Defoor m, cognetti d, bedi a, carmack d, arner j, defroda s, enrat j, frangiamore s, nuelle c, sheean a

To determine whether low resilience is predictive of worse patient-reported outcomes (PROs) or diminished improvements in clinical outcomes after joint preserving and arthroscopic surgery.

A comprehensive search of PubMed, Medline, Embase, and Science Direct was performed on September 28, 2022, for studies investigating the relationship between resilience and PROs after arthroscopic surgery in accordance with the Preferred Reported Items for Systematic Reviews and Meta-analyses guidelines.

Patient resilience is inconsistently demonstrated to affect clinical outcomes associated with joint preserving and arthroscopic surgery. However, substantial limitations in the existing literature including underpowered sample sizes, lack of standardization in stratifying patients based on pretreatment resilience, and inconsistent collection of PROs throughout the continuum of care, diminish the strength of most conclusions that have been drawn.

DeFoor MT, Cognetti DJ, Bedi A, Carmack DB Jr, Arner JW, DeFroda S, Ernat JJ, Frangiamore SJ, Nuelle CW, Sheean AJ. Patient Resilience Does Not Conclusively Affect Clinical Outcomes Associated With Arthroscopic Surgery but Substantial Limitations of the Literature Exist. Arthrosc Sports Med Rehabil. 2024 Feb 13;6(2):100812. doi: 10.1016/j.asmr.2023.100812. PMID: 38379604; PMCID: PMC10877194.

Jariwala S, Fellin C, Steiner R, Buchen J, ANders J

Peripheral nerve injuries (PNI) pose a significant clinical issue for patients, especially in the most severe cases where complete transection (neurotmesis) results in total loss of sensory/motor function. Nerve guidance conduits (NGCs) are a common treatment option that protects and guides regenerating axons during recovery. However, treatment outcomes remain limited and often fail to achieve full reinnervation, especially in critically sized defects (> 3 cm) where a lack of vascularization leads to neural necrosis. A multi-treatment approach is therefore necessary to improve the efficacy of NGCs. Stimulating angiogenesis within NGCs can help alleviate oxygen deficiency through rapid inosculation with the host vasculature, while photobiomodulation therapy (PBMT) has demonstrated beneficial therapeutic effects on regenerating nerve cells and neovascularization.

In this review, we discuss the current trends of NGCs, vascularization, and PBMT as treatments for peripheral nerve neurotmesis and highlight the need for a combinatorial approach to improve functional and clinical outcomes

Fellin CR, Steiner RC, Buchen JT, Anders JJ, Jariwala SH. Photobiomodulation and Vascularization in Conduit-Based Peripheral Nerve Repair: A Narrative Review. Photobiomodul Photomed Laser Surg. 2024 Jan;42(1):1-10. doi: 10.1089/photob.2023.0103. Epub 2023 Dec 18. PMID: 38109199.

greenlee t, bullock g, teyhen d, rhon d

Psychologic variables have been shown to have a strong relationship with recovery from injury and return to work or sports. The extent to which psychologic variables predict successful return to work in military settings is unknown.

Psychologic variables alone were unable to adequately predict who would have a subsequent injury after an initial musculoskeletal injury. This study does not minimize the value of assessing psychologic profiles of injured athletes, but rather suggests that models looking to identify injury risk should consider a multifactorial approach that also includes other nonpsychologic factors such as injury history. These findings do, however, pro- voke curiosity surrounding which outcomes best capture relevant psychologic constructs and which assessment timepoints or change scores could be the most informative.

Greenlee, Tina A. PhD1; Bullock, Garrett PT, DPT, DPhil2; Teyhen, Deydre S. PT, PhD3; Rhon, Daniel I. PT, DSc, PhD1,4. Can a Psychologic Profile Predict Successful Return to Full Duty After a Musculoskeletal Injury?. Clinical Orthopaedics and Related Research 482(4):p 617-629, April 2024. | DOI: 10.1097/CORR.0000000000002935

crowell ms, brindle ra, miller em, reilly n, ford kr, goss dl

Running is the most common cardiovascular exercise in the military. However, there is a high incidence of running-related overuse injuries that reduces military readiness. Gait retraining is a common intervention to treat running-related injuries, but the high cost of equipment and lack of clinician expertise and availability reduces utilization. Gait retraining intervention in a telehealth format might improve feasibility. The purpose of this randomized clinical trial is to determine the effectiveness of a telehealth gait retraining intervention on pain, self-reported function, and biomechanical risk factors for injury in service members who present to a Military Health System physical therapy clinic with an overuse knee injury.

Crowell, M.S., Brindle, R.A., Miller, E.M. et al. The effectiveness of telehealth gait retraining in addition to standard physical therapy treatment for overuse knee injuries in soldiers: a protocol for a randomized clinical trial. Trials 24, 672 (2023). https://doi.org/10.1186/s13063-023-07502-x

Cohen S, larkin t, weitzner a, dolomisiewicz e, wang e, hsu a, anderson-white m, smith m, zhao z

There are few efficacious treatments for mechanical neck pain, with controlled trials suggesting efficacy for muscle relaxants and topical non-steroidal anti-inflammatory drugs. Although studies evaluating topical lidocaine for back pain have been disappointing, the more superficial location of the cervical musculature suggests a possible role for topical local anesthetics.

For the primary outcome, the median reduction in average neck pain score was -1.0 (IQR -2.0, 0.0) for the lidocaine phase vs. -0.5 (IQR -2.0,.0) for placebo treatment (p=0.17). 27.7% of patients experienced a positive outcome during lidocaine treatment vs. 14.9% during the placebo phase (p=0.073). There were no significant differences between treatments for secondary outcomes, though a carryover effect on pain pressure threshold was observed for the lidocaine phase (p=0.015). 27.5% of patients in the lidocaine group and 20.5% in the placebo group experienced minor reactions, the most common of which was pruritis (p=0.036).

The differences favoring lidocaine were small and non-significant, but the trend towards superiority of lidocaine suggests more aggressive phenotyping and applying formulations with greater penetrance may provide clinically meaningful benefit.

Steven P. Cohen, Thomas M. Larkin, Aidan S. Weitzner, Edward Dolomisiewicz, Eric J. Wang, Annie Hsu, Mirinda Anderson-White, Marin S. Smith, Zirong Zhao; Multicenter, Randomized, Placebo-controlled Crossover Trial Evaluating Topical Lidocaine for Mechanical Cervical Pain. Anesthesiology 2024; 140:513–523 doi: https://doi.org/10.1097/ALN.0000000000004857

Bullock GS, Dartt Ce, Ricker EA, arden N, clifton D, danelson K, fraser jj, gomez c, greenlee ta, gregory a, gribbin t, losciale j, molloy jm, nicholson kF, polich jg, raisanen a, shah k, smuda m, teyhen ds, allard rj, collins gs, de la motte sj, rhon di

Musculoskeletal injury (MSK-I) mitigation and prevention programmes (MSK-IMPPs) have been developed and implemented across militaries worldwide. Although programme efficacy is often reported, development and implementation details are often overlooked, limiting their scalability, sustainability and effectiveness. This scoping review aimed to identify the following in military populations: (1) barriers and facilitators to implementing and scaling MSK-IMPPs; (2) gaps in MSK-IMPP research and (3) future research priorities. This review concluded that despite a robust body of literature, there is a dearth of information about programme implementation; specifically, barriers or facilitators to success. Additionally, variability in outcomes and lack of consensus on MSK-I definitions may affect the development, implementation evaluation and comparison of MSK-IMPPs. There is a need for international consensus on definitions and optimal data reporting elements when conducting injury risk mitigation research in the military.

Bullock GS, Dartt CE, Ricker EA, et al Barriers and facilitators to implementation of musculoskeletal injury mitigation programmes for military service members around the world: a scoping review. Injury Prevention Published Online First: 23 August 2023. doi: 10.1136/ip-2023-044905

Ong J, Nazarian A, Tam J, farinelli W, Korupolu s, Drake L, Isaacson B, Pasquina P, Williams D

Antimicrobial blue light (aBL) is an attractive option for managing biofilm burden at the skin-implant interface of percutaneous osseointegrated (OI) implants. However, marketed aBL devices have both structural and optical limitations that prevent them from being used in an OI implant environment. They must be handheld, preventing even irradiation of the entire skin-implant interface, and the devices do not offer sufficient optical power outputs required to kill biofilms. We present the developmental process of a unique aBL device that overcomes these limitations. Four prototypes are detailed, each being a progressive improvement from the previous iteration as we move from proof-of-concept to in vivo application. Design features focused on a cooling system, LED orientation, modularity, and “sheep-proofing”. The final prototype was tested in an in vivo OI implant sheep model, demonstrating that it was structurally and optically adequate to address biofilm burdens at the skin-implant of percutaneous OI implants. The device made it possible to test aBL in the unique OI implant environment and compare its efficacy to clinical antibiotics–data which had not before been achievable. It has provided insight into whether or not continued pursual of light therapy research for OI implants, and other percutaneous devices, is worthwhile. However, the device has drawbacks concerning the cooling system, complexity, and size if it is to be translated to human clinical trials. Overall, we successfully developed a device to test aBL therapy for patients with OI implants and helped progress understanding in the field of infection management strategies.

Ong J, Nazarian A, Tam J, Farinelli W, Korupolu S, Drake L, et al. (2023) An antimicrobial blue light device to manage infection at the skin-implant interface of percutaneous osseointegrated implants. PLoS ONE 18(8): e0290347. https://doi.org/10.1371/journal.pone.0290347

Rhon DI, Anderson DN, Konitzer LN, Pickens BB, Szymanek EB, Mayhew RJ, Laugesen MC, Greenlee TA

Physical therapy services delivered remotely are becoming more common. The purpose of this study was to summarize the acceptability and patient-centeredness of remotely delivered physical therapy. This was a survey study. Patients and clinicians from physical therapy clinics in the US Military Health System were asked to provide feedback at the conclusion of each remote visit. Platform, reason for care, components of physical therapy delivered and received, satisfaction, and perception of patient-centeredness were collected. Results were summarized as proportions and frequencies. Feedback was provided by physical therapists for 250 visits and from patients for 61 visits. Most visits were completed using audio only (n=172; 68.8%) while the rest integrated video capability (n=78; 31.2%). Overall patients perceived their care was patient-centered either completely or very much. Over 90% of visits were perceived by physical therapists as being highly patient centered. For 53.2% of visits, patients thought that same visit would have been even more impactful in person and for 52.4% of visits, physical therapists thought the visit would have been more impactful in person. In conclusion even though remotely provided physical therapy care was rated by patients to be patient-centered, approximately half of the patients responding felt the same physical therapy visit would have been more impactful in person. Similarly, physical therapists felt that their intervention would have been more impactful in person for approximately half of all visits. Physical therapy care delivered remotely was patient-centered and an acceptable alternative to in-person care for both patients and physical therapists.

Rhon, D.I., Anderson, D.N., Konitzer, L.N. et al. Patient-centeredness and acceptability of remotely delivered physical therapy care for musculoskeletal disorders in four large hospitals within the Military Health System. BMC Digit Health 1, 21 (2023). https://doi.org/10.1186/s44247-023-00017-0

Cohen SP, Doshi TL, Dolomisiewicz E, Reece DE, Zhao Z, Anderson- White M, Kasuske A, Wang EJ, Hsu A, Davis SA, Yoo Y, Pasquina PF, Youn Moon J

Non-organic signs have gained traction for identifying patients who may benefit from psychotherapy, decreasing the risk of treatment failure. In conjunction with other clinical factors, these signs may refine patient selection, but their association with clinical outcomes has not been studied for neck pain. Seventy-eight patients with cervical radiculopathy who received epidural steroid injection (ESI) were followed to determine the effects non-organic signs and other factors have on treatment outcome. A positive outcome was a > 2-point decrease in average arm pain, coupled with a score of 5 on a 7-point patient global impression of change scale. Nine tests in 5 categories (abnormal tenderness, regional disturbances deviating from normal anatomy, overreaction, discrepancies in exam findings with distraction, and pain during sham stimulation) were modified from previous studies and standardized. Other variables examined for their association with non-organic signs and outcomes included measures of disease burden, psychopathology, co-existing pain conditions, sleep dysfunction, imaging, and somatization.

Cohen, S. P., Doshi, T. L., Dolomisiewicz, E., Reece, D. E., Zhao, Z., Anderson-Whitle, M., Kasuke, A., Wang, E. J., Hsu, A., Davis, S. A., Yoo, Y., Pasquina, P. F., & Youn Moon, J. (2022). What is the Incidence of Subsequent Adjacent Joint Injury After Patellofemoral Pain? Mayo Clinical Proceedings, 98(6), 868-882. https://doi.org/10.1016/j.mayocp.2022.11.022

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

This retrospective cohort study was designed to investigate the incidence of subsequent lumbar spine, hip, and ankle-foot injuries after a diagnosis of patellofemoral pain. The results suggest that a high number of individuals with patellofemoral pain will sustain an adjacent joint injury within 2 years although causal relationships cannot be determined. Receiving therapeutic exercise for the initial knee injury reduced the risk of sustaining an adjacent joint injury. This study helps provide normative data for subsequent injury rates in this population and guide development of future studies designed to understand causal factors.

Young, J. L., Sell, T. C., Boeth, R., Foster, K., Greenlee, T. A., & Rhon, D. I. (2023). What is the Incidence of Subsequent Adjacent Joint Injury After Patellofemoral Pain? Clinical Rehabilitation. https://doi.org/10.1177/02692155231157177

Cohen SP, Doshi TL, Dolomisiewicz E, Reece DE, Zhao Z, Anderson- White M, Kasuske A, Wang EJ, Hsu A, Davis SA, Yoo Y, Pasquina PF, Youn Moon J

Neck pain is one of the top five leading causes of disability, with more than one-third being neuropathic in nature. Since 2000, the use of cervical epidural steroid injections has more than tripled, leading to increased scrutinization. The presence of nonorganic (Waddell) signs has been shown to be associated with treatment failure for back pain but has never been validated for neck pain. In a multicenter study, Waddell signs were adapted for cervical pain, with nine signs in five categories validated in a small pilot. Seventy-eight patients with cervical radiculopathy scheduled for epidural steroid injection were then evaluated with these signs for their association with outcome, with a positive outcome defined as a greater-than 2-point decrease in arm pain and a score greater than 5 on a 7-point improvement scale. Seventy-one percent had at least one nonorganic sign and 40% had at least one sign in three categories, with noncorrelative tenderness being most common (51%). Mean number of positive nonorganic categories was higher in individuals with negative outcomes (2.5 ± 1.8; 95% CI, 2.0 to 3.1) versus those with positive outcomes (1.1 ± 1.3; 95% CI, 0.7 to 1.5; P = 0.0002). Positive associations were noted between nonorganic signs and multiple pain (P = 0.011) and multiple psychiatric (P = 0.028) conditions.

Cohen, S. P., Doshi, T. L., Dolomisiewicz, E., Reece, D. E., Zhao, Z., Anderson-Whitle, M., Kasuke, A., Wang, E. J., Hsu, A., Davis, S. A., Yoo, Y., Pasquina, P. F., & Youn Moon, J. Science, Medicine, and the Anesthesiologist. Anesthesiology 2023; 138:A12–A15 doi: https://doi.org/10.1097/ALN.0000000000004586

Ong J, Godfrey R, Nazarian A, Tam J, Isaacson B, Pasquina P, Williams D

Bacterial biofilms readily develop on all medical implants, including percutaneous osseointegrated (OI) implants. With the growing rate of antibiotic resistance, exploring alternative options for managing biofilm-related infections is necessary. Antimicrobial blue light (aBL) is a unique therapy that can potentially manage biofilm-related infections at the skin-implant interface of OI implants. Antibiotics are known to have antimicrobial efficacy disparities between the planktonic and biofilm bacterial phenotypes, but it is unknown if this characteristic also pertains to aBL. In response, we developed experiments to explore this aspect of aBL therapy.

aBL had the most significant efficacy disparity between the planktonic and biofilm phenotypes (a 2.5 log10 unit difference). However, further testing against biofilms revealed that aBL had a positive correlation between increasing efficacy and exposure time, while levofloxacin encountered a plateau. While aBL efficacy was affected the most by the biofilm phenotype, its antimicrobial efficacy did not reach a maximum.

We determined that phenotype is an important characteristic to consider when determining aBL parameters for treating OI implant infections. Future research would benefit from expanding these findings against clinical S. aureus isolates and other bacterial strains, as well as the safety of long aBL exposures on human cells.

Ong J, Godfrey R, Nazarian A, Tam J, Isaacson BM, Pasquina PF and Williams DL (2023) Comparison of Staphylococcus aureus tolerance between antimicrobial blue light, levofloxacin, and rifampin. Front. Microbiol. 14:1158558. doi: 10.3389/fmicb.2023.1158558

Nowak A, Kennelley G, Hager N, Metzger E, Isaacson B, hoenig T, Hollander K, Tenforde A

We enjoyed reading the articles by Abbott, et al. that cover the important topic of stress fractures in female military personnel “Part I: Background and Clinical Considerations for Stress Fractures in Female Military Recruits” and “Part II: Risk Factors for Stress Fractures in Female Military Recruits.” Both reviews identify that female military personnel are at a greater risk for stress fractures during training than their male counterparts and detail unique risk factors that are a necessary consideration in optimizing management. While we congratulate the authors for this detailed work, it is important to highlight additional research that adds to our understanding of this injury and the approach for management and prevention of these injuries.

Andrew S Nowak, Gabrielle E Kennelley, Nelson Hager, Elizabeth C Metzger, Brad Isaacson, Tim Hoenig, Karsten Hollander, Adam S Tenforde, Stress Fractures in the Military: Opportunities to Advance Recognition, Treatment, and Prevention, Military Medicine, Volume 188, Issue 9-10, September/October 2023, Pages 244–245, https://doi.org/10.1093/milmed/usad067

Negri LB, mannaa y, Korupolu S, farinelli w, anderson r, Gelfand J

Cutaneous bacterial wound infections typically involve gram-positive cocci such as Staphylococcus aureus (SA) and usually become biofilm infections. Bacteria in biofilms may be 100–1000-fold more resistant to an antibiotic than the clinical laboratory minimal inhibitory concentration (MIC) for that antibiotic, contributing to antimicrobial resistance (AMR). AMR is a growing global threat to humanity. One pathogen–antibiotic resistant combination, methicillin–resistant SA (MRSA) caused more deaths globally than any other such combination in a recent worldwide statistical review. Many wound infections are accessible to light. Antimicrobial phototherapy, and particularly antimicrobial blue light therapy (aBL) is an innovative non-antibiotic approach often overlooked as a possible alternative or adjunctive therapy to reduce antibiotic use. We therefore focused on aBL treatment of biofilm infections, especially MRSA, focusing on in vitro and ex vivo porcine skin models of bacterial biofilm infections. Since aBL is microbicidal through the generation of reactive oxygen species (ROS), we hypothesized that menadione (Vitamin K3), a multifunctional ROS generator, might enhance aBL. Our studies suggest that menadione can synergize with aBL to increase both ROS and microbicidal effects, acting as a photosensitizer as well as an ROS recycler in the treatment of biofilm infections. Vitamin K3/menadione has been given orally and intravenously worldwide to thousands of patients. We conclude that menadione/Vitamin K3 can be used as an adjunct to antimicrobial blue light therapy, increasing the effectiveness of this modality in the treatment of biofilm infections, thereby presenting a potential alternative to antibiotic therapy, to which biofilm infections are so resistant.

Yan M, Wu M

Exercise, especially anaerobic one, can gradually increase muscle mass over time as a result of adaptive responses of muscle cells to ensure metabolic homeostasis in the tissue. Low-level light therapy (LLLT) or photobiomodulation exhibits beneficial effects on promoting muscular functions, regeneration, and recovery from exhausting exercise, although the underlying cellular mechanisms remain poorly understood. We found that hypoxia, a condition following anaerobic exercise, significantly impeded myotube differentiation from myoblasts. However, this adverse effect was blunted greatly by pre-exposure of myoblast cells to a 980 nm laser at 0.1 J/cm2 , resulting in almost nearly normal myotube differentiation. LLL pre-treatment enhanced myotube formation by 80%, with a tubular diameter of 4.28 ± 0.11 μm on average, representative of a 53.4% increase over sham light treatment. The normalized myoblast differentiation concurred with 68% more mitochondrial mass and myogenin expression over controls. Moreover, LLL pre-treatment appeared to enhance glucose uptake, prevent energy metabolic switch from oxidative phosphorylation to glycolysis, and diminish lactate production under hypoxic conditions. The observation provides valuable guidance with respect to the timing of LLLT and its potential effects on muscle strengths in concert with anaerobic exercise.

Yan, M., & Wu, M. X. (2023). Low-Level Light Pre-Conditioning Promotes C2C12 Myoblast Differentiation Under Hypoxic Conditions. Journal of Biophotonics. https://doi.org/10.1002/jbio.202100246

Ong J, Godfrey R, Nazarian A, Tam J, Drake L, Isaacson B, Pasquina P, Williams D

Biofilm contamination is often present at the skin-implant interface of transfemoral osseointegrated implants leading to frequent infection, irritation, and discomfort. New biofilm management regimens are needed as the current standard of washing the site with soap and water is inadequate to manage infection rates. We have investigated the potential of antimicrobial blue light which has reduced risk of resistance development and broad antimicrobial mechanisms. Our lab has developed an aBL device uniquely designed for an ex vivo system based on an established ovine OI implant model with Staphylococcus aureus ATCC 6538 biofilms as initial inocula. Samples were irradiated with aBL or washed for three consecutive days after which they were quantified. Colony forming unit (CFU) counts were compared to a control group (bacterial inocula without treatment). After one day, aBL administered as a single 6 h dose or two 1 h doses spaced 6 h apart both reduced the CFU count by 1.63 log10 ± .02 CFU. Over three days of treatment, a positive aBL trend was observed with a maximum reduction of ~2.7 log10 CFU following 6 h of treatment, indicating a relation between multiple days of irradiation and greater CFU reductions. aBL was more effective at reducing the biofilm burden at the skin-implant interface compared to the wash group, demonstrating the potential of aBL as a biofilm management option.

Ong, J., Godfrey, R., Nazarian, A., Tam, J., Drake, L., Isaacson, B., Pasquina, P., & Williams, D. (2023). Antimicrobial Blue Light as a Biofilm Management Therapy at the Skin-Implant Interface in an Ex Vivo Percutaneous Osseointegrated Implant Model. Journal of Orthopaedic Research. https://doi.org/10.1002/jor.25535

Yuan X, Pav V, Colahan C, Miller M, Nelson H, Pasquina P, Cohen S, Isaacson B

Low back pain (LBP) has accounted for the most medical encounters every year for the past decade among Active-Duty Service Members (ADSMs) of the U.S. Armed Forces. The objectives of this retrospective, descriptive study was to classify LBP by clinical category (Axial, Radicular, and Other) and duration (Acute, Subacute, and Chronic) and examine the LBP-related health care utilization, access to care, and private sector costs for ADSMs over a 2-year follow-up period. The Military Health System Data Repository was queried in fiscal year 2017 for all ADSMs (ages 18-62) with outpatient encounters documented with any of 67 ICD-10 diagnosis codes indicative of LBP. A 1-year clean period before the first (index) outpatient LBP encounter date was used to ensure no recent history of LBP care. Patients were eligible if continuously enrolled and on active duty for 1 year before and 2 years following the index visit. Patients were excluded for non-musculoskeletal causes for LBP, red flags, or acute trauma within 4 weeks of the index visit and/or systemic illness or pregnancy anytime during the clean or follow-up period.

Yuan, X., Pav, V., Colahan, C., Miller, M. E., Hager, N. A., Pasquina, P. F., Cohen, S. P., & Isaacson, B. M. (2022). Active-Duty Service Members Newly Presenting with Low Back Pain in Fiscal Year 2017: Health Care Utilization, Access to Care, and Private Sector Costs Over 2-year Follow-up. Military Medicine. https://doi.org/10.1093/milmed/usac363

Cohen S, Khunsriraksakul c, Yoo y, Parker E, Samen-Akinsiku c, Patel n, Cohen s, Yuan x, Cheng j, Moon j

Ketamine infusions are frequently employed for refractory complex regional pain syndrome (CRPS), but there are limited data on factors associated with treatment response. Sympathetic blocks are also commonly employed in CRPS for diagnostic and therapeutic purposes and generally precede ketamine infusions.

Factors associated with a positive response to ketamine in univariable analysis were the presence of SMP (61.0% success rate vs 26.7% in those with sympathetically independent pain; P = .009) and post-block temperature increase (5.66 ± 4.20 in ketamine responders vs 3.68 ± 3.85 in non-responders; P = .043). No psychiatric factor was associated with ketamine response. In multivariable analysis, SMP (OR 6.54 [95% CI 1.83, 23.44]) and obesity (OR 8.75 [95% 1.45, 52.73]) were associated with a positive ketamine infusion outcome.

The response to sympathetic blocks may predict response to ketamine infusion in CRPS patients, with alleviation of the affective component of pain and predilection to a positive placebo effect being possible explanations.

Pain Medicine, Volume 24, Issue 3, March 2023, Pages 316–324, https://doi.org/10.1093/pm/pnac153

Rhon D, Yuan X, Barlow B, Konitzer L, Cook C

Within a large government health system, to assess the practice of using non-specific diagnoses for knee disorders and determine how often they appear as the only diagnosis without more specificity. The secondary purpose was to identify the incidence of obscure knee disorders diagnosed: pes anserine bursitis, prepatellar bursitis, pigmented villonodular synovitis, and plica syndrome.

Rhon, Daniel & Yuan, Xiaoning & Barlow, Brian & Konitzer, Lisa & Cook, Chad. (2022). Use of Non-Specific Knee Diagnoses and Incidence of Obscure Knee Injuries in a Large Government Health System. Clinical Epidemiology. Volume 14. 1123-1133. https://doi.org/10.2147/CLEP.S375040

Tenforde A, Vogel K, Tam J, Grävare Silbernagel K

Achilles tendinopathy (AT) is a common overuse injury in runners. While the mainstay of treatment for AT is tendon loading exercises (physical therapy and exercise programme (EXER)), some patients have refractory symptoms. Extracorporeal shockwave therapy (ESWT) and photobiomodulation therapy (PBMT) have each been evaluated to facilitate tendon healing; the influence of combining treatments is unknown and limited studies have been completed in runners. This randomized control study, with an elective cross-over at 3 months, will evaluate the efficacy of three forms of treatment of non-insertional AT: (1) EXER (loading programme specific to Achilles tendon combined with physical therapy); (2) EXER and ESWT; (3) EXER, ESWT and PBMT. Sixty runners will be assigned using block randomization into one of three treatment groups (n=20). After 3 months, each participant may elect a different treatment than previously assigned and will be followed for an additional 3 months. The EXER Achilles loading programme will be standardized using the Silbernagel at-home programme. The primary outcome of interest is treatment group responses using the Victorian Institute of Sports Assessment—Achilles (VISA-A) Score. Secondary outcomes include the Patient-Reported Outcomes Measurement Information System—29 questions, the University of Wisconsin Running Injury and Recovery Index, heel raise to fatigue test, hopping test and ultrasound measurements. We will also capture patient preference and satisfaction with treatment. We hypothesize that the cohorts assigned EXER+ESWT+PBMT and EXER+ESWT will see greater improvements in VISA-A than the EXER cohort, and the largest gains are anticipated in combining ESWT+PBMT. The elective cross-over phase will be an exploratory study and will inform us whether patient preference for treatment will impact the treatment response.

Tenforde, A. S., Vogel, K. E. L., Tam, J., & Grävare Silbernagel, K. (2022). Research protocol to evaluate the effectiveness of shockwave therapy, photobiomodulation and physical therapy in the management of non-insertional Achilles tendinopathy in runners: a randomized control trial with elective cross-over design. BMJ Open Sport & Exercise Medicine. https://doi.org/http://dx.doi.org/10.1136/bmjsem-2022-001397