Persinger J, Benbassat D

Abstract submitted to Association of Military Surgeons of the United States 2022

The Department of Physical Medicine and Rehabilitation (PM&R) at the Uniformed Services University (USU) started offering a musculoskeletal (MSK) ultrasound (US) clerkship to USU medical students in 2019. It included resident didactic instruction on the fundamental principles of ultrasonography and hands-on clinical instruction using the ultrasound machine and transducers. Despite the clerkship’s tangible benefits to undergraduate medical students, it was discontinued following the 2020 pandemic’s stay-at-home orders. To ensure continued delivery of the course, the department transformed its traditional clerkship training using innovative distributed technologies.

Rhon D, Fraser J, Greenlee T, Jain T, Cook C

This abstract won the American Academy of Sports Physical Therapy 2021 Annual Meeting & Scientific Conference Research Report Award.

Ankle sprains are common, disabling, and costly. Timely rehabilitation may improve outcomes compared to delayed care. Our goal was to investigate the influence of time taken to begin physical rehabilitation on injury recurrence and one-year ankle-related medical care costs.

Rhon D, Fraser J, Westrick R, Umlauf J, Cook C

Abstract submitted to European Foot and Ankle Society Conference

While ankle-foot injuries are ubiquitous and affect ~16% of all military service-members, granularity of the evidence in this population is lacking. Therefore, the purpose of this retrospective cohort study was to characterize ankle sprains in the US military between 2009 and 2013.

Rhon D, Greenlee t, Fraser J

Abstract accepted as a poster for 2021 MHSRS

The purpose of this paper was to investigate the influence of time taken to begin physical rehabilitation after ankle sprain on injury recurrence and medical costs. Because comorbidities can influence costs, we also investigated the effect modification of select comorbidities on the relationship between the timing of rehabilitation and these outcomes (injury recurrence and injury-related costs).

Less than half of individuals that sought care for an ankle sprain received any physical rehabilitation procedures as part of their care. For patients that underwent physical rehabilitation, longer times to the first rehabilitation visit were associated with a higher risk for injury recurrence. The exception was with the isolated lateral ankle sprain group. However, the large majority of ankle sprains in the “unspecified sprain” subgroup were likely lateral ankle sprains. This was the case regardless of whether the ankle sprain was first managed in military versus civilian clinics. Longer times to rehab were also associated with greater total ankle-related medical costs for the year following the initial injury. Individuals that sought care for pain-related comorbid medical conditions in the prior year were more likely to experience a recurrent ankle sprain injury (those with anxiety and PTSD) and more likely to have increased ankle-related medical costs ( those with insomnia, sleep apnea, anxiety, PTSD, and substance abuse disorders), highlighting the potentially complex and multivariate relationships that influence recovery after injury.

This is the first study to assess the influence of timing of rehab on outcomes after ankle sprains injuries. For individuals who undergo rehab for an ankle sprain, the earlier they start rehab, the lower their likelihood of recurrence and the lower the number of downstream ankle-related visits and costs they will incur.

Ong J, Godfrey R, Peterson T, Tam J, Drake L, Navarian A, Epperson R, Isaacson B , Williams D

Abstract submitted to Military Health System Research Symposium 2021

Percutaneous osseointegrated prosthetics (POPs) are becoming available for those with limb loss as an alternative to prosthetic socket technology. POPs make it easier for amputees to attach and detach prostheses, and improve mechanical force feedback. Nevertheless, the percutaneous nature of POPs makes them susceptible to biofilm-related infection, with rates ranging as high as 30%; limiting a more widespread adoption. Infection causes skin irritation, discomfort, and may lead to deep infection if left uncontrolled. We hypothesized that antimicrobial blue light (aBL) can manage biofilm burden. However, while aBL disrupts bacterial membranes and kills cells, it may not completely eradicate biofilms as a standalone therapy. As a result, we explored the efficacy and potential synergy of oregano oil and CZ (anti-biofilm compound). Multi-day applications were tested against Staphylococcus aureus biofilms; common to POPs. These therapies may lead to more effective treatments for managing the S. aureus biofilm burden at the skin-implant interface of POPs. We built an ex vivo system using sterilized sheep skin (male/female) to simulate a POP environment translatable to an ovine model. S. aureus biofilms were grown on titanium (Ti) coupons in CDC biofilm reactors which were then used to inoculate the ex vivo skin-implant interface sites. For aBL treatment, inoculated skin samples were exposed twice daily to 405 nm aBL for 1 hour (900 J/cm2), with 6 hours between exposures; samples were covered and incubated when not treated. Oregano (10% w/v) and CZ (2% w/v) were formulated into gels. Each day, 1.5 mL of gel was aseptically applied to each sample. Samples were wrapped and incubated for 24 hours. All methods were tested at 1, 2, 3, 4, and 5-day intervals (n=8 per day). Bacteria were quantified using 10-fold dilution. Colony forming unit (CFU) counts were averaged and compared against a control set (skin inoculated with S. aureus, but not treated).

Bradley M, Tenan M, Dickens J

Abstract submitted to Military Health System Research Symposium 2021

Musculoskeletal injuries (MSKI) remain the largest source of disability, readiness impairment, non-deployable status, and separation within the US Military.  Although MSKI are of such magnitude, severity, and cost, efforts to uniformly collect and evaluate outcomes following injury and treatment are lacking due to decentralized datasets and the migratory nature of military service members. The Military Orthopaedics Tracking Injuries and Outcomes Network (MOTION) seeks to address this issue by establishing a DoD-wide enterprise system for the reliable collection of validated health outcome measures related to musculoskeletal conditions that cause the greatest impact on readiness, disability, and well-being. MOTION is an ongoing collection of clinician data along with assessments from patients who are receiving treatment of MSKI. The target population are DEERS-eligible adults, including both active duty and non-active duty retirees and beneficiaries, who will receive treatment of an upper extremity, lower extremity, or spine MSKI. Civilian dependents may serve as a “control group.” All participants are prospectively enrolled at the time of their initial presentation to the orthopaedic or allied health clinic.  Patient reported outcomes are collected electronically at the following time points: pre-operative visit, 6-weeks post-op, 6-months, 12 months, 2 years, 5 years, 10 years, 15 years, and 20 years.

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.

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.