In western nations, military populations are required to achieve and maintain high levels of physical fitness in order to keep their jobs –hence the oft heard term “military athlete”. It doesn’t make them elite, but it does make them persistent and willing to endure pain and discomfort well beyond the threshold of civilian athletes.
The recent wars in Afghanistan and Iraq have left a legacy of psychological disruption, mainly Post Traumatic Stress Disorder (PTSD) that will be significant in the years ahead. But why should a Sports Physician have any interest in PTSD?
If you deal with military patients who have been at war or on peacekeeping missions, up to 20 percent (US and Australian Armies) will have symptoms of PTSD. Many soldiers who suffered injuries while deployed will have experienced trauma of various degrees in acquiring those injuries. The same applies to emergency response workers such as police, paramedics and firemen.
A key issue in the treatment of injured soldiers is diagnosis of co-morbid psychological conditions. Many soldiers are reluctant to come forward and seek psychological assistance and many military patients have symptoms, but have not been diagnosed or identified as symptomatic.
So the first thing a sports physician can do is ask about symptoms and if suspicious administer a simple screening tool called the Post-traumatic checklist or PCL. This form can be downloaded from the internet free of charge (1). A PCL score above 50 is highly suggestive of a diagnosis of PTSD and need confirmation by a psychiatrist or a clinical psychologist. Patients will often confide in their doctor when asked specifically, but will rarely volunteer any information about symptoms.
A US Navy colleague of mine once told me that he relocated the mental health section into the physiotherapy department, because the physiotherapists were identifying so many cases of PTSD among the Marines they were treating. Having the mental health section co-located with physiotherapy automatically removed the stigma of being seen going to the mental health clinic and allowed the sports physicians to cross refer within the same building.
PTSD is an unusual disorder in that it is currently diagnosed purely upon the presence, severity and impact of symptoms only. To date there are no proven objective tests able to confirm the diagnosis. This leads to unsurprising controversy as to the validity of relying on symptoms alone, but that is a controversy I will not delve into.
From my perspective, the condition is real and early identification and effective treatment reduces symptoms significantly. This is important because if left untreated, PTSD symptoms progressively worsen leading to social and occupational impairment.
Evidence based treatments for PTSD include various forms of Cognitive Behavioural Therapy and Prolonged Exposure therapy. They are essentially desensitisation approaches which teach the patient to change the way they respond to reliving the traumatic event (2). Eye Movement Desensitisation Reprograming (EMDR) is a form of prolonged exposure therapy that also includes eye movement activities. A recent report from the Pakistani Army found that EMDR was more effective than the use of SSRI in relieving symptoms in a combat veteran cohort, with 90 percent of the EMDR group having a treatment response compared to 36 percent taking paroxetine (3).
Most treatment guidelines recommend the use of SSRI as first line treatment, primarily for their anxiolytic effect and the US DoD/VA clinical practice guidelines can be downloaded (4). The absence of a biological basis for PTSD results in therapeutic challenges, but there is some emerging evidence of a physiological basis to some of the symptoms of the disorder.
The possibility that the sustained threat environment of combat creates an abnormally sustained stress response resulting in the persisting symptoms seen in PSTD patients is not beyond the realms of probability.
One therapy that does not work is supportive counselling. If you refer a patient for psychological treatment it is important to ensure that an effective and evidence based treatment is being delivered.
In summary, if you treat injured soldiers, one in five will be suffering from symptoms of PTSD. The symptoms and associated co-morbidity may well inhibit a successful rehabilitation from injury. Doctor initiated diagnosis and treatment referral will be generally accepted by the soldier. Early identification and treatment offers the best possibility of recovery.
For more information on treating military athletes turn to Chapter 45 in Clinical Sports Medicine.
Dr Rudzki retired from the Australian Army in 2012 after 30 years of service. He was a Foundation Fellow of the Australian College of Sports Physicians. His main clinical interest is in the area of Injury Prevention and he has published a number of papers on this topic. Dr. Rudzki is currently a Regional Medical Advisor for the Australian Defence Force Joint Health Command in Canberra.
- Ougrin D. Efficacy of exposure versus cognitive therapy in anxiety disorders: systematic review and meta-analysis. BMC Psychiatry. 2011; 11: 200.
- EMDR versus Paroxetine in the treatment of PTSD – A Randomised Trial. International Congress of the Royal College of Psychiatrists (RCPsych) 2013. Poster 65. Presented July 3, 2013.