Dizziness Directly Influences Postconcussion Symptoms and Is Predictive of Poorer Mental Health in UK Military Personnel: A Retrospective Analysis.

OBJECTIVE: To investigate the contribution of dizziness to postconcussion symptoms, depression, and anxiety symptoms. SETTING: Mild traumatic brain injury (mTBI) service, Defence Medical Rehabilitation Centre, Stanford Hall. PARTICIPANTS: Two hundred eighty-three UK military personnel from the Royal Navy, Royal Airforce, Royal Marines, and British Army. DESIGN: A retrospective analysis of data from the Ministry of Defence medical records database. MAIN MEASURES: Sixteen-item Rivermead Post Concussion Symptoms Questionnaire, Generalized Anxiety Disorder 7-item scale, Patient Health Questionnaire-9, The Dizziness Handicap Inventory. RESULTS: Injuries from sports or falls were the most common mechanism of mTBI, accounting for 23%, respectively. Chi-square analysis indicated that individuals with dizziness and postconcussion symptoms (PCS) had greater severity of PCS, depression, and anxiety than those with PCS alone. Mediation analysis showed dizziness directly and independently influenced the severity of PCS, despite the indirect effects of mediating depression and anxiety symptoms. CONCLUSION: Comorbid dizziness and PCS were predictive of poorer mental health compared with PCS alone. In addition, dizziness directly influenced the severity of PCS irrespective of the indirect effects of mental health symptoms. These observations suggest that treating dizziness with vestibular rehabilitation may improve PCS and mental health.

Overcoming adversity: Building a remote interdisciplinary neurorehabilitation service during the COVID-19 pandemic.

Background: The COVID-19 pandemic necessitated rapid change in neurorehabilitation delivery at the Defence Medical Rehabilitation Centre (DMRC), with a reduction in inpatient capacity. Aims and method: An interdisciplinary remote working group developed a novel neurorehabilitation telerehabilitation (TR) model. The plan, do, study, act (PDSA) model was used to develop and monitor activity in the changing pandemic context and to identify clinical outputs, key themes and learning points. Results: Eight PDSA cycles were performed, including video outpatient clinics, multidisciplinary team meetings, virtual ward rounds and TR for patients at home. Ten patients and 21 staff members provided feedback. Qualitative themes emerged including information technology, consultation environment, access to clinical notes and record keeping, clinical considerations, consent, patient and staff feedback, and feasibility. Conclusion: COVID-19 accelerated the implementation of TR at DMRC, allowing maintenance of service during lockdown. TR was acceptable to patients but placed a significant burden on staff. Practical suggestions for establishing a TR service are provided alongside challenges and limitations.

The Stanford Hall consensus statement for post-COVID-19 rehabilitation.

The highly infectious and pathogenic novel coronavirus (CoV), severe acute respiratory syndrome (SARS)-CoV-2, has emerged causing a global pandemic. Although COVID-19 predominantly affects the respiratory system, evidence indicates a multisystem disease which is frequently severe and often results in death. Long-term sequelae of COVID-19 are unknown, but evidence from previous CoV outbreaks demonstrates impaired pulmonary and physical function, reduced quality of life and emotional distress. Many COVID-19 survivors who require critical care may develop psychological, physical and cognitive impairments. There is a clear need for guidance on the rehabilitation of COVID-19 survivors. This consensus statement was developed by an expert panel in the fields of rehabilitation, sport and exercise medicine (SEM), rheumatology, psychiatry, general practice, psychology and specialist pain, working at the Defence Medical Rehabilitation Centre, Stanford Hall, UK. Seven teams appraised evidence for the following domains relating to COVID-19 rehabilitation requirements: pulmonary, cardiac, SEM, psychological, musculoskeletal, neurorehabilitation and general medical. A chair combined recommendations generated within teams. A writing committee prepared the consensus statement in accordance with the appraisal of guidelines research and evaluation criteria, grading all recommendations with levels of evidence. Authors scored their level of agreement with each recommendation on a scale of 0-10. Substantial agreement (range 7.5-10) was reached for 36 recommendations following a chaired agreement meeting that was attended by all authors. This consensus statement provides an overarching framework assimilating evidence and likely requirements of multidisciplinary rehabilitation post COVID-19 illness, for a target population of active individuals, including military personnel and athletes.

Low-Load Resistance Training With Blood Flow Restriction Improves Clinical Outcomes in Musculoskeletal Rehabilitation: A Single-Blind Randomized Controlled Trial.

Background: There is growing evidence to support the use of low-load blood flow restriction (LL-BFR) exercise in musculoskeletal rehabilitation. Purpose: The purpose of this study was to evaluate the efficacy and feasibility of low-load blood flow restricted (LL-BFR) training versus conventional high mechanical load resistance training (RT) on the clinical outcomes of patient's undergoing inpatient multidisciplinary team (MDT) rehabilitation. Study design: A single-blind randomized controlled study. Methods: Twenty-eight lower-limb injured adults completed a 3-week intensive MDT rehabilitation program. Participants were randomly allocated into a conventional RT (3-days/week) or twice-daily LL-BFR training group. Outcome measurements were taken at baseline and 3-weeks and included quadriceps and total thigh muscle cross-sectional area (CSA) and volume, muscle strength [five repetition maximum (RM) leg press and knee extension test, isometric hip extension], pain and physical function measures (Y-balance test, multistage locomotion test-MSLT). Results: A two-way repeated measures analysis of variance revealed no significant differences between groups for any outcome measure post-intervention (p > 0.05). Both groups showed significant improvements in mean scores for muscle CSA/volume, 5-RM leg press, and 5-RM knee extension (p < 0.01) after treatment. LL-BFR group participants also demonstrated significant improvements in MSLT and Y-balance scores (p < 0.01). The Pain scores during training reduced significantly over time in the LL-BFR group (p = 0.024), with no adverse events reported during the study. Conclusion: Comparable improvements in muscle strength and hypertrophy were shown in LL-BFR and conventional training groups following in-patient rehabilitation. The LL-BFR group also achieved significant improvements in functional capacity. LL-BFR training is a rehabilitation tool that has the potential to induce positive adaptations in the absence of high mechanical loads and therefore could be considered a treatment option for patients suffering significant functional deficits for whom conventional loaded RT is contraindicated. Trial Registration: ISRCTN Reference: ISRCTN63585315, dated 25 April 2017.

The effects of low-intensity blood flow restricted exercise compared with conventional resistance training on the clinical outcomes of active UK military personnel following a 3-week in-patient rehabilitation programme: protocol for a randomized controlled feasibility study.

BACKGROUND: A challenge for rehabilitation practitioners lies in designing optimal exercise programmes that facilitate musculoskeletal (MSK) adaptations whilst simultaneously accommodating biological healing and the safe loading of an injured limb. A growing body of evidence supports the use of resistance training at a reduced load in combination with blood flow restriction (BFR) to enhance hypertrophic and strength responses in skeletal muscle. In-patient rehabilitation has a long tradition in the UK Military, however, the efficacy of low intensity (LI) BFR training has not been tested in this rehabilitation setting. The aims of this study are to determine (1) the feasibility of a randomised controlled trial (RCT) investigating LI-BFR training in a residential, multidisciplinary treatment programme and (2) provide preliminary data describing the within and between-group treatment effects of a LI-BFR intervention and a conventional resistance training group in military personnel. METHODS: This is a single-blind randomised controlled feasibility study. A minimum of 28 lower-limb injured UK military personnel, aged 18 to 50 years, attending rehabilitation at the UK Defence Medical Rehabilitation Centre (DMRC) will be recruited into the study. After completion of baseline measurements, participants will be randomised in a 1:1 ratio to receive 3 weeks (15 days) of intensive multidisciplinary team (MDT) in-patient rehabilitation. Group 1 will receive conventional resistance training 3 days per week. Group 2 will perform twice daily LI-BFR training. Both groups will also undertake the same common elements of the existing MDT programme. Repeat follow-up assessments will be undertaken upon completion of treatment. Group 2 participants will be asked to rate their pain response to LI-BFR training every five sessions. DISCUSSION: The results will provide information on the feasibility of a full-scale RCT. Recommendations for an adequately powered study to determine the efficacy of LI-BFR training during in-patient rehabilitation can then be made. The study may also provide insights into the potential effectiveness of LI-BFR training as a novel exercise modality to induce muscle adaptations in the absence of high mechanical loading of the lower-limb. TRIAL REGISTRATION: ISRCTN Reference: ISRCTN 63585315 dated 25 April 2017.

The Mayo Portland Adaptability Inventory-4 outcome measure is superior to UK FIM+FAM in a British military population.

OBJECTIVE: The aim of this study was to identify the most appropriate rehabilitation outcome measure for use in a young adult population with acquired brain injury. METHODS: A 2-year prospective study of patients admitted to a UK military neuro-rehabilitation unit with acquired brain injury to compare the appropriateness of the Functional Independence Measure/Functional Assessment Measure (FIM+FAM) vs the Mayo-Portland Adaptability Inventory Version 4 (MPAI-4) in assessing outcomes. Patients were assessed at admission, discharge and at 4-month follow-up using FIM+FAM and MPAI-4. RESULTS: The FIM+FAM total motor score showed a marked ceiling affect, 42% of patients scored the maximum on admission rising to 80% at discharge. The MPAI-4 did not show significant ceiling effects. The other sub-scales of FIM+FAM and MPAI-4 were generally comparable, no more than 17% achieved ceiling at follow-up. CONCLUSIONS: This is the first comparative study of FIM+FAM and MPAI-4 in a young adult military population following acquired brain injury. All patients showed improvements in both outcome measures following intensive inpatient rehabilitation. However, the MPAI-4 did not show ceiling effects in motor scores. This measure was, therefore, found to be more appropriate in the cohort.

Successful outcomes following neurorehabilitation in military traumatic brain injury patients in the United Kingdom.

BACKGROUND: The Defence Medical Rehabilitation Centre Headley Court is the UK military rehabilitation unit. A pilot study identified the Mayo-Portland Adaptability Inventory-4 (MPAI-4) as the most appropriate rehabilitation outcome measure in young military patients with acquired brain injury. METHODS: MPAI-4 scores were prospectively recorded for patients on admission and discharge. At 4 months, independent living and employment status were recorded. Inclusion criteria were all new admissions with traumatic brain injury (TBI). Before injury, all patients were fully employed and lived independently. RESULTS: In a 3-year period from April 2011, there were 91 TBI patients with complete admission-discharge episodes: by US Department of Defense criteria, 21 were mild, 35 were moderate, and 35 were severe. There was a significant positive relationship between TBI severity and MPAI-4 score on admission (χ = 12.77, df = 2, p = 0.0017).Median age was 27 years, and median duration of admission was 63 days. Employment and independent living status were available for 79 patients at 4 months. Seventy-three patients (92%) were in community-based employment, with 64 (81%) employed in a competitive or transitional work; 6 (8%) were unemployed or in sheltered work. Sixty-nine (87%) were living independently, and 10 (13%) were living with support in their own home, with no one requiring institutional care.Complete MPAI-4 scores were available for 79 patients. There were statistically and clinically significant improvements in MPAI-4 scores between admission and discharge for the overall group: median admission T score was 40.0 (95% confidence interval, 36.0-42.0) and on discharge was 31.0 (95% confidence interval, 27.0-36.0), a nine-point change (Z = 6.53, p < 0.0001). These improvements with rehabilitation were sustained when patients were subdivided by TBI severity or MPAI-4 limitations. CONCLUSION: This study demonstrates significant functional improvements in military TBI patients following intensive inpatient multidisciplinary rehabilitation, which includes substantial vocational rehabilitation. At 4 months, 92% were employed, and 87% were living independently. LEVEL OF EVIDENCE: Therapeutic study, level V; prognostic/epidemiologic study, level IV.

Medical lessons learnt from the US and Canadian experience of treating combat casualties from Afghanistan and Iraq.

The Winston Churchill Memorial Trust, established in 1965, funds Travelling Fellowships and both authors visited hospitals in Germany, Canada and the USA regarded as centres of excellence with expertise in the early care, reconstruction and rehabilitation of the combat casualties of our NATO Allies, as recipients of these Fellowships. This article presents some of the lessons learnt in the field of musculoskeletal trauma and rehabilitation from the Canadian and US military medical systems. In trauma, there were significant differences in wound debridement policy, use of external fixators for fractures, primary use of circular frames for open tibial fractures and a far more liberal use of bone morphogenetic protein in fracture treatment. Differences in soft tissue reconstruction policy regarding flaps for soft tissue cover over exposed bone, near-universal usage of topical negative pressure dressings and use of Allgöwer-Donati suture pattern to close all wounds were noted. Ertl amputation osteoplasty, a modified form of transtibial amputation, had also been reintroduced. In rehabilitation, the management of heterotopic ossification, in particular with imaging techniques and excision surgery, was identified. For the upper limb, we observed the patient training required to use a myoelectric hand and the future possibility of targeted muscle re-innervation to make controlling these myoelectric prostheses more natural using innate motor patterns. For the lower limb, we found we used identical above knee prostheses. For patients who have had limb reconstruction and have poor function, an energy-storing orthosis was demonstrated to compensate for the loss of range of motion and muscle power.

Dynamic pressure testing for chronic exertional compartment syndrome in the UK military population.

OBJECTIVES: Chronic exertional compartment syndrome is one of the main causes of exertional leg pain. Diagnosis is based on the history and intracompartmental muscle pressure testing during exercise prior to consideration of fasciotomy for treatment. We present the data gathered at Defence Medical Rehabilitation Centre Headley Court during the first year of a revised protocol on dynamic pressure testing from May 2007. METHODS: The exercise protocol involved exercising patients using a representative military task: the Combat Fitness Test with a 15 kg Bergen on a treadmill, set at 6.5 km/h with zero incline up to 15 min and if completed, a further 5 min at 7.5 km/h. Subjects informed us when the exertional leg pain was 7/10 on a visual analogue scale and were instructed to carry on till failure (pain 10/10) or till the test finished. Mean pressure during this time period (7/10 to 10/10) was calculated by computer. RESULTS: Over 1 year, we performed 151 intracompartmental pressure studies in 76 patients. 120 were successful in 68 patients, with 31 technical failures. All studies were performed in the anterior or deep posterior muscle compartments as these were the symptomatic compartments; no patients had symptoms in the lateral or superficial posterior compartments and these were not tested. There was only one complication with a posterior tibial artery puncture. In 119 compartment studies, the mean pressure was 97.8 mm Hg (SD 31.7). These data are normally distributed (Shapiro Wilk test, W=0.98 p=0.125). CONCLUSIONS: Our data based on this exercise protocol are comparable with the few studies that record dynamic pressure during running-based exercise. There is no accepted diagnostic pressure or exercise protocol. Due to the uncertainty of diagnostic criteria, it is necessary to perform a study measuring dynamic pressures in normal asymptomatic subjects.

The outcome of British combat amputees in relation to military service.

BACKGROUND: The study aim was to determine the outcome, in relation to military service in UK military combat amputees. PATIENTS AND METHODS: Casualties were assessed at mean 2.4 years after injury and graded by a Functional Activity Assessment (FAA) ranging from 1 (fully fit) to 5 (unfit all duties) to score vocational functional outcome. ISS were calculated and the patients were categorised as having unilateral or multiple amputations. The Short Form-36 Health Survey (SF-36) was completed. RESULTS: Of the 52, 8 patients had left the forces by medical discharge, with 44 continuing to serve. 33 of the 44 had returned to work. 50 patients had FAA grades and were at least 7.6 months post-injury. No patients were graded as FAA1, 8 as FAA2, 18 as FAA3, 19 as FAA4 and 5 as FAA5. There was a trend for the FAA score to increase with injury severity, as measured by ISS i.e. vocational functional outcome was worse with more severe injuries, although this did not reach statistical significance (p=0.095). Multiple amputee patients had significantly higher FAA grades (p<0.001) and were all FAA 4 or 5. Of the 33 patients who had returned to work, 8 were FAA2, 12 FAA3 and 12 FAA4. The mean SF-36 scores for Physical Component Summary (PCS) increased significantly from 36.4 to 43.4 (p=0.001) with rehabilitation, while Mental Component Summary (MCS) was 53.0 and remained similar at 53.6 (p=0.987). MCS scores were similar in these patients to the normal population, 50 (SD 10). CONCLUSIONS: This study is the first to report the outcomes, with regards to return to work, of the UK military amputees injured in Afghanistan and Iraq Soldiers are surviving more severe and complex injuries than before and the majority are able to return successfully to military work. SF-36 PCS scores improve significantly with rehabilitation, and while MCS scores remain constant, the initial assessments are comparable with a normal population.