Velasco T, Peel S, Hulsopple C, Gornoski L, Goss D, Leggit J

Abstract submitted to Military Health System Research Symposium 2021

Chronic exertional compartment syndrome (CECS) predominantly affects highly active individuals’ lower legs, especially among military service members. The current treatment for CECS is a surgical fasciotomy of the involved lower leg compartment.  The post-surgical patient outcomes are mixed. Emerging non-surgical treatments with botulinum toxin A (BoNT-A) and gait retraining (GR) are alluring alternatives. BoNT-A may reduce compartment pressures and pain in individuals with CECS. The predominate muscle of the lower leg anterior compartment is the tibialis anterior. Using a forefoot strike pattern while running, the tibialis anterior decreases eccentric activity and anterior compartment pressure. Using gait retraining (GR) to alter foot strike patterns from rearfoot to forefoot running decreases ground reaction forces (GRF) and reduces leg pain. Published case series on these non-surgical interventions have promising results. When GR is offered as an intervention it is through supervised clinic visits or partial home-based training during a 6-week period.  These case series obtain kinetic data through instrumented treadmills, mainly in a male population. An alternative to using an instrumented treadmill are Loadsol sensors connected to a Bluetooth device and placed inside each shoe to assess kinetic data while running. The purpose of this case study was to observe foot strike patterns and review kinetic changes identified with Loadsol sensors in a female with bilateral lower extremity CECS after BoTN-A and home-based GR.

Dintaman J, Ebert M, Sorensen I, Hisle-Gorman E

Abstract submitted to Military Health System Research Symposium 2021.

The Army Recovery Care Program (ARCP), originally the Warrior Transition Program, was created in 2007 to assist in the care, recovery, and transition of Army soldiers who required case management due to complex medical conditions or injuries. Initially, the ARCP consisted primarily of wounded or injured individuals evacuated from the wars in the Middle East but gradually grew to include soldiers with non-combat related conditions requiring prolonged and multidisciplinary care. Stabilized and recovered members of the ARCP eventually transition back to the force or are medically retired if their clinical condition prohibits further military service. A limited number of participants succumb to their injury or illness or are administratively separated from the program due to non-compliance. The early ability to identify the most appropriate transition pathway for program participants is important to ensuring program resources are directed efficiently and effectively. Whether there is a relationship between the conditions prompting entry into the ARCP and the subsequent transition pathway for soldiers is unknown.

Ebert M, Sorensen I, Dintaman J, Hisle-Gorman E

Abstract submitted to Military Health System Research Symposium 2021.

The Army Warrior Care and Transition Program (WCTP), now the Army Recovery Care Program (ARCP), was launched in 2007 as a comprehensive rehabilitation program with the primary aim of assisting wounded, ill and injured soldiers to return to the fighting force, or successfully transition from the military. Since its inception, tens of thousands of Soldiers have entered the program for treatment for a broad range of physical and mental/behavioral health conditions. However, the impact of the nature of a soldier’s entry into the program, as well as the type or types of injuries sustained on the amount of time spent in the ARCP is not known. The objective is to explore the impact of how service members entered the program, the number of conditions they presented with, and what conditions they had on how much time was spent in the ARCP.

Hisle-Gorman E, Dintaman J, Ebert M, Sorensen I

Abstract submitted to Military Health System Research Symposium 2021

An inevitable outcome of armed conflict is combat injury of service men and women. Since the initiation of conflict in Afghanistan in Oct 2001 wounded soldiers have been receiving targeted care, at Medical Centers but the formation of a formal comprehensive program was not initially available. The Army Warrior Care and Transition Program (WCTP) was launched in 2007 as a comprehensive rehabilitation program with the primary aim of assisting wounded, ill and injured soldiers to return to the fighting force, or successfully transition out of the military.  Length of time participates are in the program is an important indicators of program efficacy and cost.  The impact of programmatic, demographic and family levels factors on length of time soldiers stay in the WCTP is not known. The objective is to explore the impact of programmatic, demographic and family level factors on length of time soldiers are in the WCTP.

Sorensen I, Ebert M, Dintaman J, Hisle-Gorman E

Abstract submitted to Military Health System Research Symposium 2021

The Army Recovery Care Program (ARCP) provides care to the Army's injured and ill service members with complex care requirements. After several iterations and name changes, the program started as the Warrior Transition Battalion, then became the Warrior Care and Transition Program, and is now the ARCP. The program was created to care for service members who became ill, or were injured or wounded in during operations associated with the Global War on Terrorism. The core mission has remained similar, to provide care for soldiers with the aim of reintegrate them back into the force, or prepare them for transition to civilian life. The most recent changes focused on simplifying entry criteria, streamlining processes, and helping meet each service member's unique needs. Over time the reasons and specific conditions for soldiers entering the program have changed in response to the changing needs of the army. The objective is to analytically explore changes in entry pathway and conditions at entry in admitted soldiers in the ARCP over time.

Yuan X, Pav V, Cohen S, Pasquina P, Hager N, Isaacson B

Abstract submitted to Military Health System Research Symposium 2021

Low back pain (LBP) is both the leading cause of disability and most common reason for primary care visits, amounting to approximately $88 billion in direct and indirect costs of health care spending. Among active-duty service members (ADSM) of the United States Armed Forces, LBP and other back problems have accounted for the most medical encounters every year for the past decade. Clinical categories of LBP diagnoses can manifest as axial, radicular, or other pain. LBP is further classified by duration of symptoms as acute (LBP < 1 month), subacute (1-3 months), or chronic (> 3 months). This retrospective study of ADSM newly presenting with LBP in Fiscal Year (FY) 2017 sought to classify LBP by clinical category and duration, and record medical encounters for LBP care over two years of follow-up, including outpatient visits, radiology, physical therapy (PT), spine surgeries, and interventional pain procedures, to assess impact on readiness, health care costs, and resource utilization. This is the first LBP study to date to include MHS GENESIS data and examine associated health care costs and resource utilization for the two years leading up to the COVID-19 pandemic.

Isaacson B, Wagner L, West S, Lucio W, Dalgarno R, Johnston S, Fowler A, Mehta K, Yuan X, Pasquina P, Hager N

Abstract submitted to Military Health System Research Symposium 2021

Musculoskeletal injuries (MSI) affect approximately 800,000 Service Members annually and result in 25 million limited duty days. These conditions are the primary reasons for medical discharge and downgrade, and result in 34% of evacuations from theatre. Most concerning is that the disability discharge rate for MSI increased 13x between 1981 and 2005 (70 vs. 950 per 100,000 persons). The alarming increase of MSI has also been observed in the general population, with an estimated 126.6 million Americans (one in every two adults) affected by a musculoskeletal condition – comparable to the total percentage of Americans living with a chronic lung or heart condition and costing an estimated $213 billion. Given the strict requirements for physical fitness in the military and the impact of MSI on combat readiness, the Musculoskeletal Injury Rehabilitation Research for Operational Readiness (MIRROR) organization was established in 2019 to advance the treatment and preventive care for Service Members with non-combat related MSI.

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

Abstract Submitted to Military Health System Research Symposium 2021

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.

Miles R, Velasco T, Leggit J

This abstract won the Army Chapter of the American College of Physician's abstract competition and will be presented virtually in May 2021.

Chronic Exertional Compartment Syndrome (CECS) is a debilitating disorder that causes lower extremity pain most commonly in active populations. It is thought to arise from increased pressure in muscle compartments (commonly lower extremity anterior and lateral) leading to pain, paresthesia and an inability to tolerate exercise. The cause of CECS is unknown but is likely a combination of muscular, neurologic and vascular contributions. Current standard treatment is surgical fasciotomy, but it is only successful in 66% of patients. Many have complications and/or need repeat procedures. Efficacy is even worse in military members at 55%. Other alternative strategies have emerged such as botulinumtoxin A injections (BoNT-A) and gait retraining, but data is limited.

The objective of this study is to simultaneously assess the effectiveness of non-surgical treatments, BoNT-A injections and Supervised Gait Retraining (SGR), in terms of lower pain control and ability to return to full duty among adult active-duty service members suffering from lower extremity CECS, specifically of the anterior and/or lateral compartments.

Isaacson B, Wagner L, West S, Lucio W, Dalgarno R, Johnston S, Fowler A, Pasquina P, Hager N

Musculoskeletal injuries (MSI) affect approximately 800,000 Service Members annually and result in 25 million limited duty days. These conditions are the primary reasons for medical discharge and downgrade, and result in 34% of evacuations from theatre. Given the strict requirements for physical fitness in the military and the impact of MSI on combat readiness, the Musculoskeletal Injury Rehabilitation Research for Operational Readiness (MIRROR) organization was set up in 2019 to advance the treatment and preventive care for Service Members with non-combat related MSI. This abstract describes the purpose of MIRROR, how we support the Building Research Capacity and Infrastructure conference theme, and introduces new researchers to this collaborative forum.

Crowell M, Brindle R, Mason J, Pitt W, Miller E, Posner M, Cameron K, Goss D

Abstract submitted to Military Health System Research Symposium 2020

There is a large incidence of shoulder instability among active young athletes and military personnel which requires shoulder stabilization surgery. Acute post-operative pain is common and is usually managed with opioid pain medications. The extended use of opioid medications can have adverse effects that impair function and reduce military operational readiness, and there are currently few alternatives. However, Battlefield Acupuncture (BFA) is a minimally invasive therapy demonstrating promise as a non-pharmaceutical intervention for managing acute post-operative pain.

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

Telerehabilitation, as a component of telemedicine, is a rapidly growing clinical tool being utilized in physical therapy, optimizing care for patients that are post-surgical, have orthopedic injuries, or who have undergone lower limb amputation (LLA). The benefits include greater access to care for patients in remote locations, reduced travel burden, and decreased time and financial costs. With this in mind, the Department of Defense (DoD) and Veterans Health Administration (VHA) collaborated to implement a telerehabilitation program called the Mobile Device Outcomes-based Rehabilitation Program (MDORP) designed to enhance the rehabilitation of injured Service Members (SMs) and Veterans with lower limb loss. MDORP is a home and community-based auditory biofeedback and prescription based exercise program which utilizes a sensor-based system called The Rehabilitative Lower-limb Orthopedic Accommodating-feedback Device (ReLOAD). This study aims to evaluate the feasibility and usability of ReLOAD over a 5-month period using an anonymous post-intervention survey of participating SMs and Veterans with LLA.

Symsack A, Gaunaurd I, Springer B, Clemens S, Lucarevic J, Kristal A, Bennet C, Isaacson B, Applegate B, Gailey R, Pasquina P

This poster won the category of “Best Evidence-Based Practice” in the 12th annual DRP poster competition at WRNMMC.

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According to recent estimates, there are nearly two million people with lower limb amputation (LLA) currently living in the United States. This number is expected to double by 2050. Within the military, combat operations during the global war on terror have led to more than 1,700 service members (SMs) undergoing major limb amputation, with the majority experiencing LLA & many sustaining proximal and multiple limb loss. Those with LLA due to trauma are at a higher risk than nonamputees for multiple secondary health effects, which include joint pain, osteoarthritis, chronic lower back pain, & cardiovascular disease. In order to mitigate these adverse secondary health effects, optimize long-term function, & increase quality of life in individuals with LLA, effective rehabilitation and innovative life-long care is essential. Therefore, the Veterans Affairs (VA) & Department of Defense (DoD) implemented a program through the Joint Incentive Fund called the Mobile Device Outcomes-based Rehabilitation Program (MDORP). The primary objective of this pilot study was to determine if the implementation of MDORP improved strength, mobility, & gait quality in SMs and Veterans with LLA.

Lacey S, Cohen S, Jacobs M

Abstract submitted to the International Society of Physical and Rehabilitation Medicine 2020

Chronic low back pain is a major cause of morbidity in the U.S., with costs by some estimates exceeding $100 billion annually. Among the U.S. military population, back-related conditions have been associated with the highest 5-year cumulative risk of disability discharge. Patients with low back pain and intervertebral disc lesions identified on advanced imaging or discography are often diagnosed with “discogenic low back pain” (DLBP), which has a prevalence rate among axial low back pain sufferers estimated at 39 to 42%. The prognosis for DLBP is not favorable, with one prospective clinical study containing 279 patients finding that 87% of patients continued to have symptoms at 4 years of follow-up.

Lacey SA, Cohen SP, Jacobs MB. Intradiscal Injection Of Dehydrated Human Amnion Chorion Membrane For Treatment Of Chronic Discogenic Low Back Pain: A Case Series. Military Health System. International Society of Physical and Rehabilitation Medicine 14th World Congress. Orlando, FL; March 8, 2020.

Lacey SA, Kim G, Myers K

Abstracted submitted to the International Society of Physical and Rehabilitation Medicine 2020

60 year old man with cervical stenosis sustained a syncopal episode from a sitting height. He was found by a co-worker and reported being unable to move arms or legs. Diagnostic workup revealed C3-C4 fracture, ALL rupture and central cord syndrome. He underwent C2-C5 posterior fusion the next day and received post-operative course of steroids. Upon transfer to inpatient rehabilitation service on post-op day 11, patient was noted to have 4/5 strength in arms and 5/5 strength in legs. Patients who undergo inpatient rehabilitation after spine surgery should receive daily neurological exams and be monitored for increased pain or discomfort, especially in those with pre-operative and intra-operative risk factors.

Hager N, Isaacson B, Dickens J, Wagner L, Heller J, Lucio W, Rowland M, West S, Pasquina P

Abstracted submitted to Extremity War Injuries Symposium 2020

In order to enhance the DoD’s efforts in addressing the negative impact of MSI, we created MIRROR to study risk factors, generate prevention strategies, optimize treatments, and establish return-to-duty criteria that is based on scientific evidence rather than case-specific clinical judgment alone. Although the work at civilian facilities will be limited, investigators from these sites were included to engage national leaders in MSI research, ensure scientific rigor, enhance the mentorship of junior military clinical researchers, and scale these novel therapies for the general population.

Heller J, Roddy W, Isaacson B, Hager N, Pasquina P

Abstracted submitted to Extremity War Injuries Symposium 2020

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Within the MHS, data and analytics activities are commonly coordinated on an ad hoc basis using solutions like Microsoft Excel. This approach often acts as a barrier to efficient research and fails to scale. The development of a shared data and analytics infrastructure across MIRROR projects enables program information and insights to be communicated in an efficient, timely, and approachable manner. Ultimately, this allows military-relevant musculoskeletal injury rehabilitation research to be advanced in a data-driven way.