ANN ARBOR, MI – When it comes to musculoskeletal injuries in the military, the physical disability might be only part of the story.
While nearly two-thirds of troops deemed unfit for duty within four years of returning from Iraq suffered musculoskeletal injuries, half of them also had a psychological disorder. According to recent research, a behavioral health diagnosis was the best single predictor of a negative determination by the Physical Evaluation Board for troops with or without physical injuries. Lower socioeconomic status, as indicated by lower rank, also negatively affected continued service following injury.
“We want orthopedists to recognize the importance of behavioral health conditions and socioeconomic status in recovery, so they can optimize outcomes and mitigate the adverse impact of existing conditions,” said Andrew Schoenfeld, MD, a Robert Wood Johnson Clinical Scholar at the Department of Orthopaedic Surgery at the University of Michigan Medical School and VA Ann Arbor, MI, Healthcare System.
Schoenfeld led a team of researchers that tracked 4,122 soldiers in one combat brigade deployed to Iraq for 15 months during 2006 and 2007. During deployment, 35 died. The remainder were monitored for four years for development of chronic musculoskeletal conditions, behavioral health disorders and termination of service by the Physical Evaluation Board. The researchers examined the influence of demographic status, behavioral health and deployment-related injuries on ability to continue to serve.
In their study, recently published in the Journal of Bone and Joint Surgery, the researchers wrote that “behavioral health diagnosis was the sole significant predictor for being deemed unfit by the Physical Evaluation Board (PEB) within the musculoskeletal battle injury group.”
While in Iraq, 18% of the brigade suffered combat-related or other musculoskeletal injuries. By 2011, the PEB had found to be unfit 9.2% of the returning brigade and 12% of those with any musculoskeletal injury during deployment. Of the total number unable to continue service, 63% had disqualifying musculoskeletal conditions and 59% had prohibitive psychiatric conditions.
Overall, 163 soldiers sustained combat-related musculoskeletal trauma, while another 587 soldiers had musculoskeletal injuries not related to battle. Of the 374 soldiers found to be unfit by the PEB, 236 soldiers, 63%, were referred for at least one musculoskeletal condition. Of those 236 soldiers referred for at least one musculoskeletal condition, 116, or 49%, also had a behavioral health diagnosis. Whether or not the musculoskeletal injury was combat-related, behavioral health diagnosis and junior enlisted rank were significant variables for predicting an unfitness determination, according to the authors, who that junior enlisted rank functions well as a proxy for lower socioeconomic status, based on previous research.1
In the entire brigade, post-traumatic stress disorder (PTSD) accounted for the largest number of negative PEB determinations, followed by lower back pain and traumatic brain injury. Musculoskeletal diagnoses accounted for half of the most common reasons for medical discharge. Of the soldiers who returned from deployment, 331 sustained war trauma other than musculoskeletal injuries.
Schoenfeld told U.S. Medicine that the brigade’s experience provides insight into injuries encountered in many nonmilitary settings as well. “Everybody thinks Rambo or Seal Team Six when they think of a combat brigade, but really they are self-contained units that have those prototypical American soldiers, but also have truck drivers, fuelers, pharmacists, physicians, cooks and a whole range of other individuals representative of the American populace aged 18 to 52. While clearly some have incredibly traumatic injuries that you wouldn’t see except in a war zone, a much larger proportion have injuries not that different from those sustained in sports, motor vehicle accidents or falls down stairs.”
The authors noted that their findings have broad implications for clinicians and others working with patients who have musculoskeletal injuries. “There is no reason to assume that the predictive factors for inferior outcome identified here, including the potent and synergistic effects of mental health conditions and rank (as a proxy for socioeconomic status), are only applicable to military populations.”
The presence of psychiatric disorders may adversely affect recovery from musculoskeletal injuries because of the “effect of the acute psychological response on post-injury rehabilitation as well as patient satisfaction,” the authors suggested.
Universal access to healthcare in the military allowed the researchers to eliminate discrimination, hospital segregation and lack of insurance as explanations for poorer outcomes among servicemembers with lower rank/socioeconomic status. Instead, they postulated that “attitudes toward the use of healthcare and the health-care system, educational level, and inadequate social support networks are responsible for the elevated risk of medical separation” in these soldiers.
Schoenfeld urged increased awareness of the presence of behavioral health conditions and socioeconomic status, as those can, depending on setting, indicate coping skills, ability to navigate the American healthcare system and willingness to access care. Aggressive outreach and enhanced support for high-risk patients with musculoskeletal injuries may improve outcomes for the affected individuals and enable the military to retain more personnel.
Whether working with active-duty military, veterans or civilians, “we need to make sure these patients have access to appropriate social support systems that will help them recover from injuries,” Schoenfeld said.
The researchers intended the study to be translational in nature and to contribute significantly to an understanding of factors affecting recovery from injury in civilian as well as military populations. They noted, however, that the study had some limitations in that regard. Specifically, using medical separation as a proxy for inability to return to work in a civilian setting created some challenges as it did not allow the researchers to capture those soldiers who chose to retire or not re-enlist, perhaps because of injuries, and those who never sought care for their medical or behavioral health conditions. The study also did not evaluate medical records for mental health conditions present prior to deployment to Iraq.
1Schoenfeld AJ, Goodman GP, Burks R, Black MA, Nelson JH, Belmont PJ. The Influence of Musculoskeletal Conditions, Behavioral Health Diagnoses, and Demographic Factors on Injury-Related Outcome in a High-Demand Population. The Journal of Bone & Joint Surgery, 2014; 96 (13): e106