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.


Background
Musculoskeletal disorders are the most common reason military members seek health care, irrespective of the setting, whether deployed or at home base [1,2]. These disorders are associated with lost productivity due to sick parade attendance and lost duty days [3][4][5][6][7] and are responsible for 42% of all medical releases in the Canadian Armed Forces [3]. Approximately 1.6 million musculoskeletal injuries occur annually within the US Department of Defense, which account for 25 million lost duty days [1]. Musculoskeletal disorders are a leading contributor of healthcare visits and costs in the US military, accounting for approximately 2.4 million medical visits and US$548 million in direct patient care costs [8]. Frequently reported musculoskeletal disorders by military personnel are of the lower limb, low back, neck, and shoulder [9][10][11]. These disorders are commonly caused by overuse, exacerbations of previous injuries, sports, physical training, lifting and carrying, and walking on uneven terrain [12]. Risk factors for musculoskeletal injury in the military include poor results in running and lifting tests, high waist circumference, high body mass index, previous musculoskeletal symptoms, poor school success, old age, higher enlisted rank, female sex, months deployed, and time spent standing [13,14].
Efficient and effective strategies to manage musculoskeletal disorders in the active military are of great importance. Evidence-based treatments for musculoskeletal disorders include a focus on active versus passive treatment, structured education, exercise, and manual and cognitive behavioral therapies [15]. Strategies for implementing evidence-based practices should be tailored for specific settings and contexts [16], especially in complex systems. The military is a complex system with widely dispersed base locations that vary in size, human and facility resources, duties, and composition (e.g., full-time active duty, reserve, or National guard) [17]. Implementing services or programs of care is challenging in complex systems and is influenced by contextual factors such as the military culture, support of interest groups, chain of command, and resources. Therefore, careful consideration to implementation methods or interventions is important to facilitate uptake of evidenced-based programs of care. Implementation interventions are methods or techniques designed to change behaviors at organizational, practitioner, or patient levels [18,19] and to enhance the adoption of a clinical intervention [20]. The Cochrane Effective Practice and Organization of Care (EPOC) Group has categorized these interventions in a taxonomy of delivery arrangements, financial arrangements, governance arrangements, and implementation strategies [21]. Examples of implementation interventions include the development of multidisciplinary teams (delivery arrangements), the use of financial incentives for health professionals and organizations (financial arrangements), policies that regulate what health professionals can do (governance arrangements), and educational meetings and clinical practice guidelines (implementation strategies). Implementation interventions may be tailored to overcome barriers to implementation, using a framework such as the Behavior Change Wheel [22]. In this approach, barriers are classified using the capability, opportunity, motivation-behavior (COM-B) system and mapped onto specific interventions designed to overcome implementation barriers. Finally, appropriate outcomes are necessary to evaluate the success of healthcare interventions. Proctor et al.'s taxonomy of outcomes in implementation research distinguishes implementation outcomes, which are the effects of deliberate and purposive actions to implement new treatments, practices, and services [23], from service and client outcomes, which are usually reported on in scientific papers rather than implementation outcomes. However, it is important to report on implementation outcomes because they are key intermediate outcomes in relation to service system or clinical outcomes in treatment effectiveness and quality of care research [23,24]. Clearly, if interventions are to result in desired changes in clinical or service outcomes, they need to be implemented well [23].
Understanding the implementation of interventions-in particular how programs of care are implemented to manage musculoskeletal disorders-may inform the overall management of these disorders in active military populations, beyond the specific clinical intervention. This may ultimately help to improve patient outcomes and cost-effectiveness of care to benefit military members and the system. To the best of our knowledge, there are no previous studies synthesizing implementation interventions of musculoskeletal programs of care in this population, barriers and facilitators to implementation, or outcomes. Therefore, the purpose of this scoping review was to describe (1) implementation interventions used to deliver programs of care, (2) barriers or facilitators of implementation, and (3) outcomes of implementation used in the management of musculoskeletal disorders in the active military.

Methods
We used the modified "Arksey and O'Malley framework" to examine the extent, range, and nature of the research activity related to the implementation of musculoskeletal programs of care for military personnel [25][26][27]. This approach involves six stages: (1) identifying the research question; (2) defining the scope of the review; (3) study selection; (4) charting the data; (5) collating, summarizing, and reporting the results; and (6) stakeholder consultation.

Stage 1: Identifying the research question
Our scoping review was guided by the following research questions: "What implementation interventions have been used to deliver programs of care for managing musculoskeletal disorders among active military personnel?" and "What were the barriers, facilitators, and outcomes of implementation?" Stage 2: Defining the scope of the review We defined eligibility criteria a priori. Studies were included if they met the following criteria to explore implementation interventions, barriers and facilitators of implementation, or outcomes of implementation: 1. Population: participants were active military personnel (including reservist and National Guard). 2. Program of care or intervention: designed for the clinical management of musculoskeletal disorders. 3. Study design: any primary empirical study (e.g., quantitative, qualitative, or mixed methods) published in the peer-reviewed literature. 4. Implementation intervention: any technique or method used to implement an evidence-based musculoskeletal program of care or intervention. 5. Barriers and facilitators: any factor that either impeded or enabled the implementation of an evidence-based musculoskeletal program of care or intervention. 6. Outcomes: implementation outcomes (acceptability, adoption, appropriateness, costs, feasibility, fidelity, penetration, or sustainability); service outcomes (efficiency, safety, effectiveness, equity, patientcenteredness, or timeliness); or patient outcomes (satisfaction, function, or symptomatology) [23]. 7. Language of publication: studies published in the English language.
Studies were excluded if (1) participants were non-active duty military personnel, e.g., veterans; (2) programs of care were designed for non-musculoskeletal disorders, serious injuries, or pathologies; and (3) they were in the gray literature, e.g., theses, newsletters, and informal communication.

Stage 3: Study selection
We developed our search strategy in consultation with a health sciences librarian (Appendix). A second librarian reviewed the search using the Peer Review of Electronic Search Strategies (PRESS) checklist [28]. The following electronic databases were searched from database inception to June 1, 2018: MEDLINE (Ovid®), CINAHL (EBSCO), Embase (Ovid®), and Cochrane Central Register of Controlled Trials through Ovid® (CENTRAL). The search terms included subject headings specific to each database and free-text terms relevant to musculoskeletal disorders, the military, and implementation interventions (Appendix). We reviewed the reference lists of all eligible studies for additional studies not identified from the electronic database search. Databases containing the results of the searches were created using EndNote X6. We used the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) extension for scoping reviews (PRISMA-ScR) flow chart to track the number of studies at each stage of the review.
Two researchers screened studies using a two-step screening process. In phase I, two reviewers (CC, DS) independently screened titles and abstracts to determine eligibility. They classified studies as relevant, possibly relevant, or irrelevant. In phase II, the reviewers independently reviewed manuscripts of possibly relevant studies to make a final determination of eligibility. The reviewers met to resolve disagreements and reach consensus in both steps. A third independent reviewer was available to discuss and resolve disagreements.

Stage 4: Charting the data
Two reviewers (CC, DS) independently charted and coded the following data from eligible studies: (1) author and year of publication; (2) study design; (3) clinical setting and participant characteristics; (4) program of care and implementation intervention according to the EPOC taxonomy [21]; (5) barriers and facilitators to implementation according to the COM-B system [22]; and (6) outcomes (implementation, service, patient) according to Proctor et al.'s taxonomy of outcomes for implementation research [23].

Stage 5: Analysis
We analyzed the data using a descriptive numerical summary, a qualitative thematic analysis, and by applying meaning to our results [25][26][27].

Descriptive numerical summary
We described the characteristics of included studies, such as the number of studies included, types of study design, characteristics of the study populations, types of musculoskeletal disorders, and countries where the studies were conducted.

Qualitative thematic analysis
We categorized the data into three sections: implementation interventions of the musculoskeletal programs of care (according to EPOC [21]), barriers and facilitators of implementation (according to COM-B [22]), and the implementation research outcomes taxonomy by Proctor et al. [23].
The EPOC taxonomy includes four domains of health systems interventions: (1) delivery arrangements: changes in how, when, and where health care is organized and delivered, and who delivers health care; (2) financial arrangements: changes in how funds are collected, insurance schemes, how services are purchased, and the use of targeted financial incentives or disincentives; (3) governance arrangements: rules or processes that affect the way in which powers are exercised, particularly with regard to authority, accountability, openness, participation, and coherence; and (4) implementation strategies: interventions designed to bring about changes in healthcare organizations, the behavior of healthcare professionals, or the use of health services by healthcare recipients.
The COM-B framework is useful for understanding behavior and behavior change [22]. Capability is defined as the individual's psychological and physical capacity to engage in the desired activity. It includes having the necessary knowledge and skills, such as the knowledge to diagnose a patient with a lumbar disc herniation (psychological capacity), and the skill to take a blood sample (physical capacity). Opportunity is defined as all the factors that lie outside the individual, either in the physical or social environment, that make the behavior possible or prompt it. An example of a physical opportunity is being able to go running because you own running shoes. A social opportunity (or a lack thereof) is being able to dress casually at home but not at a business meeting. Motivation is defined as all the brain processes that energize and direct behavior, including goals, conscious and analytical decision-making, habitual processes, and emotional responding. Motivation can be reflective, involving evaluations and plans, such as deciding to buy a car based on its safety features. On the other hand, automatic motivation involves emotional and impulsive processes such as deciding to buy a car based on its attractiveness in an advertising campaign.
Finally, Proctor et al. [23] have classified the outcomes of interventions, services, or innovations as (1) implementation outcomes (acceptability, adoption, appropriateness, costs, feasibility, fidelity, penetration, and sustainability), (2) service outcomes (efficiency, safety, effectiveness, equity, patient-centeredness, and timeliness), and (3) client outcomes (symptomatology, function, and satisfaction) [23]. They defined the implementation outcomes as follows. Acceptability is the perception among implementation stakeholders that a given intervention is agreeable, palatable, or satisfactory in terms of its content, complexity, or comfort. Appropriateness is the perceived fit, relevance, or compatibility of the intervention for a given practice setting, provider, or consumer; or the perceived fit of the intervention to address a particular problem. Adoption or "uptake" is defined as the intention, initial decision, or action to try or employ an intervention. The cost impact of an implementation effort depends upon the costs of the particular intervention, the implementation strategy used, and the location of service delivery. Feasibility is defined as the extent to which an intervention can be successfully used or carried out within a given setting. Fidelity is defined as the degree to which an intervention was implemented as was intended. Penetration is defined as the integration of a practice with a service setting and its subsystems (i.e., an intervention's institutionalization). Sustainability is defined as the extent to which a newly implemented intervention is maintained or institutionalized within a setting.

Applying meaning to results
We considered the meaning of our scoping study results and the broader implications for research, policy, and practice.

Stage 6: Consultation
We consulted with available authors of the studies included in our review for the purpose of elaborating on their key findings. We also consulted with organizations (Canadian Armed Forces and the Canadian and Ontario Chiropractic Associations) and other experts during a summer institute (Knowledge Translation Canada, June 2017) for their perspectives and experiences regarding barriers and facilitators to health program implementation. We did not conduct a formal qualitative content analysis of comments from the authors, organizational representatives, or experts.
We synthesized the study results according to the implementation interventions of the musculoskeletal programs of care used as per the EPOC taxonomy (Table 1, 16 studies), barriers and facilitators of implementation using the COM-B system ( Table 2, 14 studies), and outcomes (Table 3, 16 studies).
Health care was commonly delivered in a coordinated and multidisciplinary fashion, facilitated by specific referral systems, care pathways, roles and responsibilities, communication methods, use of technology (e.g., electronic health records), and infrastructure (e.g., the co-location of team members). We observed three distinct methods of delivering multidisciplinary care, each with different gatekeepers. A common approach was that a medical physician or specialist was required to make referrals to other musculoskeletal healthcare providers such as chiropractors, physical therapists, and psychologists [29,35,36,[40][41][42]. In contrast, other studies used non-physicians as gatekeepers such as the "Physical Therapy First" [43] approach [31,37,38]. Finally, other studies described teams collectively assessing and  Expanded physical therapist role as primary screener for musculoskeletal conditions To assess overall quality of care provided by physical therapists:       managing military members with musculoskeletal disorders [30,39]. Strategies to implement interventions for managing musculoskeletal disorders included those that targeted healthcare organizations [33,43] or healthcare workers [32,33,36,38,40]. For example, implementation of interventions may be facilitated by having strong support from the organizational leadership. Strategies aimed at healthcare workers may facilitate the implementation of clinical practice guidelines, for example, such as providing workers with Table 3 Implementation outcomes of musculoskeletal programs of care in active military using the implementation research outcomes taxonomy by Proctor et al. [23] (Continued)

Author(s), year
Return to duty Green et al., 2010 [36] Resumed normal work activities, released from care Lillie et al., 2010 [40] Disability (proportion of active-duty service members seeking treatment for a work-disabling spine condition that results in the assignment of a first-career limited-duty status decreased), attrition (proportion of individuals assigned a first-career limited-duty status for a work-disabling spine condition who were referred to a Physical Evaluation Board (no observed effect)) Patient satisfaction was very high (n = 179), median score 5/5 (completely agree or completely satisfied)

Rhon et al., 2017 [41]
Refer to Table 1 for the study design, clinical setting, and participant information BCT brigade combat teams, CPG clinical practice guideline, CSH combat support hospital, HCSDB Health Care Survey of DOD Beneficiaries, CMT chiropractic manipulative therapy, LIMDU limited duty, MST musculoskeletal team, NDI neck disability index, NRS numerical rating scale, PEBs physical evaluation boards, PT physical therapist, RMDQ Roland-Morris Disability Questionnaire, SMC standard medical care, VAS visual analogue scale educational materials and meetings and identifying local opinion leaders who can advocate for the use of guidelines. One study highlighted that implementation is an iterative process. For example, the implementation of a low back pain clinical practice guidelines in four military medical settings used successive Plan-Do-Study-Act (PDSA) cycles and encouraged teams to continually evaluate successes and failures. This evaluation allowed adjustments and retesting before full implementation on a broad scale [32].
To target healthcare organizations, another study developed and assessed a process to implement low back pain clinical practice guidelines in the military healthcare system. Leadership support was established, as well as a handbook to facilitate guideline adoption within the system [33].

Barriers and facilitators of implementation Capability
The main barriers in this domain were psychological not physical [29,32,37,38,42]. For example, barriers to guideline implementation for low back pain included healthcare clinicians not fully understanding how to apply the guideline for patients with multiple conditions. Similarly, few formal training opportunities were available to nurses, physician assistants, and other support staff [32]. Facilitators to implementation included consistent coding for diagnoses and procedures across healthcare providers and sites to facilitate common language [32,42], knowledge of conditions that may delay recovery from spinal pain [42], and advanced training and expertise regarding the management of musculoskeletal conditions [38].

Opportunity
A number of studies demonstrated that implementation was affected by opportunity [29-33, 35-37, 39-43], and often, the physical environment impacted the social environment. For example, the integration of chiropractic services in military treatment facilities was facilitated by having chiropractors located in the same clinic as other providers. This enabled continual communication with other providers to ensure appropriate treatment, nonduplication of services, consistent follow-up, and that regulations were closely followed [35,36]. Other studies also demonstrated that physical proximity to different providers allowed for immediate on-site consultations, as did regular meetings to discuss cases and evidencebased approaches to care [30,[39][40][41][42]. Implementation was facilitated by sharing resources where possible [43] and having direct access to physical therapists [43]. Implementation was also facilitated by identifying an advocate or champion for the program, which can be considered to be a social opportunity [33].
In some studies, factors in the physical environment hindered implementation, such as having access to limited or improper facilities, equipment, or systems [29-32, 36, 37]. Having limited staff impacts implementation [32,37]. High staff turnover, for instance, requires repeated training for the intervention [32]. Implementing an interdisciplinary program of care can be difficult without the appropriate systems in place to facilitate information exchange [32,40,42]. Lillie et al. described how military electronic medical records are maintained in a secure network [40]. However, if a service member was referred off-base for care, that provider did not have direct access to the electronic health care notes, and arrangements had to be made for the applicable notes to be delivered and scanned into the external provider record. Finally, gaps in patterns of care can pose a challenge for implementation. A delay in the initiation of care for service members with spine conditions resulted in spine conditions that were already chronic before the interdisciplinary spine team could assess the patient [42].

Motivation
Motivational barriers can hinder implementation. An example of a motivational barrier was described by Green et al. [35]. Most flight surgeons, who are typically designated as the first points of contact for military pilots, are accustomed to collaborating with physical therapists and physiatrists rather than with chiropractors, thus challenging interdisciplinary collaboration. Reflective motivational barriers were illustrated in three studies. From survey data, teams were only moderately motivated to implement guidelines because they resisted the guidelines concept; were uncertain about the guideline implementation demonstration; were concerned about increased workload; were influenced by previous negative experiences with practice guidelines; and expected rewards from implementation such as recognition from the leadership [32]. Clinicians might have been reluctant to provide the variety of services recommended in the low back pain clinical practice guideline because they were influenced by clinical experiences and by assumptions that most cases of low back pain resolve spontaneously [33]. Healthcare providers working collaboratively in a pre-existing culture of trust and mutual sharing is an example of a reflective motivational facilitator [43].
Four studies provided evidence that the implemented programs were acceptable and appropriate to healthcare providers or patients [30,32,37,43]. Implementing interdisciplinary management of musculoskeletal injuries in a training room open-bay approach allowed for early and accurate diagnosis, early and aggressive reconditioning, coordinated care between providers, and bridging of the gap between primary care and orthopedic surgeons [30]. The concept and quality of care from having a physical therapist in an expanded primary care role was acceptable to the physician and physical therapist, and patients preferred direct access to the physical therapist clinic [37]. The feasibility of this program and others like it, and its adoption, penetration, and sustainability, was demonstrated [38]. Physical therapists now provide primary evaluations over the entire spectrum of musculoskeletal problems in US military health settings. Sustainability was demonstrated with programs such as the "Backs to Work" program in the US [31] and the "Musculoskeletal Screening Protocol" in Sweden [44]. Costs savings were also realized with a "Physical Therapy First" approach [43].

Consultation
We emailed all corresponding authors of the studies included in our review and were able to connect with four authors who shared their insights regarding interdisciplinary teams managing musculoskeletal disorders in the active military. They emphasized the importance of having clear protocols, such that all team members know exactly when and how to intervene. To do this, they stated that care pathways need to be developed that do not allow for the duplication of services, and demonstrate cost-effectiveness of care. One author discussed the importance of relationship building among team members. While this may take some time, it can be easily achieved with agreed upon team protocols and care pathways. One author also pointed out that having advocates for a particular program of care is not enough if the environment is not conducive to the program. For instance, providers should be physically situated together in a team and available at the first point of patient contact. In his experience, physical therapists were often in their own departments and thus, inaccessible when needed.
Authors also discussed that one of the largest barriers to program implementation is the constant turnover of military personnel, making it difficult to implement let alone sustain programs. One author suggested the importance of having an interdisciplinary team of civilian providers that is stationary and has the opportunity to build good working relationships. These civilian providers would serve as "pillars" needed to sustain a musculoskeletal program of care.
Finally, one author spoke about the need to invest in an infrastructure that collects important outcome measures from military patients. In his experience, important outcomes are not well captured within the military health system. There are varying opinions as to what constitutes "value" and therefore what should be measured. Some outcomes considered are patient satisfaction, costs, access to care, and having to out-source to civilian settings. He discussed that military providers want to keep patients in the military health system; however, if access times become too long, patients are referred to civilian providers.
We consulted organizations (Canadian Armed Forces and the Canadian and Ontario Chiropractic Associations) and other experts during a summer institute (Knowledge Translation Canada, June 2017) for their perspectives and experiences regarding barriers and facilitators to health program implementation. Stakeholders and experts suggested that barriers included lack of motivation and knowledge on how to change current practice patterns and behaviors, and time constraints of implementing changes, while facilitators included incentives (e.g., monetary, professional) and audit and feedback processes.

Discussion
To our knowledge, this is the first scoping study to identify implementation interventions for musculoskeletal programs of care in the active military and barriers, facilitators, and outcomes of implementation.
The most common interventions implemented in the military were delivered by coordinated multidisciplinary teams with good communication practices. Indeed, multidisciplinary interventions have increased over the last few decades given that musculoskeletal disorders and disability are influenced by somatic pathology, and psychological and social factors [45]. A common implementation strategy was using educational materials. There is little comparative effectiveness research upon which to base the selection of dissemination strategies [46]. However, there is some evidence to support a multi-component approach such as use of educational meetings/materials and opinion leaders [47,48].
Of the studies reporting barriers and facilitators to implementation, most mapped onto the opportunity component of the COM-B model, which refers to environmental factors (physical or social) facilitating or impeding program implementation. Our findings are consistent with previous studies assessing barriers to program implementation using the COM-B model, with barriers also mapping onto the opportunity component. These include studies aiming to design implementation interventions to improve smoking cessation care for pregnant indigenous smokers [49], to improve hearing-aid use in adult auditory rehabilitation [50], to reduce imaging for low back pain [51], and others [52,53]. Identifying barriers and facilitators to program implementation using a system such as COM-B, and subsequently implementing corresponding behavior change techniques, may help to improve the clinical effectiveness and impact of programs of care [54,55]. Our findings also indicate that some programs of care for musculoskeletal disorders in the active military were acceptable, appropriate, feasible, and sustainable.
Our study has research implications. Future research should better describe the implementation steps of programs of care. Some studies in our review provided little information describing how programs of care were implemented. Implementation strategies are complex social interventions addressing multifaceted processes within interpersonal, organizational, and community contexts [56][57][58]. Therefore, as with clinical intervention research, implementation interventions need to be precisely described to enable measurement and reproducibility [59] of their components [60]. Proctor and colleagues proposed guidelines for naming, defining, and operationalizing implementation interventions in terms of seven dimensions: actor, the action, action targets, temporality, dose, implementation outcomes addressed, and theoretical justification [60]. Following these guidelines may improve the understanding of how, why, when, and where implementation interventions work. Having well-described implementation interventions should allow researchers to study their effectiveness on implementation in properly conducted trials; this is a major research priority.
While a multidisciplinary approach was common, further research should explore the optimal components of this approach. For example, which types of healthcare providers/community workers should be part of the team, do they need to be co-located, and what should their roles be to optimize efficiency, safety, and clinical-and cost-effectiveness of musculoskeletal care? For instance, evidence suggests that extended scope physiotherapists provide equal or better care than physicians for musculoskeletal conditions in terms of diagnostic accuracy, treatment effectiveness, use of healthcare resources, economic costs, and patient satisfaction [61,62]. Interprofessional musculoskeletal models of care and the extension of the scope of practice for allied health professionals (e.g., therapist-led care) are becoming priorities in high-income countries due to rising healthcare costs, physician shortages, aging of the population, and the increased prevalence of chronic diseases [63]. In our current review, we observed that some team members were co-located and this was useful for consultation. Further research might explore whether team members that manage musculoskeletal conditions should be co-located or if they function similar to remote/ virtual teams in terms of safety, efficiency, and effectiveness. Nonetheless, "optimal effectiveness of clinical care teams requires a culture of trust; shared goals; effective communication; and mutual respect for the distinct skills, contributions, and roles of each member" [64].
Most of the barriers and facilitators of implementation mapped onto the opportunity component of the COM-B model; thus, they are generally modifiable. Future research should investigate the effectiveness of behavior change techniques that target these barriers [22,65]. For example, barriers to clinical practice guideline compliance, some of which were identified in the studies we reviewed, include awareness, familiarity with the content, skills, difficulty in changing usual practice, equipment, space, time, staff, and financial resources [66]. Electronic health records that support integration of guidelines at the point of care, clinical decision support tools, and financial incentives/compensation are some ways to alter the physical environment to promote guideline compliance [67,68]. In addition, leadership support and opinion leaders can create a social environment that facilitates guideline uptake by addressing provider beliefs and attitudes [69].
Finally, regarding outcomes, evaluating and reporting implementation outcomes should precede the evaluation and report of service and patient outcomes [23]. A number of implementation outcomes were either not evaluated or had limited evaluation such as fidelity, penetration, sustainability, adoption, and costs. Further, valid and reliable measures of implementation outcomes are required and should be used consistently by researchers; work is underway in this area [70].

Strengths and limitations
Our scoping review has strengths. Our health sciences librarian conducted a broad and methodologically rigorous literature search, which was reviewed by a second librarian. We outlined detailed inclusion/exclusion criteria to identify relevant studies, pairs of independent trained reviewers screened the literature, and we used theoretical frameworks (EPOC, COM-B, Proctor et al.'s taxonomy of implementation research outcomes) to map and synthesize our findings. Potential limitations include the potential for missed studies not identified through the search strategy, and the use of studies published in English only. However, evidence suggests that this language restriction would not have significantly altered our results [71][72][73]. Another limitation was that we did not qualitatively analyze comments from authors of studies, which may have provided deeper insight into our scoping review results.

Conclusion
Musculoskeletal disorders are a leading cause of disability in the military and effective treatment strategies are required to improve return to duty and maintain operational readiness. However, implementing programs of care is challenging given the complexity of the military healthcare system. We synthesized the available scientific literature regarding implementation interventions for musculoskeletal programs of care in the active military, and the barriers, facilitators, and outcomes of implementation. Further research is needed to better understand the various components and players of implementation interventions, how to overcome barriers to implementation, effectiveness of implementation interventions, and on implementation outcomes and their measurement. Once a program of care is successfully implemented, the ultimate goal is to determine whether it improves important patient outcomes such as recovery and return to duty. United States Department of Defense/