MILITARY MEDICINE, 00, 0/0:1, 2018

Physical Therapists Forward Deployed on Aircraft Carriers:

A Retrospective Look at a Decade of Service
CAPT Michael D. Rosenthal, PT, DSc, MSC, USN (ret)*; CAPT Gregg W. Ziemke, PT, MS, MHA, OCS,
MSC, USN (ret)†; LT Matthew L. Bush, PT, DPT, OCS, MSC, USN‡;
LCDR Joshua Halfpap, PT, DPT, OCS, MSC, USN§

ABSTRACT Introduction: Navy physical therapists (PTs) have been a part of ship’s company aboard Aircraft
Carriers since 2002 due to musculoskeletal injuries being the number one cause of lost duty time and disability. This
article describes a decade of physical therapy services provided aboard aircraft carriers. Materials and Methods: A ret-
rospective survey was conducted to evaluate the types of services provided, volume of workload, value of services pro-
vided, and impact of PTs on operational readiness for personnel aboard Naval aircraft carriers. Thirty-four reports
documenting workload from PTs stationed onboard aircraft carriers were collected during the first decade of permanent
PT assignment to aircraft carriers. Results: This report quantifies a 10-yr period of physical therapy services (PT and
PT Technician) in providing musculoskeletal care within the carrier strike group and adds to existing literature demon-
strating a high demand for musculoskeletal care in operational platforms. A collective total of 144,211 encounters were
reported during the 10-yr period. The number of initial evaluations performed by the PT averaged 1,448 per assigned
tour. The average number of follow-up appointments performed by the PT per tour was 1,440. The average number of
treatment appointments per tour provided by the PT and PT technician combined was 1,888. The average number of
visits per patient, including the initial evaluation, was 3.3. Sixty-five percent (65%) of the workload occurred while
deployed or out to sea during training periods. It was estimated that 213 medical evacuations were averted over the
10-yr period. There were no reports of adverse events or quality of care reviews related to the care provided by the PT
and/or PT technician. Access to early PT intervention aboard aircraft carriers was associated with a better utilization
ratio (lower average number of visits per condition) than has been reported in prior studies and suggests an effective
utilization of medical personnel resources. Conclusions: The impact of Navy PTs serving afloat highlights the impor-
tance of sustaining these billets and indicates the potential benefit of additional billet establishment to support opera-
tional platforms with high volumes of musculoskeletal injury. Access to early PT intervention can prevent and
rehabilitate injuries among operational forces, promote human performance optimization, increase readiness during war
and peace time efforts, and accelerate rehabilitation from neuromusculoskeletal injuries. With the establishment of
Electronic Health Records within all carrier medical groups a repeat study may provide additional detail related to mus-
culoskeletal injuries to guide medical planners to staff sea-based operational platforms most effectively to care for the
greatest source of battle and disease non-battle injuries and related disability in the military.

INTRODUCTION
U.S. Navy physical therapists (PTs) were first deployed on
carriers in 1996 and 1997 to perform pilot studies to deter-
mine the impact of PTs on mitigating musculoskeletal inju-
ries and expediting return to full duty following sustainment
of injuries. These trial deployments proved successful in pro-
viding prompt evaluation of acute, subacute and chronic
musculoskeletal conditions, providing work-site ergonomic
and injury prevention guidance and subsequently reduced
*School of Exercise and Nutritional Sciences, San Diego State University,
5500 Campanile Drive, San Diego, CA 92182.
†BADER Consortium, University of Delaware STAR Campus, 101
Discover Blvd, Newark, DE 19713.
‡Naval Special Warfare Logistics Support Unit ONE, 2446 Trident
Way, San Diego, CA 92155.
§Naval Medicine Training Center, Bldg 903, 2931 Harney Rd, Fort Sam
Houston, TX 78234.
doi: 10.1093/milmed/usy070
Published by Oxford University Press on behalf of Association of
Military Surgeons of the United States 2018. This work is written by (a) US
Government employee(s) and is in the public domain in the US.
lost workdays and medical evacuations (MEDEVACs). The
early success of physical therapy services led to establish-
ment of billeting for one PT and one PT Technician
(Hospital Corpsman Navy Enlisted Classification 8466) as
part of ship’s company aboard each carrier beginning in the
fall of 1998. The billeting and staffing roll-out process led to
all carriers having the routine manning of one PT and one
PT Technician by 2002.
While onboard, PTs provided direct access evaluation,
diagnosis, and management of acute and chronic neuromus-
culoskeletal injuries and dysfunction for the Carrier Strike
Group (CSG). Patients were provided with individualized
services to restore function, improve mobility, and relieve
pain in attempt to prevent or mitigate development of chronic
symptoms and future physical disability. As licensed indepen-
dent providers, PTs hold an array of clinical privileges that
facilitate efficiency in early evaluation and management
(Table I). PTs also design injury prevention and human perfor-
mance optimization (strength and conditioning) training pro-
grams. In addition to their primary functions, PTs may serve

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 Physical Therapists Forward Deployed on Aircraft Carriers

TABLE I. PT Core and Supplemental privileges1 which the services offered by the PT would not otherwise
be available to the patient. Additionally, respondents were
Core Supplemental
asked to report on special tests and supplemental privileges
Evaluation, diagnosis, and management Prescribe medications (e.g., imaging, laboratory studies, electromyography (EMG),
without referral (“Direct Access”)
nerve conduction studies (NCS) medication, casting and
Ordering imaging* (Radiographs, MRI, EMG/NCS
CT, bone scan, US) splinting) utilized by PTs using a four-point response scale
Ordering laboratory studies* Dry needling (never, rarely, occasionally, frequent).
Orthotics, splint, and cast fabrication Acupuncture • Workload: respondents reported on command collateral
Mobilization and manipulation of the Joint aspiration and duties during time at sea, and the percent of the work day
spine and extremities injections
spent on patient care versus collateral duties.
Referral/request consultation Casting for spasticity or
redistribution of forces • Medical evacuation: The impact of permanent billeted
Light duty & SIQ Perform/manage cardiac PTs on the number of MEDEVACs was reported as the
rehabilitation number of MEDEVACs saved because of musculoskeletal
Vestibular rehabilitation Neonatal physical therapy conditions. Respondents were asked to report the number
Early intervention pediatric
of musculoskeletal MEDEVACs experienced prior to PT
therapy
staffing onboard ship, and again for the period of time
EMG, electromyography; NCS, nerve conduction study; MRI, magnetic reso- after PT staffing was onboard ship. Finally, the respective
nance imaging; CT, computed tomography; US, ultrasound; SIQ, sick in quarters. Force Surgeon for Commander Naval Air Forces and the
“*” indicates core clinical privileges which were supplemental privileges Navy Physical Therapy Specialty Leader were queried for
prior to 2011.
reports of adverse events or quality of care reviews related
to cases involving use of onboard physical therapy services.
in additional roles such as Assistant Medical Department
Head, Health Promotion and Wellness Programs Officer, Sick Numeric data are tabulated and summarized using descrip-
Call Coordinator, Medical Training Team Leader, Command tive statistics (N, mean (x ̅ ), and median (M)). This is a descrip-
Watch Officer, Command Fitness Leader, and Mass Casualty tive report; no specific statistical comparisons are reported.
Training Team Leader. The Institutional Review Board at Naval Medical Center,
The purpose of this paper is to summarize clinical pro- San Diego, CA, USA was consulted and provided a determi-
ductivity and additional details of the clinical services pro- nation that this was a quality improvement project, not a
vided by carrier-based PTs during the initial decade of PT human subject research project.
assignment as a regular part of a CSG. The investigators
asked PTs, who served on Nimitz class carrier, to abstract
from existing administrative records, information on clini- RESULTS
cian productivity, integration of physical therapy services Forty-five PTs were asked to abstract data for the survey. Of
onboard ship, PT workload and impact of physical therapy the 45 candidates, 34 returned data (77% response rate), doc-
services on operational readiness. umenting workload from PTs and PT technicians. The time
period covered by the reports varied, ranged from 6 to 38 mo
(x ̅ = 21.6 mo, median (M) = 24 mo), indicative of the variable
METHODS duration in which the PT was assigned to the aircraft carrier.
Data Sources
Data for this analysis came from routine quarterly clinical Productivity
productivity reports and quality of care reviews. To facilitate A collective total of 144,211 encounters were reported dur-
the collection of these data, the investigators asked the PTs ing the 10-yr period (Table II). Of the 34 reports received,
from each carrier to record these data using an abstract form 14 reports provided comprehensive breakdown of the num-
(Supplementary Table). The abstracting form was distributed ber of initial (new) evaluations, number of follow-up evalua-
to all PTs who served onboard Nimitz class carriers during tions, and number of treatment sessions. The other (20)
the first decade of permanent PT assignment. The form reports provided total number of visits with 6 providing only
asked the PTs to abstract data related to the following areas the total number of visits, 14 providing total volume along
of professional services provided and related impact: with volume of new evaluations, follow-up evaluations, and/or
treatment sessions but not all 3. The average workload was
• Productivity: expressed in terms of number of patient 203 patient visits per month.
encounters, broken down by new evaluations, follow up The number of initial evaluations performed by the PT
evaluations, and treatment sessions. averaged 1,448 (M = 1,144) per assigned tour. The average
• Integration: expressed as whether the PT duplicated ser- number of follow-up appointments performed by the PT per
vices from other medical department personnel, or whether tour was 1,440 (M = 700). The average number of treatment
the PT represented a unique specialty care provider without appointments per tour provided by the PT and PT technician

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 Physical Therapists Forward Deployed on Aircraft Carriers
TABLE II. Physical Therapy Care Volume
Appointment Type Volume (Visits)
Initial evaluation 39,076
Follow-up evaluation 21,599
Treatment 41,517
Total visits 144,211*
*Total encounters are not a summation due to the non-uniform manner of
prospective clinical productivity reporting.
FIGURE 1. Percentage distribution of appointment types (initial evalua-
tion, follow-up evaluation, and treatment).
combined was 1,888 (M = 1,675). The average number of
visits per patient, including the initial evaluation, was 3.3.
Sixty-five percent (65%) of the workload occurred while
deployed or out to sea during training periods. The break-
down of appointment types (Fig. 1) indicates a nearly equal
number of initial evaluations (38%) in comparison to the
number of total treatment sessions (41%).
Integration
Twelve respondents indicated there were no other medical
staff aboard the ship with specialty training or interest in pro-
viding care for Sailors with orthopedic injuries. An equal num-
ber of respondents reported there were additional medical staff
that provided various types of care for orthopedic conditions.
The most common additional musculoskeletal care assets were
Hospital Corpsmen (General Duty Corpsmen, Orthopedic
Technician, Radiology Technician, Surgical Technician, and
Independent Duty Corpsmen) that provided casting and splint-
ing services aboard the carrier. The training to perform casting
and/or splinting services was received at the MTF prior to
deployment in 33% of reports while the other reports indicated
the training was performed aboard the carrier by qualified staff
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(e.g., Orthopedic Technician, PT Technician, or PT). Eight
respondents indicated additional care of musculoskeletal inju-
ries was provided by one of more personnel with the following
specialty training: Physician Assistants (three reports), General
Medical Officer (one report), Flight Surgeon (two reports),
Flight Surgeon (one report), and Doctor of Osteopathy (three
reports). Seven reports indicated that other medical staff,
despite expressed interested in providing care for musculoskel-
etal injuries, were fully engaged with non-musculoskeletal
care demands.
Additionally, ancillary ships attached to the CSG cruise
with organic medical assets, usually in the form of an
Independent Duty Corpsman (IDC). The IDC routinely con-
sults with carrier medical staff, to include the PT, for advice
on current cases. In rare instances, patients will be flown via
helicopter to the carrier, or carrier medical staff may be
flown to ancillary ships, to provide on-site diagnosis, treat-
ment and/or a management plan recommendation.
As neuromusculoskeletal subject matter experts onboard
the carrier, PTs encounter complex conditions (i.e., fractures,
dislocations, ruptures, nerve injury, etc.) via direct access
through sick call or referral/consultation as part of the
embedded medical team. While aboard the carrier, medical
staff often have the ability to consult telephonically, or via
email with shore-based specialty services such as orthopedic
and neurological surgeons to discuss management of com-
plex cases. Numerous case examples were provided via the
abstracting form indicating multi-disciplinary collaboration
among members of the carrier medical department as well as
tele-medicine consultation and collaboration with specialty
care services from regional military treatment facilities.
The reported frequency of clinical privileges utilized
(question six in the Supplementary Table) varied with the
exception of ordering radiographs (RAD) and prescribing
medications (MEDS) such as non-steroidal anti-inflamma-
tory drugs (NSAIDs) or analgesics which were reported as
utilized “frequently” (78% RAD, 74% MEDS) or “occasionally”
(22% RAD, 26% MEDS) in all reports. Casting/splinting was
the third most utilized service with 74% of reports indicating
occasional or frequent use. Services such as MRI and EMG/
NCV testing required referral to external (non-carrier) medical
resources. Referral for MRI utilization was variable with 22%
never, 11% rarely, 48% occasionally, and 19% frequently. The
least utilized services were referral for EMG/NCV, laboratory
tests, and wound care which were reported as never or rarely
provided (88%, 88%, and 78%, respectively).
Workload
Ninety-six percent of PTs reported that 75–95% of their
work day was devoted to patient care, with one report indic-
ating a period of 50% of time for direct patient care in order
to fulfill emergent medical department needs and serve as
the medical administrative officer. Time devoted to medical
department collateral duties ranged from <5% to 10% in all
3
 Physical Therapists Forward Deployed on Aircraft Carriers
but the aforementioned case. Command collateral duties
were reported to necessitate <5–15% of reporting PTs work
day. Those command duties requiring the greatest amount of
time were command fitness leader and health promotion
officer.
Medical Evacuation
All reports indicated that PTs assigned to aircraft carriers fre-
quently managed musculoskeletal conditions (i.e., fractures
involving the extremities or spine, joint dislocations, acute
radiculopathy/herniated disc, tendon ruptures, and lacera-
tions) that would often result in emergency consultation at a
local acute care facility if pier side. Numerous reports also
indicated examples of service members, with some of the
aforementioned conditions, that were allowed to deploy
based upon the availability of physical therapy services, that
would have been placed on limited duty were such services
not available. There were also multiple reports of service
members having orthopedic surgery (i.e., anterior cruciate
ligament reconstruction, pectoralis major repair, clavicle
fracture open reduction and internal fixation, etc.) and being
cleared to return to the ship while deployed knowing physi-
cal therapy services were available. Such retained and
returned to ship personnel resources are further indications of
the impact of physical therapy services. In addition to numer-
ous musculoskeletal conditions, there were multiple reports of
Sailors with non-musculoskeletal conditions being initially
evaluated by the PT and subsequently referred to carrier medi-
cal staff (i.e., physicians, physician assistant, clinical psycholo-
gist,) for further work-up. Such conditions included
pyelonephritis/nephrolithiasis, myocardial infarction, transient
ischemic attack, and multiple sclerosis.
Based upon input from the reporting PTs and associated
medical staff, it was estimated that 213 emergency
MEDEVACs were averted over the 10-yr period. There were
no reports of adverse events or quality of care reviews related
to the care provided by the PTs and/or PT technicians.
DISCUSSION
The primary mission of the Military Health System is to pro-
vide healthcare to active duty members, retirees, and eligible
family members while also enhancing readiness and protect-
ing the health of U.S. Armed Forces.2 With neuromusculos-
keletal injuries being one of the largest detractors from
military readiness and causes of disability in the military,3–5
it is essential to identify optimal manning of medical staff to
provide a high level of support for forward deployed service
members. In order to continuously maintain national strate-
gic goals, CSGs are on station and on call 24 h a day, 365 d
a year, often operating autonomously in locations beyond
out of reach for air assets. The dynamic nature, mission,
complexity, and sheer number of personnel of the CSG mis-
sion poses significant inherent risk to a higher rate of muscu-
loskeletal injuries.6–8 To support CSGs in these autonomous
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environments, its’ personnel must operate at high levels of
medical readiness. This requires medical staff capability to
independently and rapidly respond to common and life-
threatening injury, while safely returning injured personnel
to full duty as quickly as possible.
Military PTs in all branches of service have established a
track record of providing high quality evidence based neuro-
musculoskeletal care to U.S. Military personnel and benefici-
aries.9,10 Similar to the Army and Air Force, Navy PTs have
provided service in peace and wartime in unique and remote
world-wide environments ashore and afloat.9,11 Clinical set-
tings for Navy PTs span numerous types of healthcare envir-
onments from Recruit Training Centers (e.g., Recruit Training
Command, Chicago, IL, USA and Marine Corps Recruit
Depot, San Diego, CA, USA), Branch Health Clinics, major
military treatment facilities, Navy and Marine Corps Special
Warfare training units and teams (e.g., SEALs, Explosive
Ordinance Disposal, Marine Corps Special Forces, Riverine
Coastal units, etc.), Naval Hospital ships, and CSGs.
Establishment of PTs aboard aircraft carriers was the first
enterprise-wide alignment of subspecialty musculoskeletal
care services to the “deck-plates” to optimize outcomes by
way of efficient access to evidence based medical care. In
early 1998, the U.S. Navy was the first branch of service to
permanently assign PTs to operational units. Over the past
decade, built upon by the impact of PTs serving in Operation
Iraqi Freedom and Operation Enduring Freedom, all branches
of services now have some component of organic physical
therapy assets assigned to their operational forces.9
Licensed independent providers with expertise in evalua-
tion and management of musculoskeletal injuries are integral
due to the volume of such injuries, the negative impact on
readiness, and potential for development of chronic pain
and/or disability.9 Prior to the PT pilot studies in 1996 and
1997, Sailors’ access to care for specialty musculoskeletal
services (i.e., Occupational Therapy, Orthopedic Surgeon,
Physical Therapy, or Sports Medicine Physician) most often
required referral and transit to a fixed Medical Treatment
Facility (MTF) and could take days or weeks until care was
initiated. Full-time assignment of PTs to the aircraft carrier
enabled same day access to care regardless of ship’s loca-
tion. An added benefit of full-time assignment to the ship
was the immediate access to specialty care while pier side
that saved significant lost work hours previously required for
transit to and from the MTFs. With approximately 35%
(50,473) of the physical therapy related visits occurring pier
side this is an estimated time savings of 75,710 man-hours
that would have been lost in transit (1.5 h per appointment)
for MTF related appointments.
The aircraft carrier medical setting involved most patients
seeing the PT by way of direct access, without prior evalua-
tion or referral from another healthcare provider. This
method of providing care for musculoskeletal injuries has
been proven to be a safe and efficient means to expedite
return to full duty in military personnel6 and has also been
 Physical Therapists Forward Deployed on Aircraft Carriers
demonstrated as cost-effective, with improved outcomes, in
the civilian care sector (nationally and internationally).12 The
PTs reported inter-disciplinary teamwork was common
among the medical staff along with frequent utilization of
supplemental privileges by the PT. Previous reports have
also indicated the benefits of PTs in the inter-disciplinary
medical team,9,13,14 the competency of PTs in managing
musculoskeletal conditions,15 and their effectiveness in
ordering imaging studies.16 The 34 respondents (PTs)
assigned to the aircraft carriers had clinical experience rang-
ing from 3 to 15 yr of orthopedic physical therapy practice.
Seventy-one percent of the PTs had additional post-
professional board certification in specialty areas of orthope-
dics, sports, or clinical electrophysiology.
Prior analysis of MTF-based physical therapy care indi-
cated an average number of visits of 8.8 per patient for refer-
ral based care (K. Hodapp, unpublished data). The resultant
average savings of over five visits per patient further demon-
strate the benefits of early access to physical therapy care
also reported by others.12,13,17 This reduction in visits per
patient may partially be attributed to Sailors aboard the car-
rier having, in general, a higher level of medical readiness
than some of the patients receiving care at the MTF.
However, it should be noted that the average number of vis-
its per patient on the carrier was significantly less than each
of the studies analyzed in a recent systematic review of
direct access physical therapy care.12
Additional cost savings attributed to avoidance of
MEDEVACs may also be a key benefit of adding PTs to the
CSG medical staff. While only 20 respondents maintained
data related to MEDEVACs, it was reported that there were
213 MEDEVACs averted by the medical care provided by
the PT. Calculating a total cost value of evacuating, or repla-
cing, a service member from a forward deployed environment
let alone in austere sea-based environments has not been
documented. Devising a methodology for such cost is beyond
the scope of this article and the authors would argue, not only
are the factors involved numerous and individual to each
case, many factors cannot truly be estimated. Additionally,
the variability and expanse of world-wide deployable loca-
tions of Naval sea-based units which vary year to year based
on operational focus and world-wide events would make for
variable cost estimations. Ultimately, meticulous planning
goes into the precise number of Sailors and Marines required
to execute forward deployed operations and the loss of even
one service member for 1 d can impact mission readiness and
accomplishment.
This manuscript is the first to report musculoskeletal care
data across multiple operational Navy platforms over the
course of a decade. While this analysis included over
144,000 encounters for musculoskeletal injury it should be
recognized that additional musculoskeletal injuries were
likely evaluated by other medical staff or not reported by
Sailors. Capturing all outpatient injury data with ships at sea
nearly 50% of the time was challenging and burdensome
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without an automated electronic health record (EHR). There
was thus no comprehensive tracking mechanism for muscu-
loskeletal injuries in the shipboard environment that covered
the wide range of repetitive, overuse injuries (i.e., shoulder
pain/impingement) to traumatic injuries (i.e., fracture caused
by operating machinery). While occupational injuries caus-
ing traumatic injuries or significant lost work hours are com-
monly reported to the Navy Safety Office, the more common
musculoskeletal injuries without identifiable antecedent
trauma, deemed to be overuse, cumulative trauma, or insidi-
ous onset are unlikely to be reported as an occupational
injury. Additionally, under-reporting of musculoskeletal
injuries has been recognized in military populations.18
Although research has indicated PTs functioning as physi-
cian extenders for deployment related musculoskeletal care
resulted in a 97% return to duty rate9 our survey did not spe-
cifically query for return to duty rates nor the amount of
musculoskeletal care provided by non-PT medical staff. The
non-availability of data preceding PT billeting aboard car-
riers to serve as a comparison with encounter volume or
medical evacuation volume are further limitations of this
report.
CONCLUSION
This report quantifies a 10-yr period of physical therapy ser-
vices (PT and PT Technician) in providing musculoskeletal
care within the CSG and adds to existing literature demon-
strating a high demand for musculoskeletal care in opera-
tional platforms. Access to early PT intervention aboard
aircraft carriers was associated with a better utilization ratio
(lower average number of visits per condition) than has been
reported in prior studies11 and suggests an effective utiliza-
tion of medical personnel resources. With the establishment
of electronic health records within all carrier medical groups
a repeat analysis may provide additional detail related to
musculoskeletal injuries to guide medical planners to staff
sea-based operational platforms most effectively to care for
the greatest source of battle and disease non-battle injuries
and related disability in the military.
ACKNOWLEDGMENT
Special appreciation is extended to Rudi Hiebert, ScM, for providing input
on data reporting and manuscript development.
SUPPLEMENTARY MATERIAL
Supplementary material is available at Military Medicine online.
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