To provide a quantitative synthesis of randomized controlled trials examining the effect of exercise training on symptomatic fatigue in persons with multiple sclerosis (MS).Electronic databases (Web of Science, PubMed, PsycInfo, and Google Scholar) were searched for articles published between 1960 and October 2012 by using the key words "fatigue," OR "tiredness," OR "energy," OR "mood," OR "lassitude," AND "exercise," OR "physical activity," OR "rehabilitation," OR "fitness" WITH "multiple sclerosis." The initial search resulted in 311 articles, of which 74 were reviewed in detail and 17 met the inclusion criteria and provided enough data to compute effect sizes (ESs; Cohen d). The meta-analysis was conducted using a meta-analysis software program, and a random-effects model was used to calculate the overall ES, expressed as Hedge g.The weighted mean ES from 17 randomized controlled trials with 568 participants with MS was 0.45 (standard error = 0.12, 95% confidence interval = 0.22-0.68, z = 3.88, p ≤ .001). The weighted mean ES was slightly heterogeneous (Q = 29.9, df = 16, p = .019).The cumulative evidence supports that exercise training is associated with a significant small reduction in fatigue among persons with MS.
Firefighters (FFs) work in hazardous, volatile environments with considerable physical and mental demands that might influence cognitive performance. The nature and extent of such influence requires examination. PURPOSE: Determine the influence of a night-burn FF drill on new-recruit FFs' perceptual sensations (thermal, respiratory, effort), physical workload (heart rate; HR), and cognitive performance (modified Flanker task), while identifying individual risk factors. METHODS: New-recruit, male FFs (N=28; 24.96 ± 4.2 yrs) participated in a live-fire night-burn drill (48:54±03:46 mins) as part of a 6-wk training program. This involved emergency response, fire attack, and search and rescue. Aerobic fitness was estimated from 1.5-mi run time. Cognitive behavioral performance on a modified Flanker task and perceptual states (thermal sensation, RPE, respiratory distress, feelings, felt arousal, fatigue, anxiety) of each FF were measured on a separate baseline day, as well as pre- and post-firefighting (Post-0, End). HR was continuously recorded throughout. RESULTS: After accounting for baseline, M HR during drill predicted variance in post-task affect (state anxiety: 24.5%, P= 0.01); TS: 18.1%, P= 0.025; FS: 14.6%, P= 0.046); VAS nervousness: 17.4%, P= 0.028). M HR during drill also predicted cognitive performance Post-0 for Flanker Accuracy on all trials (16.8%, P= 0.033). FS change from Pre to Post-0 also explained Accuracy for all trials (14.4%, P= 0.047). 1.5-mi run time predicted variance in Post-0 Flanker SD for all trials (20.2%, P= 0.016). VAS fatigue change from Pre to Post-0 also explained Flanker SD (16.5%, P= 0.032). CONCLUSIONS: Simple, on-line tracking of HR may be able to help incident commanders recognize FFs who, indicated by greater relative HR during emergency response, may have diminished decision-making capacity on the fireground. Other factors (e.g., trait anxiety, dispositional resilience) may influence physical effort put forth in an emergency scenario and may put certain FFs at higher risk for making errors. Future research should determine trainability of such factors in order to enhance performance and, ultimately, safety for FFs. Manifestation of such changes in cognitive performance, in terms of decision making during a live-fire emergency, needs further investigation.
To compare readiness to return to duty in soldiers following recent lower-extremity versus spine injury. The secondary purposes were to provide normative data for the Selective Functional Movement Assessment Top Tier movements (SFMA-TTM) and assess the association between SFMA-TTM scores and future injury occurrence, comparing injuries of the lower extremity and thoracic/lumbar spine.SFMA was rated by trained assessors on 480 U.S. Army soldiers within 2 weeks of being cleared to return to duty after recent lower-extremity or lumbar/thoracic injury. Participants were followed for 1 year to determine incidence of subsequent time-loss injury.Only 74.4% of soldiers felt 100% mission capable when returning to full duty (73.6% lower-extremity; 76.5% spine). After 1 year, 37.9% had sustained a time-loss injury, and pain with movement at baseline was associated with higher odds for having an injury (odd ratio 1.53 95% confidence interval 1.04-2.24; P = .032). Almost all (99.8%) had at least 1 dysfunctional pattern, and 44.1% had pain with at least 1 movement (40.3% with previous lower-extremity injury; 54.6% with previous spine injury) after being cleared to return to duty.One in four patients did not feel 100% mission capable upon being cleared for full duty. Pain with movement was also associated with future injury. Regardless of recent injury type, 99.8% of soldiers returned to full unrestricted duty with at least 1dysfunctional movement pattern and 44.1% had pain with at least 1 of the SFMA-TTM movements.Level III, retrospective comparative cohort study.
The effects of firefighting (FF) (e.g. heat stress, psychological stress, physical exertion) on cognitive performance are poorly understood. PURPOSE: To add to existing data by (a) examining working memory and cognitive inhibition immediately following ∼52 min of FF activity during a night-burn training drill and (b) determining whether individual difference factors might contribute to any changes. METHODS: 57 male recruit firefighters (M age= 25.5±4.5 yrs; BMI=26.5±5.9 kg·m2; VO2est=44.46±5.2 ml·kg·min-1) completed 4 sessions: 1) resilience and trait anxiety measures; 2) practice and baseline cognitive tests; 3) cognitive testing and VAS-fatigue following Night-burn response (forcible entry, fire attack, search-and-rescue); 4) measures of tolerance for exercise intensity (TOL), perceived fitness (pF), and aerobic fitness (1.5-mile run). Cognitive tests included: inhibition (Flanker task) and working memory (N-back task), assessed ∼5-min post FF; RESULTS: Reaction time (RT) on Flanker Congruent (C) and Incongruent (IC) trials decreased, 466.33 to 442.79 ms (P < 0.001) and 529.59 to 486.99 ms (P< 0.001), respectively. Flanker accuracy (ACC) on IC trials decreased, 89.9 to 86.4% (P= 0.004). Fatigue (VAS-F) increased, 2.2±1.6 to 8.1±1.3 (P< 0.001). Correlations were found between VAS-F and TOL (r= 0.41, P=0.002); pF (r= 0.29, P=0.033); post-Flanker RT (r= 0.28, P=0.034); and post-Flanker SD (r= 0.30, P=0.024). N0, N1, & N2-Target ACC decreased, 96.2 to 92.7% (P= 0.002), 90.0 to 84.7 % (P= 0.022), 81.4 to 79.1% (but, P> 0.05), respectively. TOL was inversely correlated with Flanker ACC on All, C, and IC trials (r= -0.41, P =0.002; r= -0.37, P =0.006; r= -0.36, P =0.008, respectively). CONCLUSIONS: Cognitive performance was generally faster, but less accurate, following FF activities. Individuals having greater tolerance for intense PA may be physically exerting themselves more in FF scenarios, resulting in greater fatigue and lower accuracy post-FF than those with lower tolerance for intense PA.
Physical therapy and opioid prescriptions are common after hip surgery, but are sometimes delayed or not used.The objective of this study was to compare downstream health care utilization and opioid use following hip surgery for different patterns of physical therapy and prescription opioids.The design of this study was an observational cohort.Health care utilization was abstracted from the Military Health System Data Repository for patients who were 18 to 50 years old and were undergoing arthroscopic hip surgery between 2004 and 2013. Patients were grouped into those receiving an isolated treatment (only opioids or only physical therapy) and those receiving both treatments on the basis of timing (opioid first or physical therapy first). Outcomes included overall health care visits and costs, hip-related visits and costs, additional surgeries, and opioid prescriptions.Of 1870 total patients, 76.8% (n = 1437) received physical therapy, 71.6% (n = 1339) received prescription opioids, and 1073 (56.1%) received both physical therapy and opioids. Because 24 patients received both opioids and physical therapy on the same day, they were eventually removed the final timing-of-care analysis. Adjusted hip-related mean costs were the same in both groups receiving isolated treatments (${\$}$11,628 vs ${\$}$11,579), but the group receiving only physical therapy had significantly lower overall total health care mean costs (${\$}$18,185 vs ${\$}$23,842) and fewer patients requiring another hip surgery. For patients receiving both treatments, mean hip-related downstream costs were significantly higher in the group receiving opioids first than in the group receiving physical therapy first (${\$}$18,806 vs ${\$}$16,955) and resulted in greater opioid use (7.83 vs 4.14 prescriptions), greater total days' supply of opioids (90.17 vs 44.30 days), and a higher percentage of patients with chronic opioid use (69.5% vs 53.2%).Claims data were limited by the accuracy of coding, and observational data limit inferences of causality.Physical therapy first was associated with lower hip-related downstream costs and lower opioid use than opioids first; physical therapy instead of opioids was associated with less total downstream health care utilization. These results need to be validated in prospective controlled trials.
Abstract Background Physical therapy services delivered remotely are becoming more common. The purpose was to summarize the acceptability and patient-centeredness of remotely delivered physical therapy. Methods This was a survey study. Patients and clinicians from physical therapy clinics in the US Military Health System were asked to provide feedback at the conclusion of each remote visit. Platform, reason for care, components of physical therapy delivered and received, satisfaction, and perception of patient-centeredness were collected. Results were summarized as proportions and frequencies. Results Feedback was provided by physical therapists for 250 visits and from patients for 61 visits. Most visits were completed using audio only ( n = 172; 68.8%) while the rest integrated video capability ( n = 78; 31.2%). Overall patients perceived their care was patient-centered either completely or very much. Over 90% of visits were perceived by physical therapists as being highly patient centered. For 53.2% of visits, patients thought that same visit would have been even more impactful in person and for 52.4% of visits, physical therapists thought the visit would have been more impactful in person. Conclusion Even though remotely provided physical therapy care was rated by patients to be patient-centered, approximately half of the patients responding felt the same physical therapy visit would have been more impactful in person. Similarly, physical therapists felt that their intervention would have been more impactful in person for approximately half of all visits. Physical therapy care delivered remotely was patient-centered and an acceptable alternative to in-person care for both patients and physical therapists.
examine which combinations of variables would be able to predict future injury.This information can aid providers in care decisions when returning military tactical athletes to full duty following an injury.This document outlines the statistical analysis plan for the study.It was fully developed and published here in its final form before any analytical work was begun on the models. 2.
The personality trait resilience (R) has been shown to buffer the relationship between stress and disease. As such, R has been studied in military and other high stress occupations as important to both mental health (MH) and physical health (PH). Specifically in military populations, R predicted PH but this effect was mediated by MH. PURPOSE: Assess the extent to which R predicts PH and MH in a sample of recruit firefighters and systematically assess the interrelationships of R, MH, and PH. METHODS: Male recruit firefighters (N=51; M age = 25.80 ± 4.51 yrs) underwent 7 weeks of training at a state-mandated fire training institute. All participants completed the Dispositional Resilience Scale-15 during week 1 and the Short Form 36 Medical Outcomes Survey during weeks 1 and 7. Regression analyses were used to examine the relationships between R, PH, and MH. RESULTS: Hierarchical regression indicated that R explained 7.9% [Fchange(1,48) = 4.19, β = 0.282, P= 0.046] and 9.3% [Fchange(1,48) = 5.0, β = 0.306, P= 0.03] unique variance in PH during week 1 and week 7, respectively; after accounting for age. Additionally, R explained 11.9% [Fchange(1,47) = 6.48, β = 0.393, P= 0.014] and 9.2% [Fchange(1,47) = 4.83, β = 0.316, P= 0.033] unique variance in PH after accounting for both age and MH in weeks 1 and 7, respectively. After accounting for age, hierarchical regression indicated that R explained 21.4% [Fchange(1,48) = 13.74, β = 0.464, P=0.01] and 7.7% [Fchange(1,48) = 4.04, β = 0.279, P=0.05] unique variance in MH during weeks 1 and 7, respectively. However, MH did not significantly predict, nor was MH significantly related to PH during weeks 1 or 7. CONCLUSIONS: These findings replicate the notion that R is positively associated with MH and PH, and extends this effect to recruit firefighters. Unlike previous work with military populations, R predicted PH without mediation by MH. Further investigation into these variables seems warranted. Better understanding such variables could be useful in the recruitment of future firefighters or to other high stress occupations.
Stepped care approaches are emphasized in guidelines for musculoskeletal pain, recommending less invasive or risky evidence-based intervention, such as manual therapy (MT), before more aggressive interventions such as opioid prescriptions. The order and timing of care can alter recovery trajectories.To compare one-year downstream health care utilization in patients with spine or shoulder disorders who received only MT vs MT and opioids. The secondary aim was to compare differences based on order and timing of opioids and MT.Retrospective observational cohort.Patients with an initial consultation for a spine or shoulder disorder who received at least one visit for MT were included. Person-level data from the Military Health System Management and Reporting Tool (M2) database were aggregated by a senior health care analyst at Madigan Army Medical Center. Groups were created based on the order and timing of interventions provided. Outcomes included health care utilization (medical costs and visits) over the year following initial consultation. Control measures included metabolic, mental health, chronic pain, sleep, and substance abuse comorbidities, as well as prior opioid prescriptions. Generalized linear models with gamma log links were run due to the heavily skewed nature of cost data.From 1,876 unique patients with spine or shoulder disorders receiving MT, 1,162 (61.9%) also received prescription opioids. Mean one-year costs in the MT-only group ($5,410, 95% confidence interval [CI] = $5,109 to $5,730) were significantly lower than in the MT+opioid group ($10,498, 95% CI = $10,043 to $10,973). When patients had both treatments, mean one-year costs in the MT-first ($10,782, 95% CI = $10,050 to $11,567) were significantly lower (P = 0.030) than opioid-first ($11,938, 95% CI = $11,272 to $12,643), and MT-first had a significantly lower mean days' supply of opioids (34.2 vs 70.9, P < 0.001) and mean number of unique opioid prescriptions (3.1 vs 6.5, P < 0.001).MT alone resulted in lower downstream costs than with opioid prescriptions. Both the order of treatment (MT before opioid prescriptions) and the timing of treatment (MT < 30 days) resulted in a significant reduction of resources (costs, visits, and opioid utilization) in the year after initial consultation. Clinicians should consider the implications of first-choice decisions and the timing of care for treatment choices utilized for patients with spine and shoulder disorders.
