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Table 1 Implementation interventions of musculoskeletal programs of care for active military classified using the Effective Practice and Organization of Care (EPOC) taxonomy

From: Implementation interventions for musculoskeletal programs of care in the active military and barriers, facilitators, and outcomes of implementation: a scoping review

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
  1. MD medical doctor, RCT randomized control trial, US United States