Factors influencing medium- and long-term occupational impact following COVID-19.

BACKGROUND: Significant numbers of individuals struggle to return to work following acute coronavirus disease 2019 (COVID-19). The UK Military developed an integrated medical and occupational pathway (Defence COVID-19 Recovery Service, DCRS) to ensure safe return to work for those with initially severe disease or persistent COVID-19 sequalae. Medical deployment status (MDS) is used to determine ability to perform job role without restriction ('fully deployable', FD) or with limitations ('medically downgraded', MDG). AIMS: To identify which variables differ between those who are FD and MDG 6 months after acute COVID-19. Within the downgraded cohort, a secondary aim is to understand which early factors are associated with persistent downgrading at 12 and 18 months. METHODS: Individuals undergoing DCRS had comprehensive clinical assessment. Following this, their electronic medical records were reviewed and MDS extracted at 6, 12 and 18 months. Fifty-seven predictors taken from DCRS were analysed. Associations were sought between initial and prolonged MDG. RESULTS: Three hundred and twenty-five participants were screened, with 222 included in the initial analysis. Those who were initially downgraded were more likely to have post-acute shortness of breath (SoB), fatigue and exercise intolerance (objective and subjective), cognitive impairment and report mental health symptoms. The presence of fatigue and SoB, cognitive impairment and mental health symptoms was associated with MDG at 12 months, and the latter two, at 18 months. There were also modest associations between cardiopulmonary function and sustained downgrading. CONCLUSIONS: Understanding the factors that are associated with initial and sustained inability to return to work allows individualized, targeted interventions to be utilized.

Academic Department of Military Rehabilitation (ADMR): avoiding the pitfalls of 'the Walker Dip'.

A key research theme identified during the 2021 Strategic Delivery Plan (SDP) for Defence Medical Services (DMS) Research was preventing and treating musculoskeletal injury (MSKI). MSKI is a significant burden to military populations globally, reducing both operational strength and force readiness. It is therefore essential that research is conducted to gain a greater understanding of the epidemiology, aetiology and risk factors associated with MSKI to develop targeted prevention strategies and rehabilitation interventions. The Academic Department of Military Rehabilitation (ADMR) and the recently established MSKI research-theme working group must use a combination of balance and flexibility when coordinating research priorities to ensure they align and reflect both higher level DMS and UK Defence Rehabilitation practitioner-driven priorities. This article describes the response ADMR have taken to meet and align with the requirements of the 2021 SDP.

How long is Long-COVID? Symptomatic improvement between 12 and 18 months in a prospective cohort study.

INTRODUCTION: COVID-19 infection can precede, in a proportion of patients, a prolonged syndrome including fatigue, exercise intolerance, mood and cognitive problems. This study aimed to describe the profile of fatigue-related, exercise-related, mood-related and cognitive-related outcomes in a COVID-19-exposed group compared with controls. METHODS: 113 serving UK Armed Forces participants were followed up at 5, 12 (n=88) and 18 months (n=70) following COVID-19. At 18 months, 56 were in the COVID-19-exposed group with 14 matched controls. Exposed participants included hospitalised (n=25) and community (n=31) managed participants. 43 described at least one of the six most frequent symptoms at 5 months: fatigue, shortness of breath, chest pain, joint pain, exercise intolerance and anosmia. Participants completed a symptom checklist, patient-reported outcome measures (PROMs), the National Institute for Health cognitive battery and a 6-minute walk test (6MWT). PROMs included the Fatigue Assessment Scale (FAS), Generalised Anxiety Disorder-7 (GAD-7), Patient Health Questionnaire-9 (PHQ-9) and Patient Checklist-5 (PCL-5) for post-traumatic stress. RESULTS: At 5 and 12 months, exposed participants presented with higher PHQ-9, PCL-5 and FAS scores than controls (ES (effect size) ≥0.25, p≤0.04). By 12 months, GAD-7 was not significantly different to controls (ES <0.13, p=0.292). Remaining PROMs lost significant difference by 18 months (ES ≤0.11, p≥0.28). No significant differences in the cognitive scales were observed at any time point (F=1.96, p=0.167). At 5 and 12 months, exposed participants recorded significantly lower distances on the 6MWT (ηp 2≥0.126, p<0.01). 6MWT distance lost significant difference by 18 months (ηp 2<0.039, p>0.15). CONCLUSIONS: This prospective cohort-controlled study observed adverse outcomes in depression, post-traumatic stress, fatigue and submaximal exercise performance up to 12 months but improved by 18-month follow-up, in participants exposed to COVID-19 compared with a matched control group.

Changing characteristics of post-COVID-19 syndrome: Cross-sectional findings from 458 consultations using the Stanford Hall remote rehabilitation assessment tool.

BACKGROUND: In the UK, there have been multiple waves of COVID-19, with a five-tier alert system created to describe the transmission rate and appropriate restrictions. While acute mortality decreased, there continued to be a significant morbidity, with individuals suffering from persistent, life-restricting symptoms for months to years afterwards. A remote rehabilitation tool was created at the Defence Medical Rehabilitation Centre (DMRC) Stanford Hall to assess post-COVID-19 symptoms and their impact on the UK military.This study aims to understand changes in post-COVID-19 syndrome between wave 1 and wave 2, identify interactions between alert level and symptoms and investigate any predictive nature of acute symptoms for postacute symptomology in a young, physically active population. METHODS: Cross-sectional study of 458 consecutive remote rehabilitation assessments performed at DMRC Stanford Hall between 2 April 2020 and 29 July 2021. Consultations were coded, anonymised, and statistical analysis was performed to determine associations between acute and postacute symptoms, and between symptoms, alert levels and waves. RESULTS: 435 assessments were eligible; 174 in wave 1 and 261 in wave 2. Post-COVID-19 syndrome prevalence reduced from 43% to 2% between the waves. Acutely, widespread pain was more prevalent in wave 2 (p<0.001). Postacutely, there was increased anxiety (p=0.10) in wave 1 and increased sleep disturbance (p<0.001), memory/concentration issues (p<0.001) and shortness of breath/cough (p=0.017) in wave 2. Increasing alert level was associated with increased postacute symptom prevalence (p=0.046), with sleep disturbance increasing at higher alert level (p=0.016). Acute symptoms, including fatigue, sleep disturbance and myalgia, were associated with multiple postacute symptoms. CONCLUSIONS: This study reports the overall prevalence and symptom burden in the UK military in the first two waves of COVID-19. By reporting differences in COVID-19 in different waves and alert level, this study highlights the importance of careful assessment and contextual understanding of acute and postacute illnesses for individual management plans.

Cardiopulmonary exercise testing excludes significant disease in patients recovering from COVID-19.

OBJECTIVE: Post-COVID-19 syndrome presents a health and economic challenge affecting ~10% of patients recovering from COVID-19. Accurate assessment of patients with post-COVID-19 syndrome is complicated by health anxiety and coincident symptomatic autonomic dysfunction. We sought to determine whether either symptoms or objective cardiopulmonary exercise testing could predict clinically significant findings. METHODS: 113 consecutive military patients were assessed in a comprehensive clinical pathway. This included symptom reporting, history, examination, spirometry, echocardiography and cardiopulmonary exercise testing (CPET) in all, with chest CT, dual-energy CT pulmonary angiography and cardiac MRI where indicated. Symptoms, CPET findings and presence/absence of significant pathology were reviewed. Data were analysed to identify diagnostic strategies that may be used to exclude significant disease. RESULTS: 7/113 (6%) patients had clinically significant disease adjudicated by cardiothoracic multidisciplinary team (MDT). These patients had reduced fitness (V̇O2 26.7 (±5.1) vs 34.6 (±7.0) mL/kg/min; p=0.002) and functional capacity (peak power 200 (±36) vs 247 (±55) W; p=0.026) compared with those without significant disease. Simple CPET criteria (oxygen uptake (V̇O2) >100% predicted and minute ventilation (VE)/carbon dioxide elimination (V̇CO2) slope <30.0 or VE/V̇CO2 slope <35.0 in isolation) excluded significant disease with sensitivity and specificity of 86% and 83%, respectively (area under the receiver operating characteristic curve (AUC) 0.89). The addition of capillary blood gases to estimate alveolar-arterial gradient improved diagnostic performance to 100% sensitivity and 78% specificity (AUC 0.92). Symptoms and spirometry did not discriminate significant disease. CONCLUSIONS: In a population recovering from SARS-CoV-2, there is reassuringly little organ pathology. CPET and functional capacity testing, but not reported symptoms, permit the exclusion of clinically significant disease.

Developing UK Defence Rehabilitation research priorities: a 2020 clinical practitioner engagement exercise.

INTRODUCTION: Establishing research priorities help to address knowledge gaps and exploit emerging opportunities to develop a clinical evidence base. The previous clinical engagement exercise to determine UK Defence Rehabilitation practitioner-based research priorities was conducted in 2014. The aim of this article is to (1) describe how research priorities are established for UK Defence Rehabilitation; (2) review, reassess and rate the priorities highlighted and set by rehabilitation practitioners following the 2014 survey and (3) identify new rehabilitation research themes and topics reflecting 2020 priorities. METHODS: Stage 1: delegates (n=72) at the October 2019 Defence Medical Services Rehabilitation Conference participated in a series of focus group workshops. Stage 2: an online survey circulated through the military chain of command to all Defence Primary Health Care clinical rehabilitation staff. Stage 3: a thematic analysis of all survey submissions yielding a ranked order of priority by topic. RESULTS: 165 clinical rehabilitation staff completed an online survey. 'Rehabilitation outcomes', 'Psychological factors in rehabilitation' and 'Residential/Inpatient treatment paradigm' emerged as three clear research priorities across all three tiers of UK Defence Rehabilitation. New research priorities emerging from the 2020 survey were 'lifestyle factors during rehabilitation', 'management of pain during rehabilitation' and 'anterior knee pain'. CONCLUSION: It is essential that funding directed to musculoskeletal rehabilitation focuses on the highest research priorities in the field to ensure optimum health return on investment. The results of this survey will assist in guiding the clinical research being conducted within UK Defence Rehabilitation over the next five years.

Use of an isometric mid-thigh pull test during musculoskeletal rehabilitation: can the criterion values from the updated British Army physical employment standards be used to inform UK Defence Rehabilitation practice?

INTRODUCTION: Objective outcome measures that can quantify the force generating capacity of the lower limb are required to allow clinicians to accurately measure functional status and treatment adaptations over time. The aim of this prospective observational cohort study is to: (1) evaluate the acceptability of the isometric mid-thigh pull (IMTP) test as a measure of functional strength with military personnel undergoing residential hip pain rehabilitation; (2) compare the peak force values recorded against the updated Army physical employment standards (PES) assessment criteria and (3) assess if the minimum PES required of military personnel has the potential to inform clinical decision making and return to duty criteria within UK Defence Rehabilitation. METHODS: Acceptability was assessed against patient's adherence to the testing procedures and test burden. Clinician acceptability was assessed against ease of administration and safety of test procedure. Hip pain was recorded before, immediately following and 1 hour after testing. Net peak force was recorded using portable force plates. RESULTS: Full patient and clinician acceptability to IMTP testing procedures were demonstrated. Minimal changes in visual analogue scale (VAS) pain scores were demonstrated between baseline values at rest and follow-up. Despite being medically downgraded and functionally compromised due to chronic hip pain, 100% of patients met the PES expected on entry to the British Army and 79% met the PES expected at the end of basic training. CONCLUSION: The IMTP provides rehabilitation clinicians with an objective quantifiable measure of maximum muscle strength that can be used early in the rehabilitation care pathway. Based on our finding, it is unclear if the current British Army PES can be used as a criterion standard in Defence Rehabilitation. Therefore, further research focused on generating clinically relevant patient-specific IMTP score criteria, with a larger sample of diverse diagnostic sub-groups is required.

Cognitive functional therapy (CFT)-based rehabilitation improves clinical outcomes in UK military personnel with persistent low back pain.

INTRODUCTION: Low back pain (LBP) has been reported as the most common reason for presentation to the Medical Centre in the British Military, and the most common re-referral for the same condition. In 2015, the UK Defence Medical Rehabilitation Centre (DMRC) adopted a cognitive functional therapy (CFT) approach to spinal rehabilitation in line with National Institute for Health and Care Excellence and military best practice guidelines. The aim of this study is to evaluate the functional and psychosocial outcomes of all patients with chronic LBP treated with CFT-based multidisciplinary rehabilitation at DMRC, Headley Court. METHODS: A prospective observational service evaluation of British Military patients (n=238) with LBP who attended 3 weeks of inpatient multidisciplinary CFT-based programme from 2015 to the end of 2017 at DMRC was analysed. Functional outcomes include: multistage locomotion test (MSLT) and sit and reach test. Psychosocial outcomes include: Tampa Scale of Kinesiophobia, Oswestry Disability Index, Brief Pain Inventory (BPI), General Anxiety Disorder-7 and Patient Health Questionnaire-9. RESULTS: There were significant improvements in endurance (MSLT), range of motion, kinesiophobia, pain-related lifestyle interference (BPI-Lifestyle), anxiety and depression (p≤0.001). However, no improvements in pain intensity (BPI-Intensity) were demonstrated (p>0.05). CONCLUSION: After 3 weeks of CFT-based multidisciplinary rehabilitation, function and psychosocial health improved with symptoms of pain being less obtrusive to activities of daily activity. There were however no patient-reported reductions in pain intensity. The improvements demonstrated are indicative of outcomes that facilitate greater integration back to work or into society.