Combat and Operational Stress Control: Application in a Burn Center

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

This is a very well researched and presented paper. Additionally, it provides insight to the use of a novel structured intervention for the psychological recovery of burn patients.  The authors prevent cogent logic for why this approach should be considered and is worth of further study in the burn community. I have the following comments:

1) There is a formatting gap between lines 15 and 16

2) In the theoretical basis the phrase family and friends is used, did you consider using a broader concept such as "support network" that encompasses other important supports in civilian life such as clergy / employers?

3) In table 1, there seem to be more areas of direct cross over between the military and civilian sides of the table, such as "traumatic event management".  Why not keep these aspects in both?

4) Under "Brevity" when discussing the 5 R's you touch on pain management to help prevent re-traumatization.  When translating this to the burn unit, did you consider the timing of interventions such as wound care / surgery or other painful procedures?  For example, would routine scheduling, spacing wound care every other day where appropriate help mitigate retraumatization or adding "micro traumas"?  Does this approach offer insight into coping with the need to be in  the ongoing "combat environement".  

5) The formatting for table 3 is off and the headings are not aligned.  

Author Response

Reviewer 1

Thank you for the suggestions to improve our manuscript. We believe that the feedback you have provided helped us immensely. Below, in yellow highlight, are our responses to your comments.  Thank you for taking the time to review our article and provide constructive feedback.

____________________________________________________________________________________

This is a very well researched and presented paper. Additionally, it provides insight to the use of a novel structured intervention for the psychological recovery of burn patients.  The authors prevent cogent logic for why this approach should be considered and is worth of further study in the burn community. I have the following comments:

1) There is a formatting gap between lines 15 and 16

Thank you, we have fixed the formatting between the lines.

2) In the theoretical basis the phrase family and friends is used, did you consider using a broader concept such as "support network" that encompasses other important supports in civilian life such as clergy / employers?

Thank you for this recommendation. We modified the language in Table 2 and added the following clarification on page 5 “Also, as referenced in Table 2, we use the term “support network” which expands beyond friends and family and represents other important support people such as clergy members, employers, and support groups.

3) In table 1, there seem to be more areas of direct cross over between the military and civilian sides of the table, such as "traumatic event management".  Why not keep these aspects in both?

Thank you for this recommendation. We applied the “traumatic even management” to the burn center secondary prevention section and added the following text “Traumatic Event Management through surveillance screening and individual and or group treatment sessions”

4) Under "Brevity" when discussing the 5 R's you touch on pain management to help prevent re-traumatization.  When translating this to the burn unit, did you consider the timing of interventions such as wound care / surgery or other painful procedures?  For example, would routine scheduling, spacing wound care every other day where appropriate help mitigate retraumatization or adding "micro traumas"?  Does this approach offer insight into coping with the need to be in the ongoing "combat environment".  

This is a great consideration. We have added the following text on page 6, 4) when appropriate spacing and timing of painful procedures such as wound care, surgical procedures, and intense range of motion (ROM) sessions to mitigate re-traumatization and microtraumas (i.e., wound care every other day if appropriate or simultaneously pairing painful procedures such as wound care or surgery with ROM treatment sessions when analgesia coverage is greater to decrease the amount and duration of painful procedures experienced during the day); 5)

5) The formatting for table 3 is off and the headings are not aligned.

Thank you for identifying this formatting error, we have modified the text to correct the formatting.

Reviewer 2 Report

Comments and Suggestions for Authors

It was not until page 5 that you began to mention "success of this program" line 157. However, no where have you presented results of other studies. What does success look like? Success compared to what?

See also line 151-153 "performance is optimize; the will to survive is protected; and adverse physical, psychological, intellectual, and social health effects are prevented." while you proved two citations, provided more detail about these outcomes is needed. The reader now needs to go to those articles to find out what is meant by your statement.

Page 5 line 180 spell out OT the first time used.

Page 9 line 310-312 " Preexisting psychiatric morbidity is common in burn patients. There is a close association between a psychiatric history (depression), substance abuse disorders (alcohol and drug dependence), stressful life events, unemployment, and burns" 

The above statement needs clarification. you talk about a close association, so does that imply that psychiatric history could increase the the likelihood  of burns? you need to make clearer what this association is. Screen out people with the above and the prevalence of burns decreases?

Page 9 line 324-325 "The COSC mission has resulted in symptom and disorder amelioration in deployed soldiers." I have not seen in the article strong evidence to support this claim. You need to support this with some statistics from papers that presented this evidence. 

What I read the title of you paper, in particular the word Application, what I was looking for was supporting evidence that COSC needs to be a part of a burn patients recovery, but I never found information that would convince me. 

You did a good job presenting the principles, and the 9 functional areas, but this was more a review of the program and not an attempt to present evidence to convince the reader that this is the right treatment approach 

Author Response

Reviewer 2

Thank you for the suggestions to improve our manuscript. We believe that the feedback you have provided helped us immensely. Below, in yellow highlight, are our responses to your comments.  Thank you for taking the time to review our article and provide constructive feedback.

____________________________________________________________________________________

It was not until page 5 that you began to mention "success of this program" line 157. However, no where have you presented results of other studies. What does success look like? Success compared to what?

Thank you for this question. We have added a section titled “Effectiveness of COSC in Operational Environments” on page 5 with the following text “

Effectiveness of COSC in Operational Environments

                There are few studies that evaluate the effectiveness of mental health treatments in a deployed setting. The primary aim of a COSC unit is to help prevent behavioral health problems, preserve combat power, and increase return to duty rates for combat stress related casualties as close as safely possible to a hostile environment. A study conducted in Iraq evaluating the clinical effectiveness of a brief treatment program designed to ad-dress combat stress reactions (CSR) in soldiers suffering from deployment-related stressors was reported to be the first study to so in a deployed environment; [40]. Although there were associated limitations with regard to study design to include challenges of conducting research in a deployed setting, this study provided preliminary data to support the utility of the program and its benefits for service members in a deployed setting as evidenced by a statistically significant decrease in post-traumatic stress disorder (PTSD) symptoms after the completion of the program [40].

Another paper published in 2017 reported on a process improvement project to determine the effectiveness of a COSC Center in Afghanistan. Service members were referred to a Freedom Restoration Clinic (FRC) for participation in a 3-day program [41]. The officer in charge of the FRC was an Army OT and clinical support was provided by various members of the COSC clinic consisting of a psychiatrist, clinical psychologist, and clinical social worker. The OT personnel lead the groups (top five groups included anger management, resiliency, goal setting, stress management, and positive thinking), activities, physical training, and individual sessions as needed. Short-term

 follow up after completion of the program yielded significant improvement in stress-related symptoms com-pared to prior to initiating the program but after 30 days the results were no longer significantly improved.

It is important to mention that these studies lack long-term follow up data regarding program effectiveness. Consideration of additional measures of acute stress disorder, anxiety, or depression to assess other aspects of symptom change may also be beneficial. A study systematic review and meta-analysis published in 2021 indicated that although COSC interventions may play a valuable role in decreasing stress, decreasing absenteeism, and enabling return to duty, but is little evidence that suggesting the overall effectiveness in prevention of PTSD in military service members [42].

See also line 151-153 "performance is optimize; the will to survive is protected; and adverse physical, psychological, intellectual, and social health effects are prevented." while you proved two citations, provided more detail about these outcomes is needed. The reader now needs to go to those articles to find out what is meant by your statement.

We reworded this sentence to better articulate the intended goals of a COSC program as sited in the literature.

Page 5, line 180 spell out OT the first time used

Thank you, we have addressed this issue.

Page 9 line 310-312 " Preexisting psychiatric morbidity is common in burn patients. There is a close association between a psychiatric history (depression), substance abuse disorders (alcohol and drug dependence), stressful life events, unemployment, and burns" 

The above statement needs clarification. you talk about a close association, so does that imply that psychiatric history could increase the likelihood of burns? you need to make clearer what this association is. Screen out people with the above and the prevalence of burns decreases?

To clarify this component of the paper we have added the following text to the sentence that follows the quote above:

“These data regarding the high likelihood of concomitant premorbid mental health conditions in civilian who sustained burn injury further justify the need for and significance of COSC concepts and occupation-based care to augment the psychosocial recovery of burn survivors.”

Rather than screening these individuals out, we are highlighting the need and justification for behavioral health services in the burn population. Individuals who sustain burn injury are statistically significantly more likely to have premorbid behavior health conditions which can further complicate recovery. Utilization of the COSC concept helps to further integrate the availability of these services in this environment.

Page 9, line 324-325 "The COSC mission has resulted in symptom and disorder amelioration in deployed soldiers." I have not seen in the article strong evidence to support this claim. You need to support this with some statistics from papers that presented this evidence. 

Thank you for this insight. We have added the “Effectiveness of COSC in Operational Environments” as described above and have reworded the final paragraph of the paper to better support our claim:

“Burn rehabilitation has historically focused on a biomechanical frame of reference, addressing burn-scar contracture and the biomechanical dysfunction that follows [2, 56]. Less thoroughly incorporated into burn rehabilitation is recovery from psychosocial injury. Occupational therapy has been integral to the holistic recovery of soldiers since the origin of the profession. The positive psychosocial and physiological effects of occupation-based interventions, a fundamental principle of the profession, has justified occupational therapy’s relevance as a military asset [24, 31, 33-36]. Occupational therapists are members of the rehabilitation team as well as vital member of the COSC team in their deployment role. This ideally positions OTs to leverage skills from both of these contexts. There are preliminary data that demonstrate that the COSC mission has resulted in symptom and disorder amelioration in deployed soldiers at least in the short-term [41, 42]. It is important to understand that further study and refinement of these programs are required to assess long-term effectiveness. Nevertheless, the COSC concept does provide a viable framework to enhance the delivery of a more holistic approach to recovery that includes emphasis on psychosocial recovery. We have proposed adapting the COSC model into burn rehabilitation. We aim to develop and employ whole-person, occupation-based interventions to achieve adaptation and to reduce the risk of functional deterioration following community reintegration [24]. Future research at our burn center will focus on strategies to document and improve long-term functional outcomes following burn injury.”

What I read the title of your paper, in particular the word Application, what I was looking for was supporting evidence that COSC needs to be a part of a burn patients’ recovery, but I never found information that would convince me. 

You did a good job presenting the principles, and the 9 functional areas, but this was more a review of the program and not an attempt to present evidence to convince the reader that this is the right treatment approach.

The reviewer is correct in identifying this paper as primarily a review paper which aims to set the stage for future work.

Reviewer 3 Report

Comments and Suggestions for Authors

The article Combat and Operational Stress Control: Application in a Burn Center, written by authors Ill M. Cancio, OTD, OTR/L, CHT and Leopoldo C. Cancio, MD, FACS, represents one possibility of a holistic approach to the trauma patient.

     The authors have applied their experience and concepts of how to prevent, identify, reduce, and manage combat and operational stress reactions resulting from physical and psychological stressors in a combat environment to the care of burn patients treated in burn centers.

     From my perspective, burns treated in a burn center are always life-changing injuries that have a lifelong impact on an individual and his or her family. Burns carry a psychological and physical stigma.

    The vision of the COSC model consists of primary, secondary and tertiary prevention, in this point I would like to emphasize the primary and the need for a regular and repetitive community outreach programs.

      The six management principles of COSC are perfectly apllicable in a care of burn victims. Can be considered the same principles to the nearest family, especially in case when the patient is a child or a parent is a senior. Parents who feel the high intensity of stress can suffer from PTSD and due to it become less supportive for a child. Especially in seniors PTDS can be fundamental and a predictor of impaired cognitive functions and a health estate.

      I appreciate the implementation of the knowledge and experience of the US Army to the civilian sector as you mentined to enhance psychosocial recovery, especially in times of limited resources and in case of mass casualties.

 

Finally, I have a few questions:

- Are U.S. Army psychologists/psychiatrists participating in the COSC concept at U.S. burn centers?

- Who are the other specialists involved in the COCS program?

- Is the COCS program applied only during the time of hospitalization or does it continue in the time of recovery after the burn clinic?

- How do you address the religious needs of your injured soldiers in the COCS program?

      Thank you for the article and your time spent to improve the care of burn victims.  

Author Response

 

Reviewer 3

Thank you for the suggestions to improve our manuscript. We believe that the feedback you have provided helped us immensely. Below, in yellow highlight, are our responses to your comments.  Thank you for taking the time to review our article and provide constructive feedback.

____________________________________________________________________________________

The article Combat and Operational Stress Control: Application in a Burn Center, , represents one possibility of a holistic approach to the trauma patient.

     The authors have applied their experience and concepts of how to prevent, identify, reduce, and manage combat and operational stress reactions resulting from physical and psychological stressors in a combat environment to the care of burn patients treated in burn centers.

     From my perspective, burns treated in a burn center are always life-changing injuries that have a lifelong impact on an individual and his or her family. Burns carry a psychological and physical stigma.

    The vision of the COSC model consists of primary, secondary and tertiary prevention, in this point I would like to emphasize the primary and the need for a regular and repetitive community outreach programs.

      The six management principles of COSC are perfectly applicable in a care of burn victims. Can be considered the same principles to the nearest family, especially in case when the patient is a child, or a parent is a senior. Parents who feel the high intensity of stress can suffer from PTSD and due to it become less supportive for a child. Especially in seniors PTDS can be fundamental and a predictor of impaired cognitive functions and a health estate.

      I appreciate the implementation of the knowledge and experience of the US Army to the civilian sector as you mentioned to enhance psychosocial recovery, especially in times of limited resources and in case of mass casualties.

Finally, I have a few questions:

- Are U.S. Army psychologists/psychiatrists participating in the COSC concept at U.S. burn centers?

Thank you for this question. Yes, Psychologists and psychiatrists are members of the COSC team. We reference members of the COSC team on page three of the manuscript. We added additional text to clarify why we are focusing on the occupational thearpist’s role on the COSC team.

“Members of the COSC team may include a psychiatrist, social work officer, clinical psychologist, psychiatric nurse, occupational therapist, and enlisted specialists. For the purposes of this paper, we will focus on the occupational therapist’s role on the COSC team and how those skills can be applied in a burn center as a complimentary addition to the behavioral health mission. Occupational therapists are exposed to behavioral health populations in practice and their school curriculum includes behavioral health-specific training to include treatment techniques and options for this patient population. In addition, Army OTs are required to complete the COSC course and Management of Combat Stress Casualties Course before deploying.”

 Also, in response the recommendations from another reviewer, we added a section titled “Effectiveness of COSC in Operational Environments.” Here we reference the specific role of an occupational therapist on a COSC team in Afghanistan.

Another paper published in 2017 reported on a process improvement project to determine the effectiveness of a COSC Center in Afghanistan. Service members were referred to a Freedom Restoration Clinic (FRC) for participation in a 3-day program [41]. The officer in charge to the FRC was an Army OT and clinical support was provided by various members of the COSC clinic consisting of a psychiatrist, clinical psychologist, and clinical social worker. The OT personnel lead the groups (top five groups included anger management, resiliency, goal setting, stress management, and positive thinking), activities, physical training, and individual sessions as needed. Short-term follow up after completion of the program yielded significant improvement in stress-related symptoms com-pared to prior to initiating the program but after 30 days the results were no longer significantly improved.

- Who are the other specialists involved in the COCS program?

See comment above.

- Is the COCS program applied only during the time of hospitalization, or does it continue in the time of recovery after the burn clinic?

Thank you for this question. We did not directly comment on the timeframe the COSC program could be implemented. We indirectly addressed this on page 6:

“This approach aims to address both the acute and chronic aspects of burn injury. A major burn injury meets the definition of a chronic disease, as there is potential for decline in mental and physical health over time [4, 43, 44]. Therefore, occupational therapy ad-dresses the chronic effects of a life-changing injury, incorporating holistic concepts that promote self-care, mental resilience, and lifelong adaptive skills. The primary goal is to re-store health, and to instill wellness and the need to ‘do’ and to ‘be,’ as means to adapt and belong [21, 24, 25, 45].”

 To further clarify, we have added the following text to page 6 of the manuscript:

“The application of the COSC approach can extend beyond care in the acute hospital setting. For example, as referenced in the previous section, as part of the COSC program in Afghanistan, occupational therapists provided group treatment sessions to include topics such as anger management, resiliency, goal setting, stress management, and positive thinking. Other group topics might include topics such as spirituality. These groups can be made available to patients who are still in the hospital as well as adapted to those who have progressed to outpatient rehabilitation or come burn clinic. Logistics regarding infection control may need to be considered, however viewpoints from patients in the acute stages of recovery verses more sub-acute or long-term stages of recovery may provide varying experiences that benefit other members of the group.”

- How do you address the religious needs of your injured soldiers in the COCS program?

Thank you for this comment. We have expanded engagement and contact with ‘friends and family” to a the broader term “support network.” We think this represents a larger more diverse network of support people. We provide examples of support network on pages 6 and 7 where spiritual and clergy support people are directly referenced. We also mentioned spirituality as a possible option for a group treatment session topic.

      Thank you for the article and your time spent to improve the care of burn victims. 

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

Thank you for addressing previous questions. 

Reviewer 2 Report

Comments and Suggestions for Authors

Thank you for addressing my comments.

Reviewer 3 Report

Comments and Suggestions for Authors

All my questions and comments have been answered and implemented into changes to the text.Thank you.