Injury and Illness Surveillance During the 2016 Department of Defense Warrior Games: Review of Methods and Results.

INTRODUCTION: Surveillance systems have become a valuable tool to capture epidemiological data at multi-sport events, with findings serving to predict and prevent injury, reduce illness, and guide efficient utilization of medical resources. In 2016, the first injury and illness surveillance tool for the Department of Defense (DoD) Warrior Games was established to inform the required medical footprint. The purpose of this paper is to describe the methods and findings from the 2016 DoD Warrior Games surveillance system, which included a database of injuries and illness. MATERIALS AND METHODS: A total of 245 wounded warrior (WW) athletes were followed over 19 days, to include train-up and competition periods, as they competed for their respective teams of Army, Navy, Air Force, Marines, Special Operations, and United Kingdom. Medical personnel recorded injuries and illnesses treated utilizing a standardized surveillance form and data were entered into a daily tracker to examine patterns or areas for prevention. Reports included sex, age, event discipline, previous injury or illness, reason for presentation, and treatment provided. RESULTS: From June 3 to June 21, 2016, 114 individual encounters were recorded on the standard form and entered into the surveillance database. Athletes accounted for 67% of all encounters. Illness accounted for 30.7% of all visits, while injuries accounted for 69.2%. The incident proportion of injuries in athletes was 23.3 injuries per 100 athletes (95% CI 17.6, 30.1) and incident rate of 12.2 injuries per 1000 athlete days. Integrative medicine treatments including acupuncture, osteopathic manipulative treatment (OMT), massage therapy, and gua sha accounted for the largest forms of treatment (31%). CONCLUSIONS: From the surveillance data, staff levels and treatment supplies can be adjusted. In addition an improved surveillance tool can be created. Continuous surveillance is required to provide information on trends in injury and illness to support prevention strategies.

Clinical, Empirical, and Theoretical Rationale for Selection of Accelerated Resolution Therapy for Treatment of Post-traumatic Stress Disorder in VA and DoD Facilities.

INTRODUCTION: Post-traumatic stress disorder (PTSD) is a chronic, disabling psychiatric disorder prevalent among U.S. service members and veterans. First-line treatments for PTSD endorsed in the 2017 Veterans Affairs (VA)/Department of Defense (DoD) Clinical Practice Guideline for PTSD emphasize individual, manualized trauma-focused psychotherapies that have a primary component of exposure and/or cognitive restructuring. These include prolonged exposure (PE) therapy, cognitive processing therapy (CPT), eye movement desensitization and reprocessing (EMDR), and others. Accelerated resolution therapy (ART) is an emerging trauma-focused therapy not specifically referenced in the guideline, but one that is consistent with the recommendations and is derived directly from EMDR. One randomized clinical trial and multiple observational studies have suggested that ART can be delivered in an average of just four treatment sessions. This commentary reviews the clinical, empirical, and theoretical rationale for use of ART as a potential first-line PTSD treatment modality in VA and DoD facilities. MATERIALS AND METHODS: The clinical protocol of ART is summarized into discrete procedural steps. The theoretical rationale as to how ART may help clients process traumatic memories and resolve symptoms of PTSD is also discussed, including how repeated sets of smooth pursuit horizontal eye movements may facilitate a relaxation response and assist with processing emotionally intrusive memories. Herein, we review primary treatment results from four published studies of ART, including mean symptom score reductions on the 17-item PCL (PTSD checklist) after treatment with ART, along with effect sizes and percentage of treatment responders. Finally, the ART protocol is compared directly against specific recommended elements of trauma-focused therapy described in the VA/DoD Clinical Practice Guideline. RESULTS: The four published studies of ART reviewed (n = 291) included adult civilians and service members/veterans; the mean age was 42.3 ± 12.3 yr and 28.9% were female. Among 237 treatment completers (81.4% of the combined cohort), the mean number of ART sessions received was 3.9 ± 1.1. Across the four studies, mean treatment-related reductions in PCL scores ranged from 15.6 ± 13.2 to 25.6 ± 11.3, with a pooled mean reduction on the PCL of 20.6 ± 15.0. Effect sizes were large and ranged from 1.18 to 2.26 (p< 0.0005) across studies, with a pooled effect size of 1.38 (95% confidence interval: 1.20-1.56, p < 0.0001). Using the clinical cutpoint of >10-point reduction on the PCL instrument, clinically significant change (response) ranged from 63.8% to 100.0% across the four studies, with a pooled treatment response rate of 74.7%. Results were nominally attenuated when conservatively assuming no treatment response for non-completers. CONCLUSION: The ART protocol contains the core therapeutic elements and aligns closely with the current VA/DoD Clinical Practice Guideline. It has a plausible theoretical rationale and an evolving empirical research base that includes four studies with peer-reviewed publications, one of which was a randomized controlled trial. These features, along with the brevity of the treatment protocol, no requirement for narration, and high provider satisfaction rates, provide a rationale for the potential use of ART as a first-line PTSD treatment modality for active duty and veteran military personnel.

Building Capacity for Complementary and Integrative Medicine Through a Large, Cross-Agency, Acupuncture Training Program: Lessons Learned from a Military Health System and Veterans Health Administration Joint Initiative Project.

Introduction: Complementary and integrative medicine (CIM) use in the USA continues to expand, including within the Military Health System (MHS) and Veterans Health Administration (VHA). To mitigate the opioid crisis and provide additional non-pharmacological pain management options, a large cross-agency collaborative project sought to develop and implement a systems-wide curriculum, entitled Acupuncture Training Across Clinical Settings (ATACS). Materials and Methods: ATACS curriculum content and structure were created and refined over the course of the project in response to consultations with Subject Matter Experts and provider feedback. Course content was developed to be applicable to the MHS and VHA environments and training was open to many types of providers. Training included a 4-hr didactic and "hands on" clinical training program focused on a single auricular acupuncture protocol, Battlefield Acupuncture. Trainee learning and skills proficiency were evaluated by trainer-observation and written examination. Immediately following training, providers completed an evaluation survey on their ATACS experience. One month later, they were asked to complete another survey regarding their auricular acupuncture use and barriers to use. The present evaluation describes the ATACS curriculum, faculty and trainee characteristics, as well as trainee and program developer perspectives. Results: Over the course of a 19-mo period, 2,712 providers completed the in-person, 4-hr didactic and hands-on clinical training session. Due to the increasing requests for training, additional ATACS faculty were trained. Overall, 113 providers were approved to be training faculty. Responses from the trainee surveys indicated high satisfaction with the ATACS training program and illuminated several challenges to using auricular acupuncture with patients. The most common reported barrier to using auricular acupuncture was the lack of obtaining privileges to administer auricular acupuncture within clinical practice. Conclusion: The ATACS program provided a foundational template to increase CIM across the MHS and VHA. The lessons learned in the program's implementation will aid future CIM training programs and improve program evaluations. Future work is needed to determine the most efficient means of improving CIM credentialing and privileging procedures, standardizing and adopting uniform CIM EHR codes and documentation, and examining the effectiveness of CIM techniques in real-world settings.

Tipping points in the Department of Defense's experience with psychologists in primary care.

Psychologists played a crucial role in the successful implementation of integrated behavioral health care services in Department of Defense (DoD) primary care clinics. On the front lines of policy development, training programs, clinical care, and program evaluations, psychologists successfully promoted integrated care as a core component of the DoD patient-centered medical home. We review the development of integrated care and discuss the roles of psychologists in the DoD to provide an exemplar of the impact psychologists can have on the implementation and sustainment of integrated care.