The Military Hip Rehabilitation Outcome (MILO) Study

Overview:

Traditionally hip pain in adults was thought to have been caused by osteoarthritis. However, advances in imaging and surgery have improved our understanding of hip problems that happen before the onset of arthritis. These non-arthritic hip disorders can lead to structural changes in and around the joint that cause major hip pain and may mean that the hips do not work properly in young adults.   

The physical demands of military training expose the hip to extreme forces and stresses; non-arthritic hip pain is common amongst this young active population. It is important that health care providers have access to evidence-based recommendations for the management of patients with this complaint. To date, the results of treatment for non-arthritic hip disorders have been limited to outcomes after surgery (Hunt et al, 2012). This means that non-surgical treatment options including physiotherapy are poorly understood.   

Aims and Objectives:

The research programme included four studies. The first study described the structure, process & associated clinical outcomes of a residential multidisciplinary team (MDT) intervention for UK military personnel with non-arthritic hip pain. A second study compared the effects of a team-led intervention with individual physiotherapist led treatment for the management of non-arthritic hip pain with UK military patients in a randomised controlled trial (RCT). A third study described the design and reliability of a new questionnaire examining occupational physical loading as a risk factor for hip pain in military personnel. Study 4 study examined and reported the risk factors for the development of hip pain in military personnel using the Military Physical Loading Questionnaire (MPLQ) developed in Study 3.  This research programme aimed to improve understanding of the treatment and prevention of non-arthritic hip pain in a young active population.   

Key Findings

A large study comparing the effects of inpatient team rehabilitation versus individual (physiotherapist) outpatient treatment for hip pain did not show any differences between the two treatment approaches. However, both forms of treatment improved pain symptoms, muscle strength and the patient’s perceptions of improvement in a young, active military population. This is the first study to show evidence of improved symptoms following inpatient (residential) rehabilitation. Both approaches can be recommended for the treatment of hip pain in young adults.

A separate study found some job related (military) tasks may increase the risk of developing hip pain. A new questionnaire enquiring about lifetime exposure to common military activities showed that long periods of driving, particularly over rough and uneven ground was found to be the highest risk. This new knowledge will allow the development of targeted prevention programmes aimed at reducing the number of soldiers and other young adults from developing hip pain.

Outputs

• Coppack RJ, Bilzon JL, Wills AK, McCurdie IM, Partridge LK, Nicol AM, Bennett AN. Physical and functional outcomes following multidisciplinary residential rehabilitation for pre-arthritic hip pain among young active UK military personnel. BMJ Open Sport Exerc Med 2016;2:e000107. doi:10.1136/bmjsem-2015-000107
• Coppack RJ, Bilzon JL, Wills AK, McCurdie IM, Partridge LK, Nicol AM, Bennett AN. A comparison of multidisciplinary team residential rehabilitation with conventional outpatient care for the treatment of non-arthritic intra-articular hip pain in UK military personnel – a protocol for a randomised controlled trial. BMC Musculoskeletal Disorders (2016) 17:459 DOI 10.1186/s12891-016-1309-z
• Coppack RJ, Bilzon JL, Wills AK, McCurdie IM, Walton DT, Nicol AM, Bennett AN. (2017) Cumulative Effects of Occupational Loading as a Risk Factor for Hip Pain in UK Military Personnel - Study Protocol of a Case Control Study. Int J Sports Exerc Med 3:060. doi.org/10.23937/2469-5718/1510060
• Coppack RJ, Bilzon JL, Wills AK, Papadopoulou T, Cassidy RP, Nicol AM, Bennett AN. The test-retest reliability of the Military Physical Loading Questionnaire (MPLQ). BMJ Mil Health 2020;0: 1–6. doi:10.1136/bmjmilitary-2020-001404
• Allan R, Cassidy RP, Coppack RJ, et al.  Biomechanical and clinical outcomes in response to inpatient multidisciplinary hip and groin rehabilitation in UK military personnel.  BMJ Mil Health Published Online First: 22 February 2021. doi: 10.1136/bmjmilitary-2020-001588
• Houston AD, Coppack RJ, Bennett AN.  Effectiveness of virtual reality-based gait education in enhancing the rehabilitation outcomes of injured military personnel.  BMJ Mil Health Published Online First: 21 October 2020. doi: 10.1136/bmjmilitary-2020-001581
• Coppack RJ, Ladlow P, Bennett AN. Developing UK Defence Rehabilitation research priorities: a 2020 clinical practitioner engagement exercise BMJ Mil Health 2022;168:256-259.
• Houston A, Walters V, Corbett T, Coppack R. Evaluation of a multi-sensor Leap Motion setup for biomechanical motion capture of the hand. Journal of Biomechanics. 28 August 2021. https://doi.org/10.1016/j.jbiomech.2021.110713
• Hayhurst D, Coppack R.J, Ingram C, Conway D, Cassidy R.P, Ladlow P. Integrating blood flow restriction with low-load resistance exercise in a UK specialist military primary care rehabilitation facility. BMJ Military Health. 2021. http://dx.doi.org/10.1136/bmjmilitary-2021-001897 
• Smith S.H.L, Coppack R.J, van den Bogert A.J, Bennett A.N, Bull A.M.J. Review of musculoskeletal modelling in a clinical setting: Current use in rehabilitation design, surgical decision making and healthcare interventions. Clinical Biomechanics Feb 2021.doi.org/10.1016/j.clinbiomech.2021.105292
• Walters V, Coppack R.J, Cassidy R.P, Suffield C, Papadopoulou T, Bilzon J, and Ladlow P. Use of an isometric mid-thigh pull test during musculoskeletal rehabilitation: can the criterion values from the updated British Army physical employment standards be used to inform UK Defence Rehabilitation practice?BMJ Military Health. 20 August 2021. http://dx.doi.org/10.1136/ bmjmilitary-2021-001950
• Ladlow P, Conway D, Hayhurst D, C Suffield, R Cassidy, R Coppack. Integration of strength training into UK Defence Rehabilitation practice: current trends and future challenges BMJ Mil Health 2022; 168:314-319.

Conference Proceedings (2016-2021):

• Coppack, R. Physical and functional outcomes following multidisciplinary residential rehabilitation for pre-arthritic hip pain among young active UK military personnel. UK Defence Medical Services Rehabilitation Conference, (2016), London, UK
• Coppack, R. The Military Hip Rehabilitation Outcome (MILO) study: Background and progress of a randomised controlled trial (RCT). International Sports Hip Conference, (2018), Warwick, UK
• Coppack, R. Cumulative Effects of Occupational Loading as a Risk Factor for Hip Pain in UK Military Personnel – Study Protocol of a Case Control Study. Methods at: Defence Medical Services Innovation Conference: Prolonged Care (2018), Birmingham, UK
• Coppack, R. The test-retest reliability of the Military Physical Loading Questionnaire. Poster presentation at: British Association Sports and Exercise Medicine (BASEM) annual conference, (2019), Glasgow, UK.
• Coppack, R. The Military Hip Rehabilitation Outcome (MILO) study: The treatment of and risk factors for non-arthritic hip pain in a military population: background and progress. British Association Sports and Exercise Medicine (BASEM) spring conference, (2021), Virtual attendance, UK.

Work Package	Stratified Care and Personalised Medicine: Care
Objective	1.3
Lead	Russell Coppack
Investigators	James Bilzon (Bath), Alexander Bennett, Robyn Cassidy, Theodora Papadopoulou, Ian McCurdie, Laura Partridge, Andrew Houston Defence Medical Rehabilitation Centre, Stanford Hall Headley Court; Andrew Wills, Bristol University
Institution	University of Bath