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Introduction: Military service members with limb loss have unrestricted access to physical therapy (PT) services. Identifying PT interventions used based on clinical rationale and patient needs/goals can provide insight towards developing best practice guidelines. The purpose of this study was to identify preferred PT practice patterns for military service members with lower limb loss., Materials and Methods: This was a retrospective cohort study and was approved by the Naval Health Research Center (NHRC) Institutional Review Board. Data for 495 service members with lower limb loss was analyzed. Frequency of PT visits and units of treatment received were quantified in 3-month increments during the first year after injury and compared for individuals with unilateral limb loss distal to the knee (DIST), unilateral limb loss proximal to the knee (PROX), and bilateral limb loss (BILAT)., Results: A total of 86,145 encounters occurred during the first year after injury. Active treatments were included in 94.0% of all treatments, followed by manual therapy (15.1%), patient education (11.5%) and modalities (2.4%). The highest number of encounters, consisting of active and manual therapy, was received by the DIST group within the first 3 months, while after the first 3 months, the BILAT group had higher encounters and received more active and manual therapy. Utilization of patient education was higher in the PROX and BILAT groups compared to the DIST group throughout the first year after injury., Conclusions: Service members with limb loss utilize PT services often within the first year after injury. Trends of PT practice are most likely influenced by comorbidities and healing time variance between levels of amputation., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2019.)

Moore JL, Jackson CR, Ellis JC, Norrid C. You're the flight surgeon: myelolipoma. Aerosp Med Hum Perform. 2015; 86(4):421-423.

Little data exist regarding the acute assessment of blast concussion and the course of recovery in the combat zone, as most research has examined service members long after they have returned home. This manuscript examined a case series of 377 service members seen for acute concussion evaluation following medical evacuation from the battlefield in Helmand Province, Afghanistan. Of these, 111 were assessed for concussion prior to their return to the continental USA for other severe physical injuries. Of the remainder, and when comparing those who returned to duty (RTD)/recovered from concussion in the combat zone and those who did not, data indicate that those who did not RTD were older and were more likely to endorse symptoms of combat stress. Quicker recovery times were associated with less severe headaches and fewer acute symptoms at the time of injury as well as the absence of combat stress reaction. Variables that were not associated with RTD and/or recovery were Military Acute Concussion Evaluation (MACE) cognitive scores and whether or not individuals suffered loss of consciousness. While MACE scores were not associated with recovery, they were deemed clinically useful as a part of a serial concussion evaluation if the initial MACE was given within 6 h of the blast. Implications for battlefield concussion assessment and management as well as future research directions are discussed.

Objective: We conducted a retrospective study of metabolic data for Vietnam-era repatriated prisoners of war (RPWs) and a comparison group to determine if metabolic syndrome (MbS) was more common in those individuals with clinically diagnosed, current or lifetime posttraumatic stress disorder (PTSD) as suggested in a recent report., Methods: The metabolic data of our patients nearest the time of psychiatric evaluation (1998-2004) for PTSD were analyzed using both an analysis of variance and logistic regression., Results: Although we found elevated triglyceride levels (40 mg/dl higher) in RPWs with PTSD who met MbS criteria, overall the prevalence of MbS was the same in RPWs with and without PTSD and comparison group. Moreover, current PTSD symptom severity did not increase the likelihood of MbS., Conclusions: Our results from these repatriates who actively participate in a 37-year medical follow up program do not support the conclusion that MbS occurs more commonly in individuals with current PTSD.

Objective: We conducted a retrospective evaluation of bone mineral density data collected during routine medical follow-up evaluations of 241 Vietnam-era male repatriated prisoners of war, with and without the lifetime diagnosis of posttraumatic stress disorder (PTSD), and 79 subjects in a comparison group., Methods: Dual-energy X-ray absorptiometry scans evaluated total hip and lumbar spine T-scores. A multivariate analysis of covariance was performed on the data using age, body mass index, ethnicity, and reported alcohol consumption as covariates., Results: There was a significant effect of group on total hip, but not lumbar spine, T-scores. Pairwise comparisons revealed statistically lower total hip T-scores in repatriates with a lifetime history of PTSD in comparison to both the comparison group and repatriates without a lifetime history of PTSD., Conclusion: In this study of elderly repatriated prisoners of war, we noted an association between a lifelong history of PTSD and decreased bone mineral density at the hip.

Background: increasing numbers of women are deployed to austere settings in which menstruation may impose logistical challenges. Minimal data exists about the use of oral contraceptive pills (OCPs) for menstrual suppression in this population. Post-deployment survey was undertaken to establish prevalence of continuous OCP use, perceived barriers, and associations with menstrual burden in a military population within the austere environment., Methods: voluntary and anonymous 44-item questionnaire., Results: of 500 women, 78% (n = 390) had personal experience using OCPs and 66% (n = 330) desired menstrual suppression. However, only 40% (n = 192) reported any OCP use and only 21% (n = 99) reported continuous use during deployment. Sixty-seven percent of women reported some difficulty in daily pill compliance and nearly half (45%) missed ≥ 1 pill per week in the austere setting. Continuous users were nearly twice as compliant as conventional users (p = .019) and compliant OCP users reported significantly less menstrual burden than noncompliant users (p = .017). Almost all women (85%) desired mandatory education about menstrual suppression through OCPs., Conclusion: despite OCP experience and desire for amenorrhea, prevalence of extended cycle OCP use in this population is low. Extended OCPs users in the austere setting report improved compliance and reduced menstrual burden compared with conventional users. Education about OCPs is highly desirable for most military women and may benefit those in austere settings., (2011 Jacobs Institute of Women's Health. Published by Elsevier Inc.)

Introduction: Increasing numbers of women perform aviation duties in the combat flight environment. Oral contraceptive pills (OCPs) afford numerous health and operational benefits, including prevention of anemia and suddenly incapacitating conditions, as well as menstrual suppression when taken continuously. Until now, the use of OCPs in the combat flight environment has not been examined., Methods: An anonymous, voluntary questionnaire was distributed to 62 female U.S. Army aviation personnel who had recently deployed in support of combat flight operations to characterize continuous OCP use and perceived barriers to this practice, as well as to determine associations with menstrual burden., Results: There were 81% (N=50) of the women who had personal experiences using OCPs and 93% (N=58) were aware that continuous use can suppress menstruation. For deployment, 66% (N=41) desired menstrual suppression, yet only 33% (N=20) reported any OCP use. Even fewer (15%; N=10) reported using continuously. Of the women who did not use OCPs continuously, 35% had insufficient knowledge about OCPs and 44% of women reported difficulty in remembering to take a daily pill. Continuous OCP users were more compliant (P = 0.019), reported less spotting (P = 0.007) and fewer unexpected menstrual cycles (P = 0.03) than conventional OCP users. A trend toward reduced cramping was noted (P = 0.064). Most women (60%) desired standardized entry-level education about menstrual suppression through OCPs., Conclusions: The use of continuous OCPs is low in deployed women with aviation-related duties, yet a majority desires menstrual suppression. Continuous OCP use in this setting is associated with significantly improved compliance and significant reductions in specific menstrual burdens. Entry-level education is desirable and may reduce barriers to continuous OCP use by addressing risks, side effects, and daily pill adherence strategies. Flight surgeons should provide further education and consider continuous OCP dosing in the austere environment of combat flight.

Purpose: We were interested in studying a full range of successful aviators to discern which personality factors were present and whether these factors correlate with age, rank, and accumulated flight time., Method: The Armstrong Laboratory Aviator Personality Survey (ALAPS) was administered to 312 designated naval aviators and flight officers from a variety of aircraft communities. The sample included O-3/O-4 elite aviators who were selected for their squadron billets based on superior performance, O-5/O-6 aviators selected for command positions, and 59 flag officers., Results: The junior aviators scored higher on the factor associated with Dogmatism and lower on the factor associated with Team Orientation and Socialness. This pattern was reversed for the flag officers, while O-5/O-6 aviators received intermediate scores on each of these factors., Conclusions: The present study demonstrates a correlation between specific ALAPS factors and experience, rank, age, and flight time. The combination of high Dogmatism, low Team Orientation, and low Socialness in junior aviators could suggest lower openness to crew input and increased risk for mishaps.

Background: As evidence has accumulated for the role of HMG-CoA reductase inhibitors in the primary prevention of coronary artery disease, younger individuals with no other co-morbid conditions will be increasingly exposed to these agents. Some HMG-CoA reductase inhibitors have been reported to cause impairment of daytime cognitive processes that have the potential to directly impact the ability of pilots and other aircrew to perform. These studies suggested that there might be cognitive effects of these medications that would argue against their routine use in populations whose activities required high, sustained levels of cognitive performance. The objective of this study is to establish the effects of pravastatin and lovastatin on aircrew daytime cognitive function using tests that are correlated with actual cockpit tasks and inflight performance., Methods: Military aircrew with hypercholesterolemia were enrolled in the study and assigned to lovastatin, pravastatin or placebo groups. Baseline cognitive and vigilance testing was performed with computerized test instruments. Following a 4-wk treatment period, subjects were retested on both cognitive and vigilance tasks., Results: Laboratory studies confirmed that both medications were effective in lowering cholesterol. No major treatment-related side effects were encountered. Cognitive performance was not affected by either active treatment, and was not different from that of the placebo group., Conclusions: The tested medications did not have significant effects on performance as measured by two computerized performance tests. The data suggest that neither medication has significant effects on flight-related performance.

Objective: The objective of this study was to characterize injuries occurring to crew members aboard a U.S. Navy ship., Methods: A retrospective review of crew member medical records was conducted covering a 90-day period during which the ship was intermittently at sea. Data on new injuries were collected and sorted. Injuries were classified as soft tissue or musculoskeletal, acute or overuse, and occurring with the ship at sea or in port., Results: There was a total incidence of 16.5 injuries per 100 man-months. Acute musculoskeletal injuries contributed 2.6 injuries per 100 man-months and resulted in 79 lost and 192.5 modified work days. Overuse musculoskeletal injuries were responsible for 9.3 injuries per 100 man-months and caused 1 lost and 255.5 modified work days. Soft tissue injuries had an incidence of 4.6 injuries per 100 man-months and resulted in no lost and only 106 modified work days. The relative risk of sustaining a soft tissue injury in port compared with at sea was 1.1, but this was not statistically significant. The relative risk of sustaining an acute musculoskeletal injury in port compared with at sea was 3.5 (p = 0.01)., Conclusions: Overuse musculoskeletal injuries occurred with the greatest incidence, but acute musculoskeletal injuries were responsible for the greatest morbidity. Soft tissue injuries occurred with an intermediate incidence but had the lowest overall morbidity. The safest place for crew members assigned to this Navy ship was aboard that ship at sea. Further studies of this nature could help guide medical efforts at injury treatment and prevention for shipboard personnel.

Background: All aviation personnel in the U.S. Navy are evaluated for aeronautical adaptability (AA) in both initial and periodic examinations and for daily aeromedical disposition. By definition, all aviation personnel with a diagnosed personality disorder or those with maladaptive personality traits that have had a documented effect on safety of flight, crew coordination, or mission completion, are determined to be Not Aeronautically Adapted (NAA)., Methods: NAA dispositions were examined for demographic data, basis for disposition, and frequency of personality features., Results: NAA dispositions were made on the basis of personality disorders and maladaptive personality traits in 29% and 35% of the cases, respectively. The officer and enlisted NAA dispositions were distinctly different in terms of frequency of personality features. Obsessive-compulsive features were present in 58% of officer and 10% of enlisted NAA dispositions. Dependent and avoidant features were present in excess in comparison to psychologically healthy aviators, suggesting the incompatibility of these features with aviation.

A 28-yr-old Naval F-14 aviator presented with complaints of flight-related anxiety occurring intermittently over an 18-mo period. Symptoms included sensation of strangeness, concern over the welfare of his radar intercept officer, flushing, nausea, and intense need to immediately land the aircraft. He also described a 6-mo history of episodes wherein he would see "shooting stars" in the periphery of his vision, accompanied by dizziness and disorientation. These latter attacks were always precipitated by head turning, usually in combination with positive Gz maneuvers, and were relieved by head straightening. The anxiety symptoms were consistent with a form of panic attack, but the neurological symptoms provoked further workup. Magnetic resonance cerebral angiogram demonstrated a dominant right vertebral artery and hypoplastic left vertebral artery. All symptoms resolved once the aviator was removed from flying the aircraft. After a year of follow-up with an aviation psychiatrist, he remained asymptomatic and was reassigned to maritime patrol aircraft. This case illustrates a difficult diagnostic, therapeutic, and disposition challenge. This aviator suffered from a complex interaction of neurologic and psychiatric manifestations having a common inciting stimulus, namely flying the F-14 Tomcat. A promising aviation career was preserved upon removal of that stimulus.

The authors describe a case of chronic depression in a designated Naval Aviator with a concomitant history of hypothyroidism. The differential diagnosis of dysthymia is discussed and the associated therapeutic alternatives are reviewed. The case demonstrates the importance of comprehensive physical and psychiatric evaluation of those patients with complex or atypical presentations. Issues pertaining to the aeromedical disposition of such patients are discussed, with emphasis on the role of the flight surgeon.