Young J, Greenlee T, Rhon D

Abstract submitted to Military Health System Research Symposium 2021

Over half of all musculoskeletal injuries incurred by service members take place in the lower extremity and lumbar spine. In the first 6 months of 2019, musculoskeletal injuries alone were attributed to 59% of limited duty days. Knee disorders are some of the most common injuries of the lower extremity, contributing to high rates of osteoarthritis in service members and veterans. What is not seen as clearly is the potential influence that knee disorders have on the genesis of adjacent joint injuries. When pain and dysfunction affect the knee, do the compensatory adjustments required to manage these symptoms increase injuries in an adjacent joint (ankle, hip, spine)? Some evidence suggests that the presence of one lower extremity disorder may be a risk factor for the development of a more proximal or distal musculoskeletal disorder. Hip strength deficits have been shown to contribute to knee and foot/ankle disorders, foot disorders can impact the knee and lumbar spine, and foot and ankle symptoms have led to knee pain in patients with knee osteoarthritis. However, it is unclear what proportion of patients with a knee disorder end up sustaining an adjacent-joint injury, or what proportion of patients with a knee disorder had an adjacent joint injury prior to their knee disorder. This information can help clinicians and research teams better understand what patients may be at risk for additional injury sequelae and can help determine the content for optimal injury prevention or risk reduction strategies for these patients. Therefore, the purpose of this study was to investigate the incidence of lumbar, hip, and ankle injuries after a diagnosis of patellofemoral pain in the Military Health System. Because some evidence has shown a relationship between the spine, hip and ankle and subsequent knee disorders, a secondary aim was to identify the incidence of lumbar, hip, and ankle injuries prior to a patellofemoral pain diagnosis.

Greenlee T, Wright A, Dickens J, Rhon D

Abstract submitted to Military Health System Research Symposium 2021.

Research has shown that females in the military are at increased risk (as much as 3x greater) to sustain lower extremity musculoskeletal injuries than their male counterparts. For instance, females in Army basic training have 2.2 times the incidence of lower extremity overuse injuries as males. The hip is a commonly injured joint in the lower extremity, most often by stress fractures, and particularly problematic amongst female military members. Surgical treatment of non-acute hip pain in young athletes is becoming a mainstream intervention, with an 18-fold increase from 1999 to 2009 in the United States. In the Military Health System (MHS), hip arthroscopy is rising at similar rates. Females in other settings are considered to have worse outcomes following surgical interventions for some of these injuries, such as hip arthroscopy for femoroacetabular impingement or labral repair; however, the data on the influence of female sex on outcomes after hip arthroscopy are conflicting. Females, in general, are poorly represented in exercise and sports medicine research. It is unknown whether the current body of research has been designed to reveal differences related to sex and hip arthroscopy in the military. The recent shift within the last decade to open up combat military occupations to individuals of both sexes elevates the importance of understanding sex-specific outcomes in this setting. Females make up approximately 15% of all military service members, and 10% of service members that deploy. This has led to symposiums, task forces, and calls for a greater research focus on the issue of injuries in female military service members. These calls align strongly with a push to improve research on sex disparity in general, and specifically in female athletes which is greatly lacking.

Rhon D, Greenlee T, Farrhoki S, Young

Abstract submitted to Military Health System Research Symposium 2021.

Extremity amputation is a life-altering consequence associated with some traumatic injuries. Due to occupational hazards inherent with military service, service members are at higher risk for extremity amputation compared to their civilian counterparts. Between January 2001 and October 2017, 1705 service members with combat deployment history sustained an extremity amputation (2316 unique extremity amputations). The majority of amputations were in the lower extremity (1914 total amputations) compared to the upper extremity (402 total amputations). Unfortunately, physical disability is not limited to the loss of limb alone but also accompanied by many other medical morbidities. One of the most commonly reported is low back pain. Alteration in biomechanical, psychological, and social factors after limb amputation can contribute to the development of back pain-related symptoms and disability. Back pain with extremity amputation has been investigated in prior studies, but a more granular assessment of low-back pain-related healthcare utilization in extremity amputation and back pain has not been conducted. Characterizing the healthcare utilization provides an improved understanding of the medical burden incurred to the Military Health System by these patients specific to low back pain. The purpose of this study was to characterize back pain-related healthcare utilization in beneficiaries of the Military Health System that have undergone an amputation. A secondary aim was to assess the differences in healthcare utilization and costs between regions of amputation (upper versus lower limb).

Anderson A, Bradley M, Dalgarno R, Lucio W, Purvis H, Kilcoyne K, Tucker C, Dickens J

Abstract submitted to Military Health System Research Symposium 2021

Cold therapy (cryotherapy) has been widely used for adjuvant treatment of postoperative pain management in orthopaedic surgery. Postoperative cryotherapy with compression is proposed as a method of reducing pain and the inflammatory response in the early postoperative period after orthopaedic arthroscopic procedures. Many devices are available, but few can guarantee temperature regulation during prolonged periods of use and therefore have been criticized. The arrival of new advanced cryotherapy devices has made it possible to test the effect of prolonged cooling on rehabilitation after arthroscopic orthopaedic procedures. Therefore, the purpose of this study was to determine the impact of cryotherapy with compression (using Game Ready®) versus cryotherapy without compression (standard of care ice packs) on 1) postoperative pain control, 2) patient reported outcomes, and 3) number and dose in morphine milligram equivalents (MME) of pain medications taken after arthroscopic surgery.

Crowell M, Brindle R, Mason J, Pitt W, Miller E, Ford K, Peel S, Goss D

Abstract submitted to Military Health System Research Symposium 2021

Each year, approximately half of all military personnel sustain a musculoskeletal injury. The majority of injuries can be classified as overuse injuries, with half of those due to exercise. Running is the most frequently reported injury producing activity and the knee is one of most injured joints. During running, a non-rearfoot strike pattern reduces loading rates and knee joint work. Thus, a gait retraining intervention to alter foot strike pattern for patients with a rearfoot strike pattern during running may improve rehabilitation outcomes for patients with overuse knee injuries. The purpose of this randomized clinical trial was to determine the effects of a telehealth gait retraining intervention on self-reported pain and function in patients with an overuse knee injury. We hypothesized that patients who underwent the telehealth intervention along with standard treatment would report greater improvements in pain intensity, condition, function, and running ability compared to patients who received only standard physical therapy treatment.

Corey S, Davi S, Posner M, Donohue M, Slabaugh M, Robins R, LeClere L, Bradley M, Hood M, Dickens J, Cameron K

Abstract submitted to Military Health System Research Symposium 2021

Shoulder injuries are common within military populations and shoulder dislocation and subluxation injuries are a leading cause for surgical intervention impacting military readiness. Patient-reported outcome measures (PROMs) are important in clinical practice and may inform management and return to duty decisions; however, normative values for PROMs for the shoulder in young military populations are limited. The purpose of this study was to describe normative values for the Patient Reported Outcome Measurement Information System (PROMIS) Physical Function Scale, Single Assessment Numeric Evaluation (SANE), and Brief Resilience Scale (BRS) in active young military service members with and without a history of shoulder instability and to compare scores by sex at the time of accession.

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.

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.

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.