m Crowell, e florkiewicz, j morris, j mason, w pitt, t benedict, k cameron, d goss

Abstract accepted for platform presentation at the 2025 American Physical Therapy Association Combined Sections Meeting- Houston, TX

Purpose/hypothesis: Shoulder instability is common in active young athletes and military personnel, often requiring shoulder stabilization surgery. Acute post-operative pain is usually managed with opioid pain medications, which have adverse effects that reduce military readiness. Battlefield Acupuncture (BFA) has demonstrated promise as a non-pharmaceutical intervention for acute post-operative pain. The purpose of this randomized clinical trial was to assess the effectiveness of BFA on post-surgical pain and opioid medication usage.

i gaunaurd, m sumner, p pasquina, a symsack, j haynes, c bennett, r gailey

Abstract accepted for platform presentation at the 2025 American Physical Therapy Association Combined Sections Meeting- Houston, TX

Purpose/hypothesis: Veterans with lower limb loss (LLL) are a complex population with their own unique challenges with rehabilitation but share many commonalities with the general population. This case series highlights two examples of a physical therapist and patients with LLL who participated in the Mobile Device Outcomes Based Rehabilitation Program at the Bruce W. Carter VA Medical Center, Miami, FL using a novel mobile sensor system and application called Rehabilitative Lower Limb Orthopaedic Assistive Device (ReLOAD) to augment rehabilitation.

i gaunaurd, p pasquina, a symsack, m sumner, j haynes, t fields, a munoz-boyle, l prasso, christina sole-plasa, j stevens, c bennett, b applegate, b isaacson, r gailey

Abstract accepted for platform presentation at the 2025 American Physical Therapy Association Combined Sections Meeting- Houston, TX

Purpose/hypothesis: Supported by the DoD/VA Joint Incentive Fund, Mobile Device Outcomes-based Rehabilitation Program (MDORP) utilizes mobile technology, called Rehabilitative Lower Limb Orthopedic Assistive Device (RELOAD) to enhance the rehabilitation of Services Members (SMs) and Veterans with lower limb loss (LLL). The ReLOAD system assesses walking quality, provides auditory feedback to correct gait deviations, and recommends patient-speci c exercises that target their impaired function and limitations. The purpose of this study is to examine the use of the RELOAD system in the clinical practice of Physical Therapists (PTs) to optimize assessment and care of SMs and Veterans with LLL.

A Symsack, i gaunaurd, j haynes, m sumner, c bennett, b isaacson, p pasquina, r gailey

Abstract accepted for platform presentation at the 2025 American Physical Therapy Association Combined Sections Meeting- Houston, TX

Purpose/hypothesis: The home-based exercise program (HEP) for patients in rehabilitation following lower limb loss (LLL) is an integral part of the continuity of care outside the clinic for the maintenance and improvement of strength, mobility, and functional goals. However, clinical evidence shows that patients have varying degrees of exercise adherence to HEPs. Evidence-based exercise prescription to improve HEP adherence has suggested dosing of 20 minutes daily, minimum of three times per week or the completion of two-thirds of the prescribed exercise routine. The purpose of this study is to determine patient adherence to their HEP among SMS and Veterans with LLL using the Rehabilitative Lower Limb Orthopaedic Assistive Device (ReLOAD).

A Symsack, i gaunaurd, j haynes, m sumner, c bennett, b isaacson, p pasquina, r gailey

Abstract accepted for platform presentation at the 2025 American Physical Therapy Association Combined Sections Meeting- Houston, TX

Purpose/hypothesis: The rehabilitation for Service Members (SMS) and Veterans with lower limb loss (LLL) can involve months of prosthetic training and targeted exercises intended to improve gait quality and functional mobility. During this time, Physical Therapists (PTS) prescribe home exercise programs (HEP) as part of the plan of care, which serve to augment treatment and improve or maintain patient function while outside the clinic. The purpose of this study is to identify the targeted exercise prescription trends following initial evaluation (eval) among PTS who are participating in the Mobile Device Outcomes Based Rehabilitation Program (MDORP) for SMS and Veterans with LLL.

t velasco, n reilly, c hulsopple, k roberts, s wise, d goss, j leggit

Abstract accepted for poster presentation at the 2025 American Physical Therapy Association Combined Sections Meeting- Houston, TX

Background and Purpose: Chronic exertional compartment syndrome (CECS) is a debilitating condition for soldiers marked by lower-limb pain, paresthesia, and weakness1,2. While the gold standard treatment has long been fasciotomy, anecdotal data shows mixed results and limited predictive success following the procedure3,4. Alternative approaches to treating CECS have included pharmaceutical interventions (i.e., Botulinum toxin, BoTN-A)5,6 and structured gait retraining to ameliorate movement patterns7. However, the incorporation of a combination of non-surgical interventions for CECS has not been extensively studied in military personnel. Thus, the purpose of this case study was to evaluate a multimodal combination of treatment approaches for CECS in a soldier to identify an efficacious way to address running parameters and reduce pain to improve function.  

Case Description: A 27-year old female Soldier diagnosed with bilateral anterior and lateral lower leg CECS was recruited to participate in a larger cohort study.  She received saline injections and supervised gait retraining, including strengthening and flexibility exercises. The participant had their running gait assessed using pressure-sensitive insoles (LoadSol, Novel USA, St. Paul, MN) at the initial treatment, after 8-weeks, 3-months, and 6-months. Time points of 12- and 24-months running assessments were not collected as she moved out of network. Between the 3- and 6-months visit, the participant elected to cross-over treatment therapies and received BoTN-A. Clinical metrics included numeric pain rating scale (NPRS), the Single Assessment Numerical Evaluation (SANE) and University of Wisconsin Running Index (UWRI), as well as the Global Rating of Change scale (GROC). These metrics were obtained up to 24 months post initial injection.

Outcomes: From baseline to the 3-month mark, the participant showed improvement on clinical metrics including a 90.9% increase in UWRI and a GROC of 5. These metrics are accompanied by a 22.5% increase in cadence and a 10.2% decrease in peak ground reaction force (GRF). Notably, the patient still reported an NPRS of 5/10 (7/10 baseline) with running at 3-months. Following the BoTN-A injections, the participant at 6-months displayed a 17.9% decrease in average vertical loading rate (AVLR) and a 2.0% decrease in peak GRF. Clinically, she displayed improvements in UWRI of 47.6%, SANE of 20.0%, and a GROC of 6, along with NPRS of 0/10 with running. At 12-months, NPRS remained at 0/10 with running, but UWRI and GROC scores slightly decreased, likely from her reported knee injury. At 24-months, the participant reported no pain with running and perfect SANE, UWRI, and GROC scores.

Discussion: This case study demonstrates gait retraining can be beneficial for improving pain and function in soldiers with lower leg CECS.  The addition of BoTN-A injections in this case suggests it may be a useful supplemental modality in rehabilitation for long-term benefits for CECS patients. However, further research is needed to confirm these findings in a larger population.

m smith, x yuan, j smith, j banks deal jr, g nanos, s tintle, d reece, m miller

Abstract awarded the Jamie Dianne Bulken-Hoover Memorial- Best Hand Paper at The Society of Military Orthopedic Surgeons Annual Meeting in Nashville, TN- December 2024

Carpal tunnel release (CTR) using a mini-open (mOCTR) or endoscopic approach is the current standard of care (SOC) in the Military Health System (MHS) for management of refractory carpal tunnel syndrome (CTS), the most common peripheral entrapment neuropathy. CTR techniques have evolved over time to reduce iatrogenic tissue trauma and post-operative pain, promoting quicker recovery and improved outcomes. CTR using Ultrasound Guidance (CTR-US) is a promising treatment option under study for military beneficiaries with CTS in a trial comparing outcomes of CTR-US and mOCTR.

This single-site pragmatic randomized controlled feasibility trial at Walter Reed National Military Medical Center (WRNMMC) was approved by the Institutional Review Board (WRNMMC-2020-0278). Military beneficiaries (18-89 years) with clinical, electrodiagnostic, and sonographic findings consistent with CTS were enrolled. Exclusion criteria included prior wrist surgery, median nerve trauma, or sonographic findings precluding safe and effective CTR-US.

Participants were randomized to receive either CTR-US by board-certified Physical Medicine and Rehabilitation physicians with advanced training in ultrasound-guided procedures in a clinic procedure room with local anesthesia, or mOCTR by board-certified Orthopedic Hand Surgeons in a clinic procedure room with local anesthesia or operating room (OR) with moderate sedation. CTR-US was performed under continuous ultrasound guidance with a device featuring inflatable balloons to create space within the carpal tunnel and a retractable blade that releases the transverse carpal ligament in a retrograde manner.

Demographics and patient-reported outcome measures (PROMs) were collected at baseline. Follow-up PROMs were collected at 1, 2, 3, 4, 6 weeks, 3, 6, 12, and 24 months post-procedure. The primary outcome was the Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) at 1 month. Additional outcomes included Boston Carpal Tunnel Questionnaire – Symptom Severity Scale (BCTQ-SS), Numerical Pain Rating Scale (NPRS), Global Assessment of Satisfaction, Global Rating of Change (GROC), modified 2-item CTS Palmar Pain Scale; grip and pinch strength (3 and 12 months); procedure time and incision length; and adverse events. Descriptive analyses reported central tendencies in terms of location (e.g., mean) and scale (e.g., standard deviation) for all study variables. Inferential analyses included two-sample Welch’s T-tests (α = 0.01) for procedural data and complete-case, intention-to-treat, generalized additive models incorporating multi-level structures through patient-level random effects for all other outcomes. No confidence interval (α = 0.05) overlaps on generalized additive models indicated statistical significance.

CTS is the most common peripheral entrapment neuropathy, impacting the health of military beneficiaries. CTS treatment barriers within the MHS include limited access to subspecialty care, lack of resources, and OR procedural costs. Preliminary data from this trial suggest that CTR-US can be performed within a clinic environment by non-operative physicians with advanced training, resulting in decreased post-procedural incisional pain and non-inferior outcomes compared to mOCTR approach out to 2 years. Outcomes of this WRNMMC trial can facilitate expansion of available CTS management options within the MHS, improving access to care and operational readiness.

cheema n, ghag n, wise e, pham l, nazarian a, fuchs c, tam j, anderson r

Abstract accepted for poster presentation at the 2024 Military Health System Research Symposium

Fatigue is defined by the reduction of a muscle’s strength and performance during exercise, and it is affected by different parts of the motor pathway controlling muscle contractions. Fatigue limits performance and unless allowed to recover, continuous activity will result in musculoskeletal injuries that are commonly observed in military personnel. Light therapy has been shown to have several beneficial physiologic effects in a wide range of tissues. The musculoskeletal system can be irradiated with wavelengths in red and near infrared (NIR) regions which penetrate deep into the body. Recent studies are suggesting that photobiomodulation therapy (PBMT) can reduce pain, inflammation and enhance physical performance. However, the mechanism(s) of cellular responses by PBM in muscle is not clearly understood. There is no standardization in parameters for PBMT, with researchers and clinicians using a wide range of wavelengths, fluences, etc. Therefore, the goal of this study is to improve our understanding of the mechanism(s) of action of PBM effects on the musculoskeletal system, ultimately to inform the choice of clinical treatment parameters. We investigate the application of 830 nm and its effect on fatigue induced in intense exercise in mice. We performed a treadmill fatigue assay on mice and collected muscle tissue for histological and biochemical analysis. We observed that PBMT mice ran twice as long. Electron microscopy of fatigued muscle had some evidence of cellular stress where mitochondrial structure is altered whereas 830 nm treated muscle had a preservation of mitochondrial morphology. RNAseq data from fatigue muscle suggests that treated mice have an upregulation of genes involved in tissue remodeling, specifically cytoskeletal and vasculature markers. During muscle regeneration, mechanoreceptors, known as muscle spindle fibers form after innervation by the motor neuron. We saw increased number of muscle spindle fibers, which stimulate muscle contraction in response to stretch. Other signs of muscle regeneration, also observed in our treated muscle, are myoblast fusion and central localization of the myonucleus. In conclusion, our study suggests that 830 nm may have altered the muscle by activating regenerative genes that protect the muscle from cellular stress from intense exercise. 

Guastaldi f, monteiro j, giorgino r, tynan m, leartprapun n, nadkarni s, randolph m, redmond r

Abstract accepted for poster presentation at the 2024 Military Health System Research Symposium

Articular cartilage and the meniscus are essential for smooth joint movements, but often degenerate due to trauma and overuse. Conventional repair methods like microfracture and autologous cell implantation frequently yield fibrocartilage instead of hyaline cartilage. Tissue engineering, exemplified by dynamic Self-Regenerating Tissue (dSRT), offers a promising solution by leveraging regenerative potential of cells. Fractional laser treatment, proven effective in skin regeneration, can be an adjunct for cartilage repair. This study evaluated the use of dSRT for cartilage and meniscus repair in a swine knee model. Laser Speckle Rheological Microscopy (SHEAR) was also employed to assess biomechanical properties.

dSRT displayed successful matrix formation, with good integration observed in laser-ablated channels in cartilage. This innovative approach holds promise for articular tissue resurfacing, albeit requiring further in vivo validation for knee meniscus repair.

giorgina r, rossi n, bejar-chapa m, monteiro j, guastaldi f, kostyra d, hussey m, tynan m, peretti g, randolph m, redmond r

Abstract accepted for poster presentation at the 2024 Military Health System Research Symposium

Inflammation in shoulder and knee joints typically results in pain, stiffness and loss of function. Shoulder injuries in the military (rotator cuff tears, dislocations, etc) can lead to adhesive capsulitis ("frozen shoulder"). Similarly, arthritis involves inflammatory processes subsequent to injury. Both conditions are managed using non-steroidal anti- inflammatory drugs (NSAIDs), steroids, or surgery, with varying effectiveness and side effects. Photochemical tissue passivation (PTP) drastically reduces inflammation in wound healing and in this study we investigate PTP for reducing progressive inflammatory damage in both joints.

Reduced inflammation associated with frozen shoulder and knee osteoarthritis using PTP in rat models are highly encouraging. Findings highlight the important role of the joint capsule in frozen shoulder and the synovial tissue in the knee in the pathogenesis of arthritis.

giorgina r, monteiro j, guastaldi f, hussey m, tynan m, peretti g, randolph m, redmond r

Abstract accepted for poster presentation at the 2024 Military Health System Research Symposium

Severe ligament injuries are associated with trauma involving excessive force to the knee joint, and are common in the military. Ligaments are fundamental for the structural and functional integrity of the knee and effective strategies for surgical repair are of paramount importance for return to active duty and long-term joint health. Photochemical tissue bonding (PTB) has good potential for treating complex orthopedic conditions, PTB using light and a photoinitiator to generate crosslinks between collagen molecules to augment mechanical strength. Advantages include focal precision, a barrier to adhesion between healing and surrounding tissues, and the ability to promote healing without foreign materials or invasive mechanical devices. In cases of complete injuries, the preferred treatment is generally surgical and reconstructive. In instances of isolated and non-complete injuries, non-operative treatment is indicated. However, partial ligament injuries pose a challenge as they often do not optimally respond to conservative treatments and can lead to long-term compromise of knee stability. This study examined the application of PTB in partial ligament injuries using the medial collateral ligament (MCL) in a swine model.

Self-healing of partial ligament injuries can lead to chronic instability, increased rupture risk, and early arthritis. Improvement of partial knee ligament repair with PTB would result in better outcomes through maintaining optimal biomechanical properties.

zhang h, schulz-hildebrandt h, domingue carrerra u, panikkar a, tearney g

Abstract accepted for poster presentation at the 2024 Military Health System Research Symposium

Ultrasound guidance is essential for vascular access. However, ultrasound is limited by the unreliable visibility of the needle tip. To address this issue, our team developed a photoacoustic imaging device that differentiates between arteries and veins by inserting a fiber into the cannula for visualization. However, this technology required an external ultrasound system, which was not compatible for battlefield application. In this abstract, we report on our next generation needle tracking system that utilizes portable ultrasound to achieve robust needle tip tracking. These advances can potentially make accurate needle tip tracking practical on the battlefield. This needle tip tracking technology is based on Light- enhanced Ultrasound (LEUS) that integrates near-infrared light with ultrasound detection to enhance the capabilities of ultrasound in trauma care. LEUS features a novel photoacoustic mode that enables visualization of light-absorbing structures by detecting light-induced sound waves. Here, we utilize this effect to generate a photoacoustic beacon via fiber delivery. Specifically, we have designed a 130-um trench on the outer wall of a needle (800-um inside diameter) to contain the fiber, and we coated a 140- um photoacoustic beacon with a mixture of graphite and biocompatible epoxy at the tip of the fiber. Our coated beacon source emits the light-induced ultrasound signal with 5-mJ illumination. Additionally, we developed software to acquire ultrasound and photoacoustic signals simultaneously, enabling the real- time display of overlaid duplex images. We conducted testing by puncturing the smart beacon needle in a vascular access ultrasound phantom (VATA Inc.). In the pure Ultrasound B mode, the structure of the needle tip was challenging to discern. However, when switching to the LEUS system, the beacon signal consistently appeared as a red spot, clearly representing of the needle tip. Remarkably, the red spot remained visible at the maximum depth of 30 ± 0.23 mm. Throughout this depth range, the signal-to- noise ratio of the beacon signal remained constant at 15dB, demonstrating a stable signal suitable for vascular guidance. Here we show a portable LEUS-driven vascular access guidance system with greatly enhanced needle tip visualization. This technology has great potential for improving the accuracy of vascular access by emergency medical providers without extensive vascular training.

Metzger e, hager n, ory r, lucio w, mckee s, anders j, givens m, wagner l, isaacson b, pasquina p

Abstract accepted for Oral presentation at the 2024 Military Health System Research Symposium

Photobiomodulation (PBM) involves applying non- ionizing forms of light from various sources including lasers, light-emitting diodes (LEDs), and broadband light, in the visible and near infrared spectrum, to biologically modulate cellular activity to enhance healing. PBM treatment can enhance repair and regeneration of tissue, stimulate metabolism, and reduce inflammation and pain during injury recovery. We are investigating use of this modality to increase Warfighter quality of life, and improve operational readiness, focusing on musculoskeletal (MSK) injury, performance, recovery, self-reported behavioral health, wellness, and nerve, hearing, and wound healing.

The Defense Health Agency supported the creation of the Photomedicine to Enhance Military Readiness program. This portfolio utilizes 16 PBM studies - 7 basic science studies, 8 randomized-control clinical trials, 1 normative study - to assess and

Hollander M, hagen j, givens m, metzger e, anders j, wagner l, isaacson b, pasquina p, hager n

Abstract accepted for poster presentation at the 2024 Military Health System Research Symposium

Photobiomodulation Therapy (PBMT) utilizes light sources such as LEDs in order to provide a noninvasive means to enhance performance and accelerate recovery. Currently, practitioners utilize photobiomodulation devices in musculoskeletal injury rehabilitation, physical performance enhancement, and cognitive optimization. This study intends to address a critical gap in the understanding of PBMT technologies by providing empirical validations of the spectral and irradiance outputs of commercially available PBM devices.

This study investigated full body photobiomodulation (PBM) light beds. The study team utilized a spectrometer to determine the respective wavelengths produced by each device. Irradiance measurements were determined using a power meter and a specific area of illumination. Measurements collected at consistent intervals along the X and Y axes of the devices investigated variability across the illuminated surfaces. Additional variability assessments were based on body placement, treatment distances, and comparisons of the top and bottom canopy of PBM light beds. In addition, irradiance variations over a day of treatments and during independent sessions were measured. Utilizing these repeated measurements, the impact of temperature on irradiance was determined.

The spectral and irradiance investigations highlight the distinct characteristics of each device and help inform ideal-use scenarios between the commercial PBMT devices. These preliminary findings offer a comprehensive understanding of irradiance variability in PBMT to help preface future clinical investigations on the use of this cutting-edge technology in military contexts.

Hughes n, cornell b, gabler g, rossi r, metzger e, hager n, wagner l, isaacson b, pasquina p

Abstract accepted for poster presentation at the 2024 Military Health System Research Symposium

Special Operations Forces (SOF) train continually to maintain peak performance. Thus, they are nearly always in a state of recovery, and in need of noninvasive therapies to address the taxing workload. Photobiomodulation therapy (PBMT) is a noninvasive treatment where a low-level laser is applied to the body to enhance healing, recovery, and performance. Army Tactical Human Optimization Rapid Rehabilitation and Reconditioning (THOR3) provides a consistent avenue for implementation of PBMT as a modality. Studies in athletes have shown performance and recovery benefits with pre-and post-workout focal application of PBMT. While there is less evidence on the potential cognitive/behavioral effects of a systematic application of PBMT, self-reported fatigue has also been found to be significantly lower in groups with focal PBMT application as compared to placebo. Further, PBMT research in healthy military tactical athletes is limited. PBMT may be a promising tool for enhancing physical performance by accelerating musculoskeletal and psychological recovery in the SOF population. We aim to study the physiologic and behavioral effects of PBMT application post-exercise on performance in SOF Operators.

PBMT shows promise in accelerating musculoskeletal repair and psychological resilience, reducing injury risk, and enhancing performance in these domains. Potentially, this study may inform standards of training and care to maximize readiness among elite warfighting units.

Negri l, farinelli w, korupolu a, lee h, wang y, hui j, tam j, andy yun s, gelfand j

Abstract accepted for poster presentation at the 2024 Military Health System Research Symposium

We developed an antimicrobial blue light (ABL) device prototype for treating skin wounds, an application for which no approved devices exist. The prototype was tested in a preclinical, in vivo porcine wound model, with partial-thickness wounds heavily infected with methicillin-resistant Staphylococcus aureus (MRSA), the leading antimicrobial resistant (AMR) wound pathogen isolated worldwide.

Our prototype reduced MRSA by 4.7 logs (>99.99%) compared to untreated wounds after only two simple, once-a-day treatments (p<0.0001). These proof-of-principal results suggest ABL could reduce the number of days, doses, and costs of antibiotics for skin wounds, reducing AMR and costs of care. As a stand-alone treatment, or in combination with antimicrobials, these preclinical results support a potential role for our ABL device prototype in treating wound infections.

Karikari n, rossi r, gabler g, grogan s, schroeder j, free k, lopez p, dannenbaum j, hager n, metzger e, isaacson b, wagner l, pasquina p

Abstract accepted for poster presentation at the 2024 Military Health System Research Symposium

Lower extremity musculoskeletal injuries (MSKIs) are the primary reason for limited duty in Active-Duty Service Members (ADSMs). MSKIs account for 60% of limited duty days and 65% of medical nondeployability in ADSMs. Knee Osteoarthritis (KOA) - a degenerative joint disease resulting in cartilage loss due to wear and tear or by a force applied to the knee - is frequent in the United States Military with over 20,000 cases detected in ADSMs over a 10-year period. Photobiomodulation (PBM) and Platelet-rich Plasma (PRP) have both emerged as promising treatments for boosting knee function and decreasing stiffness and pain. Ideal PBM dosage, optimal PRP treatment, and the biological cascade of each treatment as well as the potential additive treatment of PRP and PBM together merits further investigation. This study aims to assess the effect PBM has on PRP injections for KOA treatment through evaluations of synovial and serum inflammatory and reparative biomarkers. The treatments are compared through four arms: Physical Therapy (PT) vs PT + PRP vs PT + PBM vs PT + PRP + PBM. The relationship between pain, function and treatment is analyzed in addition to the biomarkers obtained from participant biologics. These aims seek to inform KOA treatment practices and improve ADSMs return to duty.

All participants completed a blood draw and knee joint aspiration at the baseline and again at 6-weeks post-baseline. Each participant was randomized to PT, + PBM, +PRP, or + PRP + PBM. PBM was delivered three times a week for three weeks. PRP was injected at the baseline. Further data collection was completed through the Defense and Veteran’s Pain Rating Scale, Single Assessment Numeric Evaluation, Knee Injury and Osteoarthritis Outcome Score, The Veterans RAND 12 Item Health Survey questionnaires and activity logs to monitor participant progression. Participants completed the study at 6 weeks and provided a second blood draw and knee aspiration at that time

Both PRP and PBM have shown promise in aiding healing and slowing the progression of KOA. When applied together, these interventions may improve outcomes for ADSMs suffering from KOA. This has the potential to positively impact the health and performance of our warfighters.

Rossi r, gabler g, persinger j, karikari n, mckee s, schroeder j, grogan s, hager n, metzger e, isaacson b, wagner l, pasquina p

Abstract accepted for poster presentation at the 2024 Military Health System Research Symposium

Non-insertional Achilles Tendinopathy (AT) is a common overuse injury in active and sedentary adults. In the military, overuse injuries of the lower extremity (e.g., AT) are the most common category of disability and are most prevalent in the Army. Research studying the sub-population of AT amongst active duty (AD) personnel is scant and warrants analysis given its high prevalence. Current laser-induced photobiomodulation (PBMT) studies demonstrate increased cell proliferation and metabolism, which may aid the tendon repair and remodeling process. Extracorporeal shockwave therapy (SWT) is a process that delivers energy to the muscles or tendons for pain relief and to enhance tissue repair.  by stimulating an inflammatory response and healing cascade.Studies support ESWT as an effective treatment for AT when combined with eccentric strengthening (ECC). The addition of PBMT may enhance these effects by increasing cellular function and optimizing the cascade. Thus, the combination of modalities should be investigated. The primary aim of our trial is to evaluate the effects of four randomized treatment groups in the management of AT: Physical Therapy (PT), PT with SWT, PT with PBMT, and PT combined with SWT and PBMT.

Participants receive self-guided ECC PT. The PT/SWT arm receives weekly SWT for three weeks. The PT/PBMT arm receives twice weekly PBMT for three weeks. The PT/SWT/PBMT arm receives both interventions. Baseline, three-month, and six-month intervals assess ultrasound measures (cross-sectional area, width/degree of thickening within the tendon at the site of maximal circumference/maximal pain, neovascularity, and elastography), quantitative function in heel raises to fatigue, ankle strength, and ROM are assessed at baseline, three months, and six months. The following surveys are collected: Victorian Institute of Sports Assessment–Achilles, Patient-Reported Outcomes Measurement Information System, The University of Wisconsin Running Injury and Recovery Index, Defense and Veteran’s Pain Rating Scale, and Lower Extremity Functional Scale.

PBMT and SWT are effective tendinopathy treatments. Combining both modalities may elicit synergistic structural changes and modulate AT pain. This study can potentially promote positive change in the management of AT, which adversely affects the military population, by promoting novel treatment options for our warfighters.

Persinger j, mincey c, gabler g, rossi r, grogan s, hager n, schroeder j, metzger e, isaacson b, wagner l, pasquina p

Abstract accepted for poster presentation at the 2024 Military Health System Research Symposium

Musculoskeletal injuries are commonly found in active-duty service members and military recruits. The use of new non-invasive ultrasound technologies, such as microvascular flow (MVF) and shear wave elastography (SWE), may prove to be appropriate and cost effective in the early diagnosis of these injuries. The Geneva Foundation in conjunction with Uniformed Services University of the Health Sciences, and the Madigan Army Medical Center is conducting a research study to establish normative values for thickness, MVF, Power Doppler (PD), and Young’s modulii in the posterior lower leg. 

Ultrasound evaluations are conducted utilizing a Samsung RS-85 Prestige with shear wave elastography and microvascular flow capabilities.  The TeleRay Remote cloud-based platform is utilized for secure storage and ultrasound image review with the additional capacity to allow remote observation. By study completion, 206 ultrasound examinations will be conducted on asymptomatic participants by a Registered Musculoskeletal Sonographer (RMSKS) credentialed provider. Image acquisition is standardized using EZ Exam. Imaging is obtained from the Achilles insertion to the gastroc-soleus complex with stop points at the calcaneal insertion, avascular zone, gastroc-soleus junction, gastrocnemius, and soleus.  Measurements are obtained in orthogonal planes to obtain the width and height at each of the sites. Using a system preset optimized for low-flow states Power Doppler and MVF evaluation is conducted at each point with comments noting the number vessels in the region of interest. SWE interrogation is conducted utilizing a system preset optimized for tendon elastography.

MVF has been shown to be more sensitive than PD (19 instances of flow vs 3).  Further evaluation with SWE will continue to provide the normal range of values in this application. 

Fellin c, steiner r, buchen j, woodle s, yuan x, anders j,

jariwala s

Abstract accepted for poster presentation at the 2024 Military Health System Research Symposium

The most severe case of peripheral nerve injury (PNI) involves complete transection of the nerve. One therapeutic approach uses nerve guidance conduits (NGCs) to facilitate nerve regeneration. Recently, three-dimensional (3D) bioprinting has been adopted for the fabrication of biomimetic conduits. However, many of these NGC therapies fail to achieve full reinnervation making it necessary to employ a combinatorial approach that incorporates treatments in conjunction with 3D printed conduits. Photobiomodulation Therapy (PBMT) utilizes electromagnetic energy to achieve beneficial therapeutic outcomes. Most notably, exposure to near-infrared light (700 - 1100 nm) has been shown to reduce inflammation and improve neural regeneration. Herein, we investigate whether the use of a novel 3D printed NGC in conjunction with PBMT (980 nm) will improve nerve regeneration when used as a combinatorial approach in a rodent sciatic nerve transection model.

The tissue of conduit-repaired rodents displayed no sign of foreign-body reaction, inflammation, or macrophage infiltration. The conduits remained sutured to the nerve stumps and displayed a high degree of ECM integration and neovascularization. Histological analysis indicates new nerve tissue present inside the conduit lumen with typical axon and vasculature anatomical features. Rodents treated with PBMT displayed significantly more regenerating nerve tissue within the conduit.

The results of this study demonstrate successful implantation of the DLP 3D printed NGC with no observable foreign-body reaction, a high degree of ECM integration, and neovascularization. Nerve regeneration was detected within the conduit and improved with the addition of PBMT. These findings support the use of PBMT as a combinatorial approach to conduit-based peripheral nerve repair.