Research Activities
These guidelines were created as a framework for the post-operative rehabilitation program. They DO NOT substitute for any specific restrictions or requirements that are determined through the necessary shared decision-making and collaboration between the operating surgeon and treating rehabilitation team.
It is nearly impossible to overestimate the burden of chronic pain, which is associated with enormous personal and socioeconomic costs. Chronic pain is the leading cause of disability in the world, is associated with multiple psychiatric comorbidities, and has been causally linked to the opioid crisis. Access to pain treatment has been called a fundamental human right by numerous organizations. The current COVID-19 pandemic has strained medical resources, creating a dilemma for physicians charged with the responsibility to limit spread of the contagion and to treat the patients they are entrusted to care for.
In these guidelines, we provide a framework for pain practitioners and institutions to balance the often-conflicting goals of risk mitigation for health care providers, risk mitigation for patients, conservation of resources, and access to pain management services. Specific issues discussed include general and intervention-specific risk mitigation, patient flow issues and staffing plans, telemedicine options, triaging recommendations, strategies to reduce psychological sequelae in health care providers, and resource utilization.
Pain Medicine, Volume 21, Issue 7, July 2020, Pages 1331–1346, https://doi.org/10.1093/pm/pnaa127
Chronic pain causes significant suffering, limitation of daily activities and reduced quality of life. Infection from COVID-19 is responsible for an ongoing pandemic that causes severe acute respiratory syndrome, leading to systemic complications and death. Led by the World Health Organization, healthcare systems across the world are engaged in limiting the spread of infection. As a result, all elective surgeries, procedures, and patient visits, including pain management services, have been postponed or cancelled. This has impacted the care of chronic pain patients. Most are elderly with multiple comorbidities, which puts them at risk of COVID-19 infection. Important considerations that need to be recognized during this pandemic for chronic pain patients include ensuring continuity of care and pain medications, especially opioids; use of telemedicine; maintaining biopsychosocial management; use of anti-inflammatory drugs; use of steroids; and prioritizing necessary procedural visits. There are no guidelines to inform physicians and healthcare providers engaged in caring for patients with pain during this period of crisis. We assembled an expert panel of pain physicians, psychologists and researchers from North America and Europe to formulate recommendations to guide practice. As the COVID-19 situation continues to evolve rapidly, these recommendations are based on the best available evidence and expert opinion at this present time and may need adapting to local workplace policies.
Shanthanna H., Strand N.H., Provenzano D.A., Lobo C.A., Eldabe S., Bhatia A., Wegener J., Curtis K., Cohen S.P., Narouze S. (2020). Caring for patients with pain during the COVID‐19 pandemic: consensus recommendations from an international expert panel. Anesthesia. https://doi.org/10.1111/anae.15076
The past two decades have witnessed a surge in the use of lumbar facet blocks and radiofrequency ablation (RFA) to treat low back pain (LBP), yet nearly all aspects of the procedures remain controversial. Lumbar medial branch RFA may provide benefit to well-selected individuals, with MBB being more predictive than IA injections. More stringent selection criteria are likely to improve denervation outcomes, but at the expense of more false-negatives. Clinical trials should be tailored based on objectives, and selection criteria for some may be more stringent than what is ideal in clinical practice.
Cohen SP, Bhaskar A, Bhatia A, et al. (2020). Consensus practice guidelines on interventions for lumbar facet joint pain from a multispecialty, international working group. Regional Anesthesia & Pain Medicine. https://doi.org/10.1136/rapm-2019-101243
Discogenic Low Back Pain (DLBP) is a common condition with an unfavourable prognosis and limited treatment options. After experiencing insufficient response to standard conservative care of physical therapy, non-steroidal anti-inflammatory medications and activity modification, three patients with chronic DLBP were treated with intradiscal injection of dehydrated Human Amnion Chorion Membrane (dHACM). Diagnosis was established by Magnetic Resonance Imaging (MRI) revealing disc disease with anatomically concordant pain. Results indicated a trend toward reduced pain as measured by the Numerical Rating Scale for pain (NRS-Pain) and increased function as measured by the Oswestry Disability Index (ODI).
Lacey, S., Cohen, S., & Jacobs, M. (2020). Intradiscal Injection of Dehydrated Human AmnionChorion Membrane for Treatment of Chronic Discogenic Low Back Pain: A Case Series. Journal of Regenerative Medicine. https://doi.org/10.37532/jrgm.2020.9(1).155
Abstract submitted to the International Society of Physical and Rehabilitation Medicine 2020
Chronic low back pain is a major cause of morbidity in the U.S., with costs by some estimates exceeding $100 billion annually. Among the U.S. military population, back-related conditions have been associated with the highest 5-year cumulative risk of disability discharge. Patients with low back pain and intervertebral disc lesions identified on advanced imaging or discography are often diagnosed with “discogenic low back pain” (DLBP), which has a prevalence rate among axial low back pain sufferers estimated at 39 to 42%. The prognosis for DLBP is not favorable, with one prospective clinical study containing 279 patients finding that 87% of patients continued to have symptoms at 4 years of follow-up.
Lacey SA, Cohen SP, Jacobs MB. Intradiscal Injection Of Dehydrated Human Amnion Chorion Membrane For Treatment Of Chronic Discogenic Low Back Pain: A Case Series. Military Health System. International Society of Physical and Rehabilitation Medicine 14th World Congress. Orlando, FL; March 8, 2020.
Abstracted submitted to the International Society of Physical and Rehabilitation Medicine 2020
60 year old man with cervical stenosis sustained a syncopal episode from a sitting height. He was found by a co-worker and reported being unable to move arms or legs. Diagnostic workup revealed C3-C4 fracture, ALL rupture and central cord syndrome. He underwent C2-C5 posterior fusion the next day and received post-operative course of steroids. Upon transfer to inpatient rehabilitation service on post-op day 11, patient was noted to have 4/5 strength in arms and 5/5 strength in legs. Patients who undergo inpatient rehabilitation after spine surgery should receive daily neurological exams and be monitored for increased pain or discomfort, especially in those with pre-operative and intra-operative risk factors.
Choosing appropriate pharmacotherapy for acute and chronic LBP continues to pose a major challenge to health-care providers and sufferers. Identifying distinct phenotypes that respond to targeted treatments, improving diagnosis to enable mechanism-based rather than symptom-based treatment of pain (e.g. muscle relaxants for muscle spasms, antidepressants for LBP with a neuropathic character), treating concomitant conditions that may undermine effectiveness (e.g. sleep and psychological disorders) and exploring stepped care and interdisciplinary models, while monitoring for adverse effects are promising approaches that need to be studied for comparative-effectiveness against standard of care. The paucity of pharmacologic treatments for LBP has spurred a search for more efficacious and safer medications. Although they have not been extensively studied for back pain per se, intravenous infusion tests designed to identify pain mechanisms and predict response to oral analgesic therapy represents an area ripe for investigation [30]. Nerve growth factor inhibitors, cannabinoids, newer opioids, ketamine, and botulinum toxin have been evaluated in a variety of clinical studies for LBP. The evidence regarding the role of these therapies is mixed and of low quality. Table 2 provides a summary of some of the important studies on these agents in the last decade. Increasing evidence on newer options will help to optimize the treatment of this challenging and growing problem. It is also important to consider non-pharmacological options for LBP such as physical therapy and psychological treatments. Health-care providers should advise their patients with low back pain about non-pharmacological analgesic options that are supported by evidence of efficacy and safety, while informing them that many of them may not respond to currently available treatments, in which case functional restoration in the context of persistent pain may improve their quality of life.
Bhatia, A., Engle, A., & Cohen, S. P. (2020). Current and future pharmacological agents for the treatment of back pain. Expert Opinion on Pharmacotherapy, 21(8), 857–861. https://doi.org/10.1080/14656566.2020.1735353
This MIRROR-sponsored event at West Point trained 5 Sports Physical Therapy Fellows and 4 Physician Assistant Students in the Battlefield Acupuncture (BFA) technique that will be utilized within our Research Project #13. The training lays the groundwork for further sessions to certify BFA instructors within the MHS.
The shoulder is one of the most complex joints in the body, with potential pain generators such as the glenohumeral and acromioclavicular joints, multiple bursae, and numerous soft tissue structures to include multiple tendons and muscles. The lifetime prevalence of shoulder pain is estimated at 7% to 67%, with the prevalence variation stemming from differences in study populations and diagnostic criteria. According to some sources, pain arising from subacromial impingement syndrome is the most common source of chronic shoulder pain, though many patients have pain from multiple pathologies and some have pain despite minimal or no radiologic pathology. In the United States, the estimated cost of chronic shoulder pain is largely unknown, though ∼$3 billion dollars are spent each year on the evaluation and management of rotator cuff tears alone. In Australia, the average annual cost per patient with chronic shoulder pain has been estimated at AU$22,378. Yet, despite the high prevalence and economic expenditures on shoulder pain, surgical and nonsurgical treatments are characterized by high failure rates. According to one systematic review, there is no difference in pain or functional outcomes between surgical and nonsurgical management for shoulder impingement syndrome. In this issue of Pain Medicine, Eckmann et al. report their results with radiofrequency (RF) ablation of the terminal sensory articular nerves of the shoulder joint for chronic, refractory shoulder pain.
Zhao, Z., Larkin, T., & Cohen, S. (2020). Reflections on Innovative Interventional Pain-Relieving Procedures: Lessons Learned from Previous Mistakes. Pain Medicine. https://doi.org/10.1093/pm/pnz380
More than 50 military leaders, clinicians, scientists and subject-matter experts within the physical therapy, orthopaedics, physical medicine and rehabilitation, and pain management fields converged for the first time for an all-day consensus meeting to help advance service member care and identify best practices within the Army, Navy and Air Force.
The meeting was hosted by the Musculoskeletal Injury Rehabilitation Research for Operational Readiness (MIRROR) program in the Uniformed Services University’s Department of Physical Medicine and Rehabilitation, The Geneva Foundation and the Broussard Family Trust, to validate and endorse existing or commonly agreed upon postoperative physical therapy (PT) guidelines to be shared through the Military Health System and Defense Health Agency. In addition, the group met to identify research gaps in the area of optimizing postoperative PT guidelines to design, fund, and/or execute future relevant research studies in this field.
Participants came from across the country for the consensus meeting, which resulted in the standardization and approval of 13 protocols for hip, knee, ankle and shoulder injuries.
Abstracted submitted to Extremity War Injuries Symposium 2020
In order to enhance the DoD’s efforts in addressing the negative impact of MSI, we created MIRROR to study risk factors, generate prevention strategies, optimize treatments, and establish return-to-duty criteria that is based on scientific evidence rather than case-specific clinical judgment alone. Although the work at civilian facilities will be limited, investigators from these sites were included to engage national leaders in MSI research, ensure scientific rigor, enhance the mentorship of junior military clinical researchers, and scale these novel therapies for the general population.
Abstracted submitted to Extremity War Injuries Symposium 2020
Within the MHS, data and analytics activities are commonly coordinated on an ad hoc basis using solutions like Microsoft Excel. This approach often acts as a barrier to efficient research and fails to scale. The development of a shared data and analytics infrastructure across MIRROR projects enables program information and insights to be communicated in an efficient, timely, and approachable manner. Ultimately, this allows military-relevant musculoskeletal injury rehabilitation research to be advanced in a data-driven way.
