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.

ADAPTations to low load blood flow restriction exercise versus conventional heavier load resistance exercise in UK military personnel with persistent knee pain: protocol for the ADAPT study, a multi-centre randomized controlled trial.

BACKGROUND: Muscle atrophy, muscle weakness and localised pain are commonly reported following musculoskeletal injury (MSKI). To mitigate this risk and prepare individuals to return to sport or physically demanding occupations, resistance training (RT) is considered a vital component of rehabilitation. However, to elicit adaptations in muscle strength, exercise guidelines recommend lifting loads ≥ 70% of an individual's one repetition maximum (1-RM). Unfortunately, individuals with persistent knee pain are often unable to tolerate such high loads and this may negatively impact the duration and extent of their recovery. Low load blood flow restriction (LL-BFR) is an alternative RT technique that has demonstrated improvements in muscle strength, hypertrophy, and pain in the absence of high mechanical loading. However, the effectiveness of high-frequency LL-BFR in a residential rehabilitation environment remains unclear. This study will compare the efficacy of high frequency LL-BFR to 'conventional' heavier load resistance training (HL-RT) on measures of physical function and pain in adults with persistent knee pain. METHODS: This is a multicentre randomised controlled trial (RCT) of 150 UK service personnel (aged 18-55) admitted for a 3-week residential rehabilitation course with persistent knee pain. Participants will be randomised to receive: a) LL-BFR delivered twice daily at 20% 1-RM or b) HL-RT three-times per week at 70% 1-RM. Outcomes will be recorded at baseline (T1), course discharge (T2) and at three-months following course (T3). The primary outcome will be the lower extremity functional scale (LEFS) at T2. Secondary outcomes will include patient reported perceptions of pain, physical and occupational function and objective measures of muscle strength and neuromuscular performance. Additional biomechanical and physiological mechanisms underpinning both RT interventions will also be investigated as part of a nested mechanistic study. DISCUSSION: LL-BFR is a rehabilitation modality that has the potential to induce positive clinical adaptations in the absence of high mechanical loads and therefore could be considered a treatment option for patients suffering significant functional deficits who are unable to tolerate heavy load RT. Consequently, results from this study will have a direct clinical application to healthcare service providers and patients involved in the rehabilitation of physically active adults suffering MSKI. TRIAL REGISTRATION: ClinicalTrials.org reference number, NCT05719922.

The test-retest reliability of the Military Physical Loading Questionnaire (MPLQ).

INTRODUCTION: Despite the high prevalence of musculoskeletal injuries, there is a shortage of data quantifying the risk factors attributable to cumulative occupational demands among UK Military personnel. We developed a new comprehensive questionnaire that examines occupational and operational physical loading during military service. The aim of this study was to examine the test-retest reliability of the Military Physical Loading Questionnaire (MPLQ). METHODS: Intraclass correlation coefficients (ICC) were used to evaluate the test-retest reliability (4-week interval) of the MPLQ on 18 occupational and 18 operational items in 50 male (mean age: 36 years; SD ±7.9) UK military personnel. A stratified analysis based on duration of Service (0-10 years, 11-20 years and ≥21 years) was conducted to assess whether stability of task items was dependent on participant length of recall. Internal consistency was assessed by Cronbach's alpha (α) coefficients. RESULTS: Reliability of individual operational items ranged from fair to almost perfect agreement (ICC range: 0.37-0.89; α range: 0.53-0.94) with most items demonstrating moderate to substantial reliability. Overall scores related to occupational items showed substantial to almost perfect agreement between administrations (ICC range: 0.73-0.94; α range: 0.84-0.96). Stratifying by duration of Service showed similar within group reliability to the entire sample and no pattern of decreasing or increasing reliability with length of recall period was observed. CONCLUSIONS: It is essential that data used in planning UK military policy and health services are as accurate as possible. This study provides preliminary support for the MPLQ as a reliable self-report instrument for assessing the cumulative lifelong effects of occupational loading in UK military personnel. Further validation studies using larger and more demographically diverse military populations will support its interpretation in future epidemiological research.

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.

Review of musculoskeletal modelling in a clinical setting: Current use in rehabilitation design, surgical decision making and healthcare interventions.

BACKGROUND: Musculoskeletal modelling is a common means by which to non-invasively analyse movement. Such models have largely been used to observe function in both healthy and patient populations. However, utility in a clinical environment is largely unknown. The aim of this review was to explore existing uses of musculoskeletal models as a clinical intervention, or decision-making, tool. METHODS: A literature search was performed using PubMed and Scopus to find articles published since 2010 and relating to musculoskeletal modelling and joint and muscle forces. FINDINGS: 4662 abstracts were found, of which 39 relevant articles were reviewed. Journal articles were categorised into 5 distinct groups: non-surgical treatment, orthoses assessment, surgical decision making, surgical intervention assessment and rehabilitation regime assessment. All reviewed articles were authored by collaborations between clinicians and engineers/modellers. Current uses included insight into the development of osteoarthritis, identifying candidates for hamstring lengthening surgery, and the assessment of exercise programmes to reduce joint damage. INTERPRETATION: There is little evidence showing the use of musculoskeletal modelling as a tool for patient care, despite the ability to assess long-term joint loading and muscle overuse during functional activities, as well as clinical decision making to avoid unfavourable treatment outcomes. Continued collaboration between model developers should aim to create clinically-friendly models which can be used with minimal input and experience by healthcare professionals to determine surgical necessity and suitability for rehabilitation regimes, and in the assessment of orthotic devices.

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.

Physical and functional outcomes following multidisciplinary residential rehabilitation for prearthritic hip pain among young active UK military personnel.

BACKGROUND: There are no studies describing the clinical outcomes of a residential, multidisciplinary team (MDT) rehabilitation intervention for patients with prearthritic hip pain. The aim of this cohort study was to describe the functional and physical outcomes of multidisciplinary residential rehabilitation for UK military personnel with prearthritic hip pain. METHODS: Participants (N=40) with a mean age of 33 years referred to a specialist residential rehabilitation centre completed a comprehensive multidisciplinary residential intervention. The main outcome measures were mean pain, physical function (modified shuttle test (MST) and Y-balance test), hip range of motion (HROM) and a patient-reported outcome measure (The Copenhagen Hip and Groin Outcome Score, HAGOS). All scores for symptomatic hips were taken at baseline and post-treatment. RESULTS: There were improvements in the Y-balance test and HROM following rehabilitation. There were significant improvements in mean difference (T1-to-T2) for Y-balance scores (15.8 cm, 95% CI 10.7 to 20.9, p<0.001), HROM (6.5° increase in hip flexion, 95% CI 4.6 to 9.4, p<0.001) and hip internal rotation (4.6°, 95% CI 2.7 to 6.6, p<0.001). Scores for HAGOS, pain, MST and functional activity assessment showed no improvement. CONCLUSIONS: Among UK military personnel with prearthritic hip pain, MDT residential rehabilitation resulted in improvements in a functional Y-balance test, hip flexion and internal rotation. The study suggests short-term benefits across some outcomes for the current UK military approach to MDT residential rehabilitation.

A comparison of multidisciplinary team residential rehabilitation with conventional outpatient care for the treatment of non-arthritic intra-articular hip pain in UK Military personnel - a protocol for a randomised controlled trial.

BACKGROUND: Non-arthritic hip disorders are defined as abnormalities of the articulating surfaces of the acetabulum and femur before the onset of osteoarthritis, including intra-articular structures such as the acetabular labrum and chondral surfaces. Abnormal femoroacetabular morphology is commonly seen in young men who constitute much of the UK military population. Residential multidisciplinary team (MDT) rehabilitation for patients with musculoskeletal injuries has a long tradition in the UK military, however, there are no studies presenting empirical data on the efficacy of a residential MDT approach compared with individualised conventional outpatient treatment. With no available data, the sustainability of this care pathway has been questioned. The purpose of this randomised controlled trial is to compare the effects of a residential multidisciplinary intervention, to usual outpatient care, on the clinical outcomes of young active adults undergoing treatment for non-arthritic intra-articular hip pain. METHODS/DESIGN: The trial will be conducted at the Defence Medical Rehabilitation Centre, Headley Court, UK. One hundred military male participants with clinical indicators of non-arthritic intra-articular hip pain will be randomly allocated to either: (1) 7-day residential multidisciplinary team intervention, n = 50; (2) 6-week physiotherapist-led outpatient intervention (conventional care), n = 50. Measurements will be taken at baseline, post-treatment (1-week MDT group; 6-weeks physiotherapy group), and 12-weeks. The primary outcome measures are the function in daily living sub-scale of the Copenhagen Hip and Groin Outcome Score (HAGOS), the physical function subscale of the Non-arthritic Hip Score (NAHS), and VAS pain scale. Secondary outcomes include objective measures of physical capacity and general health. An intention-to-treat analysis will be performed using linear and mixed models. DISCUSSION: This study will be the first to assess the efficacy of intensive MDT rehabilitation, versus conventional outpatient care, for the management of non-arthritic hip pain. The results from this study will add to the evidence-base and inform clinical practice for the management of intra-articular non-arthritic hip pain and femoroacetabular impingement in young active adults. TRIAL REGISTRATION: ISRCTN Reference: ISRCTN 59255714 dated 11-Nov-2015.

Use of a goal setting intervention to increase adherence to low back pain rehabilitation: a randomized controlled trial.

OBJECTIVE: To examine the effects of a goal setting intervention on self-efficacy, treatment efficacy, adherence and treatment outcome in patients undergoing low back pain rehabilitation. DESIGN: A mixed-model 2 (time) × 3 (group) randomized controlled trial. SETTING: A residential rehabilitation centre for military personnel. SUBJECTS: UK military personnel volunteers (N = 48); mean age was 32.9 (SD 7.9) with a diagnosis of non-specific low back pain. INTERVENTIONS: Subjects were randomly assigned to either a goal setting experimental group (Exp, n = 16), therapist-led exercise therapy group (C1, n = 16) or non-therapist-led exercise therapy group (C2, n = 16). Treatment duration for all groups was three weeks. MAIN MEASURES: Self-efficacy, treatment efficacy and treatment outcome were recorded before and after the treatment period. Adherence was rated during regularly scheduled treatment sessions using the Sports Injury Rehabilitation Adherence Scale (SIRAS). The Biering-Sørensen test was used as the primary measure of treatment outcome. RESULTS: ANCOVA results showed that adherence scores were significantly higher in the experimental group (13.70 ± 1.58) compared with C2 (11.74 ± 1.35), (P < 0.025). There was no significant difference for adherence between the experimental group and C1 (P = 0.13). Self-efficacy was significantly higher in the experimental group compared to both C1 and C2 (P < 0.05), whereas no significant difference was found for treatment efficacy. Treatment outcome did not differ significantly between the experimental and two control groups. CONCLUSIONS: The findings provide partial support for the use of goal setting to enhance adherence in clinical rehabilitation.

Life course body mass index and risk of knee osteoarthritis at the age of 53 years: evidence from the 1946 British birth cohort study.

INTRODUCTION: The authors examined how body mass index (BMI) across life is linked to the risk of midlife knee osteoarthritis (OA), testing whether prolonged exposure to high BMI or high BMI at a particular period has the greatest influence on the risk of knee OA. METHODS: A population-based British birth cohort of 3035 men and women underwent clinical examination for knee OA at age 53 years.Heights and weights were measured 10 times from 2 to 53 years. Analyses were stratified by gender and adjusted for occupation and activity levels. RESULTS: The prevalence of knee OA was higher in women than in men (12.9% (n=194) vs 7.4% (n=108)). In men, the association between BMI and later knee OA was evident at 20 years (p=0.038) and remained until 53 years (OR per z-score 1.38 (95% CI 1.11 to 1.71)). In women, there was evidence for an association at 15 years (p=0.003); at 53 years, the OR was 1.89 (95% CI 1.59 to 2.24) per z-score increase in BMI. Changes in BMI from childhood in women and from adolescence in men were also positively associated with knee OA. A structured modelling approach to disentange the way in which BMI is linked to knee OA suggested that prolonged exposure to high BMI throughout adulthood carried the highest risk and that there was no additional risk conferred from adolescence once adult BMI had been accounted for. CONCLUSION: This study suggests that the risk of knee OA accumulates from exposure to a high BMI through adulthood.

The effects of exercise for the prevention of overuse anterior knee pain: a randomized controlled trial.

BACKGROUND: Anterior knee pain (AKP) is the most common activity-related injury of the knee. The authors investigated the effect of an exercise intervention on the incidence of AKP in UK army recruits undergoing a 14-week physically arduous training program. HYPOTHESIS: Modifying military training to include targeted preventative exercises may reduce the incidence of AKP in a young recruit population. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: A single-blind cluster randomized controlled trial was performed in 39 male and 11 female training groups (median age: 19.7 years; interquartile range, 17-25) undergoing phase 1 of army recruit training. Each group was randomly assigned to either an intervention (n = 759) or control (n = 743) protocol. The intervention consisted of 4 strengthening and 4 stretching exercises completed during supervised physical training lessons (7 per week). The control group followed the existing training syllabus warm-up exercises. The primary outcome was a diagnosis of AKP during the 14-week training program. RESULTS: Forty-six participants (3.1%; 95% confidence interval [CI], 2.3-4.1) were diagnosed with AKP. There were 36 (4.8%; 95%CI, 3.5-6.7) new cases of AKP in the control group and 10 (1.3%; 0.7-2.4) in the intervention group. There was a 75% reduction in AKP risk in the intervention group (unadjusted hazard ratio = 0.25; 95% CI, 0.13-0.52; P < .001). Three participants (0.4%) from the intervention group were discharged from the military for medical reasons compared to 25 (3.4%) in the control group. CONCLUSION: A simple set of lower limb stretching and strengthening exercises resulted in a substantial and safe reduction in the incidence of AKP in a young military population undertaking a physical conditioning program. Such exercises could also be beneficial for preventing this common injury among nonmilitary participants in recreational physical activity.