Rhon D, Greenlee T, Carreño P, Patzkowski J, and Highland K

Most individuals undergoing elective surgery expect to discontinue opioid use after surgery, but many do not. Modifiable risk factors including psychosocial factors are associated with poor postsurgical outcomes. We wanted to know whether pain catastrophizing is specifically associated with postsurgical opioid and health-care use.

Rhon, D. I., Greenlee, T. A., Carreño, P. K., Patzkowski, J. C., & Highland, K. B. (2022). Pain Catastrophizing Predicts Opioid and Health-Care Utilization After Orthopaedic Surgery A Secondary Analysis of Trial Participants with Spine and Lower-Extremity Disorders. The Journal of Bone and Joint Surgery. https://doi.org/10.2106/JBJS.22.00177

Rhon D and Tucker C

Orthopaedic surgery has revolutionized the expectations for restoration of physical function after musculoskeletal injury and, along with physical therapy, has transformed the limits of recovery. Many orthopaedic procedures have a high success rate for improving quality of life and patient-reported outcomes, yet these procedures carry some level of risk, including postoperative complications. The stepped-care model of health care delivery, when applied to musculoskeletal care, recommends implementing less-intense and lower-risk treatments with known efficacy, such as promotion and education of self-management strategies and physical therapy, before more-invasive and higher-risk treatments such as surgery. This model of managing musculoskeletal disability can improve efficiency of care delivery and reduce medical costs at the health system level. Unfortunately, there is a documented lack of implementing an appropriate course of conservative care, especially physical therapy, prior to surgery across multiple orthopaedic disciplines including sports, spine, and trauma medicine and joint arthroplasty. Failure to respond to nonsurgical treatment has been suggested as a requisite component of the surgical appropriateness criteria, yet practical application can be elusive. Multiple barriers to adequate utilization of conservative treatment exist, including U.S. payment models that increase out-of-pocket expense for patients, negative patient perception of therapy, unreasonable patient expectations from therapy versus surgery, and communication barriers between patient, surgeon, and therapist. Surgeons should ensure that high-quality guidelineappropriate care is delivered early and adequately to their patients. Rehabilitation professionals have a responsibility to deliver high-value care, properly documenting the type and extent of treatment to improve surgical decision-making between surgeons and patients. Criteria to determine appropriateness for surgery should include a standardized and extensive assessment of failed therapies prior to certain elective surgeries. Improved collaboration between surgeons and rehabilitation professionals can result in improved outcomes for patients with musculoskeletal disorders.

Rhon, D. I., & Tucker, C. J. (2022). Nonoperative Care Including Rehabilitation Should Be Considered and Clearly Defined Prior to Elective Orthopaedic Surgery to Maximize Optimal Outcomes. Arthroscopy, Sports Medicine, and Rehabilitation. https://doi.org/10.1016/j.asmr.2021.09.038

Tropf J, Colantonio D, Tucker C, Rhon D

Meniscus injuries occur at a higher rate in the military than the general population. Appropriate management and rehabilitation of meniscus injuries is important for maintaining readiness. The purpose of this study was to describe the health burden of meniscus injuries in the Military Health System (MHS) to identify the surgical intervention rate for meniscus injuries, and to determine which injury characteristics and demographic variables were associated with the likelihood of surgery after injury. The U.S. Department of Defense Management Analysis and Reporting Tool, a database of health care encounters by military personnel and dependents, was queried for encounters associated with a meniscal injury diagnosis between January 1, 2010, and December 31, 2011. Meniscus injuries were categorized into (1) isolated medial, (2) isolated lateral, (3) combined medial and lateral, and (4) unspecified cohorts. Patients under 18 and over 51 years were excluded, as well as patients without records at least 1 year prior to diagnosis or 2 years after. Relevant surgical procedures were identified with the Current Procedural Terminology (CPT) codes for arthroscopic surgery of the knee, meniscus repair, meniscectomy, and anterior cruciate ligament (ACL) reconstruction. There were 2,969 meniscus injuries meeting inclusion criteria during the study period. There were 1,547 (52.1%) isolated medial meniscus injuries, 530 (17.9%) isolated lateral meniscus injuries, 452 (15.3%) involved both menisci, and 435 (14.7%) were unspecified. The mean age was 35.5 years (standard deviation [SD] ¼ 9.3). An adjacent ligamentous injury occurred in 901 patients (30.3%). The treatment course led to arthroscopic surgery in 52.8% (n ¼ 1,568) of all meniscus injuries. Eighty-five percent (n ¼ 385) of combined medial and lateral tears, 54.9% of medial tears, and 51.6% of lateral tears underwent surgery. Partial meniscectomy was the most common procedure performed while 47.2% (n ¼ 1,401) of tears were not treated surgically. Bilateral meniscus injuries had 4.57 greater odds of undergoing knee arthroscopy (95% confidence interval [CI]: 3.46, 6.04), 2.42 times odds of undergoing a meniscus repair, and 4.59 times odds for undergoing a meniscus debridement (95% CI: 3.62, 5.82). The closed nature of the MHS allows reliable capture of surgical rates for meniscus injuries within the military population. Meniscus injuries are common in the military and impose a significant burden on the MHS. Appropriate management and rehabilitation of this injury is important for maintaining readiness.

Tropf, J. G., Colantonio, D. F., Tucker, C. J., & Rhon, D. I. (2022). Epidemiology of Meniscus Injuries in the Military Health System and Predictive Factors for Arthroscopic Surgery. The Journal of Knee Surgery. https://doi.org/10.1055/s-0042-1744189

Gaunaurd I, Gailey R, Symsack A, Isaacson B, Pasquina P

Abstract submitted to 44th ICMM World Congress on Military Medicine 2022

Service Members (SM) and Veterans with lower limb amputation (LLA) are at a high risk for developing secondary co-morbidities such as joint pain, osteoarthritis, chronic low back pain, and cardiovascular disease. To mitigate these secondary comorbidities, optimize long-term function, and increase quality of life, effective rehabilitation and innovative lifelong care is essential. Telerehabilitation has recently demonstrated to be a useful method of healthcare delivery, particularly benefitting individuals with physical limitations who are unable to attend outpatient physical therapy, such as patients following LLA. Wearable technology, such as mobile sensors, has the potential to augment current telerehabilitation practice and improve home walking and exercise compliance for those with LLA. Therefore, could this technology be used to provide “booster” prosthetic training to improve or reinforce current mobility and prosthetic use, promote an active, healthy lifestyles and mitigate adverse secondary comorbidities? To address this question, the Department of Defense (DoD) and Veterans supported the development of a program through the Joint Incentive Fund called the Mobile Device Outcomes-based Rehabilitation Program (MDORP). The MDORP is a comprehensive mobile rehabilitation program that is clinician-guided and incorporates the use of a mobile sensor system called the Rehabilitative Lower Limb Orthopedic Assistive Device (ReLOAD). The ReLOAD system provides: (1) assessment of walking quality at home and in the community for people with LLA, (2) real-time auditory feedback to correct the most prominent gait deviations, and (3) automatic prescription of home exercises that target balance and strength impairments related to their most prominent gait deviation. The primary objective of the study was to determine if the 8-week MDORP improved strength, mobility, and gait quality in SMs and Veterans with LLA.

Pasquina p, Jannace k, Nordstrom m, Gbade-Alabi o, Smolinski g

Selected for a podium presentation at the 44th ICMM World Congress on Military Medicine 2022 in Brussels

Gailey R, Gaunaurd I, Goss D, Bennett C, Isaacson B

Abstract submitted to 44th ICMM World Congress on Military Medicine 2022

Rhon D, Greenlee T, Fraser J

Abstract submitted to Military Health System Symposium 2021

In military service members, ankle injuries can substantially curtail the ability to complete duty requirements. Ankle injuries were the third leading factor of lost work time of the US Armed Forces in 2002, and by 2017-2018 they were ranked first for all U.S. Army soldiers. Timely interventions earlier in the injury course may have greater effectiveness than when care is delayed. No work has been done to look at the iterative effects of time to rehabilitation on risk for injury recurrence, or the impact of early treatment on downstream utilization of healthcare resources. It is possible that the timing of interventions influences outcomes after ankle sprain, similar to what has been found for musculoskeletal disorders in other body regions.

Isaacson B, Wagner L, West S, Lucio W, Yuan X, Hager N, Pasquina P

Abstract submitted to Military Health System Research Symposium 2022.

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 has 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. MIRROR coordinates inter-service partnerships with premier academic institutions, primary military treatment facilities (MTFs), and civilian sites that experience a high volume of MSI, but lack a robust infrastructure to conduct rigorous trials. MIRROR is based in the Department of Physical Medicine & Rehabilitation at the Uniformed Services University and closely aligns with the Defense Health Agency (DHA), Department of Defense (DoD) leadership, Joint Program Committee (JPC) chairs, and other high-level advisory groups. In addition, our Steering Committee, comprised of nationally-renowned military and civilian subject matter experts in various musculoskeletal subspecialties, provides guidance and oversight on MIRROR’s direction, scope, and overall methods. The MIRROR organization also incorporates select MSI sub-portfolios (i.e., orthopedics, interventional spine and pain management, physical and occupational therapy), under the direction of subject matter experts, to further advance our mission across all MSI research areas. Our representation across both operational leadership and research subspecialties allows MIRROR to maximize its impact throughout the MHS. To ensure that findings are clinically translational, data is collected using standardized protocol content, case report forms, and recruitment/outcomes captured through REDCap. Real-time feedback is provided using PowerBI to ensure that data can be presented in a highly efficient manger without the risk of protected health information (PHI) disclosure. This allows quick assessment of key performance indicators and provides useful data to understand healthcare disparities.

Greenlee T, Bullock G, Teyhen D, Rhon D

Abstract submitted to Military Health System Research Symposium 2022.

Prevalence and burden of musculoskeletal injuries for military service members are high, with recurrent injuries contributing to greater costs, more time lost from duty, and sub-optimal force readiness. Several psychological factors are associated with injury and return to work readiness in sport and occupational settings. We explored whether the psychological state of soldiers returning to duty following an injury could predict time-loss injury within the next year. We performed a secondary analysis of data from a longitudinal cohort study of soldiers returning to full duty after a recent thoracolumbar spine (TLS) or lower extremity (LE) injury after seeking medical care. A psychological profile (depression, anxiety, anger, fear, frustration, exercise enjoyment, job-, military-, and life-satisfaction, kinesiophobia, fear avoidance beliefs, pain catastrophizing, stress, and mood) was assessed via self-report at the point of initial return-to-duty and Soldiers were followed for one year.

Foster K, Greenlee T, Fraser J, Young J, Rhon D

Abstract submitted to Military Health System Symposium 2022

One in every four individuals with an ankle sprain went on to have a proximal joint injury in the following year, knee and lumbar spine diagnoses occurring more frequently than hip. Associated fracture with the initial ankle sprain increased the odds of sustaining a subsequent hip or lumbar spine injury. Further, females had higher risk of developing subsequent hip or lumbar spine injuries after ankle sprain whereas males were more likely to develop subsequent knee issues. Less than half of the cohort received rehabilitation following an ankle sprain, but exercise therapy was found to be preventative of secondary injuries to the knee, hip, and lumbar spine. While these associations are often discussed by clinicians, the increased understanding of prevalence of proximal joint disorders has the potential to help guide treatment and inform decisions related to returning to work and sport, improving the care for patients and decreasing the physical and financial toll of this common injury.

Rhon D, Kim M, Asche C, Allison S, Allen C, Deyle G

Physical therapy and glucocorticoid injections are initial treatment options for knee osteoarthritis, but available data indicate that most patients receive one or the other, suggesting they may be competing interventions. The initial cost difference for treatment can be substantial, with physical therapy often being more expensive at the outset, and cost-effectiveness analysis can aid patients and clinicians in making decisions. The objective of this study is to investigate the incremental cost-effectiveness between physical therapy and intra-articular glucocorticoid injection as initial treatment strategies for knee osteoarthritis. This economic evaluation is a secondary analysis of a randomized clinical trial performed from October 1, 2012, to May 4, 2017. Health economists were blinded to study outcomes and treatment allocation. A randomized sample of patients seen in primary care and physical therapy clinics with a radiographically confirmed diagnosis of knee osteoarthritis were evaluated from the clinical trial with 96.2% follow-up at 1 year.

Rhon, D., Minchul, K., Asche, C., Allison, S., Allen, C., & Deyle, G. (2022). Cost-effectiveness of Physical Therapy vs Intra-articular Glucocorticoid Injection for Knee Osteoarthritis: A Secondary Analysis From a Randomized Clinical Trial. JAMA Network Open. https://doi.org/10.1001/jamanetworkopen.2021.42709

Rhon D, Oh R, Teyhen D

The DoD has a specific mission that creates unique challenges for the conduct of clinical research. These unique challenges include (1) the fact that medical readiness is the number one priority, (2) understanding the role of military culture, and (3) understanding the highly transient flow of operations. Appropriate engagement with key stakeholders at the point of care, where research activities are executed, can mean the difference between success and failure. These key stakeholders include the beneficiaries of the study intervention (patients), clinicians delivering the care, and the military and clinic leadership of both. Challenges to recruitment into research studies include military training, temporary duty, and deployments that can disrupt availability for participation. Seeking medical care is still stigmatized in some military settings. Uniformed personnel, including clinicians, patients, and leaders, are constantly changing, often relocating every 2-4 years, limiting their ability to support clinical trials in this setting which often take 5-7 years to plan and execute. When relevant stakeholders are constantly changing, keeping them engaged becomes an enduring priority. Military leaders are driven by the ability to meet the demands of the assigned mission (readiness). Command endorsement and support are critical for service members to participate in stakeholder engagement panels or clinical trials offering novel treatments. To translate science into relevant practice within the Military Health System, early engagement with key stakeholders at the point of care and addressing mission-relevant factors is critical for success.

Rhon, D., Oh, R., & Teyhen, D. (2021). Challenges With Engaging Military Stakeholders for Clinical Research at the Point of Care in the U.S. Military Health System. Military Medicine. https://doi.org/10.1093/milmed/usab494

Rhon D, Fraser J, Sorensen J, Greenlee T, Jain T, Cook C

This article was selected by JOSPT’s award committee to receive the 2021 JOSPT Guy G. Simoneau Excellence in Research Award.

The objective of this study was to investigate the influence of time taken to begin musculoskeletal rehabilitation on injury recurrence and one-year ankle-related medical care costs.

Rhon, D., Fraser, J., Sorenson, J., Greenlee, T., Jain, T., & Cook, C. (2021). Delayed Rehabilitation is Associated with Recurrence and Higher Medical Care Use After Ankle Sprain Injuries in the United States Military Health System. Journal of Orthopaedic & Sports Physical Therapy. https://doi.org/10.2519/jospt.2021.10730

Rhon D, Greenlee T, Dickens J, Wright A

Military females sustain higher rates of lower extremity injuries compared to males. This can include intra articular pathology in the hip. Females are considered to have worse outcomes following hip arthroscopy for femoroacetabular impingement and for hip labral repair. To confirm these statements, we queried the current literature.

Rhon, D., Greenlee, T., Dickens, J., & Wright, A. (2021). Are We Able to Determine Differences in Outcomes Between Male and Female Servicemembers Undergoing Hip Arthroscopy? A Systematic Review. Orthopaedic Journal of Sports Medicine. https://doi.org/10.1177/23259671211053034

Smith M, West S, Malanga G, Hager N, Hulsopple C, Yuan X

Abstract submitted to Association of Military Surgeons of the United States 2022

The Musculoskeletal Injury Rehabilitation Research for Operational Readiness (MIRROR) organization, based out of the Department of Physical Medicine and Rehabilitation (PM&R) at the Uniformed Services University (USU), is dedicated to advancing musculoskeletal injury rehabilitative care within the Military Healthcare System (MHS) to reduce the burden of musculoskeletal injuries on operational readiness. Through its core infrastructure and inter-service collaborations, MIRROR facilitates training programs for medical education to expand and optimize treatments. Knee injuries are one of the most common musculoskeletal complaints among Active Duty military personnel. Autologous micro-fragmented adipose tissue (MFAT) has shown promise as a regenerative therapy for meniscal tears in the civilian population. MIRROR supports a randomized controlled trial (RCT) at multiple military treatment facilities (MTFs), with the objective to investigate the safety and efficacy of intrameniscal injection with autologous MFAT for symptomatic meniscal injuries in a military population. With the assistance of a peer-to-peer, two-day training program incorporating didactic cadaveric training and hands-on patient cases, clinicians at three MTFs garnered the procedural skills required to safely administer this novel intervention prior to the launch of this multi-site study.

Smith M, West S, Persinger J, Hager N, Smith J, Miller M, Yuan X, Reece D

Abstract submitted to Association of Military Surgeons of the United States 2022

The COVID-19 pandemic has taken a significant toll on global medical education and research since March 2020, prompting a surge of virtual learning. Like other research entities, the Musculoskeletal Injury Rehabilitation Research for Operational Readiness (MIRROR) organization, based out of the Department of Physical Medicine and Rehabilitation (PM&R) at the Uniformed Services University (USU), was not spared from the pandemic’s impact on research operations and adapted to persevere, despite setbacks. At the heart of the organization’s mission, MIRROR provides clinicians and researchers with the support and infrastructure to advance musculoskeletal injury rehabilitative care by facilitating training programs for medical education. According to the Defense Medical Epidemiology Database, nearly 17,000 Active Duty service members were diagnosed with carpal tunnel syndrome (CTS) in 2016, the most common peripheral entrapment neuropathy. MIRROR currently supports a study at multiple military treatment facilities (MTFs) comparing Ultrasound-Guided Carpal Tunnel Release (USCTR) to the current standard-of-care surgical release with respect to return to duty and clinical outcomes in the military population with CTS. With the aid of an innovative virtual platform, training for this enhanced intervention continued during the pandemic, propelling MIRROR’s mission to advance military medicine.

Persinger J, Benbassat D

Abstract submitted to Association of Military Surgeons of the United States 2022

The Department of Physical Medicine and Rehabilitation (PM&R) at the Uniformed Services University (USU) started offering a musculoskeletal (MSK) ultrasound (US) clerkship to USU medical students in 2019. It included resident didactic instruction on the fundamental principles of ultrasonography and hands-on clinical instruction using the ultrasound machine and transducers. Despite the clerkship’s tangible benefits to undergraduate medical students, it was discontinued following the 2020 pandemic’s stay-at-home orders. To ensure continued delivery of the course, the department transformed its traditional clerkship training using innovative distributed technologies.

Rhon D, Fraser J, Greenlee T, Jain T, Cook C

This abstract won the American Academy of Sports Physical Therapy 2021 Annual Meeting & Scientific Conference Research Report Award.

Ankle sprains are common, disabling, and costly. Timely rehabilitation may improve outcomes compared to delayed care. Our goal was to investigate the influence of time taken to begin physical rehabilitation on injury recurrence and one-year ankle-related medical care costs.

Rhon D, Fraser J, Westrick R, Umlauf J, Cook C

Abstract submitted to European Foot and Ankle Society Conference

While ankle-foot injuries are ubiquitous and affect ~16% of all military service-members, granularity of the evidence in this population is lacking. Therefore, the purpose of this retrospective cohort study was to characterize ankle sprains in the US military between 2009 and 2013.

cook c, sheean a, zhou l, kyong m, rhon d

This study aims to determine whether surgery for cruciate ligament (anterior or posterior) or meniscus injury increased risks of subsequent comorbidities in beneficiaries of the Military Health System. The study was a retrospective case-control design in which individuals with cruciate or meniscus injuries were divided into two groups (surgery or none). Data were pulled 12 months prior and 24 months following each respective event and presence of comorbidities were compared between the two groups. Bivariate analyses and logistic regression were used to determine if surgery increased the odds of comorbidities. Participants included 1,686 with a cruciate ligament injury (30.1% treated surgically) and 13,146 with a meniscus injury (44.4% treated surgically). Bivariate comparisons of surgery versus nonsurgical treatment found multiple significant differences. After adjusting for covariates, a significant (p < 0.05) protective effect was seen only for meniscus surgery for concussion, insomnia, other mental health disorders, depression, and substance abuse. Surgery had no increased/decreased risk of comorbidities for cruciate ligament injuries. For meniscus injuries, surgery demonstrated a protective effect for six of the comorbidities we assessed. The treatment approach (surgery vs. nonsurgical) did not change the risk of comorbidities in those with a cruciate ligament injury. It is noteworthy that three of the six comorbidities involved mental health disorders. Although the study design does not allow for determination of causation, these findings should compel future prospective study designs that could confirm these findings.

Cook CE, Sheean AJ, Zhou L, Min KS, Rhon DI. Does Surgery for Cruciate Ligament and Meniscus Injury Increase the Risk of Comorbidities at 2 Years in the Military System? J Knee Surg. 2023 Apr;36(5):465-474. doi: 10.1055/s-0041-1736197. Epub 2021 Oct 5. PMID: 34610640.