Implementation interventions for musculoskeletal programs of care in the active military and barriers, facilitators, and outcomes of implementation: a scoping review

Background: Musculoskeletal disorders are common in the active military and are associated with significant lost duty days and disability. Implementing programs of care to manage musculoskeletal disorders can be challenging in complex healthcare systems such as in the military. Understanding how programs of care for musculoskeletal disorders have been implemented in the military and how they impact outcomes may help to inform future implementation interventions in this population. Methods: We conducted a scoping review using the modified Arksey and O'Malley framework to identify literature on (1) implementation interventions of musculoskeletal programs of care in the active military, (2) barriers and facilitators of implementation, and (3) implementation outcomes. We identified studies published in English by searching MEDLINE, CINAHL, Embase, and CENTRAL (Cochrane) from inception to 1 June 2018 and hand searched reference lists of relevant studies. We included empirical studies. We synthesized study results according to three taxonomies: the Effective Practice and Organization of Care (EPOC) taxonomy to classify the implementation interventions; the capability, opportunity, motivation-behavior (COM-B) system to classify barriers and facilitators of implementation; and Proctor et al.'s taxonomy (Adm Policy Ment Health 38:65-76, 2011) to classify outcomes in implementation research. Results: We identified 1785 studies and 16 were relevant. All but two of the relevant studies were conducted in the USA. Implementation interventions were primarily associated with delivery arrangements (e.g., multidisciplinary care). Most barriers or facilitators of implementation were environmental (physical or social). Service and client outcomes indicated improved efficiency of clinical care and improved function and symptomology. Studies reporting implementation outcomes indicated the programs were acceptable, appropriate, feasible, or sustainable. Conclusion: Identification of evidence-based approaches for the management of musculoskeletal disorders is a priority for active-duty military. Our findings can be used by military health services to inform implementation strategies for musculoskeletal programs of care. Further research is needed to better understand (1) the components of implementation interventions, (2) how to overcome barriers to implementation, and (3) how to measure implementation outcomes to improve quality of care and recovery from musculoskeletal disorders.