Table 1 Implementation interventions of musculoskeletal programs of care for active military classified using the Effective Practice and Organization of Care (EPOC) taxonomy
Implementation interventions according to Effective Practice and Organization of Care (EPOC) taxonomy | Author(s), year, study design | Clinical setting/participants type and/or number (n) | Description of Implementation Interventions and Programs of Care | |
|---|---|---|---|---|
Delivery arrangements | ||||
How and when care is delivered | Coordination of care among different providers | Green et al., 2006 [35], case report | Military treatment facility, US US Marine Corps F/A-18 aviation instructor, age 36 | Interdisciplinary management of low back pain Flight surgeon coordinated clinical consults with neurosurgeon, hospital physiatrist, physical therapist Physical therapist discussed case with chiropractor located in the same clinic |
Kelly et al., 1997 [39], qualitative case study | Recruit Training Command Great Lakes, US 1992: n = 292 1993: n = 246 1994: n = 529 1995: n = 898 | Interdisciplinary management of musculoskeletal disorders Musculoskeletal team 3-tier approach: evaluate and diagnose injured recruit, and initiate appropriate level of treatment based on injury severity Physical therapist provided 5 days/week Well-established team protocols and an understanding of the particular injuries benefitting from physical therapist, and when to refer to physical therapist | ||
Lillie, 2010 [40], case report | Military treatment facility, US US Navy Petty Officer, age 40 | Interdisciplinary management of low back pain Primary care, chiropractic physician, and orthopedic specialist provided coordinated care in an established multidisciplinary health system | ||
Rhon et al., 2017 [41], cross-sectional | Madigan Army Medical Centre, US National Guard, 116th Cavalry Brigade Combat Team N = 284 Average age 32 years | Interdisciplinary Reverse Soldier Readiness Program, Musculoskeletal Soldier Readiness Program Clinical Pathway Patients with multiple complaints, both musculoskeletal and non-musculoskeletal disorders, were referred to primary care for care coordination | ||
Ziemke et al., 2015 [42], quasi-experimental | Naval Medical Center Portsmouth, US Naval Medical Center San Diego, US US Navy and US Marine Corps service members, aged 18–64, seeking care for a work-disabling spine condition (2007–2009) n = 667 | Interdisciplinary management of work-disabling nonspecific low back pain Service members referred to the Spine Team, where an orthopedic spine surgeon screens for a surgical or non-surgical consultation Non-surgical cases are distributed among the remaining members of the Spine Team (physical therapist, physician assistant, physiatrist, chiropractor) Referral by any team member to psychologist | ||
Where care is provided and changes to the healthcare environment | Site of service delivery | Boudreau et al., 2006 [29], pilot | Outpatient department, Archie McCallum Hospital, Canadian Forces Base Stadacona, Canada Chiropractor (n = 2) MD (n = 12) Consecutive active military members with low back pain (n = 102) | Interdisciplinary management of musculoskeletal disorders On-site, outpatient treatment at military hospital for musculoskeletal disorders |
Green et al., 2006 [35], case report | Military treatment facility, US US Marine Corps F/A-18 aviation instructor, age 36 | Interdisciplinary management of low back pain Chiropractor and physical therapist located in the same clinic | ||
James et al., 1981 [38], mixed methods | US army hospital, US Army Health Services Command data Physical therapists (n = 5) Active duty military (n = 3291) | Expanded physical therapist role as primary screener of musculoskeletal conditions Musculoskeletal evaluation clinic operates in conjunction with the regular physical therapist clinic | ||
Kelly et al., 1997 [39], qualitative case study | Recruit Training Command Great Lakes, US 1992: n = 292 1993: n = 246 1994: n = 529 1995: n = 898 | Interdisciplinary management of musculoskeletal disorders Musculoskeletal team of physician, physical therapists, podiatrists, physician assistants, independent duty corpsmen, physical therapist technicians Share expertise in diagnosis and treatment of musculoskeletal injuries Training room created within the recruit medical clinic, and musculoskeletal team worked in collaboration with the Recruit Rehabilitation Unit (RRU) and the Recruit Convalescent Unit (RCU) | ||
Lillie, 2010 [40], case report | Military treatment facility, US US Navy Petty Officer, age 40 | Interdisciplinary management of low back pain Primary care manager co-located with patient allowed for monitoring of progress and coordination of care | ||
McGee et al., 2017 [43], mixed methods | Moody Air Force Base, US 23rd Medical Group (outpatient clinic) (n = 12): physicians, physician assistants, nurse practitioners, physical therapists | “Physical Therapy First” orthopedic performance improvement initiative designed within Consolidated Framework for Implementation Research model Improve appropriate referrals and decrease inappropriate resource utilization for musculoskeletal injuries Orthopedic care provided through a private managed care network, changed by having consults further screened to allow for specialty care at US Navy Jacksonville Orthopedic Department (local to encourage collaboration between programs within a specific region) | ||
Environment | Brawley et al., 2012 [30], historical cohort | Marine Corps Base Camp Lejeunce Mainside and Camp Geiger, US Active duty service member placed on limited duty for primary upper or lower extremity injury (n = 8299) | Sports Medicine and Reconditioning Team (SMART) clinic model replacing traditional problem-based clinic model Athletic training room model with an open-bay configuration allowing for coordinated multidisciplinary approach, direct transition of care, communication between team members | |
Kelly et al., 1997 [39], qualitative case study | Recruit Training Command Great Lakes, US 1992: n = 292 1993: n = 246 1994: n = 529 1995: n = 898 | Interdisciplinary management of musculoskeletal disorders Training room format based on college athletic training room model | ||
Who provides care and how the healthcare workforce is managed | Role expansion | James et al., 1975 [37], mixed methods | Non-teaching army hospital, US Physical therapist s (n = 8) Baseline phase (n = 950) Screening phase (n = 2296) | Expanded physical therapist role as primary screener for low back pain complaint using a decision guide Physical therapist role: evaluate patient, request x-rays, determine patient care, refer to physician for further evaluation |
Coordination of care and management of care processes | Care pathways | Larsson et al., 2012 [44], non-experimental | Swedish Armed Forces who started military training: 2003: n = 120 (artillery) 2004: n = 356 (Ranger) 2004: n = 407 (engineer) | Musculoskeletal Screening Protocol: questionnaire (lifestyle factors, self-rated health) and physical tests for musculoskeletal complaints and functional limitations within first week of soldiers’ arrival Provided early rehabilitation or physical training/exercise programs |
McGee et al., 2017 [43], mixed methods | Moody Air Force Base, US Moody Air Force Base, US 23rd Medical Group (outpatient clinic) (n = 12): physicians, physician assistants, nurse practitioners, physical therapists | “Physical Therapy First” orthopedic performance improvement initiative designed within Consolidated Framework for Implementation Research model -Improve appropriate referrals and decrease inappropriate resource utilization for musculoskeletal injuries physical therapy was the first line of care and conservative treatment was exhausted before orthopedic specialty referral | ||
Communication between providers | Boudreau et al., 2006 [29], pilot study | Outpatient department, Archie McCallum Hospital, Canadian Forces Base Stadacona, Canada Chiropractor (n = 2) MD (n = 12) Consecutive active military members with low back pain (n = 102) | Interdisciplinary management of musculoskeletal disorders Initial report (examination findings, clinical impression, treatment plan, prognosis) Progress update after 10 treatments to MD for approval for further care | |
Lillie 2010 [40], case report | Military treatment facility, US US Navy Petty Officer, age 40 | Interdisciplinary management of low back pain Encourage weekly meetings with specialty providers | ||
Packages of care | Goertz et al., 2013 [34], pilot RCT study | William Beaumont Army Medical Center (WBAMC), US US active-duty military personnel, age 18–35, low back pain < 4 weeks duration Chiropractic manipulative therapy, n = 45 Standard medical care, n = 46 | Interdisciplinary management of low back pain Chiropractic manipulative therapy, 2/week for 4 weeks High velocity low amplitude manipulation, plus brief massage, ice/heat lumbar region, stretching or McKenzie exercises, advice on activites of daily living, postural/ergonomic advice, mobilization, with standard medical care Standard Medical Care: history and physical exam, diagnostic imaging as indicated, self-management education including activity as tolerated, pharmacological management (analgesics, anti-inflammatory agents), physical therapy, modalities, e.g., heat/ice, referral to pain clinic | |
Green et al., 2006 [35], case report | Military treatment facility, US US Marine Corps F/A-18 aviation instructor, age 36 | Interdisciplinary management of low back pain Chiropractor informed flight surgeon of the course of care Chiropractor and physical therapist discussed case to ensure care was complimentary and not redundant | ||
Referral systems | Boudreau et al., 2006 [29], pilot study | Outpatient department, Archie McCallum Hospital, Canadian Forces Base Stadacona, Canada Chiropractor (n = 2) MD (n = 12) Consecutive active military members with low back pain (n = 102) | Interdisciplinary management of musculoskeletal disorders Referral required by general practitioner or medical specialist to access chiropractor | |
Green et al., 2006 [35], case report | Military treatment facility, US US Marine Corps F/A-18 aviation instructor, age 36 | Interdisciplinary management of low back pain Flight surgeon ordered consults with neurosurgeon, hospital physiatrist, and physical therapist | ||
Green et al., 2010 [36], case report | Naval hospital, US US Marine Corps F/A-18 aviation instructor, age 38 | Interdisciplinary management of neck pain Flight surgeon referral to on-station chiropractor | ||
James et al., 1975 [37], mixed methods | Non-teaching army hospital, US Physical therapists (n = 8) Baseline phase (n = 950) Screening phase (n = 2296) | Expanded role as primary screener for low back pain complaint using a decision guide Referral to physical therapist by physician or non-physician health care worker (e.g., army corpsman, nurse clinician, physicians’ assistant) | ||
James et al., 1981 [38], mixed methods | US army hospital, US Army Health Services Command data Physical therapists (n = 5) Active duty military (n = 3291) | Expanded physical therapist role as primary screener musculoskeletal conditions Musculoskeletal evaluation clinic Patients assigned in order, with other patients to physical therapists in expanded musculoskeletal role | ||
Lillie, 2010 [40], case report | Military treatment facility, US US Navy Petty Officer, age 40 | Interdisciplinary management of low back pain Primary care manager (naval flight surgeon) manages and coordinates care of each patient Referral to orthopedic specialist and chiropractor | ||
McGee et al., 2017 [43], mixed methods | Moody Air Force Base, US 23rd Medical Group (outpatient clinic) (n = 12): physicians, physician assistants, nurse practitioners, physical therapists | “Physical Therapy First” orthopedic performance improvement initiative designed within Consolidated Framework for Implementation Research model Improve appropriate referrals and decrease inappropriate resource utilization for musculoskeletal injuries Physical Therapist Director acted as gatekeeper for all musculoskeletal consults requested by primary care staff Resource Management Officer consolidated all active duty orthopedic consults daily coordinating care between military treatment facility and civilian network | ||
Rhon et al., 2017 [41], cross-sectional | Madigan Army Medical Centre, US National Guard, 116th Cavalry Brigade Combat Team N = 284 Average age 32 years | Interdisciplinary Reverse Soldier Readiness Program, Musculoskeletal Soldier Readiness Program Clinical Pathway Soldier Readiness Program process occurred during one day in which the medical screener referred patients with primarily musculoskeletal injuries to Musculoskeletal Soldier Readiness Program Clinical Pathway which included physical therapist, physiatrist, and sports medicine physician. Care provided within 72 h Musculoskeletal Soldier Readiness Program Clinical Team gatekeepers to orthopedic surgeons, podiatry, and occupational therapist | ||
Ziemke et al., 2015 [42], quasi-experimental | Naval Medical Center Portsmouth, US Naval Medical Center San Diego, US US Navy and US Marine Corps service members, aged 18–64, seeking care for a work-disabling spine condition (2007-2009) n = 667 | Interdisciplinary management of work-disabling nonspecific low back pain Service members are referred to the Spine Team Orthopedic spine surgeon screens for a surgical or non-surgical consultation Non-surgical cases are distributed among the remaining members of the Spine Team (physical therapist, physician assistant, physiatrist, chiropractor) Referral by any team member to psychologist | ||
Teams | Boudreau et al., 2006 [29], pilot study | Outpatient department, Archie McCallum Hospital, Canadian Forces Base Stadacona, Canada Chiropractor (n = 2) MD (n = 12) Consecutive active military members with low back pain (n = 102) | Interdisciplinary management of musculoskeletal disorders Individual chiropractors encouraged to work with other hospital departments on shared patients | |
Campello et al., 2012 [31], pilot RCT study | Naval Medical Center, Portsmouth, Virginia, US Active duty service members presenting for low back pain at Sewell’s Point Branch Medical Clinic (n = 33) | Multidisciplinary ‘Backs to Work’ program compared to current standard care “Backs to Work” coordinated multidisciplinary, reconditioning program by physical therapist, MD and psychologist. Graded, goal-oriented active physical reconditioning program that includes aerobic conditioning, strength training, flexibility exercise, cognitive behavioural therapy (education about how psychosocial variables affect pain, relaxation training, modification of maladaptive beliefs, problem solving) Care providers worked as a team led by a clinical coordinator, who was responsible for coordination of care and communication among all healthcare providers and the service members command and/or workplace | ||
Kelly et al., 1997 [39], qualitative case study | Recruit Training Command Great Lakes, US 1992: n = 292 1993: n = 246 1994: n = 529 1995: n = 898 | Interdisciplinary management of musculoskeletal disorders Environment of systematic collaboration Formal weekly team meetings to discuss progress Continual education and “curb-side” consults with physical therapist allowed for proper prescription of physical therapy treatment | ||
Larsson et al., 2012 [44], non-experimental | Swedish Armed Forces who started military training: 2003: n = 120 (artillery) 2004: n = 356 (ranger) 2004: n = 407 (engineer) | Musculoskeletal Screening Protocol Enhanced teamwork between officers and unit physiotherapists to give more awareness of early problems and adjust soldiers’ load Testing was led by physiotherapist; officers registered results of the testing | ||
Lillie, 2010 [40], case report | Military treatment facility, US US Navy Petty Officer, age 40 | Interdisciplinary management of low back pain Primary care manager, chiropractor, orthopedic specialist (military and civilian) | ||
Rhon et al., 2017 [41], cross-sectional | Madigan Army Medical Centre, US National Guard, 116th Cavalry Brigade Combat Team N = 284 Average age 32 years | Interdisciplinary Reverse Soldier Readiness Program, Musculoskeletal Soldier Readiness Program Clinical Pathway Musculoskeletal Soldier Readiness Program Clinical Pathway team which included physical therapist, physiatrist and sports medicine physician. Musculoskeletal Soldier Readiness Program Clinical Team gatekeepers to orthopedic surgeons, podiatry and occupational therapist (not co-located with Musculoskeletal Soldier Readiness Program Clinical Pathway team) | ||
Ziemke et al., 2015 [42], quasi-experimental | Naval Medical Center Portsmouth, US Naval Medical Center San Diego, US US Navy and US Marine Corps service members, aged 18–64, seeking care for a work-disabling spine condition (2007–2009) n = 667 | Interdisciplinary management of work-disabling nonspecific low back pain Spine team: 2 orthopedic spine surgeons; 1–2 orthopedic physical therapists (1 specialized training in spine), clinical psychologist with specialized training in pain management, physician, physiatrist | ||
Information and communication technology (ICT) | Lillie, 2010 [40], case report | Military treatment facility, US US Navy Petty Officer, age 40 | Interdisciplinary management of low back pain Electronic health record has built in referral process to facilitate referral, e.g., to chiropractor Electronic health record accessible to all military providers | |
Implementation strategies | ||||
Interventions targeted at healthcare organizations | Organizational culture | Feuerstein et al., 2006 [33], cross-sectional | Military health service healthcare services within the continental US, fiscal years 1998–2002 Military health service beneficiaries, age 18–65, who completed a Health Care Survey of Department of Defense Beneficiaries (HCSDB) | Implementation of clinical practice guideline for the diagnosis and management of acute low back pain Establish leadership support Handbook to guide adoption of low back pain clinical practice guideline within Military Health Service |
McGee et al., 2017 [43], mixed methods | Moody Air Force Base, US 23rd Medical group (n = 12): physicians, physician assistants, nurse practitioners, physical therapists Active duty members (n = 4500) | “Physical Therapy First” orthopedic performance improvement initiative designed within Consolidated Framework for Implementation Research model Improve appropriate referrals and decrease inappropriate resource utilization for musculoskeletal injuries Initiative endorsed and facilitated by leadership to include the Medical Group Commander, the Chief of Staff and the full executive staff Engage professional staff (physicians, physician assistants, nurses, therapist) to develop consensus on proposed changes | ||
Interventions targeted at healthcare workers | Educational materials | Cretin et al., 2001 [32], mixed methods | Army community hospitals (n = 3), Army medical center (n = 1), Great Plains Region, US Multidisciplinary implementation teams Teams (n = 4) | Integration of Department of Defense/Veteran Affairs low back pain clinical practice guideline (algorithms with annotations, discussion, references to graded evidence) Low back pain toolkit Patient education materials (brochures, curricula for classes, videos, CD-ROMs web sites) Physician education materials (annotated guideline, patient case examples, videos, CD-ROM, continuing medical education modules, Internet resources), documentation forms, drug formulary, recommended devices, or equipment Team Manual: develop and monitor a guideline implementation plan |
Feuerstein et al., 2006 [33], cross-sectional | Military Health Service healthcare services within the continental US, fiscal years 1998–2002 Military Health Service beneficiaries, age 18–65, who completed a Health Care Survey of Department of Defense | Implementation of clinical practice guideline for the diagnosis and management of acute low back pain System-wide educational efforts across facilities and providers Website: clinical practice guideline downloadable and printable, clinical practice guideline key elements, tools to facilitate implementation | ||
Educational meetings | Cretin et al., 2001 [32], mixed methods | Army community hospitals (n = 3), Army medical center (n = 1), Great Plains Region, US Multidisciplinary implementation teams Teams (n = 4) | Integration of Department of Defense/Veteran Affairs low back pain clinical practice guideline (algorithms with annotations, discussion, references to graded evidence) Teams attend 1 1/2 day workshop to review low back pain clinical practice guideline and toolkit Introduction of low back pain clinical practice guideline to primary care providers and other clinic staff | |
James et al., 1981 [38], mixed methods | US army hospital, US Army Health Services Command data Physical therapists (n = 5) Active duty military (n = 3291) | Expanded physical therapist role as primary screener of musculoskeletal conditions Physical therapists performing musculoskeletal evaluations must complete 2-week musculoskeletal Assessment Course at US Army Academy of Health Sciences or civilian equivalent | ||
Larsson et al., 2012 [44], non-experimental | Swedish Armed Forces who started military training: 2003: n = 120 (artillery) 2004: n = 356 (ranger) 2004: n = 407 (engineer) | Musculoskeletal Screening Protocol Officers received training in ergonomics, recognizing musculoskeletal problems, first aid for musculoskeletal injuries, and exercise physiology through classroom instruction and practical exercises | ||
Lillie, 2010 [40], case report | Military treatment facility, US US Navy Petty Officer, age 40 | Interdisciplinary management of low back pain Primary care manager visited, and medicine residents observed in chiropractic clinic Chiropractor provided in-service Chiropractor on sports medicine and research teams | ||
Continuous quality improvement | Cretin et al., 2001 [32], mixed methods | Army community hospitals (n = 3), Army medical center (n = 1), Great Plains Region, US Multidisciplinary implementation teams Teams (n, range 7–19) | Integration of Department of Defense/Veteran Affairs low back pain clinical practice guideline (algorithms with annotations, discussion, references to graded evidence) Develop action plan by site for introduction and implementation of low back pain clinical practice guideline Run small-scale test prior to implantation on a wide scale Utilize Plan-Do-Study-Act Cycles to refine change ideas and build support for facility wide adoption | |
Feuerstein et al., 2006 [33], cross-sectional | Military Health Service healthcare services within the continental US, fiscal years 1998–2002 Military Health Service beneficiaries, age 18–65, who completed a Health Care Survey of Department of Defense Beneficiaries | Implementation of clinical practice guideline for the diagnosis and management of acute low back pain Manual for facility champions—7 step implementation process: (1) importance of knowing clinical practice guideline elements; (2) assess current practice; (3) compare current practice with clinical practice guideline recommendations; (4) identify gaps in current practice; (5) develop action plan to close gaps; (6) implement plan; (7) develop a system to monitor practice change | ||
Green et al., 2010 [36], case report | Naval hospital, US US Marine Corps F/A-18 aviation instructor, age 38 | Interdisciplinary management of neck pain Close working relationship between flight surgeon and chiropractor ensures appropriate modalities, consistent follow-up, and adherence to regulations | ||
James et al., 1981 [38], mixed methods | US army hospital, US Army Health Services Command data Physical therapists (n = 5) Active duty military (n = 3291) | Expanded physical therapist role as primary screener for musculoskeletal conditions To assess overall quality of care provided by physical therapists: treatment records reviewed for legibility, completeness, medical appropriateness | ||
Communities of practice | Cretin et al., 2001 [32], mixed methods | Army community hospitals (n = 3), Army medical center (n = 1), Great Plains Region, US Multidisciplinary implementation teams Teams (n, range 7–19) | Integration of Department of Defense/Veteran Affairs low back pain clinical practice guideline (algorithms with annotations, discussion, references to graded evidence) Teams encouraged to share information about successes and failures through video conferences, teleconferences and e-mail list servers, to incorporate change recommendations to the centrally disseminated toolkit | |
Local opinion leaders | Feuerstein et al., 2006 [33], cross-sectional | Military Health Service healthcare services within the continental US, fiscal years 1998–2002 Military Health Service beneficiaries, age 18–65, who completed a Health Care Survey of Department of Defense Beneficiaries | Implementation of clinical practice guideline for the diagnosis and management of acute low back pain Identification of clinical practice guideline advocate | |