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.

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.

Use of symptom-guided physical activity and exercise rehabilitation for COVID-19 and other postviral conditions.

There are many similarities in symptoms between postviral conditions, including clinical features such as fatigue, reduced daily activity and postexertional symptom exacerbation. Unfavourable responses to exercise have influenced the wider debate on how to reintegrate physical activity (PA) and exercise while simultaneously managing symptoms during recovery from post-COVID-19 syndrome (or Long COVID). This has resulted in inconsistent advice from the scientific and clinical rehabilitation community on how and when to resume PA and exercise following COVID-19 illness. This article provides commentary on the following topics: (1) controversies surrounding graded exercise therapy as a treatment modality for post-COVID-19 rehabilitation; (2) evidence supporting PA promotion, resistance exercise and cardiorespiratory fitness for population health, and the consequences of physical inactivity in patients with complex rehabilitation needs; (3) population-based challenges for UK Defence Rehabilitation practitioners for the management of postviral conditions; and (4) 'symptom guided PA and exercise rehabilitation' as an appropriate treatment option for managing individuals with multifaceted medical needs.

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.

Rehabilitation post-COVID-19: cross-sectional observations using the Stanford Hall remote assessment tool.

INTRODUCTION: The multisystem COVID-19 can cause prolonged symptoms requiring rehabilitation. This study describes the creation of a remote COVID-19 rehabilitation assessment tool to allow timely triage, assessment and management. It hypotheses those with post-COVID-19 syndrome, potentially without laboratory confirmation and irrespective of initial disease severity, will have significant rehabilitation needs. METHODS: Cross-sectional study of consecutive patients referred by general practitioners (April-November 2020). Primary outcomes were presence/absence of anticipated sequelae. Binary logistic regression was used to test association between acute presentation and post-COVID-19 symptomatology. RESULTS: 155 patients (n=127 men, n=28 women, median age 39 years, median 13 weeks post-illness) were assessed using the tool. Acute symptoms were most commonly shortness of breath (SOB) (74.2%), fever (73.5%), fatigue (70.3%) and cough (64.5%); and post-acutely, SOB (76.7%), fatigue (70.3%), cough (57.4%) and anxiety/mood disturbance (39.4%). Individuals with a confirmed diagnosis of COVID-19 were 69% and 63% less likely to have anxiety/mood disturbance and pain, respectively, at 3 months. CONCLUSIONS: Rehabilitation assessment should be offered to all patients suffering post-COVID-19 symptoms, not only those with laboratory confirmation and considered independently from acute illness severity. This tool offers a structure for a remote assessment. Post-COVID-19 programmes should include SOB, fatigue and mood disturbance management.

Defence Medical Rehabilitation Centre (DMRC) COVID-19 Recovery Service.

Coronavirus disease 2019 (COVID-19) causes significant mortality and morbidity, with an unknown impact in the medium to long term. Evidence from previous coronavirus epidemics indicates that there is likely to be a substantial burden of disease, potentially even in those with a mild acute illness. The clinical and occupational effects of COVID-19 are likely to impact on the operational effectiveness of the Armed Forces. Collaboration between Defence Primary Healthcare, Defence Secondary Healthcare, Defence Rehabilitation and Defence Occupational Medicine resulted in the Defence Medical Rehabilitation Centre COVID-19 Recovery Service (DCRS). This integrated clinical and occupational pathway uses cardiopulmonary assessment as a cornerstone to identify, diagnose and manage post-COVID-19 pathology.

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.

Prospective 12-month functional and vocational outcomes of hip arthroscopy for femoroacetabular impingement as part of an evidence-based hip pain rehabilitation pathway in an active military population.

BACKGROUND: Femoroacetabular impingement (FAI) is common with an estimated prevalence of 10-15% among young active individuals. The natural history of the disorder is progression to early osteoarthritis. Hip arthroscopy is recommended if conservative treatments fail; however, outcomes are unclear, particularly in highly active populations. AIM: To evaluate the functional and vocational outcome of hip arthroscopy, as part of an evidence-based rehabilitation hip pain pathway, for the treatment of FAI in an active military population. METHODS: All patients in the defence rehabilitation hip pain pathway, with a confirmed diagnosis of FAI who failed conservative treatment, were assessed prior to surgery and at 2, 6 and 12 months postsurgery. Outcome measures included the Visual Analogue Scale (VAS) for hip pain, Non-Arthritic Hip Score (NAHS) for function, and vocational assessments including functional activity assessment (FAA) and Joint Medical Employment Standard for military employability and deployability. RESULTS: 101 patients completed the study (mean age=33 years) (male:female:75:26) (Royal Navy/British Army/Royal Air Force: 13%/48%/39%). Outcomes demonstrated significant improvements with large effect size. Preoperative NAHS mean=62.9 (SD 16.4), 12-month postoperative NAHS mean=78.8 (18.3), mean improvement in NAHS=15.9 (95% CI 12.3 to 19.5, p<0.001). Preoperative VAS pain mean=51.3 (20.9), 12-month postoperative VAS pain=25.6 (24.5). Mean improvement 25.7 (95% CI 19.4 to 31.99, p<0.001). 73% of patients had a deployable medical category at 12 months postoperative. CONCLUSIONS: These data confirm that hip arthroscopy as part of a structured evidence-based multidisciplinary care pathway produces significant and continued symptomatic, functional and vocational improvements over a 12-month period in a military population exposed to high intensity, weight-bearing exercise in uncontrolled and unforgiving environments.