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Introduction Low back pain (LBP) has accounted for the most medical encounters every year for the past decade among Active Duty Service Members (ADSMs) of the U.S. Armed Forces. The objectives of this retrospective, descriptive study were to classify LBP by clinical category (Axial, Radicular, and Other) and duration (Acute, Subacute, and Chronic) and examine the LBP-related health care utilization, access to care, and private sector costs for ADSMs over a 2-year follow-up period. Materials and Methods The Military Health System Data Repository was queried in fiscal year 2017 for all ADSMs (ages 18-62) with outpatient encounters documented with any of 67 ICD-10 diagnosis codes indicative of LBP. A 1-year clean period before the first (index) outpatient LBP encounter date was used to ensure no recent history of LBP care. Patients were eligible if continuously enrolled and on active duty for 1 year before and 2 years following the index visit. Patients were excluded for non-musculoskeletal causes for LBP, red flags, or acute trauma within 4 weeks of the index visit and/or systemic illness or pregnancy anytime during the clean or follow-up period. Results A total of 52,118 ADSMs met the inclusion criteria, and the cohort was classified by duration of LBP symptoms as Acute [17,916 (34.4%)], Subacute [4,119 (7.9%)], and Chronic [30,083 (57.7%)]. Over 2-year follow-up, 419,983 outpatient visits were recorded, with the majority occurring at MTFs [363,570 (86.6%)]. 13,237 (25.4%) of ADSMs in the total cohort were documented with no other LBP-related visits beyond their index encounter. In contrast, the Chronic cohort comprised the highest number of encounters [371,031 (89.2% of total encounters)], including 86% of imaging studies performed for LBP, and accounted for $9,986,606.17 (94.9%) of total private sector costs over the 2-year follow-up period. Interventional pain procedures ($2,983,767.50) and physical therapy ($2,298,779.07) represented the costliest categories in the private sector for the Chronic cohort, whereas Emergency Department ($283,307.43) and physical therapy ($137,035.54) encounters were the top contributors to private sector costs for the Acute and Subacute cohorts, respectively. Overall reliance on the private sector was highest for specialty care, including 10,721 (75.4%) interventional pain procedures and 306 (66.4%) spine surgeries. Conclusions Uncovering current trends in health care utilization and access to care for ADSMs newly presenting with LBP is vital for timely and accurate diagnosis, as well as early intervention to prevent progression to chronic LBP and to minimize its negative impact on military readiness and quality of life. This retrospective, descriptive study highlights the burden of chronic LBP on health care utilization and costs within the Military Health System, including reliance on the private sector care, amounting to $10,524,332.04 over the study period.

Introduction Telehealth is an increasingly common approach to improve healthcare delivery, especially within the Veterans Health Administration and Department of Defense (DoD). Telehealth has diminished many challenges to direct access for clinical follow-up; however, the use of mobile telehealth for specialty rehabilitative care is emerging and is referred to as telerehabilitation. As early adopters of telehealth, the Veterans Affairs and DoD have supported collaborated efforts for programs designed to increase the access and quality of rehabilitative care while improving the functional ability of our service members (SMs) and veterans with lower limb amputation (LLA). The DoD and Veterans Health Administration collaborated on a Mobile Device Outcomes-based Rehabilitation Program (MDORP) to help injured SMs and veterans with LLA. The MDORP project utilized a mobile health system called the Rehabilitative Lower Limb Orthopedic Accommodating Device (ReLOAD) to assess walking quality. The ReLOAD system includes real-time auditory biofeedback to notify the user of their most prominent gait deviation and then recommends exercises that address specific balance and strength impairments. The purpose of this study was to describe the responses to a postintervention survey evaluating the feasibility and usability of ReLOAD completed by SMs and veterans with LLA who used the system for 5 months. Materials and Methods A link to an anonymous usability survey was emailed to all participants who completed MDORP. The survey was modeled after the System Usability Scale, with agreeableness to items rated on a 5-point Likert-style questionnaire in addition to open feedback. Data visualization of Likert-style questionnaires was conducted using ggplot2 and reshape2 statistical packages and was analyzed using R. We obtained institutional review board approval through both Miami Veterans Affairs Healthcare System and Walter Reed National Military Medical Center. Results The majority of participants reported that they would use the system again for home rehabilitation (65%) and that auditory biofeedback helped them walk better (59%). Participants also suggested that future work should include a greater variety of exercise options and the use of smart phones for the ReLOAD application in addition to the iPad tablet. Conclusions The participants provided positive and constructive feedback that will enhance the value and usability of telerehabilitation interventions like the ReLOAD system for future users.

Introduction The objective was to determine if the Mobile Device Outcomes-based Rehabilitation Program (MDORP) improved strength, mobility, and gait quality in service members (SMs) and Veterans with lower limb amputation (LLA). Methods Seven SMs and 10 Veterans with LLA enrolled and were trained to use a mobile sensor system, called Rehabilitative Lower Limb Orthopedic Analysis Device (ReLOAD). ReLOAD provided participants with real-time assessment of gait deviations, subsequent corrective audio feedback, and exercise prescription for normalizing gait at home and in the community. After baseline testing, prosthetic gait and exercise training, participants took ReLOAD home and completed an 8-week walking and home exercise program. Home visits were conducted every 2 weeks to review gait training and home exercises. Results Significant improvements in hip extensor strength, basic and high-level mobility, musculoskeletal endurance, and gait quality (P Conclusion Preliminary MDORP results are promising in its ability to improve basic and high-level mobility, lower limb strength, and gait quality in a group of SMs and Veterans with LLA. In addition, “booster” prosthetic training may be justified in an effort helps maintain an active lifestyle, promotes prosthetic use, and mitigates secondary health effects.

Introduction Acquired Brain Injury, whether resulting from Traumatic brain injury (TBI) or Cerebral Vascular Accident (CVA), represent major health concerns for the Department of Defense and the nation. TBI has been referred to as the “signature” injury of recent U.S. military conflicts in Iraq and Afghanistan – affecting approximately 380,000 service members from 2000 to 2017; whereas CVA has been estimated to effect 795,000 individuals each year in the United States. TBI and CVA often present with similar motor, cognitive, and emotional deficits; therefore the treatment interventions for both often overlap. The Defense Health Agency and Veterans Health Administration would benefit from enhanced rehabilitation solutions to treat deficits resulting from acquired brain injuries (ABI), including both TBI and CVA. The purpose of this study was to evaluate the feasibility of implementing a novel, integrative, and intensive virtual rehabilitation system for treating symptoms of ABI in an outpatient clinic. The secondary aim was to evaluate the system’s clinical effectiveness. Materials and Methods Military healthcare beneficiaries with ABI diagnoses completed a 6-week randomized feasibility study of the BrightBrainer Virtual Rehabilitation (BBVR) system in an outpatient military hospital clinic. Twenty-six candidates were screened, consented and randomized, 21 of whom completed the study. The BBVR system is an experimental adjunct ABI therapy program which utilizes virtual reality and repetitive bilateral upper extremity training. Four self-report questionnaires measured participant and provider acceptance of the system. Seven clinical outcomes included the Fugl-Meyer Assessment of Upper Extremity, Box and Blocks Test, Jebsen-Taylor Hand Function Test, Automated Neuropsychological Assessment Metrics, Neurobehavioral Symptom Inventory, Quick Inventory of Depressive Symptomatology-Self-Report, and Post Traumatic Stress Disorder Checklist- Civilian Version. The statistical analyses used bootstrapping, non-parametric statistics, and multilevel/hierarchical modeling as appropriate. This research was approved by the Walter Reed National Military Medical Center and Uniformed Services University of the Health Sciences Institutional Review Boards. Results All of the participants and providers reported moderate to high levels of utility, ease of use and satisfaction with the BBVR system (x̄ = 73–86%). Adjunct therapy with the BBVR system trended towards statistical significance for the measure of cognitive function (ANAM [x̄ = −1.07, 95% CI −2.27 to 0.13, p = 0.074]); however, none of the other effects approached significance. Conclusion This research provides evidence for the feasibility of implementing the BBVR system into an outpatient military setting for treatment of ABI symptoms. It is believed these data justify conducting a larger, randomized trial of the clinical effectiveness of the BBVR system.

The use of explosive armaments during Operation Iraqi Freedom, Operation Enduring Freedom, and Operation New Dawn has resulted in a significant number of injured U.S. service members. These weapons often generate substantial extremity trauma requiring multiple surgical procedures to preserve life, limb, and restore function. For those individuals who require multiple surgeries, the use of patient-controlled analgesia (PCA) devices can be an effective way to achieve adequate pain management and promote successful rehabilitation and recovery during inpatient treatment. A subpopulation of patients are unable to independently control a PCA device because of severe multiple limb dysfunction and/or loss. In response to the needs of these patients, our team designed and developed a custom adaptor to assist service members who would otherwise not be able to use a PCA. Patient feedback of the device indicated a positive response, improved independence, and overall satisfaction during inpatient hospitalization.