A Novel Nurse-managed Stress Fracture Rehabilitation Program: A Pilot Study

The Army’s Chief of Staff has made military readiness the number-one priority. Musculoskeletal injuries remain the number one reason Service Members (SM) seek medical care, resulting in over 140,000 lost workdays. Stress fractures are particularly problematic because recovery is prolonged, re-injury rates are high, females are disproportionately affected, and medical discharge rates among service members (SM) with stress fractures are four times higher. Despite the high morbidity associated with stress fractures, there currently exists
no evidence-based rehabilitation guideline for rehabilitation.

The human skeleton is highly adaptable and actively responds to the biomechanical forces placed upon it. Research into bone remodeling and strengthening has found that the best response is achieved by alternating between stressing the bone and allowing a rest period in a cyclical fashion. The research has determined the work/rest cycle is optimized by dividing the workload into two shorter episodes within the same day as opposed to the typical pattern of one workout per day. Standard stress fracture rehabilitation programs tend to use a generic systematically progressive “walk to run” model with the workout confined to one episode per day. Rehabilitation that requires individuals to follow a structured and lengthy program often suffers from nonadherence. This is especially true of programs which are done at home and may result in some degree of discomfort to the individual. Research has found, however, that people who believe they have both the autonomous ability to perform an activity and the support needed to do it are more likely to complete the task. A motivational theory which focuses on this autonomy of action is Self-Determination Theory (SDT). SDT identifies three basic psychological needs that, 1) increase a person’s volition to engage in a particular activity (autonomy), 2) help them recognize their capability (competence), and 3) feel connected and supported (relatedness). Supporting these needs is uniquely suited to nurses who are adept at encouraging patients to
achieve autonomy, improve task competence, and engage in clear communication.

The purpose of this pilot study is to compare the efficacy and adherence of a novel, nurse-guided Graduated Exercise Program (GEP) for tibia stress fractures to the current standard of rehabilitative care. The specific aims are to: 1) compare the difference in program efficacy between SMs with a mild lower extremity stress fracture who undergo a GEP versus SMs receiving a physical therapist-directed standard of care (SOC) rehabilitative program, and 2) evaluate differences in program adherence between SMs in a program incorporating RN-guided autonomy support compared to SMs who do not receive autonomy support. A prospective, randomized, longitudinal study design will evaluate the effectiveness of the pilot study among service members stationed at Fort Bragg, North Carolina. Inclusion criteria are: SMs 18 – 50 years old, MRI diagnosed tibia stress fracture (Grade I-III), no PCS or deployments within six months of enrollment, and
cleared by the study physical therapist to begin full weight bearing activity. Exclusion criteria includes: endocrinopathies, bone disorders, current / previous diagnosis of eating disorders, pregnancy or history of irregular menses, and abnormal vitamin D or calcium levels.

Service members will be measured as they progress through one of the two rehabilitation programs. Service members in the SOC will be managed by the physical therapist and only follow up as medically required. Service members in the GEP will also be medically followed by the physical therapist but will also receive support from an RN who will utilize autonomy support mechanisms to facilitate the service members’ perception of autonomy, competence and relatedness. Data collected includes demographics, physiologic/ psychological measures, activity, adherence, and re-injury. Between-group differences in continuous outcome variables will be assessed using mixed ANCOVA while accounting for control variables (age, BMI, and military occupational specialty (MOS), self-regulation, motivation, and health care climate questionnaires). Categorical outcomes’ variables will be assessed using Chi-square and logistic regression to account for control
variables. Statistical significance will be set at the p .05 threshold.

This proposed pilot study targets the TSNRP research priorities “fit and ready force” and “patient outcomes.” The study is expected to provide the foundation for an evidence-based nurse monitored stress fracture rehabilitation program. The study will broaden our understanding of the team based patient care roles nurses  can provide within the Patient-Centered Medical Home. Nurses' comprehensive view of healing and rehabilitation, excellent interpersonal and communication skills, and ability to work effectively within an interdisciplinary team make them ideally suited to lead this novel rehabilitation program.