Sorensen I, Ebert M, Dintaman J, Hisle-Gorman E

Abstract submitted to Military Health System Research Symposium 2021

The Army Recovery Care Program (ARCP) provides care to the Army's injured and ill service members with complex care requirements. After several iterations and name changes, the program started as the Warrior Transition Battalion, then became the Warrior Care and Transition Program, and is now the ARCP. The program was created to care for service members who became ill, or were injured or wounded in during operations associated with the Global War on Terrorism. The core mission has remained similar, to provide care for soldiers with the aim of reintegrate them back into the force, or prepare them for transition to civilian life. The most recent changes focused on simplifying entry criteria, streamlining processes, and helping meet each service member's unique needs. Over time the reasons and specific conditions for soldiers entering the program have changed in response to the changing needs of the army. The objective is to analytically explore changes in entry pathway and conditions at entry in admitted soldiers in the ARCP over time.

Yuan X, Pav V, Cohen S, Pasquina P, Hager N, Isaacson B

Abstract submitted to Military Health System Research Symposium 2021

Low back pain (LBP) is both the leading cause of disability and most common reason for primary care visits, amounting to approximately $88 billion in direct and indirect costs of health care spending. Among active-duty service members (ADSM) of the United States Armed Forces, LBP and other back problems have accounted for the most medical encounters every year for the past decade. Clinical categories of LBP diagnoses can manifest as axial, radicular, or other pain. LBP is further classified by duration of symptoms as acute (LBP < 1 month), subacute (1-3 months), or chronic (> 3 months). This retrospective study of ADSM newly presenting with LBP in Fiscal Year (FY) 2017 sought to classify LBP by clinical category and duration, and record medical encounters for LBP care over two years of follow-up, including outpatient visits, radiology, physical therapy (PT), spine surgeries, and interventional pain procedures, to assess impact on readiness, health care costs, and resource utilization. This is the first LBP study to date to include MHS GENESIS data and examine associated health care costs and resource utilization for the two years leading up to the COVID-19 pandemic.

Isaacson B, Wagner L, West S, Lucio W, Dalgarno R, Johnston S, Fowler A, Mehta K, Yuan X, Pasquina P, Hager N

Abstract submitted to Military Health System Research Symposium 2021

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 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.

Symsack A, Gaunaurd I, Thaper A, Springer B, Bennet C, Clemens S, Lucarevic J, Kristal A, Sumner M, Isaacson B, Pasquina P, Gailey R

Abstract Submitted to Military Health System Research Symposium 2021

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.

Knotkova H, Hamani C, Sivanesan E, Elgueta Le Beuffe MF, Moon JY, Cohen SP, Huntoon MA

Neuromodulation is an expanding area of pain medicine that incorporates an array of non-invasive, minimally invasive, and surgical electrical therapies. In this Series paper, we focus on spinal cord stimulation (SCS) therapies discussed within the framework of other invasive, minimally invasive, and non-invasive neuromodulation therapies. These therapies include deep brain and motor cortex stimulation, peripheral nerve stimulation, and the non-invasive treatments of repetitive transcranial magnetic stimulation, transcranial direct current stimulation, and transcutaneous electrical nerve stimulation. SCS methods with electrical variables that differ from traditional SCS have been approved. Although methods devoid of paraesthesias (eg, high frequency) should theoretically allow for placebo-controlled trials, few have been done. There is low-to-moderate quality evidence that SCS is superior to reoperation or conventional medical management for failed back surgery syndrome, and conflicting evidence as to the superiority of traditional SCS over sham stimulation or between different SCS modalities. Peripheral nerve stimulation technologies have also undergone rapid development and become less invasive, including many that are placed percutaneously. There is low-to-moderate quality evidence that peripheral nerve stimulation is effective for neuropathic pain in an extremity, low quality evidence that it is effective for back pain with or without leg pain, and conflicting evidence that it can prevent migraines. In the USA and many areas in Europe, deep brain and motor cortex stimulation are not approved for chronic pain, but are used off-label for refractory cases. Overall, there is mixed evidence supporting brain stimulation, with most sham-controlled trials yielding negative findings. Regarding non-invasive modalities, there is moderate quality evidence that repetitive transcranial magnetic stimulation does not provide meaningful benefit for chronic pain in general, but conflicting evidence regarding pain relief for neuropathic pain and headaches. For transcranial direct current stimulation, there is low-quality evidence supporting its benefit for chronic pain, but conflicting evidence regarding a small treatment effect for neuropathic pain and headaches. For transcutaneous electrical nerve stimulation, there is low-quality evidence that it is superior to sham or no treatment for neuropathic pain, but conflicting evidence for non-neuropathic pain. Future research should focus on better evaluating the short-term and long-term effectiveness of all neuromodulation modalities and whether they decrease health-care use, and on refining selection criteria and treatment variables.

Knotkova, H., Hamani, C., Sivanesan, E., Elgueta Le Beuffe, M., Youn Moon, J., Cohen, S., & Huntoon, M. (2021). Neuromodulation for chronic pain. The Lancet. https://doi.org/10.1016/S0140-6736(21)00794-7

Fitzcharles MA, Cohen SP, Clauw DJ, Littlejohn G, Usui C, Häuser W

Nociplastic pain is the semantic term suggested by the international community of pain researchers to describe a third category of pain that is mechanistically distinct from nociceptive pain, which is caused by ongoing inflammation and damage of tissues, and neuropathic pain, which is caused by nerve damage. The mechanisms that underlie this type of pain are not entirely understood, but it is thought that augmented CNS pain and sensory processing and altered pain modulation play prominent roles. The symptoms observed in nociplastic pain include multifocal pain that is more widespread or intense, or both, than would be expected given the amount of identifiable tissue or nerve damage, as well as other CNS-derived symptoms, such as fatigue, sleep, memory, and mood problems. This type of pain can occur in isolation, as often occurs in conditions such as fibromyalgia or tension-type headache, or as part of a mixed-pain state in combination with ongoing nociceptive or neuropathic pain, as might occur in chronic low back pain. It is important to recognize this type of pain, since it will respond to different therapies than nociceptive pain, with a decreased responsiveness to peripherally directed therapies such as anti-inflammatory drugs and opioids, surgery, or injections.

Fitzcharles MA, Cohen SP, Clauw DJ, Littlejohn G, Usui C, Häuser W. (2021). Nociplastic Pain: Towards an Understanding of Prevalent Pain Conditions. The Lancet. https://doi.org/10.1016/S0140-6736(21)00392-5

Cohen S, Vase L, Hooten W

Chronic pain exerts an enormous personal and economic burden, affecting more than 30% of people worldwide according to some studies. Unlike acute pain, which carries survival value, chronic pain might be best considered to be a disease, with treatment (eg, to be active despite the pain) and psychological (eg, pain acceptance and optimism as goals) implications. Pain can be categorized as nociceptive (from tissue injury), neuropathic (from nerve injury), or nociplastic (from a sensitized nervous system), all of which affect work-up and treatment decisions at every level; however, in practice there is considerable overlap in the different types of pain mechanisms within and between patients, so many experts consider pain classification as a continuum. The biopsychosocial model of pain presents physical symptoms as the denouement of a dynamic interaction between biological, psychological, and social factors. Although it is widely known that pain can cause psychological distress and sleep problems, many medical practitioners do not realize that these associations are bidirectional. While predisposing factors and consequences of chronic pain are well known, the flipside is that factors promoting resilience, such as emotional support systems and good health, can promote healing and reduce pain chronification. Quality of life indicators and neuroplastic changes might also be reversible with adequate pain management. Clinical trials and guidelines typically recommend a personalized multimodal, interdisciplinary treatment approach, which might include pharmacotherapy, psychotherapy, integrative treatments, and invasive procedures.

Cohen SP, Vase L, Hooten WM. (2021). Chronic Pain: An Update on Burden, Best Practices, and New Advances. Lancet. https://doi.org/10.1016/S0140-6736(21)00393-7

April 2021

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.

April 2021

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.

April 2021

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.

April 2021

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.

April 2021

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.

April 2021

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.

April 2021

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.

April 2021

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.

Knox N, Lee C, Moon J, Cohen S

The objective of this multicenter prospective study was to determine the prevalence and breakdown of pain symptoms among patients with coronavirus disease 2019 (COVID-19) infection admitted for non-pain symptoms and the association between the presence of pain and intensive care unit (ICU) admission and death. Data on the intensity and type of pain were collected on 169 patients with active severe acute respiratory syndrome coronavirus 2 infection at 2 teaching hospitals in the United States and Korea and on 8 patients with acute pain at another large teaching hospital between February 1, 2020, and June 15, 2020. Results showed that acute pain is common during active COVID-19 infection with the most common manifestations being headache, chest pain and spine pain. Individuals without pain were more likely to require intensive care and expire than those with pain. Reasons why pain may be associated with reduced mortality include that an intense systemic stimulus (eg, respiratory distress) might distract pain perception or that the catecholamine surge associated with severe respiratory distress might attenuate nociceptive signaling.

Knox N, Lee C, Moon JY, Cohen SP. (2021). Pain Manifestations of COVID-19 and Their Association with Mortality: A Multicenter Prospective Observational Study. Mayo Clinic Proceedings. https://doi.org/10.1016/j.mayocp.2020.12.014.

Chen Y, Vu T, Chinchilli V, Farrag M, Roybal A, Huh A, Cohen ZO, Becker A, Arvanaghi B, Agrawal M, Ogden J, Cohen S

There has been a surge in interest in radiofrequency ablation (RFA) of the genicular nerves over the past decade, with wide variability in selection, technique and outcomes. The aim of this study is to determine factors associated with treatment outcome. They retrospectively evaluated the effect of 23 demographic, clinical and technical variables on outcomes in 265 patients who underwent genicular nerve RFA for knee pain at 2 civilian and 1 military hospital. A primary outcome was designated as a > 30% decrease in average knee pain score lasting at least 3 months without cointerventions.

Chen, Y., Vu, T. N., Chinchilli, V., Farrag, M., Roybal, A., Huh, A., Cohen, Z., Becker, A., Arvanaghi, B., Agrawal, M., Ogden, J., & Cohen, S. (2021). Clinical and technical factors associated with knee radiofrequency ablation outcomes: A multicenter analysis. Regional Anesthesia & Pain Medicine. https://doi.org/10.1136/rapm-2020-102017

The Association of Military Osteopathic Physicians & Surgeons (AMOPS) hosted their 2021 Annual Meeting at the MIRROR office space in Bethesda, MD.

MIRROR is proud to support AMOPS and their service to osteopathic physicians in the uniformed services, and looks forward to future collaborative efforts to further benefit our service members.

Kohan L, Durbhakula S, Zaidi M, Phillips C, Rowan C, Brenner G, Cohen S

The coronavirus disease 2019 (COVID-19) pandemic is a public health crisis of unprecedented proportions that has altered the practice of medicine. The pandemic has required pain clinics to transition from in-person visits to telemedicine, postpone procedures, and cancel face-to-face educational sessions. There are no data on how fellowship programs have adapted. A 17-question survey was developed covering topics including changes in education, clinical care, and psychological stress due to the COVID pandemic. Results showed a shift to online alternatives for clinical care and education, with correlations between per capita infection rates, and clinical care demands and redeployment, but not with overall trainee anxiety levels. It is likely that medicine in general, and pain medicine in particular, will change after COVID-19, with greater emphasis on telemedicine, virtual education, and greater national and international cooperation. Physicians should be prepared for these changes.

Kohan, L., Durbhakula, S., Zaidi, M., Phillips, C., Rowan, C., Brenner, G., & Cohen, S. (2021). Changes in Pain Medicine Training Programs Associated With COVID-19: Survey Results. Anesthesia & Analgesia. https://doi.org/10.1213/ANE.0000000000005314

Cohen S, Doshi T, Kurihara C, Dolomisiewicz E, Liu R, Dawson T, Hager N, Durbhakula S, Verdun A, Hodgson J, Pasquina P

The rising use of injections to treat low back pain (LBP) has led to efforts to improve selection. Nonorganic (Waddell) signs have been shown to portend treatment failure for surgery and other therapies but have not been studied for minimally invasive interventions. This study prospectively evaluated the association between Waddell signs and treatment outcome in 3 cohorts: epidural steroid injections (ESI) for leg pain and sacroiliac joint (SIJ) injections and facet interventions for LBP. Categories of Waddell signs included nonanatomic tenderness, pain during sham stimulation, discrepancy in physical examination, overreaction, and regional disturbances divulging from neuroanatomy. The primary outcome was change in patient-reported “average” numerical rating scale for pain intensity (average NRS-PI), modeled as a function of the number of Waddell signs using simple linear regression. Secondary outcomes included a binary indicator of treatment response. Secondary and sensitivity analyses were conducted to account for potential confounders. Whereas this study found no consistent relationship between Waddell signs and decreased mean pain scores, a significant relationship between the number of Waddell signs and treatment failure was observed.

Cohen, S., Doshi, T., Kurihara, C., Dolomisiewicz, E., Liu, R., Dawson, T., Hager, N., Durbhakula, S., Verdun, A., Hodgson, J., & Pasquina, P. (2021). Waddell (Nonorganic) Signs and Their Association with Interventional Treatment Outcomes for Low Back Pain. Anesthesia & Analgesia. https://doi.org/10.1213/ANE.0000000000005054