Air Force Physical Therapy Assignments

US military physical therapists have a proud history of providing medical care during operational deployments ranging from war to complex humanitarian emergencies. Regardless of austerity of environment or intensity of hostility, US military physical therapists serve as autonomous providers, evaluating and treating service members with and without physician referral. This perspective article suggests that the versatility of US military physical therapist practice enables them not only to diagnose musculoskeletal injuries but also to provide a wide range of definitive care and rehabilitation, reducing the need for costly evacuation. War is not sport, but the delivery of skilled musculoskeletal physical therapy services as close to the point of injury as possible parallels the sports medicine model for on- or near-field practice. This model that mixes direct access with near-immediate access enhances outcomes, reduces costs, and allows other health care team members to work at the highest levels of their licensure.

The purpose of this perspective article is to provide a recent historical account for the roles and use of military physical therapists in treating service members with musculoskeletal injuries during Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF). Military physical therapists have established a long and respected tradition of setting the highest clinical practice standards in caring for military beneficiaries (active duty, dependents of active duty, retired, and dependents of retired), the example of which has been used to help develop the physical therapy profession as a whole. Practice standards continue to advance through emerging evidence, newer technology, more informed practice, and evidence-based guidelines.

Over the past 46 years, US Army physical therapists have had the advantage of being able to care for soldiers and other beneficiaries by means of direct access.1 Physical therapists in the US Air Force, and to a limited extent in the US Navy, have served their beneficiary populations in a similar role over the past few decades. The impact of physical therapists on improving the health and military readiness of service members has garnered the support of the military's medical leadership to such a degree that they are regularly credentialed by local military hospitals and health care facilities with clinical privileges to: safely examine patients with and without physician referral; order diagnostic imaging; prescribe medications; order laboratory tests; refer patients to other practitioners; initiate duty limitations; and perform electromyographic and nerve conduction studies.1–6 Military physical therapists are often the first credentialed health care provider in the process of care to diagnose and treat patients with musculoskeletal injuries. Direct access to military physical therapists for treatment of patients with musculoskeletal conditions has proven to be effective, with minimal risk.2–4,7–14

What makes military physical therapist practice in combat worthy of our attention today? US Army physical therapists have served in combat zones during previous wars in our nation's history; however, their contributions were often overlooked and so did not lead to changes in Army medical doctrine or policies that would institutionalize the role of physical therapists in future conflicts. Obviously, combat is not an athletic pursuit; however, the construct of treating service members as athletes provides many strategic advantages. Specifically, treating service members as tactical athletes provides a value model for preventing and treating musculoskeletal injuries closer to the point and time of injury.7 It now adds a rehabilitation capability to the combat zone whereby military physical therapists fully incorporate their vast competencies and capacity to treat patients under the most austere and dangerous environments. Physical therapist practice under these conditions not only entails all facets of evidence-based practice in injury prevention and human performance optimization but also prompt and accurate diagnosis and intervention for musculoskeletal injuries and minor wounds. Treating service members closer to the point and time of injury, particularly in combat, is intended to maximize recovery and minimize secondary or chronic morbidity.1,7

This musculoskeletal injury management practice is not new to physical therapists. It has been a large part of US Army physical therapist practice for more than 4 decades.1 Additionally, it obviates unnecessary medical evacuation within the combat zone or to higher levels of care in Germany or the United States, maintaining organizational integrity and eliminating costly personnel replacement. In general, early access to physical therapy has been demonstrated to result in higher quality of care, reduced costs, improved patient satisfaction, enhanced recovery time, decreased work absenteeism, and prevention of chronic complaints.15–17 The availability of orthopedically oriented physical therapists in the combat zone also has permitted surgeons, other physicians, and physician assistants time to treat service members with more complicated trauma or illness.7 This advance reduces nonsurgical referrals to orthopedic surgeons located at the Combat Support Hospitals (CSHs) and the need for service members to travel in dangerous convoys to seek orthopedic care for mild musculoskeletal injuries.7

Historically, musculoskeletal injuries are the primary cause for ambulatory visits among soldiers to military health care facilities.1,7,18 In 2010, approximately 2.5 million ambulatory visits for musculoskeletal injuries were recorded, accounting for $548 million in direct patient care costs.18 During this period, musculoskeletal injuries seen in all military health care facilities around the world, principally in the United States, represented 67% of all limited duty profiles (adjusted physical work requirements).18 Additionally, >80% of all musculoskeletal injuries were overuse injuries, with lower extremity overuse injuries listed as the number one cause of lost and limited days.18 The musculoskeletal injury rates are not unique to stateside assignments and occur in higher frequency in combat environments.19 In a deployed setting (combat zone), nonbattle musculoskeletal injuries account for 87% of all injuries.19 The rate of musculoskeletal injuries in deployed settings is estimated to occur 6.5 to 7 times more frequently than combat-related injuries.19 More than 75% of all medical evacuations from the OIF/OEF theater of operations were for noncombat musculoskeletal injuries associated with back, knee, foot and ankle, shoulder, hand and wrist, and neck pain.19 Belmont et al20 reported similar findings in a 15-month longitudinal cohort analysis of disease nonbattle injuries sustained by one US Army Brigade Combat Team (BCT). Of the 4,122 soldiers deployed, there were 1,324 disease nonbattle injuries, of which musculoskeletal injuries accounted for 50.4%.20

Although military physical therapists have the capacity to practice autonomously in managing musculoskeletal injuries, they do so as an integral member of an interdependent medical team that includes physicians, physician assistants, nurses, technicians, medics, and administrative personnel.7 Whereas respective military regulations allow a great degree of independence and encourage physical therapists to utilize their advanced practice privileges, local medical leadership might limit or expand the privilege list, depending on the practice setting, provider experience, and available resources. Military physical therapists routinely provide care in traditional settings such as hospitals or clinics in fixed, safe locations. However, today they also function in a variety of nontraditional, and sometimes highly austere, hostile settings with little to no equipment or supplies.7 For example, over the past decade, US Army physical therapists have been assigned to Army Special Operations units (eg, Rangers, Special Forces, Special Operations Aviation Regiments), BCTs, and CSHs.7 They have provided care for military personnel at bases across the United States, Europe, Southwest Asia, and Southeast Asia. Military physical therapists also routinely deploy to austere locations around the world to provide care in combat zones, most recently in Iraq and Afghanistan. In these settings, military physical therapists are primarily providing direct access care for patients with musculoskeletal injuries by use of their advanced practice privileges. The military attempts to define the various medical practice settings by describing levels of care (Tab. 1).

Table 1

Overview of Settings in Which Military Medicine Is Conducted

Level of Care Description of Care Capabilities 
Soldiers and combat medics provide care; Battalion Aide Stations may be staffed with primary care or emergency medicine physicians or physician assistants for Advanced Trauma Life Support. This level is the most austere and close in proximity to the battle frontlines.a
Brigade-level facility is located within a Brigade Combat Team’s area of responsibility. It might provide basic radiography, laboratory, and patient holding, and it may be staffed with primary care or emergency medicine physicians, physician assistants, and physical therapists. This facility also is very mobile, located very close to the battle frontlines, but usually behind the Battalion Aide Stations. 
Combat Support Hospital has full surgical and hospital capabilities; has operating theaters, radiography (including computed tomography), and laboratory (including blood banking); and has 44- to 248-bed configurations. Physical therapists are one of many providers assigned. This facility is less mobile, usually located within 10 to 30 miles to the battle frontlines, depending on mission to support warfighters. 
Full surgical and hospital capabilities augmented with specialty services (eg, renal dialysis); typically a medical center. The Landstuhl Regional Medical Center in Landstuhl, Germany, has served this level of care for OIF/OEF. Several physical therapists are assigned. 
Military hospitals located in the United States provide major surgical operations and treatment for burns; allow for the provision of intensive and rehabilitative care; and can extend to the Veterans Administration Health Care System. Several physical therapists are assigned. 
Level of Care Description of Care Capabilities 
Soldiers and combat medics provide care; Battalion Aide Stations may be staffed with primary care or emergency medicine physicians or physician assistants for Advanced Trauma Life Support. This level is the most austere and close in proximity to the battle frontlines.a
Brigade-level facility is located within a Brigade Combat Team’s area of responsibility. It might provide basic radiography, laboratory, and patient holding, and it may be staffed with primary care or emergency medicine physicians, physician assistants, and physical therapists. This facility also is very mobile, located very close to the battle frontlines, but usually behind the Battalion Aide Stations. 
Combat Support Hospital has full surgical and hospital capabilities; has operating theaters, radiography (including computed tomography), and laboratory (including blood banking); and has 44- to 248-bed configurations. Physical therapists are one of many providers assigned. This facility is less mobile, usually located within 10 to 30 miles to the battle frontlines, depending on mission to support warfighters. 
Full surgical and hospital capabilities augmented with specialty services (eg, renal dialysis); typically a medical center. The Landstuhl Regional Medical Center in Landstuhl, Germany, has served this level of care for OIF/OEF. Several physical therapists are assigned. 
Military hospitals located in the United States provide major surgical operations and treatment for burns; allow for the provision of intensive and rehabilitative care; and can extend to the Veterans Administration Health Care System. Several physical therapists are assigned. 

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Historical Perspective

The origin of physical therapy in the United States dates to utilization of “reconstruction aides” in stateside military hospitals during World War I.21 US Army physical therapists served in every theater of operation in World War II and served during the Korean War.22 During the Vietnam War, their role and responsibilities were expanded as physician extenders. This development came about principally because orthopedic surgeons struggled to manage the high volume of nonsurgical cases in addition to the overwhelming number of surgical cases they faced.1 Between 1966 and 1973, 43 US Army physical therapists served in 3 of the 4 combat zones in Vietnam.22,23 These physical therapists treated soldiers, civilians, and prisoners of war from all allied nations participating in the war, in addition to US soldiers wounded in combat.22,23 These experiences yielded anecdotal evidence that early intervention by a military physical therapist improved the prognosis, outcome, morale, and return-to-duty status of soldiers in a combat environment.22,23

During Operation Desert Shield, nontraumatic orthopedic problems accounted for the highest incidence of primary health care visits.24 Of the 180 patients evacuated from Operation Desert Shield and Desert Storm (ODSS) just to Madigan Army Medical Center in Fort Lewis, Washington, 52% had at least 1 orthopedic diagnosis, 45% did not require surgery and were able to return to duty without further treatment, and 38% had a condition that existed before deployment.25 Despite the negative impact of nontraumatic orthopedic injuries in a deployed setting and the significant contributions by forward- deployed US Army physical therapists during prior combat operations, only 5 physical therapists deployed to Southwest Asia in support of ODSS during the 1990–1991 conflict. One of these physical therapists provided an after-action report indicating he had treated 233 soldiers with musculoskeletal injuries.26 Each patient required an average of only 3 visits, with 90% of these patients returning to duty without requiring any further intervention.26 In comparison with the overall number of soldiers evacuated during ODSS with soft tissue injuries, an average of 21 days was required to evacuate the more than 1,177 soldiers at an estimated per-soldier replacement cost of $836,885.27

US Army physical therapists have been deployed to conflicts in Bosnia and Kosovo, as well as humanitarian operations in El Salvador, Ethiopia, Thailand, and Sri Lanka. While deployed, they provided musculoskeletal evaluations, developed and implemented field-expedient rehabilitation programs, and implemented injury prevention programs.26 In addition, a few US Army physical therapists served as subject matter experts to assist developing nations in the implementation of emerging rehabilitation training programs for physical therapists.26

During a deployment in Bosnia (1996–1997), a total of 3,475 patients were seen by various providers assigned to the 21st CSH. The lone physical therapist provided care to 19.2% (667/3,475) patients, the vast majority being those with musculoskeletal injuries.8 Of these, 78% (522/667) were able to return to duty without restrictions, whereas 20% (133/667) required a temporary duty restriction of a few days.8 Perhaps most important, only 2% (13/667) of the patients seen were required to miss duty, to be medically evacuated, or to be hospitalized overnight.8 In addition to direct patient care, the physical therapist established a multidisciplinary wellness program for deployed soldiers and traveled to remote military compounds to evaluate and treat soldiers at their duty location, mitigating the need of transport to the hospital.

US Army physical therapists were first placed in Army Ranger Battalions in 2000, and the impact of their presence was significant in the first year. Before the physical therapists' arrival, the operational readiness rate averaged 88% of Rangers that were healthy and ready for their wartime mission.26 “Operational readiness” is a general term used to indicate whether a commander feels his or her unit is capable of deploying. Different units use varied metrics (eg, number of soldiers available and not sick or injured, vehicles that are ready and maintenance free, all training requirements current) to determine operational readiness. Twelve percent of the Rangers were unable to deploy or operate under the Command's mission standards.26 Within 10 months, the deployment readiness rate for the Ranger Battalions averaged 95%.26 These successes were attributed to the Ranger physical therapist being able to provide direct access, early intervention, injury prevention and human performance optimization.26

After the success of the Ranger physical therapy model, the US Army Special Operations Command requested assignment of physical therapists to support the Special Forces mission. Beginning in 2003, US Army physical therapists began serving in Army Special Forces Groups. US Army physical therapists assigned to these elite forces blazed remarkable new paths for their profession not only within the Army, but throughout the Armed Forces. Soon thereafter, US Navy physical therapists were assigned on aircraft carriers and are now assigned with the Navy Special Operations Command, Sea, Air and Land (SEAL) teams and US Marine Special Operations Command. US Air Force physical therapists also have been recently assigned to a number of special operations units across the Air Force. On the basis of extensive anecdotal feedback and the continued expansion of the physical therapist's role, there is little question that the military services highly value the “sports medicine on the battlefield” concept.7

Although several US Army physical therapists have been temporarily attached to other Army combat organizations to support deployment since 2005, the practice of permanently assigning physical therapists as a standing member of BCTs and regimental organizations began in 2006.7 In this capacity, 62 US Army physical therapists have deployed during combat operations in Iraq and Afghanistan, and this number continues to grow.7 The National Guard began assigning citizen soldier physical therapists to their combat brigades in 2004, and the US Army Reserves continue to mobilize physical therapists for partner capacity building missions, United Nations efforts, and to support disaster relief in the United States and abroad.

US Military Physical Therapists in OIF/OEF

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Salary estimated from 16 employees, users, and past and present job advertisements on Indeed in the past 36 months. Last updated: December 1, 2017
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