Table 2 Barriers and facilitators of implementing musculoskeletal programs of care in active military using capability, opportunity, motivation-behavior (COM-B) system

 Psychological capability (knowledge of psychological skills, strength or stamina to engage in the necessary mental processes)

DC treated service member with respect and concern

DC able to respond to patient questions

Patient uncertainty regarding recovery expectations

Boudreau et al., 2006 [29]

No formal training sessions for nurses, medics, physician assistants, and other support staff

Uncertainty in applying CPG in multiple ailment cases

Cretin et al., 2001 [32]

Chiefs of Professional Service, Department of Clinics and Radiology believed that the PT demonstrated capability to provide quality medical care in the screening role

James et al., 1975 [37]

PTs with specialized training in musculoskeletal evaluation

James et al., 1981 [38]

Use of current procedural terminology (CPT) code for patient education because reassurance and information demonstrated to be effective for spine conditions (this code not consistently used for spine cases)

Use of specific coding by all members of Spine Team to differentiate care from that of other providers

Cases that present with a premorbid psychological or psychiatric diagnosis should be identified because different outcomes may be expected

Ziemke et al., 2015 [42]

 Physical capability (physical skill, strength, or stamina)

 Physical opportunity (opportunity afforded by the environment involving time, resources, locations, cues, physical “affordance”)

Direct access to x-rays in hospital

Medical referral required for CT scan, MRI, or other diagnostic tests

Improper equipment, e.g., medical treatment tables provided by the hospital rather than chiropractic tables

Boudreau et al., 2006 [29]

Immediate on-site consultations between sport medicine physicians, athletic trainer, PT

Brawley et al., 2012 [30]

Decreased patient privacy associated with open-bay configuration of the Sports and Medicine Reconditioning Team (SMART) clinic model

Brawley et al., 2012 [30]

“Backs to Work” program modified from 5 to 3 days as patients unwilling to spend time away from work or unable to secure complete release from duty for treatment

Campello et al., 2012 [31]

Different low back pain diagnostic codes made it difficult to compare across sites. Resolved by having sites agree to a single ICD-9 code

Staff turnover resulted in repeated training

Delays in distributing toolkit items

Difficulty accessing web-based system to facilitate information exchange

Differences in medical and administrative assets

Cretin et al., 2001 [32]

Health providers available and ideally with primary care or first point of contact, e.g., PTs in separate department and inaccessible when needed (author)

Feuerstein et al., 2006 [33]

DC in same clinic with PT

Green et al., 2006 [35]

Limited equipment, e.g., no dual inclinometry for range of motion assessment

Green et al., 2010 [36]

Too little time available for individual patients (increased workload without an increase in staffing)

Lack of scheduling and resultant cyclic nature of workload

Poor examination facilities

Overall troop strengths, troop activities, weather conditions and epidemiological status of population influence number of visits to PT clinic

James et al., 1975 [37]

Legibility problems with PT hand writing

James et al., 1981 [38]

Development of MSK team and a training room created in the recruit medical clinic

Kelly et al., 1997 [39]

Electronic medical record has built in referral process for specialty services

Electronic medical record maintained in a secure network and are unavailable to off-base providers; thus, applicable notes need to be delivered

Lillie, 2010 [40]

Some care shifted to local private PT managed care network (to offset increased workload from “Physical Therapy First” approach)

Sharing DoD resources through interagency collaboration

PT as first line of care

PT Director gatekeeper for all MSK consults requested by Primary Care staff

Conservative treatment exhausted prior to referral to orthopedic specialty

Allow specialty care referral to US Navy Jacksonville Orthopedic Department instead of private managed care network

Active duty orthopedic consults consolidated daily by the Resource Management Officer

Primary care provider informed patients that an orthopedic referral would occur after consultation with the MSK team

McGee et al., 2017 [43]

Development of MSK Soldier Readiness Processing (SRP) Pathway to expedite access to MSK team (PT, physiatrist, sports medicine physician) among soldiers returning from deployment with MSI

Constant turnover of military personnel. Leaders are usually only in their position for 1–3 years, which means in a 5–7-year period you can have a complete turnover of staff. This leads to ongoing reinvention and makes it very difficult to gather traction for something that will last for a decent amount of time. Cannot assume that current leaders’ priorities and goals will be the same as the follow-on leader (author)

Rhon et al., 2017 [41]

Develop a system for triaging service members with spine conditions to the Spine Team for care early after injury onset

Use an evidence-based algorithm to allocate treatment

DC part of primary care Spine Team (DC, PT, orthopedic surgeon or physiatrist) (author)

DC is direct access while PT is not (author)

DC saw most cases initially, would do a trial of therapy and then either discharge or refer to PT (author)

Delay in initiation of care for spine conditions, suggest that the condition was chronic before the Spine Team saw the patient

Gaps in patterns of care: service members with spine conditions received follow-up conservative care from their operational medical team, which is not always reflected in the Composite Health Care System records

DC saw one patient at a time, compared to PT who saw 2–3 patients at a time (author)

Need a clear interdisciplinary team protocol, as well as an algorithm to avoid service duplication (author)

Personnel turnover is a challenge for continuation of service implementation (author)

Ziemke et al., 2015 [42]

 Social opportunity (opportunity afforded by interpersonal influences, social cues, and cultural norms that influence the way that we think about things, e.g., the words and concepts that make up our language)

Cognitive behavioural therapy included education about how psychosocial variables affect pain, relaxation training, modification of maladaptive beliefs, and problem solving

Campello et al., 2012 [31]

Competing demands for resources and staff time

Sites were slow to establish monitoring procedures, in part due to delays in providing “official” system-wide low back pain metrics

Cretin et al., 2001 [32]

Advocate for low back pain CPG

Feuerstein et al., 2006 [33]

Flight surgeon coordinated ordering and follow-up of clinical consults

PT and DC communication to ensure non-duplication of service

Green et al., 2006 [35]

Close working relationship between flight surgeon and DC

Suboptimal treatment frequency due to scheduling conflicts

Green et al., 2010 [36]

Formal weekly meetings to discuss progress of more seriously injured recruits

Kelly et al., 1997 [39]

DC attend weekly meeting with specialty providers to discuss specific cases

Lillie, 2010 [40]

Specialists exchange evidence-based approaches to care

Primary care manager visited DC clinic and was familiar with the approach to care

Family medicine residents’ observations in DC clinic

DC provide in-service presentations

Endorsed and facilitated by leadership to include the Medical Group Commander, the Chief of Staff, and the full executive staff

Implementation champion (PT)

Professional staff (physicians, physician assistants, nurses, and therapists) engaged in forum to develop consensus on proposed protocol changes

Professional staff briefed with background and supporting evidence at monthly staff meeting to promote buy-in

Clinical interventions and pathways reviewed each quarter

Professional staff received feedback on clinical metrics and issues as they arose

Audit and feedback reporting to professional staff to reinforce that their referral behaviors were being monitored

Clinical autonomy of primary care teams respected

Emphasizing benefits for each stakeholder group: improved surgical/procedural throughput for network and military orthopedic specialists; transparency and constant reporting enabled primary care staff to observe benefits associated with following evidence-based guidelines

Fear that changes would result in increased burden to the provider, offset by single step to minimize workflow disruption and protected PT time for chart review

McGee et al., 2017 [43]

 Reflective (reflective process involving plans (self-conscious intentions) and evaluations (beliefs about what is good and bad))

Buy-in from authorities as well as clinicians affected by the program (author)

Campello et al., 2012 [31]

Teams moderately motivated to implement CPG due to resistance to the concept of guidelines, uncertainty about the implementation demonstration, and concerns about increased workload

Previous experience with guidelines

Expected rewards from implementation

Cretin et al., 2001 [32]

Low rate of adherence to low back pain CPG likely resulted from providers assuming that most cases of low back pain resolve spontaneously

Primary care providers thought they knew how to manage low back pain (author)

Primary care providers did not think the low back pain CPG was defensible despite being evidence-based (author)

Providers heavily influenced by patient desires, e.g., patient requests MRI even though CPG was clear that MRI was not indicated (author)

Feuerstein et al., 2006 [33]

Coping with too-often-obvious gain phenomena in many patients, e.g., obtain benefits or be excused from duty

James et al., 1975 [37]

Create a plan, then brief it at varying levels until you reach authorities who can make it happen. Much of it is salesmanship, doing your homework to answer the “business” questions, make sure it addresses “perceived needs,” etc. (author)

Outcomes are not captured very well in military health system. Varying opinions as to what constitutes “value” and what should be measured. A system to create outcome measures needs to be created, but the direct cost/benefit is uncertain therefore difficult to sell. Assessed patient satisfaction (which is not good measure of quality), costs, access to care, and leakage to civilian settings (goal to keep as many patients in the military system and maintain access times, so not referred to civilian settings) (author)

Rhon et al., 2017 [41]

Primary care and PT teams worked collaboratively in pre-existing culture of trust and mutual sharing

McGee et al., 2017 [43]

 Automatic (automatic processes involving emotional reactions, desires (wants and needs), impulses, inhibitions, drive states, and reflex responses)

Most flight surgeons (designated first point of contact) are accustomed to collaborating with physiatrists and PTs but not DCs

Green et al., 2006 [35]