Research Activities
Cohen SP, Provenzano DA, Narouze S. (2021). Facet guidelines, serial medial branch blocks and issues surrounding recommending procedures with no mechanistic foundation. Regional Anesthesia & Pain Medicine. https://doi.org/10.1136/rapm-2020-101634.
This abstract won the Army Chapter of the American College of Physician's abstract competition and will be presented virtually in May 2021.
Chronic Exertional Compartment Syndrome (CECS) is a debilitating disorder that causes lower extremity pain most commonly in active populations. It is thought to arise from increased pressure in muscle compartments (commonly lower extremity anterior and lateral) leading to pain, paresthesia and an inability to tolerate exercise. The cause of CECS is unknown but is likely a combination of muscular, neurologic and vascular contributions. Current standard treatment is surgical fasciotomy, but it is only successful in 66% of patients. Many have complications and/or need repeat procedures. Efficacy is even worse in military members at 55%. Other alternative strategies have emerged such as botulinumtoxin A injections (BoNT-A) and gait retraining, but data is limited.
The objective of this study is to simultaneously assess the effectiveness of non-surgical treatments, BoNT-A injections and Supervised Gait Retraining (SGR), in terms of lower pain control and ability to return to full duty among adult active-duty service members suffering from lower extremity CECS, specifically of the anterior and/or lateral compartments.
Brad Isaacson, PhD, MBA, MSF, PMP, MIRROR Chief of Research and Operations, was featured in The Geneva Foundation’s press release, “14 Geneva Military Medical Researchers Who Inspired Us in 2020,” for his work on the Tri-Service Post-Operative Rehabilitation Consensus Meeting in January 2020.
Read the full article on The Geneva Foundation’s website here.
The Geneva Foundation recognized the MIRROR program for their facilitation of the publication of 11 Tri-Service musculoskeletal injury protocols in May 2020. In January 2021, the article was featured in The Geneva Foundation’s top ten most-read news stories of 2020.
Read the full article on The Geneva Foundation’s website here.
There is a large incidence of shoulder instability among active young athletes and military personnel. Shoulder stabilization surgery is the commonly employed intervention for treating individuals with instability. Following surgery, a substantial proportion of individuals experience acute post-operative pain, which is usually managed with opioid pain medications. Unfortunately, the extended use of opioid medications can have adverse effects that impair function and reduce military operational readiness, but there are currently few alternatives. However, Battlefield Acupuncture (BFA) is a minimally invasive therapy demonstrating promise as a non-pharmaceutical intervention for managing acute post-operative pain.
Crowell, M., Brindle, R., Mason, J., Pitt, W., Miller, E., Posner, M., Cameron, K., & Goss, D. (2020). The effectiveness of battlefield acupuncture in addition to standard physical therapy treatment after shoulder surgery: a protocol for a randomized clinical trial. Trials. https://doi.org/10.1186/s13063-020-04909-8
Telehealth is an increasingly common approach to improve healthcare delivery, especially within the Veterans Health Administration and Department of Defense (DoD). Telehealth has diminished many challenges to direct access for clinical follow-up; however, the use of mobile telehealth for specialty rehabilitative care is emerging and is referred to as telerehabilitation. As early adopters of telehealth, the Veterans Affairs and DoD have supported collaborated efforts for programs designed to increase the access and quality of rehabilitative care while improving the functional ability of our service members (SMs) and veterans with lower limb amputation (LLA). The DoD and Veterans Health Administration collaborated on a Mobile Device Outcomes-based Rehabilitation Program (MDORP) to help injured SMs and veterans with LLA. The MDORP project utilized a mobile health system called the Rehabilitative Lower Limb Orthopedic Accommodating Device (ReLOAD) to assess walking quality. The ReLOAD system includes real-time auditory biofeedback to notify the user of their most prominent gait deviation and then recommends exercises that address specific balance and strength impairments. The purpose of this study was to describe the responses to a postintervention survey evaluating the feasibility and usability of ReLOAD completed by SMs and veterans with LLA who used the system for 5 months.
Symsack, A., Gaunaurd, I., Thaper, A., Springer, B., Bennett, C., Clemens, S., Lucarevic, J., Kristal, A., Sumner, M., Isaacson, B., Pasquina, P., & Gailey, R. (2020). Usability Assessment of the Rehabilitation Lower-limb Orthopedic Assistive Device by Service Members and Veterans with Lower Limb Loss. Military Medicine. https://doi.org/10.1093/milmed/usaa428
Six MIRROR-affiliated physicians were trained on the Lipogems® system in sessions conducted at Uniformed Services University and Fort Belvoir Community Hospital.
The Lipogems® system is a sterile single-use medical device intended for the closed-loop processing and transferring of autologous adipose tissue in a single surgical step. MIRROR Project #11 utilizes this technology to determine the safety and efficacy of minimally invasive (percutaneous) intrameniscal injection with autologous, micro-fragmented adipose tissue under ultrasound guidance for symptomatic meniscal injuries.
Two physicians and several members of the research support team were trained on procedures for the SX-One MicroKnife® with ultrasound guidance for carpal tunnel release.
In support of MIRROR Project #10, “Clinical Outcomes of Carpal Tunnel Release With and Without Ultrasound Guidance,” this training was the second-to-last in the series leading up to the beginning of study activities.
The cost of health care in the United States has increased exponentially over the past 60 years, soaring from $27.2 billion in 1960 (5% of gross domestic product) and $147 per resident to $3.5 trillion (17.9% of gross domestic product) and $11 000 per resident in 2017. Health care expenditures continue to rise significantly faster than the median household income, and this poses a financial strain for patients, providers, and the health care system alike. Removing unnecessary variation through evidence-based medicine is critical to improving outcomes and making care more affordable. This may be accomplished through standardized protocols, order sets, and check lists, with positive results previously demonstrated for obstetrics/gynecology, critical care, pediatrics, gastrointestinal surgery, orthopedics, and rehabilitation. Effective communication with a multidisciplinary team has also shown to enhance quality of treatment, reduce complications, and decrease postoperative issues. Although treatment normalization is a pragmatic solution for removing health care waste, evidence supports that even when guidelines are available, only two-thirds of patients receive the recommended care, and another quarter get treatment that may be unnecessary and/or harmful.
Isaacson B., Miranda M., Hager N., Wagner L., West S., Lucio W., Heller J., Dalgarno R., Dickens J., Schoomaker E., Pasquina P. (2020). Standardizing Postoperative Rehabilitation Protocols for the Tri-Service: A Consensus Meeting Hosted by the Musculoskeletal Injury Rehabilitation Research for Operational Readiness Organization. Military Medicine. https://doi.org/10.1093/milmed/usaa207
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. 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 set up in 2019 to advance the treatment and preventive care for Service Members with non-combat related MSI. This abstract describes the purpose of MIRROR, how we support the Building Research Capacity and Infrastructure conference theme, and introduces new researchers to this collaborative forum.
Chronic exertional compartment syndrome is a debilitating condition primarily associated in highly active individuals with an estimated incidence of approximately 1 in 2000 persons/year. The etiology remains unclear to date. The differential diagnosis includes, but is not limited to stress fractures, medial tibial stress syndrome, and popliteal artery entrapment syndrome. Clinical signs and symptoms include pain in the involved compartment with exertion dissipating quickly after activity. Diagnostic tests include intramuscular compartment pressure testing, magnetic resonance imaging, near-infrared spectrometry as well as shear wave electrography. Treatments consist of nonsurgical, surgical, or the combination of the two. Gait retraining and the use of botulinum toxin appear most promising. Diagnostic lidocaine injections are emerging as a prognostic and mapping tool. Minimal invasive surgical options are being utilized allowing quicker return to activity and decreased morbidity. This article reviews the anatomy, clinical signs and symptoms, diagnostics, nonsurgical, and surgical treatments for chronic exertional compartment syndrome.
Velasco, Teonette O. PT, DPT, OCS; Leggit, Jeffrey C. MD, CAQSM. Chronic Exertional Compartment Syndrome: A Clinical Update. Current Sports Medicine Reports 19(9):p 347-352, September 2020. https://doi.org/10.1249/JSR.0000000000000747
Abstract submitted to Military Health System Research Symposium 2020
There is a large incidence of shoulder instability among active young athletes and military personnel which requires shoulder stabilization surgery. Acute post-operative pain is common and is usually managed with opioid pain medications. The extended use of opioid medications can have adverse effects that impair function and reduce military operational readiness, and there are currently few alternatives. However, Battlefield Acupuncture (BFA) is a minimally invasive therapy demonstrating promise as a non-pharmaceutical intervention for managing acute post-operative pain.
Telerehabilitation, as a component of telemedicine, is a rapidly growing clinical tool being utilized in physical therapy, optimizing care for patients that are post-surgical, have orthopedic injuries, or who have undergone lower limb amputation (LLA). The benefits include greater access to care for patients in remote locations, reduced travel burden, and decreased time and financial costs. With this in mind, the Department of Defense (DoD) and Veterans Health Administration (VHA) collaborated to implement a telerehabilitation program called the Mobile Device Outcomes-based Rehabilitation Program (MDORP) designed to enhance the rehabilitation of injured Service Members (SMs) and Veterans with lower limb loss. MDORP is a home and community-based auditory biofeedback and prescription based exercise program which utilizes a sensor-based system called The Rehabilitative Lower-limb Orthopedic Accommodating-feedback Device (ReLOAD). This study aims to evaluate the feasibility and usability of ReLOAD over a 5-month period using an anonymous post-intervention survey of participating SMs and Veterans with LLA.
This poster won the category of “Best Evidence-Based Practice” in the 12th annual DRP poster competition at WRNMMC.
According to recent estimates, there are nearly two million people with lower limb amputation (LLA) currently living in the United States. This number is expected to double by 2050. Within the military, combat operations during the global war on terror have led to more than 1,700 service members (SMs) undergoing major limb amputation, with the majority experiencing LLA & many sustaining proximal and multiple limb loss. Those with LLA due to trauma are at a higher risk than nonamputees for multiple secondary health effects, which include joint pain, osteoarthritis, chronic lower back pain, & cardiovascular disease. In order to mitigate these adverse secondary health effects, optimize long-term function, & increase quality of life in individuals with LLA, effective rehabilitation and innovative life-long care is essential. Therefore, the Veterans Affairs (VA) & Department of Defense (DoD) implemented a program through the Joint Incentive Fund called the Mobile Device Outcomes-based Rehabilitation Program (MDORP). The primary objective of this pilot study was to determine if the implementation of MDORP improved strength, mobility, & gait quality in SMs and Veterans with LLA.
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.
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.
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.
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.
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.
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.
