Persinger J and Hager N

Abstract submitted to American Institute of Ultrasound in Medicine 2022

The Physical Medicine and Rehabilitation Clinic (PM&R) at Walter Reed National Military Medical Center (WRNMMC) augmented their high frequency ultra-sound systems with an ultra-high frequency ultrasound (UHFUS) system for use in the diagnosing and treatment of musculoskeletal (MSK) and nerve injury warfighters. The Visualsonics VevoMD is an UHFUS system with operating frequencies in the 24–70 MHz range as compared to the typical POC and tertiary care ultrasound systems operating in the15–22 MHz range. Access to this system afforded a unique opportunity to explore the usefulness of this cutting-edge technology in the unique settings of limb loss and multi-trauma in the military.

Super E, Smith M, Persinger J, Hager N, Smith J, Miller M, Yuan X

Abstract Submitted to WRNMMC Research and Innovation Month 2022

Carpal tunnel syndrome (CTS) is the most common peripheral nerve entrapment. Interventional procedures for CTS include carpal tunnel (CT) injections and CT release (CTR). Variant anatomy increases the risk of iatrogenic injury and complications, impairing recovery and leading to post-procedural functional deficits. The objective of this study was to evaluate anatomic variations associated with CTS or at risk of injury during procedures using high-frequency ultrasound (HFUS). In this cross-sectional, observational study of 100 eligible patients (age: 44.4 ± 13.0 years, 37.0% female) referred for upper extremity (UE) electrodiagnostic studies (EDX), the MN was systematically evaluated using high-frequency ultrasound (HFUS) from the elbow to the CT outlet. The presence/absence of Martin-Gruber anastomosis (MGA), palmaris longus, and lumbrical intrusion with dynamic finger flexion at the CT inlet were documented, along with the course of the palmar cutaneous branch of the MN (PCBMN) and thenar motor branch (TMB. The cross-sectional area (CSA) of the MN at the level of the CT inlet and the transverse safe zone (TSZ) for CTR were measured. Statistical analyses were conducted using GraphPad Prism. All data are presented as mean ± standard deviation or percentage (%).

Smith M, Bradley M, Kasuske A, Smith J, Nanos G, Tintle S, Reece D, Yuan X, Miller M

Submitted to WRNMMC Research and Innovation Month 2022

Within the Military Healthcare System (MHS), endoscopic and mini-open carpal tunnel release (mOCTR) procedures are the current standard of care for management of refractory Carpal Tunnel Syndrome (CTS), the most common peripheral neuropathy. Carpal Tunnel Release using Ultrasound Guidance (CTR-US), which involves a single 4-6 mm incision, is showing potential as a treatment option for eligible candidates within the military population with CTS in an ongoing randomized controlled trial (RCT) at Walter Reed National Military Medical Center (WRNMMC).

Smith M, Huszar M, Pav V, Hando B, Deal J, Yuan X

Abstract submitted to SOMOS 64h Annual Meeting

Carpal Tunnel Syndrome (CTS) is the most common peripheral entrapment neuropathy, impacting the health, performance, and readiness of Active-Duty service members (ADSMs) of the U.S. Military. However, for ADSMs who seek surgical management for severe or refractory CTS with Carpal Tunnel Release (CTR), access to subspecialty providers within direct care (DC) Military Treatment Facilities (MTFs) can be limited, leading to reliance on care outside MTFs within the private sector (PS). It is currently unknown how the COVID-19 pandemic has impacted provision of and access to care for CTS and CTRs across DC and PS. Therefore, the purpose of this study is to describe regional trends and variation in CTRs performed across Defense Health Agency (DHA) markets within the Military Health System (MHS) over Fiscal Years (FY) 2019-2021. All study procedures were approved by the Uniformed Services University’s Institutional Review Board. We queried the MHS Data Repository to identify all ADSMs with outpatient encounters in DC and PS by International Classification of Diseases, Tenth Revision diagnosis codes for CTS, and CTRs by Current Procedural Terminology codes, during FYs 2019-2021. We further classified CTRs by FY, DC vs. PS, DHA markets, and setting [e.g., Ambulatory Surgical Center (ASC), clinic]. PS encounters were derived using per person per day logic and mapped to DHA markets by zip codes within 40 miles of MTF Service Areas.

Gaunaurd I, Gailey R, Symsack A, Isaacson B, Pasquina P

Abstract submitted to 44th ICMM World Congress on Military Medicine 2022

Service Members (SM) and Veterans with lower limb amputation (LLA) are at a high risk for developing secondary co-morbidities such as joint pain, osteoarthritis, chronic low back pain, and cardiovascular disease. To mitigate these secondary comorbidities, optimize long-term function, and increase quality of life, effective rehabilitation and innovative lifelong care is essential. Telerehabilitation has recently demonstrated to be a useful method of healthcare delivery, particularly benefitting individuals with physical limitations who are unable to attend outpatient physical therapy, such as patients following LLA. Wearable technology, such as mobile sensors, has the potential to augment current telerehabilitation practice and improve home walking and exercise compliance for those with LLA. Therefore, could this technology be used to provide “booster” prosthetic training to improve or reinforce current mobility and prosthetic use, promote an active, healthy lifestyles and mitigate adverse secondary comorbidities? To address this question, the Department of Defense (DoD) and Veterans supported the development of a program through the Joint Incentive Fund called the Mobile Device Outcomes-based Rehabilitation Program (MDORP). The MDORP is a comprehensive mobile rehabilitation program that is clinician-guided and incorporates the use of a mobile sensor system called the Rehabilitative Lower Limb Orthopedic Assistive Device (ReLOAD). The ReLOAD system provides: (1) assessment of walking quality at home and in the community for people with LLA, (2) real-time auditory feedback to correct the most prominent gait deviations, and (3) automatic prescription of home exercises that target balance and strength impairments related to their most prominent gait deviation. The primary objective of the study was to determine if the 8-week MDORP improved strength, mobility, and gait quality in SMs and Veterans with LLA.

Pasquina p, Jannace k, Nordstrom m, Gbade-Alabi o, Smolinski g

Selected for a podium presentation at the 44th ICMM World Congress on Military Medicine 2022 in Brussels

Gailey R, Gaunaurd I, Goss D, Bennett C, Isaacson B

Abstract submitted to 44th ICMM World Congress on Military Medicine 2022

Isaacson B, Wagner L, West S, Lucio W, Yuan X, Hager N, Pasquina P

Abstract submitted to Military Health System Research Symposium 2022.

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 has 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. MIRROR coordinates inter-service partnerships with premier academic institutions, primary military treatment facilities (MTFs), and civilian sites that experience a high volume of MSI, but lack a robust infrastructure to conduct rigorous trials. MIRROR is based in the Department of Physical Medicine & Rehabilitation at the Uniformed Services University and closely aligns with the Defense Health Agency (DHA), Department of Defense (DoD) leadership, Joint Program Committee (JPC) chairs, and other high-level advisory groups. In addition, our Steering Committee, comprised of nationally-renowned military and civilian subject matter experts in various musculoskeletal subspecialties, provides guidance and oversight on MIRROR’s direction, scope, and overall methods. The MIRROR organization also incorporates select MSI sub-portfolios (i.e., orthopedics, interventional spine and pain management, physical and occupational therapy), under the direction of subject matter experts, to further advance our mission across all MSI research areas. Our representation across both operational leadership and research subspecialties allows MIRROR to maximize its impact throughout the MHS. To ensure that findings are clinically translational, data is collected using standardized protocol content, case report forms, and recruitment/outcomes captured through REDCap. Real-time feedback is provided using PowerBI to ensure that data can be presented in a highly efficient manger without the risk of protected health information (PHI) disclosure. This allows quick assessment of key performance indicators and provides useful data to understand healthcare disparities.

Greenlee T, Bullock G, Teyhen D, Rhon D

Abstract submitted to Military Health System Research Symposium 2022.

Prevalence and burden of musculoskeletal injuries for military service members are high, with recurrent injuries contributing to greater costs, more time lost from duty, and sub-optimal force readiness. Several psychological factors are associated with injury and return to work readiness in sport and occupational settings. We explored whether the psychological state of soldiers returning to duty following an injury could predict time-loss injury within the next year. We performed a secondary analysis of data from a longitudinal cohort study of soldiers returning to full duty after a recent thoracolumbar spine (TLS) or lower extremity (LE) injury after seeking medical care. A psychological profile (depression, anxiety, anger, fear, frustration, exercise enjoyment, job-, military-, and life-satisfaction, kinesiophobia, fear avoidance beliefs, pain catastrophizing, stress, and mood) was assessed via self-report at the point of initial return-to-duty and Soldiers were followed for one year.

Foster K, Greenlee T, Fraser J, Young J, Rhon D

Abstract submitted to Military Health System Symposium 2022

One in every four individuals with an ankle sprain went on to have a proximal joint injury in the following year, knee and lumbar spine diagnoses occurring more frequently than hip. Associated fracture with the initial ankle sprain increased the odds of sustaining a subsequent hip or lumbar spine injury. Further, females had higher risk of developing subsequent hip or lumbar spine injuries after ankle sprain whereas males were more likely to develop subsequent knee issues. Less than half of the cohort received rehabilitation following an ankle sprain, but exercise therapy was found to be preventative of secondary injuries to the knee, hip, and lumbar spine. While these associations are often discussed by clinicians, the increased understanding of prevalence of proximal joint disorders has the potential to help guide treatment and inform decisions related to returning to work and sport, improving the care for patients and decreasing the physical and financial toll of this common injury.

Smith M, West S, Malanga G, Hager N, Hulsopple C, Yuan X

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

The Musculoskeletal Injury Rehabilitation Research for Operational Readiness (MIRROR) organization, based out of the Department of Physical Medicine and Rehabilitation (PM&R) at the Uniformed Services University (USU), is dedicated to advancing musculoskeletal injury rehabilitative care within the Military Healthcare System (MHS) to reduce the burden of musculoskeletal injuries on operational readiness. Through its core infrastructure and inter-service collaborations, MIRROR facilitates training programs for medical education to expand and optimize treatments. Knee injuries are one of the most common musculoskeletal complaints among Active Duty military personnel. Autologous micro-fragmented adipose tissue (MFAT) has shown promise as a regenerative therapy for meniscal tears in the civilian population. MIRROR supports a randomized controlled trial (RCT) at multiple military treatment facilities (MTFs), with the objective to investigate the safety and efficacy of intrameniscal injection with autologous MFAT for symptomatic meniscal injuries in a military population. With the assistance of a peer-to-peer, two-day training program incorporating didactic cadaveric training and hands-on patient cases, clinicians at three MTFs garnered the procedural skills required to safely administer this novel intervention prior to the launch of this multi-site study.

Smith M, West S, Persinger J, Hager N, Smith J, Miller M, Yuan X, Reece D

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

The COVID-19 pandemic has taken a significant toll on global medical education and research since March 2020, prompting a surge of virtual learning. Like other research entities, the Musculoskeletal Injury Rehabilitation Research for Operational Readiness (MIRROR) organization, based out of the Department of Physical Medicine and Rehabilitation (PM&R) at the Uniformed Services University (USU), was not spared from the pandemic’s impact on research operations and adapted to persevere, despite setbacks. At the heart of the organization’s mission, MIRROR provides clinicians and researchers with the support and infrastructure to advance musculoskeletal injury rehabilitative care by facilitating training programs for medical education. According to the Defense Medical Epidemiology Database, nearly 17,000 Active Duty service members were diagnosed with carpal tunnel syndrome (CTS) in 2016, the most common peripheral entrapment neuropathy. MIRROR currently supports a study at multiple military treatment facilities (MTFs) comparing Ultrasound-Guided Carpal Tunnel Release (USCTR) to the current standard-of-care surgical release with respect to return to duty and clinical outcomes in the military population with CTS. With the aid of an innovative virtual platform, training for this enhanced intervention continued during the pandemic, propelling MIRROR’s mission to advance military medicine.

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.