DTIC ADA563325: The Changing Face of Disability in the US Army: The Operation Enduring Freedom and Operation Iraqi Freedom Effect

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by  Defense Technical Information Center

The Changing Face of Disability
in the US Army: The Operation
Enduring Freedom and Operation
Iraqi Freedom Effect
Abstract
CPTJeanneC.Patzkowski,MD, Orthopaedic disorders account for significant disability among
MC,USA adults in the United States. Previous studies have demonstrated
CPTJessicaC.Rivera,MD long-term disability in military personnel with musculoskeletal
conditions. However, these studies focused primarily on battlefield-
COLJamesR.Ficke,MD
injured service members and did not evaluate the entire population.
JosephC.Wenke,PhD
The goal of this study was to determine and compare the disabling
conditions of the entire United StatesArmy during peacetime and
war. We identified the conditions leading to separation from military
service before and during Operation Iraqi Freedom and Operation
Enduring Freedom. During war, more soldiers are found to be unfit
for duty, and they have more conditions per individual that make
them unfit. Orthopaedic conditions account for the greatest number
of soldiers separated from military service at both time points
studied (ie, January through March 2001, January through March
2009). Back pain and osteoarthritis are the two most common
causes of separation from military service; these conditions are
FromtheUnitedStatesArmy responsible for the most disability during peacetime and war.
InstituteofSurgicalResearch
(Dr.PatzkowskiandDr.Wenke)and
theSanAntonioMilitaryMedical
Center(Dr.Patzkowski,Dr.Rivera, Musculoskeletalconditionscause portdifficultyperformingroutineac-
andDr.Ficke),FortSamHouston,
significant disability and ac- tivities of daily living without assis-
TX.
countforsubstantialhealthcarecosts tance due to a medical condition;
Thisstudywasconductedundera
inthecivilianpopulationintheUnited more than half of these are due to
protocolreviewedandapprovedby
theBrookeArmyMedicalCenter States.1-4 The World Health Organi- musculoskeletal conditions.6 Muscu-
InstitutionalReviewBoard,andin zation reports that musculoskeletal loskeletal conditions account for
accordancewiththeapproved
disordersaccountforthethirdgreat- most occupational injuries sustained
protocol.Theopinionsorassertions
estnumberofdisability-adjustedlife- intheUnitedStates.7Suchconditions
containedhereinaretheprivate
viewsoftheauthorsandarenotto years globally, that is, potential life are more severe and cause signifi-
beconstruedasofficialoras yearslostastheresultofthemortal- cantlymoredaysofworklostdueto
reflectingtheviewsofthe
ity and morbidity of disease. Ische- injury than any other nonfatal work
DepartmentoftheArmyorthe
mic heart disease and cerebrovascu- siteinjuries.Musculoskeletalinjuries
DepartmentofDefense.
lar disease, respectively, account for cause substantial disability within
JAmAcadOrthopSurg2012;
the greatest and second greatest the entire population and detract
20(suppl1):S23-S30
number of disability-adjusted life- from the productivity of the civilian
http://dx.doi.org/10.5435/
years.5IntheUnitedStates,nearly50% workforce.
JAAOS-20-08-S23
ofadultsaged≥18yearsreportamus- The burden of musculoskeletal in-
Copyright2012bytheAmerican
culoskeletal condition.6 Twenty-nine jury affects the military population
AcademyofOrthopaedicSurgeons.
millionadultsintheUnitedStatesre- aswell,intheformofinjuryanddis-
2012,Vol20,Supplement1 S23
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1. REPORT DATE 3. DATES COVERED
AUG 2012 2. REPORT TYPE 00-00-2012 to 00-00-2012
4. TITLE AND SUBTITLE 5a. CONTRACT NUMBER
The Changing Face of Disability in the US Army: The Operation
5b. GRANT NUMBER
Enduring Freedom and Operation Iraqi Freedom Effect
5c. PROGRAM ELEMENT NUMBER
6. AUTHOR(S) 5d. PROJECT NUMBER
5e. TASK NUMBER
5f. WORK UNIT NUMBER
7. PERFORMING ORGANIZATION NAME(S) AND ADDRESS(ES) 8. PERFORMING ORGANIZATION
Army Institute of Surgical Research,3698 Chambers Pass,Fort Sam REPORT NUMBER
Houston,TX,78234-6315
9. SPONSORING/MONITORING AGENCY NAME(S) AND ADDRESS(ES) 10. SPONSOR/MONITOR’S ACRONYM(S)
11. SPONSOR/MONITOR’S REPORT
NUMBER(S)
12. DISTRIBUTION/AVAILABILITY STATEMENT
Approved for public release; distribution unlimited
13. SUPPLEMENTARY NOTES
14. ABSTRACT
Orthopaedic disorders account for significant disability among adults in the United States. Previous studies
have demonstrated long-term disability in military personnel with musculoskeletal conditions. However,
these studies focused primarily on battlefieldinjured service members and did not evaluate the entire
population. The goal of this study was to determine and compare the disabling conditions of the entire
United States Army during peacetime and war. We identified the conditions leading to separation from
military service before and during Operation Iraqi Freedom and Operation Enduring Freedom. During
war, more soldiers are found to be unfit for duty, and they have more conditions per individual that make
them unfit. Orthopaedic conditions account for the greatest number of soldiers separated from military
service at both time points studied (ie, January through March 2001, January through March 2009). Back
pain and osteoarthritis are the two most common causes of separation from military service; these
conditions are responsible for the most disability during peacetime and war.
15. SUBJECT TERMS
16. SECURITY CLASSIFICATION OF: 17. LIMITATION OF 18. NUMBER 19a. NAME OF
ABSTRACT OF PAGES RESPONSIBLE PERSON
a. REPORT b. ABSTRACT c. THIS PAGE Same as 8
unclassified unclassified unclassified Report (SAR)
Standard Form 298 (Rev. 8-98)
Prescribed by ANSI Std Z39-18
TheChangingFaceofDisabilityintheUSArmy:TheOperationEnduringFreedomandOperationIraqiFreedomEffect
ability. Recent studies performed at willberelatedtocombatinjury,train- tions for each time period studied
our institution indicate that muscu- inginjury,andnon-battlefieldinjuries, were grouped into categories consis-
loskeletal injuries account for most whilethehealthissuespresentduring tent with Veterans’ Administration
combatwounds,demandthegreatest peacetimepersist.ThesumofPEBre- Schedule for Rating Disabilities
numbers of hospital resources, and sults collected during a time of war codes(Table1).Unfittingconditions
representtheprimarysourceofboth therebyencompassesthegeneralhealth not related to the musculoskeletal
separation from military service and issuesfoundinthemilitarypopulation system were analyzed based on the
long-termdisability.8-10 asawhole,alongwiththeconditions anatomicsystemaffected.Orthopae-
Disability within the US Army is resultingfromwarwoundsandtrain- dic unfitting conditions were further
determined by the Army Physical ing. separated into anatomic regions for
EvaluationBoard(PEB),anadminis- Inthisstudy,wedescribethepeace- data analysis. The disability rating
trative body consisting of medical timedistributionofdisablingdiseasein for each unfitting condition was de-
personnelandArmyofficerswhode- theUSArmyandattempttodetermine termined, and the average disability
terminewhetheranillorinjuredsol- howtheArmy’sparticipationinOper- rating associated with each category
dierisabletoperformhisorherjob. ation Enduring Freedom and Opera- of conditions was calculated. The
The PEB result includes whether the tion Iraqi Freedom has changed this impact factor for each unfitting con-
soldier is fit for duty. A soldier who distribution.Wehypothesizedthator- dition was calculated as the product
is found to be unfit may be removed thopaedic conditions account for the ofthefrequencyoftheconditionand
from active-duty service through mostcommonunfittingconditionsdur- theaveragepercentdisability.8
medical retirement or separation ingpeacetimeandwarandthatcondi- Thepercentageofsoldierswitheach
basedontheseverityoftheunfitting tions such as traumatic brain injury unfittingconditionandtheaveragedis-
condition or conditions, or the sol- (TBI), posttraumatic stress disorder ability ratings between the two time
dier may petition to continue on ac- (PTSD), and orthopaedic trauma ac- pointswerecompared.TheFisherex-
tiveduty. countforthegreatestnumberofunfit- acttestwasusedtodeterminewhether
Unfitting conditions are grouped tingconditionsduringwar. thepercentageofunfittingconditions
by region of the body or systems af- changed,andunpairedStudentttests
fectedandarecodedusingtheVeter- were used to determine whether the
ans’ Administration Schedule for Methods mean disability ratings changed be-
Rating Disabilities code.11 Each un- tween time points. Statistical signifi-
fitting condition is also assigned a ThePEBdatabasewasqueriedforall cancewasdefinedasP<0.05.
percent disability rating. This rating soldiers who were medically retired
isameasureofthewayinwhichthe or separated in January through
condition detracts from the soldier’s March 2001, before the wars began, Results
ability to perform his or her job and and in January through March of
determines eligibility for disability 2009, when both conflicts were well In the first quarter of 2009, 3,143
benefits. established.(Thesedataareincluded soldiers were medically retired or
Theconditionsthatresultinmedical in the US Army PEB database and separated, compared with 1,673 in
retirementorseparationfromthemil- werestudiedthroughanInstitutional thefirstquarterof2001.Thisdiffer-
itaryrepresentthehealthconcernsof Review Board–approved protocol at encerepresentsan88%increasedur-
the military population as a whole. ourinstitutionandtheVeterans’Ad- ing war, despite an increase of only
During peacetime, these conditions ministration.Thesedataarenotpub- 2.7% in total Army population in
likely represent the distribution of liclyavailable.)Onlythelistofunfit- thesametimeperiod.Thenumberof
health problems seen in the active tingconditionsleadingtoseparation unfitting conditions per subject in-
young civilian population. It is ex- or retirement was provided; demo- creasedfromapproximately1to1.7,
pected that, during a time of war, a graphic data and medical histories yielding an additional 3,670 total
greaternumberofunfittingconditions were not analyzed. Unfitting condi- unfitting conditions among soldiers
Dr.Fickeoranimmediatefamilymemberservesasaboardmember,owner,officer,orcommitteememberoftheAmerican
OrthopaedicFootandAnkleSociety,AmericanAcademyofOrthopaedicSurgeons,SocietyofMilitaryOrthopaedicSurgeons,and
AirliftResearchFoundation.Dr.WenkeoranimmediatefamilymemberhasreceivedresearchorinstitutionalsupportfromBionova
Medical.Neitherofthefollowingauthorsnoranyimmediatefamilymemberhasreceivedanythingofvaluefromorownsstockina
commercialcompanyorinstitutionrelateddirectlyorindirectlytothesubjectofthisarticle:Dr.PatzkowskiandDr.Rivera.
S24 JournaloftheAmericanAcademyofOrthopaedicSurgeons
CPTJeanneC.Patzkowski,MD,MC,USA,etal
Table1
DefinitionofCategoriesofUnfittingConditionsintheUSArmy
Category Description
Nonorthopaedicunfittingconditions
Blood Anyconditionofthebloodorhematopoieticsystem
Cancer Anymalignancy
Cardiovascular/peripheralvascular Disordersresultingfromillnessorinjurytotheheartorperipheralvasculardisease
disease
Ear/hearing Lossofhearingorotherinjurytotheearand/orvestibularorgans
Endocrinology Diseaseoftheendocrinesystemresultinginanunfittingcondition
Eye/vision Lossofsightorotherinjurytotheeyeorocularmuscles
Femalereproductive Anypathologyofthefemalereproductivetractresultinginanunfittingcondition
Gastrointestinal Diseaseofthegastrointestinalsystemresultinginanunfittingcondition
Genitourinary Diseaseofthegenitourinarysystemresultinginanunfittingcondition
Infection Infectionatanysiteinwhichtheinfectionitselfisthecauseofanunfittingcondition
Skin Anydermatologicdiseaseorinjurytotheskin,includingburns
Neurologic Anycentralorperipheralneurologicdisorder,excludinginjurytoaperipheralnerve
Psychiatric Diagnosisofanypsychiatriccondition
Posttraumaticstressdisorder Diagnosisofposttraumaticstressdisorder
Respiratory Diseaseoftherespiratorysystemresultinginanunfittingcondition
Rheumatologic Diseaseduetoarheumatologiccause,resultinginanunfittingcondition
Traumaticbraininjury Diagnosisoftraumaticbraininjury
Orthopaedicunfittingconditions
Amputation Anylossoflimborpartofalimb,excludingisolatedamputationsofthefingersortoes
Backpain/vertebralcondition Backpainresultingfromnondiscogeniccausesanddisordersofthevertebrae
Degenerativeorherniateddisk Backpainresultingfromdiscogeniccauses,includingnerverootsymptoms
Footandankle Anyconditioncausingpainorlossoffunctionofthefootand/orankle,includingosteoarthritis
Fibromyalgia Diagnosisoffibromyalgiainwhichfibromyalgiaitselfisanunfittingcondition
Knee Anyconditioncausingpaininorlossoffunctionoftheknee
Miscellaneous Allotherdisordersresultinginanunfittingconditionnototherwiseclassified
Muscle Anyconditionresultinginphysicalmusclelossordecreaseinmusclefunction
Osteoarthritis Arthritisofajointresultingfromdegenerativeorposttraumaticconditionsandexcluding
inflammatoryarthropathies
Otherlowerextremity Allotherlowerextremitydisordersresultinginanunfittingconditionnototherwiseclassified
Peripheralnerve Injurytoaperipheralnerveresultinginnervepainorlossoffunction
Totaljointarthroplasty Anyshoulder,hip,orkneereplacement
Otherupperextremity Allotherupperextremitydisordersresultinginanunfittingconditionnototherwiseclassified
who appeared before the PEB in TBI increased dramatically, whereas eral nerve, and lower and upper
2009. Orthopaedic diagnoses ac- the percentage of unfitting condi- extremities (Table 4). A significant
counted for most conditions at both tions such as cancer, infection, and reduction was noted in the percent-
time points (75% in 2001, 64% in respiratory disorders decreased (Ta- age of soldiers with knee disorders.
2009)(Table2). ble3).Significantincreaseswereseen Although the percentage of soldiers
Thepercentageofsoldiersfoundto inthepercentageofsoldiersfoundto foundtobeunfitbecauseofosteoar-
be unfit because of nonorthopaedic be unfit as the result of amputations thritis (OA) decreased from 2001 to
conditions did not change signifi- and back pain, including vertebral 2009, the absolute frequency of sol-
cantly between time points for most conditions and degenerative/herni- dierswithOAincreased,from602in
conditions. However, the percentage ated disks, as well as disorders re- 2001to987in2009.
of psychiatric disorders, PTSD, and lated to the foot and ankle, periph- At both time points, OA and back
2012,Vol20,Supplement1 S25
TheChangingFaceofDisabilityintheUSArmy:TheOperationEnduringFreedomandOperationIraqiFreedomEffect
Table2
CharacteristicsofUSArmyPhysicalEvaluationBoardResultsa
ParameterEvaluated Jan–Mar2001 Jan–Mar2009 Increase(%)
TotalUSArmypopulation 1,384,812 1,421,668 2.7
Soldiersmedicallyretiredor 1,673 3,143 88
separatedthroughthePEB
Unfittingconditionspersoldier 1.01 1.69 67
Percentageoforthopaedic 75% 64% N/A
unfittingconditions
N/A=notapplicable,PEB=PhysicalEvaluationBoard
aThesedataareincludedintheUSArmyPhysicalEvaluationBoarddatabaseandwerestudiedthroughanInstitutionalReviewBoard–
approvedprotocolatourinstitutionandtheVeterans’Administration.Thesedataarenotpubliclyavailable.
Table3
NonorthopaedicUnfittingConditionsa
Jan–Mar2001 Jan–Mar2009
UnfittingCondition Frequency %(n=1,673) Frequency %(n=3,143) PValue
Blood 3 0.18 4 0.13 NS
Cancer 15 0.9 16 0.51 <0.05
Cardiac/PVD 30 1.79 53 1.69 NS
Ear/hearing 11 0.66 50 1.59 <0.05
Endocrine 21 1.26 47 1.50 NS
Eye/vision 8 0.48 34 1.08 <0.05
Femalereproductive 5 0.30 12 0.38 NS
Gastrointestinal 31 1.85 64 2.04 NS
Genitourinary 13 0.78 28 0.89 NS
Infection 10 0.60 7 0.22 <0.05
Skin 11 0.66 79 2.51 <0.0001
Neurologic 55 3.29 221 7.03 NS
Psychiatric 78 4.66 277 8.81 <0.0001
PTSD 5 0.30 627 19.95 <0.0001
Respiratory 106 6.34 116 3.69 <0.0001
Rheumatologic 10 0.60 28 0.89 NS
TBI 11 0.66 249 7.92 <0.0001
NS=notstatisticallysignificant,PTSD=posttraumaticstressdisorder,PVD=peripheralvasculardisease,TBI=traumaticbraininjury
aThesedataareincludedintheUSArmyPhysicalEvaluationBoarddatabaseandwerestudiedthroughanInstitutionalReviewBoard–
approvedprotocolatourinstitutionandtheVeterans’Administration.Thesedataarenotpubliclyavailable.
pain were the most common overall throughthefirstquarterof2009,the and other upper extremity condi-
unfitting conditions, and orthopae- average percent disability increased tions (Table 7). At both time points,
dicconditionsaccountedfor5ofthe for PTSD and psychiatric disorders, mostoftheconditionswiththehigh-
top10conditions(Table5).In2009, butitdidnotchangesignificantlyfor est average percent disability were
OA and back pain were far more any other nonorthopaedic condition nonorthopaedic in nature (Table 8).
prevalent than PTSD; TBI; amputa- (Table 6). The average percent dis- Amongorthopaedicconditions,only
tion; conditions of the foot, ankle, ability significantly increased for all amputation and total joint arthro-
and lower extremity; and peripheral orthopaedic conditions, with the ex- plasty were found in the top 10 at
nervedisorders. ceptionofamputation,fibromyalgia, both time points. Cancer, infection,
From the first quarter of 2001 other lower extremity conditions, TBI, cardiac/peripheral vascular dis-
S26 JournaloftheAmericanAcademyofOrthopaedicSurgeons
CPTJeanneC.Patzkowski,MD,MC,USA,etal
Table4
OrthopaedicUnfittingConditionsa
Jan–Mar2001 Jan–Mar2009
UnfittingCondition Frequency %(n=1,673) Frequency %(n=3,143) PValue
Amputation 1 0.06 33 1.05 <0.0001
Backpainb 376 22.47 1,348 42.89 <0.0001
Footandankle 54 3.23 324 10.31 <0.0001
Fibromyalgia 14 0.84 31 0.99 NS
Knee 62 3.71 32 1.02 <0.0001
Miscellaneous 25 1.49 74 2.35 NS
Muscle 43 2.57 110 3.50 NS
Osteoarthritis 602 35.98 987 31.40 <0.05
Otherlowerextremity 25 1.49 197 6.27 <0.0001
Peripheralnerve 30 1.79 134 4.26 <0.0001
Totaljointarthroplasty 4 0.24 12 0.38 NS
Otherupperextremity 27 1.61 83 2.64 <0.05
NS=notstatisticallysignificant
aThesedataareincludedintheUSArmyPhysicalEvaluationBoarddatabaseandwerestudiedthroughanInstitutionalReviewBoard–
approvedprotocolatourinstitutionandtheVeterans’Administration.Thesedataarenotpubliclyavailable.
bBackpainincludesconditionsofthevertebralcolumn,herniatednucleuspulposus,anddegenerativediskdisease.Itdoesnotinclude
disordersofthespinalcord.
ease, rheumatologic conditions, and
Table5
genitourinary conditions were
among the top 10 disability ratings MostFrequentUnfittingConditionsintheFirstQuarterof2001andthe
FirstQuarterof2009a
atbothtimepoints.However,ortho-
paedic conditions were responsible RankOrder 2001 2009
for very high impact factors at both
1 Osteoarthritis Backpain
time points. Back pain and OA re-
2 Backpain Osteoarthritis
sultedinthefirstandsecondhighest
3 Respiratory PTSD
impact factors in 2001 and the sec-
4 Footandankle/LE Footandankle/LE
ond and third highest, respectively,
5 Psychiatric Psychiatric
in2009(Table9).
6 Knee TBI
7 Neurologic Neurologic
Discussion and 8 Muscle Peripheralnerve
Conclusions 9 GI Respiratory
10 Cardiac/PVD Muscle
Ourresultsconfirmthatorthopaedic
disorderscausethemajorityofunfit- GI=gastrointestinal,LE=lowerextremity,PTSD=posttraumaticstressdisorder,
PVD=peripheralvasculardisease,TBI=traumaticbraininjury
ting conditions in the US Army re- aThesedataareincludedintheUSArmyPhysicalEvaluationBoarddatabaseandwere
gardless of the presence or absence studiedthroughanInstitutionalReviewBoard–approvedprotocolatourinstitutionandthe
Veterans’Administration.Thesedataarenotpubliclyavailable.
ofcombatoperations.Despiteavery
small increase in the overall popula-
tion, there was a large increase in PEBin3,143soldiers.Consideredin mostcommonunfittingconditionsat
the number of soldiers separated the context of the entirety of both each time point were orthopaedic
through the PEB. The number of wars, these findings suggest that the disorders.Backpain,OA,andcondi-
unfitting conditions per soldier in- total additional wartime burden of tions of the foot, ankle, and lower
creased, as well. In one 3-month pe- disease in the form of disabling con- extremity were among the five most
riod alone, >3,600 additional unfit- ditions approaches or exceeds the prevalentunfittingconditionsduring
ting conditions were reported to the tensofthousands.Fiveofthetop10 peacetime and war. As expected,
2012,Vol20,Supplement1 S27
TheChangingFaceofDisabilityintheUSArmy:TheOperationEnduringFreedomandOperationIraqiFreedomEffect
conditions that could reasonably be
Table6
anticipated to be the result of war
ChangeinAveragePercentDisabilityforNonorthopaedicUnfitting
trauma (eg, PTSD, TBI, orthopaedic
ConditionsFrom2001to2009a
trauma) all increased from their pre-
UnfittingCondition Jan–Mar2001 Jan–Mar2009 PValue
war frequencies, whereas other non-
orthopaedic conditions remained Blood 10 13 NS
mostly unchanged. Despite large in-
Cancer 82 75 NS
creases in the occurrence of PTSD,
Cardiac/PVD 36 44 NS
TBI, and orthopaedic trauma, back
Ear/hearing 12 8 NS
painandOAwerefarmorecommon
Endocrine 19 14 NS
than these other three diagnoses at
Eye/vision 21 35 NS
bothtimepoints.
Femalereproductive 12 23 NS
The average percent disability as-
Gastrointestinal 38 27 NS
sociatedwithorthopaedicconditions
Genitourinary 32 43 NS
increased for most impairments but
Infection 51 50 NS
hasremainedunchangedforthema-
Skin 24 21 NS
jority of nonorthopaedic conditions.
Neurologic 32 30 NS
However, the highest disability rat-
Psychiatric 26 37 <0.0001
ings are typically assigned to nonor-
PTSD 26 50 <0.0001
thopaedic conditions. Only amputa-
Respiratory 27 30 NS
tions and total joint arthroplasty
Rheumatologic 34 46 NS
were represented in the top 10 at ei-
TBI 49 39 NS
ther time point (ie, first quarter
2001, first quarter 2009). The large
NS=notstatisticallysignificant,PTSD=posttraumaticstressdisorder,PVD=peripheral
increase in the average percent dis- vasculardisease,TBI=traumaticbraininjury
ability for amputations is likely the aThesedataareincludedintheUSArmyPhysicalEvaluationBoarddatabaseandwere
studiedthroughanInstitutionalReviewBoard–approvedprotocolatourinstitutionandthe
result of the increased severity of in- Veterans’Administration.Thesedataarenotpubliclyavailable.
juriessustainedincombat.However,
because there was only one soldier
with an amputation in the group porting only service members evacu- ysis of the effect of musculoskeletal
from 2001, it is difficult to draw an ated from theater because of battle- conditions on the US population.6
adequatecomparison.Ingeneral,the field injury demonstrated that OA, Basedontheresultsofthe2005Na-
average percent disability was low nerve injuries, and back conditions tional Health Interview Survey, the
for orthopaedic conditions. How- are among the most frequent dis- reviewers found that >107 million
ever, the combination of their dis- abling conditions.8-10 Of soldiers adultsintheUnitedStatesreporteda
ability rating and frequency led to evacuated with a primary diagnosis musculoskeletalcondition,represent-
very high impact factors for these of penetrating chest or abdominal ing nearly 50% of the population
conditionscomparedwiththenonor- wounds with associated extremity aged≥18years.Incomparison,28%
thopaedic disorders. Back pain and injuries,theprimaryunfittingcondi- reported circulatory conditions and
OA account for the top two impact tion was orthopaedic in 76% of 24% reported respiratory condi-
factorsduringpeacetimeandaresec- thosewhopresentedtothePEB. tions. Three of the four most com-
ond only to PTSD during war. Al- Our results are consistent with mon medical conditions reported
though back pain and OA are the those in the civilian literature. The were musculoskeletal in nature, in-
most common disabilities, their dis- large burden of musculoskeletal dis- cluding low back pain, chronic joint
ability ratings are relatively low ease on the adult population of the pain, and arthritis. Low back pain
(17% and 12%, respectively). The UnitedStateshasbeendemonstrated wasthemostcommonmusculoskele-
calculated PTSD impact factor is previously,includinghundredsofbil- tal condition reported, found in 62
highbecauseoftheaverage50%dis- lionsofdollarsindirectandindirect million adults (ie, 28% of the adult
ability rating. Back pain and OA costs,difficultywithdailytasks,and population). Young adults aged 18
combined affect nearly four times substantialresourceutilization.1,3,4 to 44 years were found to be sub-
moresoldiersthandoesPTSD. In 2008, the United States Bone stantiallyaffectedbymusculoskeletal
Previousresultsfromourcenterre- and Joint Decade published an anal- conditions, with 38% reporting at
S28 JournaloftheAmericanAcademyofOrthopaedicSurgeons
CPTJeanneC.Patzkowski,MD,MC,USA,etal
and more than half of these condi-
Table7
tions were musculoskeletal. Muscu-
ChangeinAveragePercentDisabilityforOrthopaedicUnfitting
loskeletal conditions also accounted
ConditionsFrom2001to2009a
for the greatest number of lost work
UnfittingCondition Jan–Mar2001 Jan–Mar2009 PValue
days and bed days among American
Amputation 40 76 NS adults. Indirect costs, primarily in
Backpainb 13 17 <0.05 the form of lost wages resulting
Footandankle 11 15 <0.0001 from musculoskeletal disorders, tal-
lied $340 billion from 2002 through
Fibromyalgia 24 27 NS
2004. Direct costs of medical care
Knee 14 18 <0.05
fortheseconditionswasestimatedto
Miscellaneous 2 13 <0.0001
be$510billion.6
Muscle 6 24 <0.0001
Thisstudyhasseverallimitations.It
Osteoarthritis 6 12 <0.0001
isretrospective,anditwasnotpossi-
Otherlowerextremity 14 15 NS
bletofullyinvestigatethemedicalhis-
Peripheralnerve 10 17 <0.05
tory of each soldier separated from
Totaljointarthroplasty 30 81 <0.05
active-dutyservice.Therefore,itisnot
Otherupperextremity 19 22 NS
possibletocommentonthefrequency
NS=notstatisticallysignificant of posttraumatic OA compared with
aThesedataareincludedintheUSArmyPhysicalEvaluationBoarddatabaseandwere degenerativeOAortoprovideamean-
studiedthroughanInstitutionalReviewBoard–approvedprotocolatourinstitutionandthe
ingfulassessmentoftheseverityofin-
Veterans’Administration.Thesedataarenotpubliclyavailable.
bBackpainincludesconditionsofthevertebralcolumn,herniatednucleuspulposus,and dividualunfittingconditions.Thistopic
degenerativediskdisease.Itdoesnotincludedisordersofthespinalcord.
warrants further study. Additionally,
thestudyreliesontheassumptionthat
Table8 the3-monthperiodschosenwererep-
resentativeoftheirrespectivetimepe-
ConditionsWiththeHighestAveragePercentDisabilityin2001and
2009a riods. Each individual soldier is re-
ferredtothePEBwhenheorshehas
RankOrder Jan–Mar2001 Jan–Mar2009
reachedthemaximummedicalbenefit
1 Cancer Totaljointarthroplasty oftreatment,andthistimingisunique
2 Infection Amputation toeachsoldier.Furthermore,thepath-
3 TBI Cancer way to the PEB is self-reported, and
4 Amputation Infection theremaybebiasrelativetotheassess-
5 GI PTSD mentofdisability.Overall,theperiod
6 Cardiac/PVD Rheumatologic chosenlikelyisadequatelyrepresenta-
7 Rheumatologic Cardiac/PVD tive of both the war and peacetime
8 GU GU populations.
9 Neurologic TBI
10 Totaljointarthroplasty Psychiatric
Summary
GI=gastrointestinal,GU=genitourinary,PTSD=posttraumaticstressdisorder,
PVD=peripheralvasculardisease,TBI=traumaticbraininjury
aThesedataareincludedintheUSArmyPhysicalEvaluationBoarddatabaseandwere Review of nearly 5,000 PEB records
studiedthroughanInstitutionalReviewBoard–approvedprotocolatourinstitutionandthe clearly demonstrates that orthopae-
Veterans’Administration.Thesedataarenotpubliclyavailable.
dic unfitting conditions account for
thegreatestnumberofsoldierssepa-
least one. Of the young adults who werefoundtohavealargeimpacton rated from active-duty service and
reported a medical condition, >20% a patient’s ability to perform activi- for the highest military-related dis-
reportedchronicjointpainorarthri- ties of daily living and go to work. ability costs during both peacetime
tis and nearly 28% reported back More than 29 million adults (ie, and war. Although the time periods
pain in the lumbar region, with 13%ofthepopulation)reporteddif- analyzed are short compared with
nearly 15% reporting neck pain. ficulty performing activities of daily the overall length of the wars, it is
These musculoskeletal conditions living due to a medical condition, clear that more soldiers are found to
2012,Vol20,Supplement1 S29
TheChangingFaceofDisabilityintheUSArmy:TheOperationEnduringFreedomandOperationIraqiFreedomEffect
Table9
RankofUnfittingConditionsbyImpactin2001and2009a
Jan–Mar2001 Jan–Mar2009
RankOrder UnfittingCondition Impactb UnfittingCondition Impactb
1 Backpain 4,888 PTSD 31,350
2 Osteoarthritis 3,612 Backpain 22,916
3 Respiratory 2,862 Osteoarthritis 11,844
4 Psychiatric 2,028 Psychiatric 10,249
5 Neurologic 1,760 TBI 9,711
6 Cancer 1,230 Foot/ankle/LE 7,815
7 GI 1,178 Neurologic 6,630
8 Cardiac/PVD 1,080 Respiratory 3,480
9 Foot/ankle/LE 948 Muscle 2,640
10 Knee 868 Amputation 2,508
GI=gastrointestinal,LE=lowerextremity,PTSD=posttraumaticstressdisorder,PVD=peripheralvasculardisease,TBI=traumaticbrain
injury
aThesedataareincludedintheUSArmyPhysicalEvaluationBoarddatabaseandwerestudiedthroughanInstitutionalReviewBoard–
approvedprotocolatourinstitutionandtheVeterans’Administration.Thesedataarenotpubliclyavailable.
bFrequency×averagepercentdisability
be unfit for duty during war than Rosemont,IL,AmericanAcademyof
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S30 JournaloftheAmericanAcademyofOrthopaedicSurgeons