Goss D, Ignacio G, Helton M, Gonnella M, Reilly N, Haltiwanger, Yang K, Gailey

Abstract submitted to American College of Sports Medicine Annual Meeting & World Congresses 2023

Musculoskeletal injuries (MSI) affect approximately 800,000 service members and 25 million days of limited duty annually. There is a need for quick screening assessments that can classify and predict the risk of lower extremity (LE) MSI prior to activity. An Injury Risk Index (IRI) could facilitate improved decision-making and reduce the negative impact associated with selected MSI. The purpose of this study is to determine the frequency and distribution of Soldiers’ risk of MSI injury after performing sensors-based objective LE tests for static and dynamic stability. As of December 2022, 263 (92% male, 8% female) United States Army Soldiers were recruited, and provided demographic and previous joint-specific injury history information. Soldiers donned a sleeve with two inertial measurement unit sensors over each knee. They performed single limb stance (SLS) tests to obtain Region of Limb Stability (ROLS) values, which measures static LE stability. A four-meter sidestep test (FmSST) was used to obtain the Transitional Angular Displacement of Segments (TADS) values as a metric of dynamic joint stability. The ROLS and TADS symmetry values between LEs is calculated for both tests and the values are used to determine IRI category as low, moderate, or high risk for injury. [RN1] Total assessment time was < 15 minutes per Soldier. Descriptive statistics and frequency distributions were used to characterize the study population.

Crowell M, Pitt W, Mason J, Posner M, Cameron K, and Goss D

Abstract selected for a podium presentation at 2023 American Physical Therapy Association Combined Sections Meeting in San Diego, California

Shoulder instability is common in active young athletes and military personnel, often requiring shoulder stabilization surgery. Acute post-operative pain is usually managed with opioid pain medications, which have adverse effects that reduce military readiness. Battlefield Acupuncture (BFA) has demonstrated promise as a non-pharmaceutical intervention for acute post-operative pain. The purpose of this randomized clinical trial was to assess the effectiveness of BFA on post-surgical pain and opioid medication usage.

Symsack A, Haynes J, Gaunaurd I, Clemens S, Gruenhagen Lucarevic J, Bennet C, Isaacson B, Pasquina P, Gailey R

Abstract selected for a podium presentation at 2023 American Physical Therapy Association Combined Sections Meeting in San Diego, California

Veterans with lower limb loss (LLL) face many challenges (time and cost) to receive appropriate prosthetic training and exercises that could improve their gait quality and functional mobility. The VA and DoD supported the development of the Mobile Device Outcomes-based Rehabilitation Program (MDORP). MDORP is a comprehensive mobile rehabilitation program that includes a wearable sensor system called the Rehabilitative Lower Limb Orthopedic Assistive Device (ReLOAD). The ReLOAD system assesses gait and provides real-time audio feedback during home walks to correct specific gait deviations and subsequently recommend targeted exercises. The purpose of this study was to examine the changes in mobility, gait quality, and strength for lower functioning Veterans with LLL after completing the 8-week MDOR Pprogram

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

Miller E, mason J, Pitt w, Crowell M, Wear A, Reilly N, Haltiwanger H, Gonnella M, Goss D

Abstract selected for a podium presentation at 2023 American Physical Therapy Association Combined Sections Meeting 2023 in San Diego, California

Previous research has identified numerous biomechanical variables that may relate to musculoskeletal injury risk. Gait retraining interventions have successfully altered running biomechanical risk factors for overuse knee injury in non-military populations. However, constraints on patient time and frequency of in-clinic visits limits implementation of gait retraining interventions in the Military Health System (MHS). The purpose of this randomized clinical trial was to determine the effect of a telehealth gait retraining intervention on the running kinematics in patients with an overuse knee injury.

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

RHON D, TEYHEN D, COLLINS G, BULLOCK G

Abstract submitted to The World Congress of Sports Physical Therapy 2022

Using the same data, compare performance between an injury prediction model categorizing predictors and one that did not, and compare selection of predictors based on univariate significance versus assessing non-linear relationships. Validation and replication of a previously developed injury prediction model in a cohort of 1466 healthy military service members followed for one year after physical performance, medical history, and sociodemographic variables were collected. The original model dichotomized 8 predictors. The second model (M2) kept predictors continuous but assumed linearity, the third model (M3) conducted non-linear transformations. The fourth model (M4) chose predictors the proper way (clinical reasoning and supporting evidence) which led to an addition of 7 additional predictors (15 predictors total), but still kept predictors dichotomized. Model performance was assessed with R2, calibration in the large, calibration slope, and discrimination. Decision curve analyses were performed with risk thresholds from 0.25 to 0.50.

Persinger J and Hager N

Abstract submitted to American Institute of Ultrasound in Medicine 2022

The Physical Medicine and Rehabilitation Clinic (PM&R) at Walter Reed National Military Medical Center (WRNMMC) augmented their high frequency ultra-sound systems with an ultra-high frequency ultrasound (UHFUS) system for use in the diagnosing and treatment of musculoskeletal (MSK) and nerve injury warfighters. The Visualsonics VevoMD is an UHFUS system with operating frequencies in the 24–70 MHz range as compared to the typical POC and tertiary care ultrasound systems operating in the15–22 MHz range. Access to this system afforded a unique opportunity to explore the usefulness of this cutting-edge technology in the unique settings of limb loss and multi-trauma in the military.

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

Rhon D, Teyhen D, Collins G, Bullock G

Abstract submitted to The World Congress of Sports Physical Therapy 2022

Using the same data, compare performance between an injury prediction model categorizing predictors and one that did not, and compare selection of predictors based on univariate significance versus assessing non-linear relationships. Validation and replication of a previously developed injury prediction model in a cohort of 1466 healthy military service members followed for one year after physical performance, medical history, and sociodemographic variables were collected. The original model dichotomized 8 predictors. The second model (M2) kept predictors continuous but assumed linearity, the third model (M3) conducted non-linear transformations. The fourth model (M4) chose predictors the proper way (clinical reasoning and supporting evidence) which led to an addition of 7 additional predictors (15 predictors total), but still kept predictors dichotomized. Model performance was assessed with R2, calibration in the large, calibration slope, and discrimination. Decision curve analyses were performed with risk thresholds from 0.25 to 0.50.

Rhon, D. I., Teyhen, D. S., Collins, G. S., & Bullock, G. S. (2022). Predictive Models for Musculoskeletal Injury Risk: Why statistical Approach Makes All the Difference. BMJ Open Sport & Exercise Medicine. https://doi.org/10.1136/bmjsem-2022-001388

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

Investigate the burden of knee, hip, and lumbar spine disorders occurring in the year following an ankle sprain and the influence therapeutic exercise (TE) has on this burden. 33,361 individuals diagnosed with ankle sprain in the Military Health System between 2010 and 2011 were followed for 1 year. Prevalence of knee, hip, and lumbar care-seeking injuries sustained after sprain was identified. Relationships between demographic groups, ankle sprain type, and use of TE with rate of proximal injuries were evaluated using Cox Proportional Hazard Models to determine Hazard Rate effect modification by attribute. Observed impact of TE for ankle sprain on rate of injury to proximal joints was evaluated using Kaplan-Meier survival analyses.

Foster, K. S., Greenlee, T. A., Fraser, J. J., Young, J. L., & Rhon, D. I. (2022). The Influence of Therapeutic Exercise after Ankle Sprain on the Incidence of Subsequent Knee, Hip, and Lumbar Spine Injury. Medicine & Science in Sports & Exercise. https://doi.org/10.1249/MSS.0000000000003035

Foster K, Greenlee T, Young J, Janney C, Rhon D

Posterior tibial tendon dysfunction (PTTD) and tarsal tunnel syndrome (TTS) are debilitating conditions reported to occur after ankle sprain due to their proximity to the ankle complex. The objective of this study was to investigate the incidence of PTTD and TTS in the 2 years following an ankle sprain and which variables are associated with its onset. In total, 22,966 individuals in the Military Health System diagnosed with ankle sprain between 2010 and 2011 were followed for 2 years. The incidence of PTTD and TTS after ankle sprain was identified. Binary logistic regression was used to identify potential demographic or medical history factors associated with PTTD or TTS. In total, 617 (2.7%) received a PTTD diagnosis and 127 (0.6%) received a TTS diagnosis. Active-duty status (odds ratio [OR] 2.18, 95% confidence interval [CI] 1.70-2.79), increasing age (OR 1.03, 95% CI 1.02-1.04), female sex (OR 1.58, 95% CI 1.28-1.95), and if the sprain location was specified by the diagnosis (versus unspecified location) and did not include a fracture contributed to significantly higher (p < 0.001) risk of developing PTTD. Greater age (OR 1.06, 95% CI 1.03-1.09), female sex (OR 2.73, 95% CI 1.74-4.29), history of metabolic syndrome (OR 1.73, 95% CI 1.03-2.89), and active-duty status (OR 2.28, 95% CI 1.38-3.77) also significantly increased the odds of developing TTS, while sustaining a concurrent ankle fracture with the initial ankle sprain (OR 0.45, 95% CI 0.28-0.70) significantly decreased the odds. PTTD and TTS were not common after ankle sprain. However, they still merit consideration as postinjury sequelae, especially in patients with persistent symptoms. Increasing age, type of sprain, female sex, metabolic syndrome, and active-duty status were all significantly associated with the development of one or both subsequent injuries. This work provides normative data for incidence rates of these subsequent injuries and can help increase awareness of these conditions, leading to improved management of refractory ankle sprain injuries

Foster, K. S., Greenlee, T. A., Young, J. L., Janney, C. F., & Rhon, D. I. (2022). How Common is Subsequent Posterior Tibial Tendon Dysfunction or Tarsal Tunnel Syndrome After Ankle Sprain Injury? The Journal of Knee Surgery. https://doi.org/10.1055/s-0042-1751246

Powell J, Sparling T, Yuan X

Globally, 57.7 million people lived with traumatic limb loss in 2017, with the prevalence of amputation in the United States alone expected to reach 3.6 million by 2050. Pain is a common complication after limb loss, with up to 59% of patients experiencing residual limb pain (RLP). Although RLP is often due to a structural etiology, it is difficult to treat, as the exact structure involved is frequently not apparent on history and physical exam alone. This narrative review aims to summarize the available literature on diagnostic ultrasound (US) of the residual limb and examine the utility of US in identifying specific pathology. A total of 31 peer-reviewed manuscripts published between 1989 and 2021 were included, grouped by pathology. While US presents a promising and cost-effective approach to identifying pathology within the residual limb, many gaps remain in the current knowledge, and no specific protocol for a sonographic assessment of the residual limb has ever been proposed. Future studies of diagnostic US of the residual limb should focus on replicable sonographic techniques and standardized exam protocols.

Powell, J. E., Sparling, T. L., & Yuan, X. (2022). Diagnostic Ultrasound of the Residual Limb: A Narrative Review. PM&R. https://doi.org/10.1002/pmrj.12896

Super E, Smith M, Persinger J, Hager N, Smith J, Miller M, Yuan X

Abstract Submitted to WRNMMC Research and Innovation Month 2022

Carpal tunnel syndrome (CTS) is the most common peripheral nerve entrapment. Interventional procedures for CTS include carpal tunnel (CT) injections and CT release (CTR). Variant anatomy increases the risk of iatrogenic injury and complications, impairing recovery and leading to post-procedural functional deficits. The objective of this study was to evaluate anatomic variations associated with CTS or at risk of injury during procedures using high-frequency ultrasound (HFUS). In this cross-sectional, observational study of 100 eligible patients (age: 44.4 ± 13.0 years, 37.0% female) referred for upper extremity (UE) electrodiagnostic studies (EDX), the MN was systematically evaluated using high-frequency ultrasound (HFUS) from the elbow to the CT outlet. The presence/absence of Martin-Gruber anastomosis (MGA), palmaris longus, and lumbrical intrusion with dynamic finger flexion at the CT inlet were documented, along with the course of the palmar cutaneous branch of the MN (PCBMN) and thenar motor branch (TMB. The cross-sectional area (CSA) of the MN at the level of the CT inlet and the transverse safe zone (TSZ) for CTR were measured. Statistical analyses were conducted using GraphPad Prism. All data are presented as mean ± standard deviation or percentage (%).

Pendlebury G, Rimmert B, Yuan X

Ischiofemoral impingement (IFI) is an uncommon etiology of hip pain, first reported in three patients after total hip arthroplasty and proximal femoral osteotomy. IFI is defined as a narrowing of the ischiofemoral space (IFS) between the lesser trochanter and ischium, leading to edema of the quadratus femoris (QF) muscle and sciatic nerve compression. Abnormalities of the QF may lead to hip, buttock, and groin pain radiating distally from the posterior thigh, likely due to irritation of the sciatic nerve adjacent to the QF.² Existing literature on this condition is limited, including case reports of congenital variants in women and children.³ We report the case of a 50-year-old woman with chronic right hip pain who was diagnosed with ischiofemoral impingement syndrome (IFIS) by physical examination findings and magnetic resonance imaging (MRI) results.

Pendlebury, G., Rimmert, B., & Yuan, X. (2022). Ischiofemoral Impingement Syndrome: Case Report and Treatment Review. Practical Pain Management

Smith M, Bradley M, Kasuske A, Smith J, Nanos G, Tintle S, Reece D, Yuan X, Miller M

Submitted to WRNMMC Research and Innovation Month 2022

Within the Military Healthcare System (MHS), endoscopic and mini-open carpal tunnel release (mOCTR) procedures are the current standard of care for management of refractory Carpal Tunnel Syndrome (CTS), the most common peripheral neuropathy. Carpal Tunnel Release using Ultrasound Guidance (CTR-US), which involves a single 4-6 mm incision, is showing potential as a treatment option for eligible candidates within the military population with CTS in an ongoing randomized controlled trial (RCT) at Walter Reed National Military Medical Center (WRNMMC).

Yuan X, Lowder R, Avilles- Wetherell K, Skroce C, Yao K, Soo Hoo J

Rehabilitation is the key to management of patients with subacromial impingement syndrome to prevent disability and loss of function. While point-of-care musculoskeletal ultrasound aids clinical diagnosis of subacromial impingement syndrome, many patients do not demonstrate the classic findings of dynamic supraspinatus tendon impingement beneath the acromion on ultrasound. The objective of this study was to establish the most reliable shoulder ultrasound measurements for subacromial impingement, by evaluating the intra-rater and inter-rater reliability of measurements in asymptomatic participants.

Yuan, X., Lowder, R., Aviles-Wetherell, K., Skroce, C., Yao, K. V., & Soo Hoo, J. (2022). Reliability of point-of-care shoulder ultrasound measurements for subacromial impingement in asymptomatic participants. Frontiers in Rehabilitation Science. https://doi.org/10.3389/fresc.2022.964613

Smith M, Huszar M, Pav V, Hando B, Deal J, Yuan X

Abstract submitted to SOMOS 64h Annual Meeting

Carpal Tunnel Syndrome (CTS) is the most common peripheral entrapment neuropathy, impacting the health, performance, and readiness of Active-Duty service members (ADSMs) of the U.S. Military. However, for ADSMs who seek surgical management for severe or refractory CTS with Carpal Tunnel Release (CTR), access to subspecialty providers within direct care (DC) Military Treatment Facilities (MTFs) can be limited, leading to reliance on care outside MTFs within the private sector (PS). It is currently unknown how the COVID-19 pandemic has impacted provision of and access to care for CTS and CTRs across DC and PS. Therefore, the purpose of this study is to describe regional trends and variation in CTRs performed across Defense Health Agency (DHA) markets within the Military Health System (MHS) over Fiscal Years (FY) 2019-2021. All study procedures were approved by the Uniformed Services University’s Institutional Review Board. We queried the MHS Data Repository to identify all ADSMs with outpatient encounters in DC and PS by International Classification of Diseases, Tenth Revision diagnosis codes for CTS, and CTRs by Current Procedural Terminology codes, during FYs 2019-2021. We further classified CTRs by FY, DC vs. PS, DHA markets, and setting [e.g., Ambulatory Surgical Center (ASC), clinic]. PS encounters were derived using per person per day logic and mapped to DHA markets by zip codes within 40 miles of MTF Service Areas.

Persinger J and Hager N

The Physical Medicine and Rehabilitation Clinic (PM&R) at Walter Reed National Military Medical Center (WRNMMC) augmented their high frequency ultra-sound systems with an ultra-high frequency ultrasound(UHFUS) system for use in the diagnosing and treatment of musculoskeletal (MSK) and nerve injury warfighters. The Visualsonics VevoMD is an UHFUS system with operating frequencies in the 24–70 MHz range as compared to the typical POC and tertiary care ultrasound systems operating in the15–22 MHz range. Access to this system afforded a unique opportunity to explore the usefulness of this cutting-edge technology in the unique settings of limb loss and multi-trauma in the military.

Persinger, J. E., & Hager, N. (2022). Unique Diagnostic Capabilities and Impact of Ultra-High Frequency Ultrasound in the Musculoskeletal Clinical Setting. Journal of Ultrasound in Medicine. https://doi.org/https://onlinelibrary.wiley.com/doi/epdf/10.1002/jum.16028

Cook C, Zhou L, Bolognesi M, Sheean A, Barlow B, Rhon D

Concomitant cruciate and meniscus injuries of the knee are generally associated with acute trauma and commonly treated with surgical intervention. Comorbidities (simultaneous presence of two or more medical conditions) may be acquired from changes in activity levels and lifestyle after an injury and/or treatment. This study aimed to compare differences in comorbidity proportions between surgical and nonsurgical approaches in Military Health System beneficiaries who had concurrent cruciate and meniscus injuries. The retrospective case control design included 36-month data that were analyzed to reflect 12 months prior to injury/surgery and 24 months after injury/surgery. A comparison of differences within and between groups in surgical and nonsurgical approaches was calculated and logistic regression was used to determine if surgery increased or decreased the odds of comorbidities at 24 months. In our sample of 2,438 individuals with concurrent meniscus and cruciate injury, 79.1% (n¼1,927) received surgical intervention and 20.9% (n¼511) elected for nonoperative management. All comorbidities demonstrated significant within-group differences from pre- to post surgery for those with a surgical intervention; approximately, half the comorbidities increased (i.e., concussion or traumatic brain injury, insomnia, other sleep disorders, anxiety, posttraumatic stress disorder, and tobacco abuse disorder), whereas the other half decreased (i.e., chronic pain, apnea, cardiovascular disease, metabolic syndrome, mental health other, depression, and substance abuse disorders). The odds of acquiring a comorbid diagnosis after surgery reflected the bivariate comparisons with half increasing and half decreasing in odds. To our knowledge, this is the first study to explore comorbidity changes with a control group for individuals with concurrent meniscus and cruciate injuries.

Cook, C. E., Liang, Z., Bolognesi, M., Sheean, A. J., Barlow, B. T., & Rhon, D. I. (2022). Does Surgery for Concomitant Cruciate and Meniscus Injuries Increase or Decrease Subsequent Comorbidities at 2 Years? The Journal of Knee Surgey. https://doi.org/10.1055/s-0042-1750046