Deployment-related concussion and long-term health-related quality of life among US military personnel.

PURPOSE: To examine the relationship between deployment-related concussion and long-term health-related quality of life (HRQoL) among injured US military personnel. METHODS: The study sample included 810 service members with deployment-related injuries between 2008 and 2012 who responded to a web-based longitudinal health survey. Participants were categorized into three injury groups: concussion with loss of consciousness (LOC; n = 247), concussion without LOC (n = 317), or no concussion (n = 246). HRQoL was measured using the 36-Item Short Form Health Survey physical and mental component summary (PCS and MCS) scores. Current post-traumatic stress disorder (PTSD) and depression symptoms were examined. Multivariable linear regression models assessed the effects of concussion on PCS and MCS scores, while controlling for covariates. RESULTS: A lower PCS score was observed in participants with concussion with LOC (B = - 2.65, p = 0.003) compared with those with no history of concussion. Symptoms of PTSD (PCS: B = - 4.84, p < 0.001; MCS: B = - 10.53, p < 0.001) and depression (PCS: B = - 2.85, p < 0.001; MCS: B = - 10.24, p < 0.001) were the strongest statistically significant predictors of lower HRQoL. CONCLUSION: Concussion with LOC was significantly associated with lower HRQoL in the physical domain. These findings affirm that concussion management should integrate physical and psychological care to improve long-term HRQoL and warrant a more detailed examination of causal and mediating mechanisms. Future research should continue to incorporate patient-reported outcomes and long-term follow-up of military service members to further define the lifelong impact of deployment-related concussion.

Barriers and facilitators to implementation of musculoskeletal injury mitigation programmes for military service members around the world: a scoping review.

INTRODUCTION: Musculoskeletal injury (MSK-I) mitigation and prevention programmes (MSK-IMPPs) have been developed and implemented across militaries worldwide. Although programme efficacy is often reported, development and implementation details are often overlooked, limiting their scalability, sustainability and effectiveness. This scoping review aimed to identify the following in military populations: (1) barriers and facilitators to implementing and scaling MSK-IMPPs; (2) gaps in MSK-IMPP research and (3) future research priorities. METHODS: A scoping review assessed literature from inception to April 2022 that included studies on MSK-IMPP implementation and/or effectiveness in military populations. Barriers and facilitators to implementing these programmes were identified. RESULTS: From 132 articles, most were primary research studies (90; 68.2%); the remainder were review papers (42; 31.8%). Among primary studies, 3 (3.3%) investigated only women, 62 (69%) only men and 25 (27.8%) both. Barriers included limited resources, lack of stakeholder engagement, competing military priorities and equipment-related factors. Facilitators included strong stakeholder engagement, targeted programme design, involvement/proximity of MSK-I experts, providing MSK-I mitigation education, low burden on resources and emphasising end-user acceptability. Research gaps included variability in reported MSK-I outcomes and no consensus on relevant surveillance metrics and definitions. CONCLUSION: Despite a robust body of literature, there is a dearth of information about programme implementation; specifically, barriers or facilitators to success. Additionally, variability in outcomes and lack of consensus on MSK-I definitions may affect the development, implementation evaluation and comparison of MSK-IMPPs. There is a need for international consensus on definitions and optimal data reporting elements when conducting injury risk mitigation research in the military.

Research Letter: Prevalence of Spine Injuries Among US Military Personnel With Combat-Related Concussion.

OBJECTIVE: To describe the prevalence of spine injuries among US service members with combat-related concussion. DESIGN AND PARTICIPANTS: A retrospective review of medical records for US service members injured during combat operations in Iraq and Afghanistan between 2002 and 2020. The study sample included 27 897 service members categorized into 3 groups: concussion with loss of consciousness (LOC, n = 4631), concussion non-LOC ( n = 5533), and non-concussion ( n = 17 333). MAIN MEASURES: Spine injuries were identified by International Classification of Diseases, Ninth Revision, Clinical Modification ( ICD-9-CM ) codes and classified by body region and nature of injury using the Barell injury diagnosis matrix. Differences in prevalence of spine injuries by concussion group were evaluated using χ 2 tests. RESULTS: Spine injuries were most prevalent among service members with concussion LOC (31.1%), followed by concussion non-LOC (18.3%), and non-concussion (10.0%, P < .001). Sprains and strains were the most prevalent spine injury category, with injuries to the cervical, thoracic, and lumbar regions significantly more prevalent in the concussion groups ( P values < .001), particularly individuals with LOC compared with non-concussion. CONCLUSION: The US military personnel with combat-related concussion, especially individuals with LOC, may also have spine injuries. Routine assessment for spine injury is recommended during concussion screening because this may impact clinical management and rehabilitation.

Participant-Level Analysis of the Effects of Interventions on Patient-Reported Outcomes in Patients With Chronic Ankle Instability.

CONTEXT: Intervention studies for chronic ankle instability (CAI) often focus on improving physical impairments of the ankle complex. However, using an impairments-focused approach may miss psychological factors that may mediate function and recovery. Patient-reported outcome (PRO) measures can be used to assess several dimensions of the health-related quality of life (HRQoL) and deliver enhanced patient-centered care. Therefore, the purpose of this investigation was to evaluate group-level improvements in HRQoL and treatment response rates following various interventions in patients with CAI. DESIGN: Cross-sectional. METHODS: Data from 7 previous studies were pooled by the chronic ankle instability outcomes network for participant-level analysis, resulting in 136 patients with CAI. Several interventions were assessed including balance training, gait biofeedback, joint mobilizations, stretching, and strengthening, with treatment volume ranging from 1 to 4 weeks. Outcome measures were PROs that assessed ankle-specific function (Foot and Ankle Ability Measure), injury-related fear (Tampa Scale of Kinesiophobia and Fear Avoidance Belief Questionnaire), and global well-being (Disablement in the Physically Active); the PROs assessed varied between studies. Preintervention to postintervention changes were evaluated using separate Wilcoxon signed-rank tests and effect sizes, and a responder analysis was conducted for each PRO. RESULTS: Significant, moderate to large improvements were observed in PROs that assessed ankle-specific function, injury-related fear, and global well-being following intervention (P < .001). Responder rates ranged from 39.0% to 53.3%, 12.8% to 51.4%, and 37.8% for ankle specific function, injury-related fear, and global well-being, respectively. CONCLUSIONS: Various interventions can lead to positive improvements in HRQoL in patients with CAI. Treatment response rates at improving HRQoL are similar to response rates at improving impairments such as balance, further reinforcing the need for individualized treatment approaches when treating a patient with CAI.

Muscle Engagement Monitoring Using Self-Adhesive Elastic Nanocomposite Fabrics.

Insight into, and measurements of, muscle contraction during movement may help improve the assessment of muscle function, quantification of athletic performance, and understanding of muscle behavior, prior to and during rehabilitation following neuromusculoskeletal injury. A self-adhesive, elastic fabric, nanocomposite, skin-strain sensor was developed and validated for human movement monitoring. We hypothesized that skin-strain measurements from these wearables would reveal different degrees of muscle engagement during functional movements. To test this hypothesis, the strain sensing properties of the elastic fabric sensors, especially their linearity, stability, repeatability, and sensitivity, were first verified using load frame tests. Human subject tests conducted in parallel with optical motion capture confirmed that they can reliably measure tensile and compressive skin-strains across the calf and tibialis anterior. Then, a pilot study was conducted to assess the correlation of skin-strain measurements with surface electromyography (sEMG) signals. Subjects did biceps curls with different weights, and the responses of the elastic fabric sensors worn over the biceps brachii and flexor carpi radialis (i.e., forearm) were well-correlated with sEMG muscle engagement measures. These nanocomposite fabric sensors were validated for monitoring muscle engagement during functional activities and did not suffer from the motion artifacts typically observed when using sEMGs in free-living community settings.

Effects of Midfoot Joint Mobilization on Perceived Ankle-Foot Function in Chronic Ankle Instability: A Crossover Clinical Trial.

CONTEXT: To investigate the effects of midfoot joint mobilization and a 1-week home exercise program, compared with a sham intervention, and home exercise program on pain, patient-reported outcomes, ankle-foot joint mobility, and neuromotor function in young adults with chronic ankle instability. DESIGN: Crossover clinical trial. METHODS: Twenty participants with chronic ankle instability were instructed in a stretching, strengthening, and balance home exercise program and were randomized a priori to receive either midfoot joint mobilizations (forefoot supination, cuboid glide, and plantar first tarsometatarsal) or a sham laying of hands on the initial visit. Changes in foot morphology, joint mobility, strength, dynamic balance, and patient-reported outcomes assessing pain, physical, and psychological function were assessed pre to post treatment and 1 week following post treatment. Participants crossed over to receive the alternate treatment and were assessed pre to post treatment and 1 week following. Linear modeling was used to assess changes in outcomes. RESULTS: Participants demonstrated significantly greater perceived improvement immediately following midfoot mobilization in the single assessment numeric evaluation (sham: 5.0% [10.2%]; mobilization: 43.9% [26.2%]; ß: 6.8; P < .001; adj R2: .17; Hedge g: 2.09), and global rating of change (sham: -0.1 [1.1]; mobilization: 1.1 [3.0]; ß: 1.8; P = .01; adj R2: .12; Hedge g: 0.54), and greater improved 1-week outcomes in rearfoot inversion mobility (sham: 4.4° [8.4°]; mobilization: -1.6° [6.1°]; ß: -6.37; P = .01; adj R2: .19; Hedge g: 0.81), plantar flexion mobility (sham: 2.7° [6.4°]; mobilization: -1.7° [4.3°]; ß: -4.36; P = .02; adj R2: .07; Hedge g: 0.80), and posteromedial dynamic balance (sham: 2.4% [5.9%]; mobilization: 6.0% [5.4%]; ß: 3.88; P = .04; adj R2: .10; Hedge g: 0.59) compared to the sham intervention. CONCLUSION: Greater perceived improvement and physical signs were observed following midfoot joint mobilization.

Association of Ankle Sprain Frequency With Body Mass and Self-Reported Function: A Pooled Multisite Analysis.

CONTEXT: Ankle sprains result in pain and disability. While factors such as body mass and prior injury contribute to subsequent injury, the association of the number of ankle sprains on body anthropometrics and self-reported function are unclear in this population. Therefore, the purpose of this investigation was to assess differences in anthropometric measurements and self-reported function between the number of ankle sprains utilizing a large, pooled data set. DESIGN: Cross-sectional. METHODS: Data were pooled from 14 studies (total N = 412) collected by the Chronic Ankle Instability Outcomes Network. Participants were categorized by the number of self-reported sprains. Anthropometric data and self-reported function were compared between those who reported a single versus >1 ankle sprain as well as among groups of those who had 1, 2, 3, 4, and ≥5 ankle sprains, respectively. RESULTS: Those who had >1 ankle sprain had higher mass (P = .001, d = 0.33) and body mass index (P = .002, d = 0.32) and lower Foot and Ankle Ability Measure-Activities of Daily Living (P < .001, r = .22), Foot and Ankle Ability Measure-Sport (P < .001, r = .33), and Cumberland Ankle Instability Tool (P < .001, r = .34) scores compared to the single ankle sprain group. Those who had a single ankle sprain weighed less than those who reported ≥5 sprains (P = .008, d = 0.42) and had a lower body mass index than those who reported 2 sprains (P = .031, d = 0.45). CONCLUSIONS: Some individuals with a history of multiple ankle sprains had higher body mass and self-reported disability compared to those with a single sprain, factors that are likely interrelated. Due to the potential for long-term health concerns associated with ankle sprains, clinicians should incorporate patient education and interventions that promote physical activity, healthy dietary intake, and optimize function as part of comprehensive patient-centered care.

Symptom profiles following combat injury and long-term quality of life: a latent class analysis.

PURPOSE: The purpose of this study was to identify symptom profiles among U.S. military personnel within 1 year after combat injury and assess the relationship between the symptom profiles and long-term quality of life (QoL). METHODS: The study sample consisted of 885 military personnel from the Expeditionary Medical Encounter Database who completed (1) a Post-Deployment Health Assessment (PDHA) within 1 year following combat injury in Iraq or Afghanistan, and (2) a survey for the Wounded Warrior Recovery Project (WWRP), a longitudinal study tracking patient-reported outcomes (e.g., QoL) in injured military personnel. Fifteen self-reported symptoms from the PDHA were assessed using latent class analysis to develop symptom profiles. Multivariable linear regression assessed the predictive effect of symptom profiles on QoL using the physical (PCS) and mental (MCS) component summary scores from the 36-Item Short Form Survey included in the WWRP. Time between PDHA and WWRP survey ranged from 4.3 to 10.5 years (M = 6.6, SD = 1.3). RESULTS: Five distinct symptom profiles were identified: low morbidity (50.4%), multimorbidity (15.6%), musculoskeletal (14.0%), psycho-cognitive (11.1%), and auditory (8.9%). Relative to low morbidity, the multimorbidity (ß = - 5.45, p < 0.001) and musculoskeletal (ß = - 4.23, p < 0.001) profiles were associated with lower PCS, while the multimorbidity (ß = - 4.25, p = 0.002) and psycho-cognitive (ß = - 3.02, p = 0.042) profiles were associated with lower MCS. CONCLUSION: Multimorbidity, musculoskeletal, and psycho-cognitive symptom profiles were the strongest predictors of lower QoL. These profiles can be employed during screening to identify at-risk service members and assist with long-term clinical planning, while factoring in patient-specific impairments and preferences.

Ultrasound Measures of Intrinsic Foot Muscle Size and Activation Following Lateral Ankle Sprain and Chronic Ankle Instability.

CONTEXT: Tibial nerve impairment and reduced plantarflexion, hallux flexion, and lesser toe flexion strength have been observed in individuals with recent lateral ankle sprain (LAS) and chronic ankle instability (CAI). Diminished plantar intrinsic foot muscles (IFMs) size and contraction are a likely consequence. OBJECTIVES: To assess the effects of ankle injury on IFM size at rest and during contraction in young adults with and without LAS and CAI. SETTING: Laboratory. DESIGN: Cross-sectional. PATIENTS: A total of 22 healthy (13 females; age = 19.6 [0.9], body mass index [BMI] = 22.5 [3.2]), 17 LAS (9 females; age = 21.8 [4.1], BMI = 24.1 [3.7]), 21 Copers (13 females; age = 20.8 [2.9], BMI = 23.7 [2.9]), and 20 CAI (15 females; age = 20.9 [4.7], BMI = 25.1 [4.5]). MAIN OUTCOME MEASURES: Foot Posture Index (FPI), Foot Mobility Magnitude (FMM), and ultrasonographic cross-sectional area of the abductor hallucis, flexor digitorum brevis, quadratus plantae, and flexor hallucis brevis were assessed at rest, and during nonresisted and resisted contraction. RESULTS: Multiple linear regression analyses assessing group, sex, BMI, FPI, and FMM on resting and contracted IFM size found sex (B = 0.45; P < .001), BMI (B = 0.05; P = .01), FPI (B = 0.07; P = .05), and FMM × FPI interaction (B = -0.04; P = .008) accounted for 19% of the variance (P = .002) in resting abductor hallucis measures. Sex (B = 0.42, P < .001) and BMI (B = 0.03, P = .02) explained 24% of resting flexor digitorum brevis measures (P < .001). Having a recent LAS (B = 0.06, P = .03) and FMM (B = 0.04, P = .02) predicted 11% of nonresisted quadratus plantae contraction measures (P = .04), with sex (P < .001) explaining 13% of resting quadratus plantae measures (B = 0.24, P = .02). Both sex (B = 0.35, P = .01) and FMM (B = 0.15, P = .03) predicted 16% of resting flexor hallucis brevis measures (P = .01). There were no other statistically significant findings. CONCLUSIONS: IFM resting ultrasound measures were primarily determined by sex, BMI, and foot phenotype and not injury status. Routine ultrasound imaging of the IFM following LAS and CAI cannot be recommended at this time but may be considered if neuromotor impairment is suspected.

Multimorbidity and quality of life after blast-related injury among US military personnel: a cluster analysis of retrospective data.

BACKGROUND: Blast injury emerged as a primary source of morbidity among US military personnel during the recent conflicts in Iraq and Afghanistan, and led to an array of adverse health outcomes. Multimorbidity, or the presence of two or more medical conditions in an individual, can complicate treatment strategies. To date, there is minimal research on the impact of multimorbidity on long-term patient-reported outcomes. We aimed to define multimorbidity patterns in a population of blast-injured military personnel, and to examine these patterns in relation to long-term quality of life (QOL). METHODS: A total of 1972 US military personnel who sustained a blast-related injury during military operations in Iraq and Afghanistan were identified from clinical records. Electronic health databases were used to identify medical diagnoses within the first year postinjury, and QOL was measured with a web-based assessment. Hierarchical cluster analysis methods using Ward's minimum variance were employed to identify clusters with related medical diagnosis categories. Duncan's multiple range test was used to group clusters into domains by QOL. RESULTS: Five distinct clusters were identified and grouped into three QOL domains. The lowest QOL domain contained one cluster with a clinical triad reflecting musculoskeletal pain, concussion, and mental health morbidity. The middle QOL domain had two clusters, one with concussion/anxiety predominating and the other with polytrauma. The highest QOL domain had two clusters with little multimorbidity aside from musculoskeletal pain. CONCLUSIONS: The present study described blast-related injury profiles with varying QOL levels that may indicate the need for integrated health services. Implications exist for current multidisciplinary care of wounded active duty and veteran service members, and future research should determine whether multimorbidity denotes distinct post-blast injury syndromes.

Foot impairments contribute to functional limitation in individuals with ankle sprain and chronic ankle instability.

PURPOSE: To investigate the clinical measures of foot posture and morphology, multisegmented joint motion and play, strength, and dynamic balance in recreationally active young adults with and without a history of a lateral ankle sprain (LAS), copers, and chronic ankle instability (CAI). METHODS: Eighty recreationally active individuals (healthy: n = 22, coper: n = 21, LAS: n = 17, CAI: n = 20) were included. Foot posture index (FPI), morphologic measures, joint motion (weight-bearing dorsiflexion (WBDF), rearfoot dorsiflexion, plantar flexion, inversion, eversion; forefoot inversion, eversion; hallux flexion, extension), joint play (proximal and distal tibiofibular; talocrural and subtalar, forefoot; 1st tarsometatarsal and metatarsophalangeal), strength (dorsiflexion, plantar flexion, inversion, eversion, hallux flexion, lesser toe flexion), and Star Excursion Balance Test (SEBT) (anterior, posteromedial, posterolateral) were assessed. RESULTS: There were no group differences in FPI or morphological measures. LAS and CAI groups had decreased ankle dorsiflexion (p = 0.001) and greater frontal plane motion (p < 0.001), first MT plantar flexion, and sagittal excursion (p < 0.001); increased talocrural glide (p = 0.02) and internal rotation (p < 0.001) and decreased forefoot inversion joint play (p < 0.001); and decreased strength in all measures (p < 0.001) except dorsiflexion compared to healthy controls. The LAS group also demonstrated decreased distal tibiofibular (p = 0.04) and forefoot general laxity (p = 0.05) and SEBT performance (anterior: p = 0.02; posteromedial: p < 0.001; posterolateral: p < 0.001). CONCLUSION: Individuals with LAS or CAI have increased pain, impaired physiologic and accessory joint motion, ligamentous tenderness, and strength in the foot and ankle. Clinicians should assess the multiple segments of the ankle-foot complex when caring for individuals with an LAS or CAI. LEVEL OF EVIDENCE: II.

Effects of a 4-Week Intrinsic Foot Muscle Exercise Program on Motor Function: A Preliminary Randomized Control Trial.

Context: Intrinsic foot muscle (IFM) exercises are utilized clinically in the treatment of foot and ankle conditions. However, the effectiveness of training on IFM motor function is unknown. Objective: To study the effects of a 4-week IFM exercise program on motor function, perceived difficulty, and IFM motor activation measured using ultrasound imaging (USI) during 3 IFM exercises. Design: Single-blinded randomized control trial. Setting: Laboratory. Participants: A total of 24 healthy, recreationally active young adults without history of ankle-foot injury who have never performed IFM exercises participated (12 males and 12 females; mean age = 21.5 [4.8] y; body mass index = 23.5 [2.9] kg/m2) Intervention: Following randomization, participants allocated to the intervention group received a 4-week progressive home IFM exercise program performed daily. Participants in the control group did not receive any intervention. Main Outcome Measures: Clinician-assessed motor performance (4-point scale: 0 = does not initiate movement and 3 = performs exercise in standard pattern), participant-perceived difficulty (5-point Likert scale: 1 = very easy and 5 = very difficult), and USI motor activation measures (contracted measurementresting measurement) of the abductor hallucis, flexor digitorum brevis, quadratus plantae, and flexor hallucis brevis were assessed during toe-spread-out, hallux-extension, and lesser-toe-extension exercises. Results: The intervention group demonstrated significant improvement in motor performance in the toe-spread-out exercise (pre = 1.9 [0.5], post = 2.6 [0.5], P = .008) and less perceived difficulty in the toe-spread-out (pre = 3.1 [1.3], post = 2.3 [1.2], P = .01), hallux-extension (pre = 3.2 [1.5], post = 2.0 [1.2], P = .005), and lesser-toe-extension (pre = 1.9 [0.7], post = 1.2 [0.4], P = .03) exercises. Both groups demonstrated increased USI motor activation in the abductor hallucis during the toe-spread-out exercise (intervention: pre = 1.07 [0.06], post = 1.11 [0.08] and control: pre = 1.08 [0.06], post = 1.11 [0.06]; P = .05). No other significant main effects or group by time interactions were observed. Conclusion: A 4-week IFM exercise intervention resulted in improved motor performance and decreased perceived difficulty when performing the exercises, but not changes in USI measures of IFM activation compared with a control group.

Does manual therapy improve pain and function in patients with plantar fasciitis? A systematic review.

OBJECTIVE: To assess if manual therapy (MT) in the treatment of plantar fasciitis (PF) patients improves pain and function more effectively than other interventions. METHODS: A systematic review of all randomized control trials (RCTs) investigating the effects of MT in the treatment of human patients with PF, plantar fasciosis, and heel pain published in English on PubMed, CINAHL, Cochrane, and Web of Science databases was conducted. Research quality was appraised utilizing the PEDro scale. Cohen's d effect sizes (ES) and associated 95% confidence intervals (CI) were calculated between treatment groups. RESULTS: Seven RCTs were selected that employed MT as a primary independent variable and pain and function as dependent variables. Inclusion of MT in treatment yielded greater improvement in function (6 of 7 studies, CI that did not cross zero in 14 of 25 variables, ES = 0.5-21.5) and algometry (3 of 3 studies, CI that did not cross zero in 9 of 10 variables, ES = 0.7-3.0) from 4 weeks to 6 months when compared to interventions such as stretching, strengthening, or modalities. Though pain improved with the inclusion of MT, ES calculations favored MT in only 2 of 6 studies (3 of 13 variables) and was otherwise equivalent in effectiveness to comparison interventions. DISCUSSION: MT is clearly associated with improved function and may be associated with pain reduction in PF patients. It is recommended that clinicians consider use of both joint and soft tissue mobilization techniques in conjunction with stretching and strengthening when treating patients with PF. LEVEL OF EVIDENCE: Treatment, level 1a.

Surface electromyography and plantar pressure during walking in young adults with chronic ankle instability.

PURPOSE: Lateral ankle sprains are common and can manifest into chronic ankle instability (CAI) resulting in altered gait mechanics that may lead to subsequent ankle sprains. Our purpose was to simultaneously analyse muscle activation patterns and plantar pressure distribution during walking in young adults with and without CAI. METHODS: Seventeen CAI and 17 healthy subjects walked on a treadmill at 4.8 km/h. Plantar pressure measures (pressure-time integral, peak pressure, time to peak pressure, contact area, contact time) of the entire foot and nine specific foot regions and medial-lateral location of centre of pressure (COP) were measured. Surface electromyography (EMG) root mean square (RMS) amplitudes throughout the entire stride cycle and area under RMS curve for 100 ms pre-initial contact (IC) and 200 ms post-IC for anterior tibialis, peroneus longus, medial gastrocnemius, and gluteus medius were collected. RESULTS: The CAI group demonstrated a more lateral COP throughout the stance phase (P < 0.001 and Cohen's d > 0.9 for all 10 comparisons) and significantly increased peak pressure (P = 0.025) and pressure-time integral (P = 0.049) under the lateral forefoot. The CAI group had lower anterior tibialis RMS areas (P < 0.001) and significantly higher peroneus longus, medial gastrocnemius, and gluteus medius RMS areas during 100 ms pre-IC (P < 0.003). The CAI group had higher gluteus medius sEMG amplitudes during the final 50 % of stance and first 25% of swing (P < 0.05). CONCLUSIONS: The CAI group had large lateral deviations of their COP location throughout the entire stance phase and increased gluteus medius muscle activation amplitude during late stance through early swing phase. LEVEL OF EVIDENCE: III.

Factors Associated With Poor Outcome in Childhood Swimming Pool Submersions.

OBJECTIVES: The aims of the study were to determine factors associated with poor outcome in childhood swimming pool submersions and to study the association of bystander resuscitation with clinical outcome. METHODS: This was a retrospective study of swimming pool submersion victims younger than 18 years in a metropolitan area from 2003 to 2007. Submersion, prehospital, and victim data were obtained from hospital, Emergency Medical Services, and fatality records. Outcome based on survival at hospital discharge was favorable (baseline/mild impairment) or poor (death/severe impairment). Logistic regression determined factors associated with poor outcome. RESULTS: There were 260 submersions. Outcomes were available for 211 (81%). The median age was 4 years; 68% were males. Most incidents occurred at single residential pools (48%) and multiresidential pools (35%). Mortality was 23%; 75% had favorable outcomes. Favorable outcomes occurred in 8.6% (3/35) of victims with absent pulse at the scene. Descriptive analyses revealed significant differences in submersions that occurred on weekdays, during the summer, submersions lasting 5 minutes or more, with on-scene apnea or cardiac arrest needing cardiopulmonary resuscitation, rescuer type, and transfer to tertiary care. Logistic regression revealed that poor outcome was significantly associated with prolonged submersions and those that occurred on a weekday. Furthermore, hospitalization reduced the odds of a poor outcome by 81% when compared with victims who were not hospitalized. Bystander resuscitation was not significantly associated with outcome. CONCLUSIONS: Childhood swimming pool submersions, which occur on weekdays and with prolonged submersion times, are associated with poor outcome. Bystander resuscitation is not significantly associated with outcome.

Spatial analysis of paediatric swimming pool submersions by housing type.

OBJECTIVE: Drowning is a major cause of unintentional childhood death. The relationship between childhood swimming pool submersions, neighbourhood sociodemographics, housing type and swimming pool location was examined in Harris County, Texas. STUDY DESIGN AND SETTING: Childhood pool submersion incidents were examined for spatial clustering using the Nearest Neighbor Hierarchical Cluster (Nnh) algorithm. To relate submersions to predictive factors, an Markov Chain Monte Carlo (MCMC) Poisson-Lognormal-Conditional Autoregressive (CAR) spatial regression model was tested at the census tract level. RESULTS: There were 260 submersions; 49 were fatal. Forty-two per cent occurred at single-family residences and 36% at multifamily residential buildings. The risk of a submersion was 2.7 times higher for a child at a multifamily than a single-family residence and 28 times more likely in a multifamily swimming pool than a single family pool. However, multifamily submersions were clustered because of the concentration of such buildings with pools. Spatial clustering did not occur in single-family residences. At the tract level, submersions in single-family and multifamily residences were best predicted by the number of pools by housing type and the number of children aged 0-17 by housing type. CONCLUSIONS: Paediatric swimming pool submersions in multifamily buildings are spatially clustered. The likelihood of submersions is higher for children who live in multifamily buildings with pools than those who live in single-family homes with pools.

Sex Differences in Postinjury Health Profiles Among U.S. Military Personnel Following Deployment-Related Concussion.

Background: Women in the U.S. military are now authorized to serve in direct combat occupations. This may increase their risk of combat injuries, such as concussion, in future conflicts. Knowledge of sex differences in health profiles after concussion is paramount for military medical planning efforts. The purpose of this study was to assess sex-related differences in health profiles among U.S. military personnel following deployment-related concussion. Materials and Methods: We conducted a retrospective study of service members who sustained a concussion during combat deployment between 2004 and 2013. Postinjury diagnoses were abstracted from outpatient encounters in electronic health records for 24 months after concussion. We used hierarchical clustering to identify clusters, termed "health profiles," and logistic regression to determine whether sex predicted membership in the health profiles. Results: The study sample included 346 women and 4536 men with deployment-related concussion. Five postinjury health profiles were identified and classified as no morbidity, back pain, tinnitus/memory loss, posttraumatic stress disorder/postconcussion syndrome, and multimorbidity. Women relative to men had higher odds of membership in the back pain (odds ratio [OR] = 1.32; 95% confidence interval [CI] = 1.05-1.67) and multimorbidity profiles (OR = 1.44; 95% CI = 1.03-2.00) and lower odds than men in the tinnitus/memory loss profile (OR = 0.62; 95% CI = 0.42-0.91). Conclusions: Postinjury health profiles among U.S. service members differ by sex following deployment-related concussion, particularly with a higher burden of multimorbidity among women than men, which may require interdisciplinary care. Women also had higher odds of membership in the back pain profile and lower odds in the tinnitus/memory loss profile than men. To prepare for future military operations where women may have greater exposure to combat, continued research elucidating health-related sex differences after deployment-related concussion is imperative.

Burden and risk factors for Achilles tendinopathy in the military population from 2006 to 2015. A retrospective cohort study.

CONTEXT: Ankle-foot injuries are ubiquitous in the US military, with Achilles tendinopathy (AT) a common condition that affects function and health-related quality of life. OBJECTIVE: To evaluate the burden and associated factors of AT. DESIGN: Descriptive Epidemiology Study. SETTING: The Defense Medical Epidemiological Database was utilized to identify relevant healthcare encounters. PATIENTS OR OTHER PARTICIPANTS: All active duty and reserve military members who served between 2006 to 2015 (officers: n= 2 149 887; enlisted: n= 9 503 995). MAIN OUTCOME MEASURES: Multi-year prevalence of AT care episodes were calculated and compared by year, service branch, and military rank. Unadjusted and adjusted assessment of injury burden were calculated. RESULTS: Officers incurred 37,939 episodes at a prevalence of 17.65 per 1000 servicemembers (male officers: 18.20 per 1000 servicemembers; female officers: 14.80 per 1000 servicemembers). Among enlisted personnel, there were 116,122 episodes of AT that occurred in 12.22 per 1000 servicemembers (male enlisted: 12.07 per 1000 servicemembers; female enlisted: 13.22 per 1000 servicemembers). All officer specialties had significantly higher burden of AT episodes compared to the ground and naval gunfire officers (prevalence ratio [PR]: 1.04-1.43), except for aviation that demonstrated a significantly lower burden (PR: 0.65). Among enlisted occupations, maritime/naval specialties had lower burden of AT compared to infantry (PR: 0.82) and all other specialties, except for aviation, had significantly higher burden (PR: 1.07-1.71). There were multiple associated factors identified, to include sex, age, rank, military occupation, and service branch. CONCLUSION: AT was ubiquitous in the US military, with a progressive increase in prevalence during the study epoch. There were multiple associated factors identified, to include sex, age, rank, military occupation, and service branch. These findings highlight both the need for prophylactic interventions and identification of the populations with the greatest need.

Macrotraumatic Fractures of the Multisegmented Ankle-Foot Complex in Military Tactical Athletes: A Cohort Study.

BACKGROUND: Ankle-foot injuries are common in military personnel and substantially degrade function and force readiness. The purpose of this retrospective cohort study was to assess the incidence and contributing factors of traumatic ankle-foot fractures in the US military. METHODS: A population-based study of all service members in the US military was performed assessing the factors of sex, occupation, service branch, rank, and year on segmental tibia-fibula, rearfoot, and forefoot fracture incidence between 2006 and 2015. The Defense Medical Epidemiology Database was queried for the number of individuals with fractures of the tibia-fibula, rearfoot, and forefoot using International Classification of Diseases, Ninth Revision, Clinical Modification on the initial medical encounter. Unadjusted relative risk (RR) calculations were performed assessing sex and occupation. A negative binomial regression assessed the adjusted factors of sex, branch, rank, and year. RESULTS: During this study, 95,540 enlisted service members (8.4 per 1,000 person-years) and 13,318 military officers (5.8 per 1,000 person-years) were diagnosed with ankle-foot fractures. In the adjusted analysis, sex was found to only be a significant factor in forefoot fractures (RR, 1.54), with female service members having a significantly higher risk. There were no significant sex-related differences observed in tibia-fibula or rearfoot fractures. US Navy and Air Force personnel had significantly lower risk of tibia-fibula fractures (RR range, 0.76-0.84) compared with the US Army. Forefoot fracture risk was significantly higher in the US Marine Corps (RR, 1.47) compared with the US Army. Officers had consistently lower risk for fractures in each segment (RR range, 0.68-0.77) compared with enlisted personnel. Enlisted engineers, aviation, and artillery/gunnery compared to infantry, and ground/naval gunfire officers had the greatest relative risk compared all other officer fields (RR range, 1.11-3.67). CONCLUSIONS: Sex, occupation, branch, and rank were salient factors for macrotraumatic ankle-foot fractures. These findings can be used to inform and increase precision in medical planning and in the targeted development of preventive interventions.