The military is an ideal system for studying young, active patient populations. But the benefits of military knowledge transfer for civilian lower extremity practitioners don’t end there.
By L.W. Barnes
The military – a wellness utopia of active and healthy young adults who must maintain fitness and weight standards to remain in good standing. Personnel medical histories are part of vast military databases that practitioners and researchers use to chart trends and examine the evolution of treatments. Unlike with civilian medicine, patients and their outcomes can be followed through years-long stretches, offering a view that is otherwise hard to come by.
So what better place, you might think, to study the impacts of injury and healing, to share a vast, captured knowledge?
“It comes up all the time – the question of the transferability of what we do in the military to those in the civilian world,” said LTC Brett Owens, MD, an orthopedic surgeon at Keller Army Hospital in West Point, NY.
Comparing athletes to athletes
The answer, say military practitioners, is in most cases a commonsense one. Owens’ practice, which is hospital based and made up entirely of military personnel, focuses on sports medicine. He and his colleagues treat many patients with knee injuries, such as anterior cruciate ligament (ACL) tears, in addition to overuse injuries such as plantar fasciitis, (think: solider shouldering a 70-pound rucksack and rifle in the field).
What Owens has learned about treatments, he says, is directly applicable to a young, healthy population with the same kinds of injuries – particularly college and recreational athletes. One study on the epidemiology of plantar fasciitis, which he co-authored this year in the Journal of Bone and Joint Surgery, found female sex and increasing age to be risk factors for this condition. This work was shared widely with the civilian practitioners (see “The epidemiology of plantar fasciitis.”)
“My practice is very similar to those who take care of athletes at any university and others who care for a young population,” Owens said. “The injuries sustained by military athletes are similar to those experienced by athletes anywhere – we just have a population that is almost entirely young athletes.
“I’ve had colleagues come into the hospital and say ‘I have a research interest in this [disease],’ but there aren’t cases. As a researcher you have to consider what your strengths are. In military orthopedics, it’s a young, active population.”
Which is terrific news for civilians who are also young and healthy—the regular beneficiaries, doctors say, of that military knowledge transfer.
Craig Bottoni, MD, an orthopedic surgeon, served15 years in the Army before leaving to join a private practice. He was later recruited as a civilian doctor and returned to Tripler Army Medical Center in Honolulu, where he works now.
Like Owens, his patients are young, healthy and active, typical military. Whether they’re injuries are sustained in battle or on the basketball court, they’re motivated to get back to their units. No couch potatoes. No ignoring physical therapy.
While Bottoni says his research is only applicable to a similar set of civilian patients and their practitioners (the elderly and chronically ill need not apply), what he has learned is not only applicable to the civilian population, but is also incredibly useful.
He points to studies he’s conducted on both shoulder and knee operations. His patients, unlike most civilians, have very strict, very demanding physical requirements. They must be able to run and march long distances, often carrying impossibly heavy packs. It’s not your everyday stroll to Starbucks. It’s analogous, he says, to the very heavy demands placed on Division I athletes. If you can’t perform, you’re out.
His hypothesis was this: if he could develop medical strategies that work for an Army population that demands high-level physical exertion, then surely these treatments would work for the recreational or occasional athlete.
“If an operation succeeds in the kid who has to do sit-ups and pull-ups and endure 10 mile forced marches with a 70-pound rucksack and a machine gun,” Bottoni said, so too will it work on the weekend warrior.
In 2007 Bottoni was honored with the O’Donohue Sports Injury Research Award—presented at that year’s annual meeting of the American Orthopedic Society for Sports Medicine—for his prospective, randomized comparison of delayed vs. acute reconstruction of the anterior cruciate ligament. The study was conducted comparing a group of active duty athletes.
While Bottoni said it is usually the standard procedure in athletes or non-athletes to wait three to six weeks before performing the reconstruction (allowing time for the swelling to go down and some motion to return), Bottoni showed that the surgeries performed acutely succeeded as well or better than those performed four to six weeks after the injury.
“That’s a game changer,” Bottoni explained. “These [soldiers] had to get back to full activities, the better they could perform their jobs and get back into the fight. That’s applicable to the civilian world. Take that college athlete and do ACL reconstruction and not wait one or three months and still do as well and get back to training and competition sooner.”
Apply this and other treatment regimens to an older and perhaps sick population, and the outcomes might change dramatically. But take the treatment to like populations and the pieces fit.
“If I get blown off my vehicle and dislocate my shoulder or jump off a vehicle with a heavy load and tear my ACL, is that any different from a guy playing football? Bottoni said.
Advances for amputees
LTC Kevin Kirk, DO, is chief of orthopedic surgery at Brooke Army Medical Center in Fort Sam Houston, TX, the only level one trauma center in the U.S. Department of Defense. It is where Kirk and his colleagues do reconstructive limb salvage and definitive amputations on soldiers who have sustained injuries in Iraq and Afghanistan.
Although their patient populations differ greatly from those who’ve suffered amputations as a result of vascular disease or diabetes, the work being done by military practitioners to advance the function of prosthetics for soldiers has an impact on the civilian world. Aspects of the technology eventually do trickle down to the level of less-active patients, but the biggest impact is felt by younger, healthier patients who—like their uniformed counterparts—have suffered traumatic injury.
Historically, most of the advancements in prosthetics have occurred during war time in a military setting. Since this latest conflict began, more than 1000 amputations have been conducted, Kirk said. And those patients have a desire to return to a high level of activity. That, Kirk said, has pushed providers to help those patients reach their goals as they relate to physical activity.
“A diabetic who walks from living room to bedroom and loses a leg due to infection will get a prosthesis with the expectation that he’ll be able to get back to that level of ambulation in his own house,” Kirk said.
Those who are healthy and active have different expectations, he said.
“They require more sophistication in their prosthetics, and that’s where the advances are coming,” Kirk said. “It’s hard to replace the joint mechanics and functions you were given at birth, but these wounded warriors push the envelope and say ‘Hey, this could be better.’ They know what’s lacking in their care, and it’s being developed.”
Basic training basics
Of the approximately one million outpatient visits that Army doctors see each year, 50% or more are the result of overuse injuries. It is the most common type of injury, according to Bruce Jones, MD, MPH, a physician-epidemiologist, who manages the Injury Prevention Program at the Army Public Health Command in Aberdeen Proving Ground, MD.
According to surveys conducted by Army researchers, 25% to 60% of injuries to soldiers are related to running. As many as 60% of trainees in basic complain of these injuries—including stress fractures, Achilles tendinitis, and plantar fasciitis. As a result, the Army, and doctors like Jones, have spent many years and resources trying to identify and remedy the problems.
“While we can give soldiers a ride to some places,” Jones said wryly, “we can’t give them a ride everywhere.”
Research began in the 1980s with reviews of the literature for the primary risk factors: weight-bearing training exercises, marching, and running.
The more soldiers ran, the more they were subject to overuse injuries. Not surprising, perhaps, was the correlation between the soldiers’ overall level of fitness and their risk of injury, particularly during basic training – the more fit soldiers were, the less they got injured.
Based on those two primary factors (as well as others), Jones and his fellow researchers made a series of recommendations to the Army’s Training and Doctrine Command that running be conducted within ability groups, as well as to reduce running mileage (less distance, more short fast runs).
Since the recommendations were implemented in 2003, the rates of injury in basic combat training have decreased 30% to 40%, Jones said.
His belief that “the mechanisms of injuries for soldiers are the same for civilians” may explain why the work he has done with his colleague Joseph Knapik, ScD, has resonated with a national audience. Even if most enlisted military personnel are conditioned to be fit, the injury risks faced by cadets who enter basic training without adequate physical training are more analogous to those facing civilians who are transitioning to exercise programs of their own.
In 2006, the Institute of Medicine asked Jones to be part of a 30-member workshop panel sponsored by the U.S. Department of Health and Human Services titled “Adequacy of Evidence for Physical Activity Guidelines Development.” The panel was charged with considering whether a comprehensive set of physical activity guidelines for Americans should be developed.
Jones was heavily referenced in the committee report, which was published in 2007 and contained a chapter penned by him called “Physical Activity and Risk – Maximizing Benefits.”
That work was used as the basis for HHS’s 2008 Physical Activity Guidelines for Americans (www.health.gov/paguidelines).Since then, the guidelines have been widely disseminated among sports and physical activity groups, as well as the orthopedic and physical therapy communities that deal with athletes.
“There’s no reason to believe soldiers are biomechanically different from [civilians] of the same age,” Jones said. “But because of our interest and because of the uniqueness of unit training for our population, we’ve been at the cutting-edge of the relationships between physical training, physical fitness and injuries.”
Those knowledge-transfer relationships reach beyond the active military to the many, many thousands of veterans and others being treated for such conditions as diabetic neuropathy. And sometimes those relationships have unexpected origins.
In defense of diabetes
Take the work of Paul W. Brand, MD. The late surgeon and humanitarian is not unfamiliar to physicians who work in foot and ankle orthopedics.
In the 1940s, Brand worked at the Christian Medical College & Hospital in Vellore, India where he studied the ravages of leprosy, or Hansen’s Disease, of which the secondary symptoms include distal neuropathy. His work, much of which he did years later under the auspices of the U.S. government, led to the treatment of other diseases that affect the extremities.
It was Brand who began the first rehabilitation research program for Hansen’s disease patients, which studied the biomechanics of deformity of the hands and feet. The development of amputation prevention techniques were later developed and today help people with diabetes, among other diseases.
“You can take the small population of those with Hansen’s Disease and transfer it to the 18 million diabetics in the United States, said U.S. Public Health Officer CAPT James Foto, BSME, CPed, chief of operations management and a biomedical research engineer at the Health Resources and Services Administration’s National Hansen’s Disease Programs (NHDP) in Baton Rouge, LA. “It’s a great example of transferring the knowledge and technology of what the federal government is involved in.”
Foto has lectured and published widely on the pathomechanics of ulceration. One of his areas of expertise has been adaptive neuropathic footwear, specifically the understanding of the interface between the foot and the shoe.
One of the campaigns that originated from the NHDP was LEAP (Lower Extremity Amputation Prevention), which is taught to footcare practitioners ranging from orthopedic surgeons to certified pedorthists.
LEAP, which was launched in 1992, is a comprehensive program that can dramatically reduce lower extremity amputations in individuals with diabetes mellitus, Hansen’s disease, or any condition that results in loss of protective sensation in the feet.
For his part, Foto said it was a desire to answer the yet-unanswered questions that compelled him to work in research. His work has and continues to focus on finding materials and their combinations that can bring “the ground up to the foot” of those suffering from neuropathy and bony protrusions.
It is the federal government, he says, that has made research like this possible and available to the public. And it’s no coincidence, industry observers agree, that some of the top research on diabetic foot care has also come from Veterans Affairs hospitals in places like Chicago, Seattle, and Tucson, AZ.
“If it weren’t for a university or the government,” asks Foto, “Who would do it?”
L.W. Barnes is a freelance writer and editor based in Alexandria, VA.