Greece: a five-year follow-up 

study. Int Dent J. 2011;61(1):19-24.

17. Aida J, Ando Y, Akhter R, Aoyama H, Masui M, 

Morita M. Reasons for permanent tooth extractions 

in Japan. J Epidemiol. 2006;16(5):214-219.

18. Hull PS, Worthington HV, Clerehugh V, Tsirba R, 

Davies RM, Clarkson JE. The reasons for tooth 

extractions in adults and their validation. J Dent. 

1997;25(3-4):233-237.

19. Hamp SE, Johansson LA. Dental prophylaxis 

for youths in their late teens. I. Clinical effect 

of different preventive regimes on oral hygiene, 

gingivitis and dental caries. J Clin Periodontol. 

1982;9(1):22-34.

20. Infante-Rivard C. Prevalence and development of 

possible risk factors for dental caries. J Can Dent 

Assoc. 1984;50(6):488-491.

21. Honkala E, Nyyssonen V, Kolmakow S, Lammi S. 

Factors predicting caries risk in children. Scan J 

Dent Res. 1984;92(2):134-140.

22. Dunn WJ, Langsten RE, Flores S, Fandell JE. Dental Emergency rates at two expeditionary medical 

support facilities supporting operations Enduring 

and Iraqi Freedom. Mil Med. 2004;169(7):510-514.

23. Chaffin J. US Army dental emergency rates in Bosnia. Mil Med. 2001;166(12):1074-1078.

24. Policy on Oral Health and Readiness. Washington, DC:US Dept of Defense; 2006. Health Affairs 

Policy 06-001. Available at: http://www.health.mil/

Policies?&query=06-001. Accessed November 24, 

2015.

25. Department of Defense Instruction 6025.19. Individual Medical Readiness (IMR). Washington, 

DC:US Dept of Defense; 2014:10. Available at: 

http://www.dtic.mil/whs/directives/corres/pdf/

602519p.pdf. Accessed November 24, 2015.

26. Kojima K, Inamoto K, Nagamatsu K, et al. Success rate of endodontic treatment of teeth with 

vital and nonvital pulps. A meta-analysis. Oral 

Surg Oral Med Oral Pathol Oral Radiol Endod. 

2004;97(1):95-99.

27. Sorensen JA, Martinhoff JT. Intracoronal reinforcement and coronal coverage:a study of 

endodontically treated teeth. J Prosthet Dent. 

1984;51(6):780-784.

28. Zadik Y, Sandler V, Bechor R, Salehrabi R. Analysis of factors related to extraction of endodontically 

treated teeth. Oral Surg Oral Med Oral Pathol 

Oral Radiol Endod. 2008;106(5):e31-e35.

29. Vire DE. Failure of endodontically treated 

teeth: classification and evaluation. J Endod. 

1991;17(7);338-342.

30. Richards D. Review finds that severe periodontitis 

affects 11% of the world population. Evid Based 

Dent. 2014;15(3);70-71.

31. Houshmand M, Holtfreter B, Berg MH, et al. Refining definitions of periodontal disease and caries 

for prediction models of incident tooth loss. J Clin 

Periodontol. 2012;39(7):635-644.

32. Thorstensson H, Johansson B. Why do some people lose teeth across their lifespan whereas others 

retain a functional dentition into very old age?. 

Gerodontology. 2010;27(1):19-25.

33. Bouchard P, Boutouyrie P, Mattout C, Bourgeois 

D. Risk assessment for severe clinical attachment loss in an adult population. J Periodontol. 

2006;77(3):479-489.

34. Albandar JM, Brunelle JA, Kingman A. Destructive periodontal disease in adults 30 years of age 

and older in the United States, 1988-1999. J Periodontol. 1999;70(1):13-29.

35. Young DA, Featherstone JD. Caries management 

by risk assessment. Community Dent Oral Epidemiol. 2013;41(1):53-63.

36. Petersen PE. Social inequalities in dental health. 

Towards a theoretical explanation. Community 

Dent Oral Epidemiol. 1990;18(3):153-158.

37. Dominguez-Rojas V, Astasio-ArbizaP, OrtegaMolina P, Gordillo-Florencio E, Garcia-Nunez 

JA, Bascones-Martinez A. Analysis of several risk 

factors involved in dental caries through multiple 

logistic regression. Int Dent J. 1993;43(2):149-156.

38. Gratrix D, Holloway PJ. Factors of deprivation associated with dental caries in young children. Community Dent Health. 1994;11(2):66-70.

Authors

MAJ Jamghili is with the Kimbrough Ambulatory Care 

Center, Fort George G. Meade, Maryland.

COL Greenwood is Commander, Fort Benning Dental 

Activity, Fort Benning, Georgia.

COL Guevara is Program Director, Advanced Education 

in General Dentistry Two-Year Program, Schofield Barracks, Hawaii. He is also the General Dentistry Consultant to the Army Surgeon General.

Col Dunn is Commander, Detachment 1, 711 Human 

Performance Wing, Joint Base San Antonio, Texas, and 

is Military Consultant to the Surgeon General for Dental 

Research.
92 http://www.cs.amedd.army.mil/amedd_journal.aspx
Submission of Manuscripts to the Army Medical Department Journal

The United States Army Medical Department Journal is published quarterly to expand knowledge of domestic and international 

military medical issues and technological advances; promote collaborative partnerships among the Services, components, Corps, 

and specialties; convey clinical and health service support information; and provide a professional, high quality, peer reviewed print 

medium to encourage dialogue concerning health care issues and initiatives.

Review Policy

All manuscripts will be reviewed by the AMEDD Journal’s Editorial Review Board and, if required, forwarded to the appropriate 

subject matter expert for further review and assessment.

Identification of Potential Conflicts of Interest

1. Related to individual authors’ commitments: Each author is responsible for the full disclosure of all financial and personal relationships that might bias the work or information presented in the manuscript. To prevent ambiguity, authors must state explicitly 

whether potential conflicts do or do not exist. Authors should do so in the manuscript on a conflict-of-interest notification section 

on the title page, providing additional detail, if necessary, in a cover letter that accompanies the manuscript.

2. Assistance: Authors should identify Individuals who provide writing or other assistance and disclose the funding source for this 

assistance, if any.

3. Investigators: Potential conflicts must be disclosed to study participants. Authors must clearly state whether they have done so 

in the manuscript.

4. Related to project support: Authors should describe the role of the study sponsor, if any, in study design; collection, analysis, 

and interpretation of data; writing the report; and the decision to submit the report for publication. If the supporting source had 

no such involvement, the authors should so state.

Protection of Human Subjects and Animals in Research

When reporting experiments on human subjects, authors must indicate whether the procedures followed were in accordance with 

the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki 

Declaration of 1975, as revised in 2000. If doubt exists whether the research was conducted in accordance with the Helsinki Declaration, 

the authors must explain the rationale for their approach and demonstrate that the institutional review body explicitly approved the 

doubtful aspects of the study. When reporting experiments on animals, authors should indicate whether the institutional and national 

guide for the care and use of laboratory animals was followed.

Informed Consent

Identifying information, including names, initials, or hospital numbers, should not be published in written descriptions, photographs, 

or pedigrees unless the information is essential for scientific purposes and the patient (or parent or guardian) gives written informed 

consent for publication. Informed consent for this purpose requires that an identifiable patient be shown the manuscript to be 

published. Authors should disclose to these patients whether any potential identifiable material might be available via the Internet 

as well as in print after publication. Patient consent should be written and archived, either with the Journal, the authors, or both, 

as dictated by local regulations or laws.

Guidelines for Manuscript Submissions

1. Manuscripts may be submitted either via email (preferred) or by regular mail. Mail submissions should be in digital format (preferably an MS Word document on CD/DVD) with one printed copy of the manuscript. Ideally, a manuscript should be no longer than 

24 double-spaced pages. However, exceptions will always be considered on a case-by-case basis.

2. The American Medical Association Manual of Style governs formatting in the preparation of text and references. All articles 

should conform to those guidelines as closely as possible. Abbreviations/acronyms should be limited as much as possible. Inclusion of a list of article acronyms and abbreviations can be very helpful in the review process and is strongly encouraged.

3. A complete list of references cited in the article must be provided with the manuscript, with the following required data:

• Reference citations of published articles must include the authors’ surnames and initials, article title, publication title, 

year of publication, volume, and page numbers.

• Reference citations of books must include the authors’ surnames and initials, book title, volume and/or edition if appropriate, 

place of publication, publisher, year of copyright, and specific page numbers if cited.

• Reference citations for presentations, unpublished papers, conferences, symposia, etc, must include as much identifying 

information as possible (location, dates, presenters, sponsors, titles).

4. Either color or black and white imagery may be submitted with the manuscript. Color produces the best print reproduction 

quality, but please avoid excessive use of multiple colors and shading. Digital graphic formats (JPG, TIFF, GIF) are preferred. 

Editable versions with data sets of any Excel charts and graphs must be included. Charts/graphs embedded in MS Word cannot 

be used. Prints of photographs are acceptable. If at all possible, please do not send photos embedded in PowerPoint or MS Word. 

Images submitted on slides, negatives, or copies of X-ray film will not be published. For clarity, please mark the top of each 

photographic print on the back. Tape captions to the back of photos or submit them on a separate sheet. Ensure captions and 

photos are indexed to each other. Clearly indicate the desired position of each photo within the manuscript.

5. The authors’ names, ranks or academic/certification credentials, titles or positions, current unit of assignment, and contact 

information must be included on the title page of the manuscript. Submit manuscripts to:

DSN 471-6301

Comm 210-221-6301

Email: usarmy.jbsa.medcom-ameddcs.list.amedd-journal@mail.mil

Editor, AMEDD Journal

AHS CDD AMEDDC&S

3630 Stanley RD STE B0204 

JBSA Fort Sam Houston, TX 78234-6100
PIN: 105692-000