UK DefenceRehabilitation

Within the British Armed Forces, there is a predominance of musculoskeletal injury (MSKI), leading to 54% of all medical discharges between 2015 and 2020 and 56% of medical downgrades between 2010 and 2020.2 3 This finding is replicated in the prospective cohort study of Keijsers et alin 930 Dutch military recruits, with two-thirds and one-third reporting a mild or moderate MSKI during their first 12 weeks of basic training.4 As such, MSKI makes up the vast majority of Def Rehab workload, however, Def Rehab also manage service personnel (SP) recovering from traumatic and non-traumatic injurie and sequelae of acute and chronic medical problems.

Def Rehab services are provided through a tiered network within the Defence Medical Services (DMS), extending across all aspects of military activity and flexible enough to meet the main effort. Each tier introduces increased clinical capability and capacity to manage increasing case complexity, with a shift from the medical to the biopsychosocial paradigm of treatment. At the base of the pyramid, unit-level Primary Care Rehabilitation Facilities (PCRFs) offer local physiotherapy and exercise rehabilitation instructor (ERI) MSKI treatment; larger multidisciplinary team (MDT) support is available at Regional Rehabilitation Units (RRUs) providing outpatient and residential clinical management with fast-track clinical investigations and referrals; and tertiary level care is at the Defence Medical Rehabilitation Centre (DMRC) at Stanford Hall including consultant-led MDT teams delivering MSKI, neurological, medical and trauma rehabilitation, alongside outpatient rheumatology, pain and prosthetic services.

The core principles of military rehabilitation are early assessment, use of the MDT, active case management, functional exercise-based rehabilitation, rapid access to further specialist opinion and a focus on vocational outcomes.1 Evidence-based treatment is provided using Best Practice Guidelines. The ambition of Def Rehab is to maximise number of SP fit for operations. When this is not feasible, the aim is to achieve the best possible physical, psychological and social health.

Research in rehabilitation

Research is encouraged across all tiers and professions within Def Rehab. Clinical research is the priority, with an aim to provide evidence that directly influences care at the interface between rehabilitation practitioner and patient. This research includes a range of study designs from pilot, feasibility and cross-sectional studies to large prospective cohort studies and randomised controlled trials (RCTs). Within the cadre, there is a wealth of academic MDT clinicians, including ERIs, physiotherapists, occupational therapists, nurses and medical officers, both in and out of uniform, supported by biomechanics, physiologists and other members of staff, generating up-to-date patient-centred, clinically focused outcomes.

The Academic Department of Military Rehabilitation (ADMR) mission is to Advance the Scientific Basis of Rehabilitation Medicine to Maximise the Number of Personnel Fit for Operations. ADMR coordinates higher level research through the research coordination group, screening proposals against a priori criteria (Box 1), and provides mentoring during planning, delivery, and analysis. It recently underwent a clinical practitioner engagement exercise to dovetail a ‘bottom up’ approach to the ‘top down’ DMS research strategy,5 6 already bearing fruit in the key areas of lower-limb injury and outcome measures within the tier one DMS MSKI rehabilitation research priority.7–10

Measurement

Within the constraints of ever-decreasing resources, clinical and research prioritisation is required. Measurement of the presence and impact of conditions can be done in many forms, from broad surveillance data11 to specific outcome measures: both patient-reported (PROMs)9 12 and clinician assessed.7 10 As a result, a significant amount of research is dedicated to ensuring the outcome measures are reliable, valid and are actually recording what the end user is hoping to record.

Coppack et al report the creation of a new, military-specific tool to record the impact of occupational role on hip injuries, using epidemiological data to identify the risk of job role to injury, in this case, hip injury.9 Allan et al highlight the benefits of PROMs allied to biomechanical assessment for individualised management, while raising the risks of inconsistency and bias.7 Further detail on these limitations is discussed by Conway et al who identify the impact of pain, kinesiophobia and psychological comorbidities on PROMs in their small prospective cohort study.12 Using a medically downgraded chronic hip pain population, Walters et al 10 assessed the feasibility and acceptability of the isometric midthigh pull (IMTP) test, an outcome measure used within the Army physical employment standards (PES). They determined that the IMTP PES are too low to inform clinical practice and warrant further investigation.

Prevention

To reduce the burden of MSKI, there has been a shift from training focusing on aerobic capacity and muscular endurance, to muscle strength and explosive capability. This reflects the physical activity and functional requirements of the Armed Forces, with reciprocal changes in Army fitness assessment. However, MSKIs are still common, and understanding why is critical.

Hauschild et al identified the high-risk activity of bench press, and high-risk areas of training establishments and deployments, for pectoral muscle injury allowing specific injury prevention interventions, and will prospectively use the same methodology to monitor intervention effectiveness.11 Within specific job roles, certain injuries are higher risk, with Gomes et al demonstrating this within their cross-sectional study of 28 fighter pilots. They used PROMs and strength testing to reveal nearly 80% of the pilots had low back pain, made worse by fatigable muscles, thus recommending preventative lateral trunk strengthening to mitigate and reduce this injury.13

Strategies

Rehabilitation programmes are personalised, informed by injury complexity and chronicity. Simple injuries can be self-managed, or managed as an outpatient, with severe or chronic injuries often requiring intensive residential MDT management. Individualised evidence-based multimodal rehabilitation programmes are developed that take into consideration the nature of the injury, while also meeting the needs of the SP and the occupational demands of their job role. These programmes are designed to also address any underlying risk factors that may prevent reoccurrence of injury.

Ladlow et al raise some of the challenges associated with integrating the principles of strength and conditioning (S&C) programmes into the existing paradigm of Def Rehab rehabilitation. These include designing rehabilitation programmes that facilitate favourable changes in neuromuscular function, while concurrently accommodating biological healing, recovery and patient safety.8 Mazzone et al demonstrate the improvement in pain and function following an individualised outpatient gait retraining programme on US SP with chronic foot pain, highlighting that movement pattern retraining is an important adjunct to S&C training in injury management and prevention.14 Allan et al discuss the benefits of phenotyping chronic hip injury patterns, and therefore facilitating personalised care in the management of these conditions in a residential setting, demonstrating improvements in pain and functional movements.7

Further examples of the benefits of specialist MDT inpatient care are seen following acquired and progressive neurological injury by Wilkins et al and O’Sullivan et al, with the former supporting the updated Defence heat injury management policy,15 and the latter demonstrating the importance of ongoing holistic support in enabling SP to remain in military service despite life-changing diagnoses.16 Both showcase the breadth of clinical disciplines offered within the neurorehabilitation department, replicated in all DMRC inpatient locations.

Innovation

With the move to Stanford Hall from Headley Court, Def Rehab obtained cutting-edge technology for the clinical care of the SP; including a 360° Computer Assisted Rehabilitation Environment (CAREN) and a 30 m biomechanics performance laboratory with 32-motion capture cameras and 14 built-in force plates. Houston et al report the use of virtual reality for gait education (using the CAREN) in a small exploratory cohort study, with universally positive patient feedback,17 and further work is planned to demonstrate benefit in clinical outcome measures. Also featured in two studies is the use of three-dimensional motion capture for biomechanical analysis, increasing potential for individualised movement pattern re-education.7 14

Hayhurst et al introduce blood flow restriction (BFR) training, demonstrating the clinical utility of this equipment within a PCRF. BFR therapy was able to elicit favourable changes in rehabilitation outcomes at considerably less load than conventional resistance training methods. An ADMR-led multicentre RCT, the ADAPTation to therapeutic resistance training study (ADAPT), is due to start in mid-2022, which will expand on this work in an RRU setting.18

Ongoing and future research

Recent large ADMR studies are finishing, with Military Hip Rehabilitation Outcome (MILO) due to report its findings soon, and Chronic Tendinopathy Biomechanical Associations and Efficacy of Injectional Therapy (BEFIT) morphing into an enduring clinical service. Also underway are two longitudinal cohort studies, the 20-year Armed Services Trauma and Rehabilitation Outcomes study (ADVANCE), with nearly 600 battlefield-injured SP with matched controls, with nested studies exploring specific outcomes including biomechanical adaptations, development of osteoarthritis, and the impact of traumatic brain injury, and Military COVID-19 Observational Outcomes in a Viral Infectious Disease (M-COVID) which aims to understand the long-term impact on COVID-19 on SP across the spectrum of severity.