Cin H, Mincey C, Persinger J, Hager N, Yimyam C, Metzger E, Isaacson B, Wagner L, Pasquina P

Abstract accepted for a poster session at the 2023 Military Health System Research Symposium

Physical activity limiting conditions are incompatible with maintaining a fit and ready fighting force and improving the health and wellness of those entrusted to our care. This study may produce new scientific knowledge about optimal dosing parameters of PBMT to best reduce pain and improve function for those who are limited by PF. This innovative therapy has the potential to promote a fit and ready fighting force by returning service members to duty quickly, reducing health care costs, and promoting operational readiness. The long-term goals of this research team include: 1) developing PBMT protocols for broad application to other painful and duty-limiting conditions, and 2) exploring the application of this portable device in forward-deployed environments.

Cheema N, Nazarian A, Pham L, Ghag N, Fuchs C, Tam J, Anderson R

Abstract accepted for a poster session at the 2023 Military Health System Research Symposium

Fatigue is defined by the reduction of a muscle’s strength and performance during exercise, and it is affected by different parts of the motor pathway controlling muscle contractions. Fatigue can occur in the central nervous system and affects neuronal signaling to the muscle whereas peripheral fatigue affects the site of neuromuscular junctions present on the muscle. Fatigue limits performance and unless allowed to recover, continuous activity will result in muscle dysfunction and musculoskeletal injuries that are commonly observed in military personnel. Light therapy has been shown to have several beneficial physiologic effects in a wide range of tissues. The musculoskeletal system can be irradiated with wavelengths in red and near infrared (NIR) regions which penetrate deep into the body. Application of NIR light is a noninvasive procedure and there is minimal heat generated by the light emitting diodes (LEDs), making it an appealing therapeutic strategy for muscle damage. Recent studies are suggesting that photobiomodulation therapy (PBMT) can reduce pain, inflammation and enhance physical performance. However, the mechanism(s) of cellular responses by PBM in muscle is not clearly understood. There is no standardization in parameters for PBMT, with researchers and clinicians using a wide range of wavelengths, fluences, treatment duration/frequency, etc. in PBM applications. Therefore, the goal of this study is to improve our understanding of the mechanism(s) of action of PBM effects on the musculoskeletal system, ultimately to inform the choice of clinical treatment parameters. We investigate two wavelengths in NIR light, 980 nm and 810 nm, and their effect on fatigue induced in intense exercise in cells and mice.

Metzger E, Hager N, Wagner L, Isaacson B, Pasquina P

Abstract accepted for a poster session at the 2023 Military Health System Research Symposium

Noncombat, musculoskeletal injuries account for nearly 60% of warfighters’ limited duty days and 65% of warfighters on non-deployable status. Often the treatment and the rehabilitation modalities available for common musculoskeletal conditions have little impact on the progression of the condition. A safe, patient friendly, and effective modality that could advance the treatment of these conditions would be extremely impactful. Photobiomodulation (PBM) – (formerly known as low-power laser therapy or low-level laser therapy), involves applying non-ionizing forms of light from various sources including lasers, light-emitting diodes (LEDs), and broadband light, in the visible and near infrared spectrum, in order to biologically modulate cellular activity to enhance healing. Current research reveals that PBM treatment can influence repair and regeneration of several tissue lines, stimulate metabolism, and most importantly for the injured warfighter - reduce inflammation and pain while recovering from injury. The PBM research portfolio is investigating the influence of this modality as it serves to enhance human performance, recovery, operational readiness, and warfighter quality of life with guided research efforts into the following areas of interest and aimed outcomes:

1. Musculoskeletal (MSK) injury: increased function and decreased pain for issues such as knee osteoarthritis, plantar fasciitis, tendinopathy, and bone stress injury.

2. Performance: improved maximum isometric voluntary contraction, sprint time, and countermovement jump measures.

3. Recovery: decreased inflammatory and oxidative stress biomarkers, and physical activity disability.

4. Self-reported behavioral health: decreased delayed-onset muscle soreness, perceived exertion, fatigue, and mental athletic energy used, and increased sense of wellbeing.

5. Sleep: increased sleep efficiency and self-reported quality of sleep.

6. Nerve: increased nerve strength post-reparative common peripheral nerve surgery and comparative use of analogous, commercially available, or manufactured sealing mechanisms.

7. Hearing: preventative protective treatment to noise exposure.

8. Wound: increased reduction in pathogens during the healing process.

Bradley M, Yuan X

Abstract accepted for a poster session at the 2023 Military Health System Research Symposium

 This study demonstrates the influence of the APDACAP on the structure of the foot, particularly on talus positioning, for the first time in a large sample of humans and elucidates previously misunderstood concepts about pronation. We determined that the current, most widely used method for categorizing foot type (CIA) is not the most accurate for diagnostic screening. Instead, the investigators propose a new, more accurate categorization system for foot type, which includes the CIA’s three categories of low, medium, and high arch heights, and further stratifies to describe the wide spectrum of flexible and rigid foot types within each arch height category, by considering the degrees of APDACAP and TDA. Although the following still needs to be verified in a prospective trial, it is expected that the most often misdiagnosed/mistreated foot types are to be (1) low arch height yet rigid midfoot (i.e., low CIA & high APDACAP/TDA), (2) high arch height yet flexible midfoot (i.e., high CIA & low APDACAP/TDA), and (3) medium arch height with APDACAP/TDA values toward the outer extremes of the flexible/rigid continuums. The implications of the new categorization system will enable better awareness and care to prevent and treat lower extremity injuries.

Smith M, Yuan X, Smith J, Deal B, Nanos G, Tintle S, Reece D, Miller M

Abstract accepted for a poster session at the 2023 Military Health System Research Symposium

CTS is the most common peripheral entrapment neuropathy, impacting the health, performance, and readiness of Active Duty service members and military beneficiaries. Military occupations often require repetitive movements, forceful grip, and exposure to vibration, which are risk factors for CTS, illustrating the importance of access to novel CTR techniques that facilitate return to functional activity. Current barriers to CTS treatment within the MHS include limited access to subspeciality care in rural areas, lack of resources, and OR procedural costs and staffing requirements. Clinic-based procedures have demonstrated utility in decreasing costs and increasing access to care within the MHS. Preliminary data from this pragmatic randomized controlled feasibility trial at WRNMMC suggest that CTR-US can be performed by non-operative physicians with advanced training within a clinic environment and yield positive outcomes that compare favorably to the current SOC mOCTR approach. Outcomes of this trial comparing CTR-US and mOCTR at WRNMMC can further expand available CTS management options within the MHS, improving access to care, practice efficiency, operational readiness, and long-term functional outcomes for service members.

Goss D, Weart A, Miller E, McHenry P, Haltiwanger H, Gonnella M, Ford K, Reilly N, Crowell M

Abstract accepted for a breakout session at the 2023 Military Health System Research Symposium

By the nature of their work, active-duty service members (ADSMs) are exposed to greater risks of musculoskeletal injury in comparison to the general population. The prevalence of musculoskeletal injury presents significant financial and temporal strains on the Military Health System (MHS) as costs for treatment and collective time lost from active duty accumulate, respectively. As a result, one of every twenty-five ADSMs are unable to deploy or fulfill their duties due to injury at any given time. Despite the inherently dangerous nature of combat, the most prevalent cause of injury in the ADSM population is running. Effective treatments for running-related pain are needed that modify known risk factors for running-related knee pain (i.e., gait retraining to alter problematic movement patterns).” Previous research has identified numerous biomechanical parameters indicative of increased mechanical strain and corresponding increases in musculoskeletal injury risk.  Examples include, but are not limited to, greater peak vertical ground reaction forces (GRF), greater average vertical loading rates upon foot strike, and greater peak braking forces. Unfortunately, the ADSM population does not have ready access to the laboratory-grade facilities and analytical techniques (i.e., kinetics via force plates, kinematics via three-dimensional motion capture) often utilized to conduct traditional gait retraining assessments. As a result, gait kinetics are often not considered clinically when forming treatment plans following a running-related injury, leaving any underlying problematic mechanical patterns to persist following the resolution of the initial injury and predisposing the patient to an increased risk of a follow-up, potentially more severe injury. Recent advances in the capabilities of telehealth have expanded the spectrum of treatment modalities for a variety of pathologies. However, it has yet to be seen whether telehealth can be utilized effectively to treat running-related injuries based on targeted feedback stemming from biomechanical parameters associated with injury risk. To date, the use of telehealth to implement gait retraining to supplement clinical management plans and expedite the return-to-duty process in the ADSM population has been largely unexplored.

Gaunaurd I, Goss D, Helton M, Gonella M, Reilly N, Haltiwanger H, Mulier L, Gailey R

Musculoskeletal injuries (MSI) affect approximately 800,000 service members annually and 25 million days of limited duty. There is a need for quick screen assessments that can classify and predict the risk of lower extremity (LE) MSI prior to activity. An Injury Risk Index (IRI) could facilitate improved decision-making and reduce the negative impact associated with selected MSI. The purpose of this study is to determine the frequency and distribution of Soldiers’ risk of MSI after performing sensors-based objective LE tests for static and dynamic stability. The number of Soldiers with prior lower limb MSI who had worse static and dynamic stability symmetry could be a concern for reinjury and/or less than ideal physical performance while on duty. The ability to identify the risk of injury in Soldiers, athletes or people with previous injuries may promote preventative interventions or pre-habilitation to reduce re-injury. 

Dowe JN, Bradley MW, Dickens JF

Abstracted accepted for a poster session at the 2023 Military Health System Research Symposium

Musculoskeletal injuries are some of the most prevalent issues in the military, being a significant contributor to functional limitations, duty restrictions, and impaired military readiness. In particular, shoulder instability events, such as dislocations and subluxations, are a disproportionately burdensome condition among military Service Members (SM), with SM being 20 times more likely to experience a shoulder instability event than their civilian counterparts. Furthermore, a common consequence of instability events is bone loss to the glenohumeral joint, which increases risk of re-injury (currently around 80% re-injury rate). As the amount of bone loss increases, so do the failure rates following nonoperative and operative treatment, leading to recurrent instability that contributes to inferior long-term outcomes and impaired biomechanics. With the military population being the most at-risk population for shoulder instability injuries, understanding the unique anatomical structure of a patient’s shoulder joint is essential in advancing treatment and surgical decision making. Additionally, the high costs associated with these injuries highlights the need for enhanced management and care. Imaging modalities, such as magnetic resonance imaging (MRI) and computed tomography (CT), are used to assess the extent of injury in patients who experience shoulder instability. These assessments help guide decisions regarding the direction of care for patients. However, these imaging modalities each have certain advantages and disadvantages in analyzing a patient’s joint structure. Currently, the closest to a gold standard for assessing bone loss in the shoulder is by obtaining a three-dimensional (3D) CT scan and then utilizing a 3D reconstruction. Though valuable, the current evaluation process can be improved to provide more efficiency and ease from both a clinician and patient perspective. The process of obtaining a 3D view of the shoulder joint from an MRI, although less common, can be completed to effectively assess bone loss and determine treatment, while also solving some of the issues associated with the use of CT.

Reilly N, Velasco T, Roberts K, Hulsopple C, Wise S, Goss D, Leggit J

Abstracted accepted for a poster session at the 2023 Military Health System Research Symposium

Active-duty service members (ADSMs) regularly run and perform vigorous physical activity per their training and physical fitness requirements. As such, ADSMs are at a higher risk of developing acute and persistent running-related musculoskeletal pathologies. As such, chronic exertional compartment syndrome (CECS) presents a significant clinical problem among the ADSM population. The condition impacts the ability to run as the repetitive mechanical strains incurred during gait result in localized pain, weakness, and/or paresthesia, predominantly in the musculature of the lower legs. Troublingly, the exact pathophysiology of CECS is not thoroughly understood, and surgical interventions to treat the condition (i.e., fasciotomy) have generally seen mixed outcomes regarding clinical success. As a result, alternative, non-surgical approaches have received increased attention. Two such approaches include 1) pharmaceutical interventions via botulinum toxin A (BoNT-A) to reduce lower limb pain and symptoms and perhaps reduce intramuscular compartment pressure, and 2) structured gait retraining to modify running mechanics (i.e., transition to forefoot strike pattern) to decrease skeletal muscle activity and stresses of the lower limbs. Prior research and case series utilizing each modality have reported promising results and clinical outcomes regarding pain and overall function during running. However, the implementation of these non-surgical interventions for patients with CECS has, to date, been limited in scope due to the availability of laboratory-grade equipment and analytical expertise for corresponding biomechanical gait data. The combination of these modalities on specific biomechanical gait parameters associated with injury risk in patients with CECS is mainly unexplored.

Rhon D, Sell T, Boeth R, Foster K, Greenlee T, Young J

Abstract presented at the World Physiotherapy Congress 2023 organized by World Confederation for Physical Therapy (WCPT)

Main outcome measures of study were frequency of adjacent joint injuries in the 2-year period after initial patellofemoral pain injury, and hazard ratios (HR) with 95% confidence interval (CI) and Kaplan–Meier survival curves for risk of adjacent joint injury based on receiving therapeutic exercise for the initial injury. After initial patellofemoral pain diagnosis, 42,983 (46.6%) individuals sought care for an adjacent joint injury. Of these, 19,587 (21.2%) were subsequently diagnosed with a lumbar injury, 2837 (3.1%) a hip injury, and 10,166 (11.0%) an ankle-foot injury. One in five (19.5%; n = 17,966) received therapeutic exercise which reduced the risk of having a subsequent lumbar (HR = 0.78, 95% CI 0.76–0.81), hip (HR = 0.93, 95% CI 0.87–0.98) or ankle-foot (HR = 0.86, 95% CI 0.83–0.90) injury.

Smith m, Abboud Chalhoub c, Hogaboom n, St Laurent m, Yuan x, Nordstrom m

Abstract accepted as a poster for 2023 USU Reserach Days

Chronic neck pain is a common health condition for Active Duty military personnel across all occupational specialties. The reduction of cervical lordosis in forward head posture (FHP) can lead to muscular imbalances, degenerative spinal changes, and heightened neck pain. The efficacy of a FHP therapy collar is being explored within the military population with chronic neck pain in an ongoing randomized waitlist-controlled trial at the Walter Reed National Military Medical Center (WRNMMC).

Evaluating the treatment effect of a simple, non-invasive, wearable device for neck pain is highly relevant to the military. This ongoing trial at WRNMMC will shed further light on the potential utility of this novel device in reducing neck pain due to FHP, and thereby improve functional outcomes and operational readiness.

Wentz G, Landry P, Yang K, Reilly N, Gonnella M, Wilson V, Goss D

Abstract submitted to American College of Sports Medicine Annual Meeting & World Congresses 2023

This clinical case involved a 38-year-old male soldier presented with lateral knee instability and pain, sustained 1.5 months previously during downhill trail running. Mechanism of injury was reported valgus knee collapse while planting out of a creek. Post-injury follow-up revealed unremarkable imaging for acute pathologies. Initial subjective measures collected included Single Assessment Numeric Evaluation (SANE) of 70% and resting Numeric Pain Rating Scale (NPRS) score of 2 out of 10. Patient demonstrated minimal effusion. Squat test highlighted pain from 30 to 60 degrees of knee flexion and moderate valgus with internal rotation collapse. Pain with end range knee flexion, painful knee extension (NPRS: 5 of 10) with manual muscle test. Tenderness of lateral joint line and lateral femoral condyle was observed. Patient exhibited positive signs during Thessaly test, varus stress test at 0 and 30 degrees, and Nobles and Rennes test.

Eliason A, Weart A, Miller E, Reilly N, Haltiwanger H, Gonnella M, Crowell M, Goss D

Abstract submitted to American College of Sports Medicine Annual Meeting & World Congresses 2023

Despite the inherently dangerous nature of combat, the most prevalent cause of injury observed in military servicemembers (MSMs) stems from running, possibly due to the large cumulative mechanical stresses incurred. Running-related injuries in the military have primarily been addressed by in-person rehabilitation, but limitations exist inequipment and clinician availability. Recently, telehealth has emerged as a method to reach and provide rehabilitative care to a greater number of patients as well as populations without ready access to laboratory-grade assessment tools. However, applications of telehealth for targeting biomechanical parameters associated with running-related injury in the armed services to improve clinical outcomes have not been explored. The purpose is to evaluate the viability of telehealth gait retraining as a modality to identify and modify gait-related kinetic parameters conducive to running-related injury risk in MSMs.

Yang K, Weart A, Miller E, Reilly N, Crowell M, Ford K, Mulier L, Goss D

Abstract submitted to American College of Sports Medicine Annual Meeting & World Congresses 2023

Running is the primary cause of musculoskeletal injury and lost or limited duty days in military service members (MSMs). Telehealth gait retraining is an accessible healthcare intervention showing promise in altering foot strike patterns that influences kinetic and spatiotemporal parameters, reducing mechanical strain and potentially reducing injury risk. However, it is inconclusive whether biomechanical changes resulting from telehealth gait retraining persist after the intervention is completed. The purpose is to determine the long-term efficacy of an 8-week telehealth gait retraining program to target and modify gait-related kinematic parameters.

Reilly N, Miller E, Weart A, Haltiwanger H, McHenry P, Ford K, Crowell M, Goss D

Abstract submitted to American College of Sports Medicine Annual Meeting & World Congresses 2023

Running is the most common mechanism of injury in the military service member (MSM) population. Specifically, cumulative stresses incurred using suboptimal kinematic patterns continuously predispose MSMs to increased risks of running-related injury. The gold-standard laboratory-grade equipment and time requirements necessary for biomechanical analyses of gait are unavailable for the MSM population. Recently, the advent of telehealth has diversified options and access to clinical treatment for a variety of pathologies. However, the effectiveness of telehealth to address risk factors contributing to running-related injury for MSMs is, to date, largely unexplored. The purpose is to evaluate the efficacy of telehealth gait retraining in addressing kinematic risk factors associated with running-related musculoskeletal injury in military personnel.

Goss D, Ignacio G, Helton M, Gonnella M, Reilly N, Haltiwanger, Yang K, Gailey

Abstract submitted to American College of Sports Medicine Annual Meeting & World Congresses 2023

Musculoskeletal injuries (MSI) affect approximately 800,000 service members and 25 million days of limited duty annually. There is a need for quick screening assessments that can classify and predict the risk of lower extremity (LE) MSI prior to activity. An Injury Risk Index (IRI) could facilitate improved decision-making and reduce the negative impact associated with selected MSI. The purpose of this study is to determine the frequency and distribution of Soldiers’ risk of MSI injury after performing sensors-based objective LE tests for static and dynamic stability. As of December 2022, 263 (92% male, 8% female) United States Army Soldiers were recruited, and provided demographic and previous joint-specific injury history information. Soldiers donned a sleeve with two inertial measurement unit sensors over each knee. They performed single limb stance (SLS) tests to obtain Region of Limb Stability (ROLS) values, which measures static LE stability. A four-meter sidestep test (FmSST) was used to obtain the Transitional Angular Displacement of Segments (TADS) values as a metric of dynamic joint stability. The ROLS and TADS symmetry values between LEs is calculated for both tests and the values are used to determine IRI category as low, moderate, or high risk for injury. [RN1] Total assessment time was < 15 minutes per Soldier. Descriptive statistics and frequency distributions were used to characterize the study population.

Crowell M, Pitt W, Mason J, Posner M, Cameron K, and Goss D

Abstract selected for a podium presentation at 2023 American Physical Therapy Association Combined Sections Meeting in San Diego, California

Shoulder instability is common in active young athletes and military personnel, often requiring shoulder stabilization surgery. Acute post-operative pain is usually managed with opioid pain medications, which have adverse effects that reduce military readiness. Battlefield Acupuncture (BFA) has demonstrated promise as a non-pharmaceutical intervention for acute post-operative pain. The purpose of this randomized clinical trial was to assess the effectiveness of BFA on post-surgical pain and opioid medication usage.

Symsack A, Haynes J, Gaunaurd I, Clemens S, Gruenhagen Lucarevic J, Bennet C, Isaacson B, Pasquina P, Gailey R

Abstract selected for a podium presentation at 2023 American Physical Therapy Association Combined Sections Meeting in San Diego, California

Veterans with lower limb loss (LLL) face many challenges (time and cost) to receive appropriate prosthetic training and exercises that could improve their gait quality and functional mobility. The VA and DoD supported the development of the Mobile Device Outcomes-based Rehabilitation Program (MDORP). MDORP is a comprehensive mobile rehabilitation program that includes a wearable sensor system called the Rehabilitative Lower Limb Orthopedic Assistive Device (ReLOAD). The ReLOAD system assesses gait and provides real-time audio feedback during home walks to correct specific gait deviations and subsequently recommend targeted exercises. The purpose of this study was to examine the changes in mobility, gait quality, and strength for lower functioning Veterans with LLL after completing the 8-week MDOR Pprogram

Miller E, mason J, Pitt w, Crowell M, Wear A, Reilly N, Haltiwanger H, Gonnella M, Goss D

Abstract selected for a podium presentation at 2023 American Physical Therapy Association Combined Sections Meeting 2023 in San Diego, California

Previous research has identified numerous biomechanical variables that may relate to musculoskeletal injury risk. Gait retraining interventions have successfully altered running biomechanical risk factors for overuse knee injury in non-military populations. However, constraints on patient time and frequency of in-clinic visits limits implementation of gait retraining interventions in the Military Health System (MHS). The purpose of this randomized clinical trial was to determine the effect of a telehealth gait retraining intervention on the running kinematics in patients with an overuse knee injury.

RHON D, TEYHEN D, COLLINS G, BULLOCK G

Abstract submitted to The World Congress of Sports Physical Therapy 2022

Using the same data, compare performance between an injury prediction model categorizing predictors and one that did not, and compare selection of predictors based on univariate significance versus assessing non-linear relationships. Validation and replication of a previously developed injury prediction model in a cohort of 1466 healthy military service members followed for one year after physical performance, medical history, and sociodemographic variables were collected. The original model dichotomized 8 predictors. The second model (M2) kept predictors continuous but assumed linearity, the third model (M3) conducted non-linear transformations. The fourth model (M4) chose predictors the proper way (clinical reasoning and supporting evidence) which led to an addition of 7 additional predictors (15 predictors total), but still kept predictors dichotomized. Model performance was assessed with R2, calibration in the large, calibration slope, and discrimination. Decision curve analyses were performed with risk thresholds from 0.25 to 0.50.