martin c, nocera m, mercer j, marshall s, davi s, curtin j, cameron k

Mobile applications (apps) may be beneficial to promote self-management strategies to mitigate the risk of developing post-traumatic osteoarthritis in military members following a traumatic knee injury. This study investigated the efficacy of a mobile app in facilitating behavior modification to improve function and symptomology among military members.

This is a preliminary pre and post hoc analysis of a randomized control trial. The MARX scale, Intermittent and Constant Osteoarthritis Pain (ICOAP) questionnaire, and the Knee Injury and Osteoarthritic Outcome Score Readiness to Manage Osteoarthritis Questionnaire were completed at baseline, 6-week, 6-month, and 12-month follow-up. Participants in the treatment arm completed the System Usability Scale. Data were analyzed using descriptive statistics, the Wilcoxon sum of ranks test, the Wilcoxon signed-rank test, and Cohen’s d effect size.

A total of 28 participants were included. Between-group differences for baseline and 6-week follow-up were significantly improved in the injured knee ICOAP constant pain score for the treatment group (treatment: −4.2 ± 12, 95% CI: −11.5, 3.1; control: 5.5 ± 9.9, 95% CI: 0.9, 10.1; P = .035, effect size = 0.905). Within-group differences for baseline and 6-week follow-up demonstrated a significant decline in the injured knee ICOAP constant pain score among the control group (signed-rank: 16.0, P = .031, Cohen’s d = 0.339). No other significant differences were observed. A good System Usability Scale score for usability was found (76.6 ± 8.8).

These results indicate that the mobile app is easy to use and may contribute to improved constant pain symptomology for patients at risk for post-traumatic osteoarthritis.

Chelsea Leonard Martin, Maryalice Nocera, Jeremy Mercer, Stephen W Marshall, Steven M Davi, Jessica J Curtin, Kenneth L Cameron, Efficacy of a Novel Telehealth Application in Health Behavior Modification and Symptomology in Military Service Members at Risk for Post-traumatic Osteoarthritis, Military Medicine, 2023;, usad435, https://doi.org/10.1093/milmed/usad435

Juman L, Schneider E, Clifton D, Koehlmoos T

Injuries are the leading cause of medical encounters with over 2 million medical encounters for musculoskeletal (MSK) conditions and over 700,000 acute injuries per year. Musculoskeletal injuries (MSKIs) are by far the leading health and readiness problem of the U.S. Military. The Proceedings of the International Collaborative Effort on Injury Statistics published a list of 12 data elements deemed necessary for injury prevention in the civilian population; however, there are no standardized list of common data elements (CDEs) across the DoD specifically designed to study MSKIs in the Military Health System (MHS). This study aims to address this gap in knowledge by defining CDEs across the DoD for MSKIs, establishing a CDE dictionary, and compiling other necessary information to quantify MSKI disease burden in the MHS.

Luke Juman, Eric B Schneider, Dan Clifton, Tracey Perez Koehlmoos, Common Data Elements and Databases Essential for the Study of Musculoskeletal Injuries in Military Personnel, Military Medicine, 2024;, usae241, https://doi.org/10.1093/milmed/usae241

Nowak A, Kennelley G, Hager N, Metzger E, Isaacson B, hoenig T, Hollander K, Tenforde A

We enjoyed reading the articles by Abbott, et al. that cover the important topic of stress fractures in female military personnel “Part I: Background and Clinical Considerations for Stress Fractures in Female Military Recruits” and “Part II: Risk Factors for Stress Fractures in Female Military Recruits.” Both reviews identify that female military personnel are at a greater risk for stress fractures during training than their male counterparts and detail unique risk factors that are a necessary consideration in optimizing management. While we congratulate the authors for this detailed work, it is important to highlight additional research that adds to our understanding of this injury and the approach for management and prevention of these injuries.

Andrew S Nowak, Gabrielle E Kennelley, Nelson Hager, Elizabeth C Metzger, Brad Isaacson, Tim Hoenig, Karsten Hollander, Adam S Tenforde, Stress Fractures in the Military: Opportunities to Advance Recognition, Treatment, and Prevention, Military Medicine, Volume 188, Issue 9-10, September/October 2023, Pages 244–245, https://doi.org/10.1093/milmed/usad067

Yuan X, Pav V, Colahan C, Miller M, Nelson H, Pasquina P, Cohen S, Isaacson B

Low back pain (LBP) has accounted for the most medical encounters every year for the past decade among Active-Duty Service Members (ADSMs) of the U.S. Armed Forces. The objectives of this retrospective, descriptive study was to classify LBP by clinical category (Axial, Radicular, and Other) and duration (Acute, Subacute, and Chronic) and examine the LBP-related health care utilization, access to care, and private sector costs for ADSMs over a 2-year follow-up period. The Military Health System Data Repository was queried in fiscal year 2017 for all ADSMs (ages 18-62) with outpatient encounters documented with any of 67 ICD-10 diagnosis codes indicative of LBP. A 1-year clean period before the first (index) outpatient LBP encounter date was used to ensure no recent history of LBP care. Patients were eligible if continuously enrolled and on active duty for 1 year before and 2 years following the index visit. Patients were excluded for non-musculoskeletal causes for LBP, red flags, or acute trauma within 4 weeks of the index visit and/or systemic illness or pregnancy anytime during the clean or follow-up period.

Yuan, X., Pav, V., Colahan, C., Miller, M. E., Hager, N. A., Pasquina, P. F., Cohen, S. P., & Isaacson, B. M. (2022). Active-Duty Service Members Newly Presenting with Low Back Pain in Fiscal Year 2017: Health Care Utilization, Access to Care, and Private Sector Costs Over 2-year Follow-up. Military Medicine. https://doi.org/10.1093/milmed/usac363

Rhon D, Oh R, Teyhen D

The DoD has a specific mission that creates unique challenges for the conduct of clinical research. These unique challenges include (1) the fact that medical readiness is the number one priority, (2) understanding the role of military culture, and (3) understanding the highly transient flow of operations. Appropriate engagement with key stakeholders at the point of care, where research activities are executed, can mean the difference between success and failure. These key stakeholders include the beneficiaries of the study intervention (patients), clinicians delivering the care, and the military and clinic leadership of both. Challenges to recruitment into research studies include military training, temporary duty, and deployments that can disrupt availability for participation. Seeking medical care is still stigmatized in some military settings. Uniformed personnel, including clinicians, patients, and leaders, are constantly changing, often relocating every 2-4 years, limiting their ability to support clinical trials in this setting which often take 5-7 years to plan and execute. When relevant stakeholders are constantly changing, keeping them engaged becomes an enduring priority. Military leaders are driven by the ability to meet the demands of the assigned mission (readiness). Command endorsement and support are critical for service members to participate in stakeholder engagement panels or clinical trials offering novel treatments. To translate science into relevant practice within the Military Health System, early engagement with key stakeholders at the point of care and addressing mission-relevant factors is critical for success.

Rhon, D., Oh, R., & Teyhen, D. (2021). Challenges With Engaging Military Stakeholders for Clinical Research at the Point of Care in the U.S. Military Health System. Military Medicine. https://doi.org/10.1093/milmed/usab494

Symsack A, Gaunaurd I, Thaper A, Springer B, Bennett C, Clemens S, Lucarevic J, Kristal A, Sumner M, Isaacson B, Pasquina P, Gailey R

Telehealth is an increasingly common approach to improve healthcare delivery, especially within the Veterans Health Administration and Department of Defense (DoD). Telehealth has diminished many challenges to direct access for clinical follow-up; however, the use of mobile telehealth for specialty rehabilitative care is emerging and is referred to as telerehabilitation. As early adopters of telehealth, the Veterans Affairs and DoD have supported collaborated efforts for programs designed to increase the access and quality of rehabilitative care while improving the functional ability of our service members (SMs) and veterans with lower limb amputation (LLA). The DoD and Veterans Health Administration collaborated on a Mobile Device Outcomes-based Rehabilitation Program (MDORP) to help injured SMs and veterans with LLA. The MDORP project utilized a mobile health system called the Rehabilitative Lower Limb Orthopedic Accommodating Device (ReLOAD) to assess walking quality. The ReLOAD system includes real-time auditory biofeedback to notify the user of their most prominent gait deviation and then recommends exercises that address specific balance and strength impairments. The purpose of this study was to describe the responses to a postintervention survey evaluating the feasibility and usability of ReLOAD completed by SMs and veterans with LLA who used the system for 5 months.

Symsack, A., Gaunaurd, I., Thaper, A., Springer, B., Bennett, C., Clemens, S., Lucarevic, J., Kristal, A., Sumner, M., Isaacson, B., Pasquina, P., & Gailey, R. (2020). Usability Assessment of the Rehabilitation Lower-limb Orthopedic Assistive Device by Service Members and Veterans with Lower Limb Loss. Military Medicine. https://doi.org/10.1093/milmed/usaa428

Isaacson B, Miranda M, Hager N, Wagner L, West S, Lucio W, Heller J, Dalgarno R, Dickens J, Schoomaker E, Pasquina P

The cost of health care in the United States has increased exponentially over the past 60 years, soaring from $27.2 billion in 1960 (5% of gross domestic product) and $147 per resident to $3.5 trillion (17.9% of gross domestic product) and $11 000 per resident in 2017. Health care expenditures continue to rise significantly faster than the median household income, and this poses a financial strain for patients, providers, and the health care system alike. Removing unnecessary variation through evidence-based medicine is critical to improving outcomes and making care more affordable. This may be accomplished through standardized protocols, order sets, and check lists, with positive results previously demonstrated for obstetrics/gynecology, critical care, pediatrics, gastrointestinal surgery, orthopedics, and rehabilitation. Effective communication with a multidisciplinary team has also shown to enhance quality of treatment, reduce complications, and decrease postoperative issues. Although treatment normalization is a pragmatic solution for removing health care waste, evidence supports that even when guidelines are available, only two-thirds of patients receive the recommended care, and another quarter get treatment that may be unnecessary and/or harmful.

Isaacson B., Miranda M., Hager N., Wagner L., West S., Lucio W., Heller J., Dalgarno R., Dickens J., Schoomaker E., Pasquina P. (2020). Standardizing Postoperative Rehabilitation Protocols for the Tri-Service: A Consensus Meeting Hosted by the Musculoskeletal Injury Rehabilitation Research for Operational Readiness Organization. Military Medicine. https://doi.org/10.1093/milmed/usaa207