Galvin J, Rooney P, Tokish J, Grassbaugh J, Masini B, Free K, Bastian M, Gillette L, Colburn Z

Abstract accepted for platform presentation at the 2023 Washington State Orthopaedic Association (WSOA) Annual Meeting

Currently the measurement of serum or synovial biomarkers does not have a role in diagnosis or monitoring of injury severity in young patients with recurrent anterior shoulder instability. The purpose of this study was to compare gene expression differences in the peripheral blood and tissue of young patients with recurrent anterior shoulder instability with and without significant glenoid bone loss (GBL). Additionally, we sought to determine a peripheral blood transcriptomic biomarker for the reliable delineation of the severity of GBL in anterior shoulder instability patients.

There are significant gene expression differences in the peripheral blood of anterior shoulder instability patients with and without significant (≥10%) GBL. The differential expression of 5 genes allowed development of an accurate predictive model and transcriptomic classifier to predict the severity of GBL. This novel peripheral blood transcriptomic biomarker may assist in tracking glenoid bone loss and injury severity and progression in young patients with recurrent anterior shoulder instability.

Bullock GS, Dartt Ce, Ricker EA, arden N, clifton D, danelson K, fraser jj, gomez c, greenlee ta, gregory a, gribbin t, losciale j, molloy jm, nicholson kF, polich jg, raisanen a, shah k, smuda m, teyhen ds, allard rj, collins gs, de la motte sj, rhon di

Musculoskeletal injury (MSK-I) mitigation and prevention programmes (MSK-IMPPs) have been developed and implemented across militaries worldwide. Although programme efficacy is often reported, development and implementation details are often overlooked, limiting their scalability, sustainability and effectiveness. This scoping review aimed to identify the following in military populations: (1) barriers and facilitators to implementing and scaling MSK-IMPPs; (2) gaps in MSK-IMPP research and (3) future research priorities. This review concluded that despite a robust body of literature, there is a dearth of information about programme implementation; specifically, barriers or facilitators to success. Additionally, variability in outcomes and lack of consensus on MSK-I definitions may affect the development, implementation evaluation and comparison of MSK-IMPPs. There is a need for international consensus on definitions and optimal data reporting elements when conducting injury risk mitigation research in the military.

Bullock GS, Dartt CE, Ricker EA, et al Barriers and facilitators to implementation of musculoskeletal injury mitigation programmes for military service members around the world: a scoping review. Injury Prevention Published Online First: 23 August 2023. doi: 10.1136/ip-2023-044905

Ong J, Nazarian A, Tam J, farinelli W, Korupolu s, Drake L, Isaacson B, Pasquina P, Williams D

Antimicrobial blue light (aBL) is an attractive option for managing biofilm burden at the skin-implant interface of percutaneous osseointegrated (OI) implants. However, marketed aBL devices have both structural and optical limitations that prevent them from being used in an OI implant environment. They must be handheld, preventing even irradiation of the entire skin-implant interface, and the devices do not offer sufficient optical power outputs required to kill biofilms. We present the developmental process of a unique aBL device that overcomes these limitations. Four prototypes are detailed, each being a progressive improvement from the previous iteration as we move from proof-of-concept to in vivo application. Design features focused on a cooling system, LED orientation, modularity, and “sheep-proofing”. The final prototype was tested in an in vivo OI implant sheep model, demonstrating that it was structurally and optically adequate to address biofilm burdens at the skin-implant of percutaneous OI implants. The device made it possible to test aBL in the unique OI implant environment and compare its efficacy to clinical antibiotics–data which had not before been achievable. It has provided insight into whether or not continued pursual of light therapy research for OI implants, and other percutaneous devices, is worthwhile. However, the device has drawbacks concerning the cooling system, complexity, and size if it is to be translated to human clinical trials. Overall, we successfully developed a device to test aBL therapy for patients with OI implants and helped progress understanding in the field of infection management strategies.

Ong J, Nazarian A, Tam J, Farinelli W, Korupolu S, Drake L, et al. (2023) An antimicrobial blue light device to manage infection at the skin-implant interface of percutaneous osseointegrated implants. PLoS ONE 18(8): e0290347. https://doi.org/10.1371/journal.pone.0290347

wentz g, landry p, Reilly N, Gonnella M, Haltiwanger H, wilson v, goss d

Abstract accepted for a breakout session at the 2023 Military Health System Research Symposium

Active-duty service members (ADSMs) are required to perform regular bouts of running and vigorous physical activity in accordance with the nature of their roles and responsibilities. As a result, ADSMs are at an inherently higher risk of sustaining a running-related injury compared to the general population. Prior research has identified numerous biomechanical parameters associated with an increased risk of injury, particularly regarding joint kinematics during gait. The gold standard for assessing joint kinematics of gait is three-dimensional motion capture. However, conducting three-dimensional motion capture analyses typically requires sophisticated laboratory equipment and a designated, open testing space. These conditions are often not feasible for a clinical environment, and thus populations that do not have ready access to biomechanics laboratory settings, including ADSMs. As a result, gait kinematics are often not considered when forming treatment and management plans for ADSMs following a running-related musculoskeletal injury. However, recent technological advances have strived to bring laboratory-grade motion capture technologies to clinical settings to reach patients that could benefit from the information and context that can be derived from these types of gait analyses. Therefore, the purpose of this case study was to evaluate the effectiveness of a portable, clinic-friendly three-dimensional motion capture system to supplement the treatment of and recovery from a running-related injury for an active-duty service member.

Galvin J, Rooney p, Egan a, tokish j, Grassbaugh j, Masini b, free k, bastian m, gillette l, colburn z

Abstracted accepted for a poster session at the 2023 Military Health System Research Symposium

Currently, the measurement of serum or synovial biomarkers does not have a role in diagnosis or monitoring of injury severity in young patients with recurrent anterior shoulder instability. The purpose of this study was to compare gene expression differences in the blood and tissue of young patients with anterior shoulder instability with and without significant glenoid bone loss (GBL). Additionally, we sought to identify a blood transcriptomic biomarker for the reliable delineation of the severity of GBL.

There are significant gene expression differences in the blood of anterior shoulder instability patients with and without significant (≥10%) GBL.

The differential expression of 5 genes allowed development of an accurate predictive model and transcriptomic biomarker to predict the severity of GBL.

This novel blood transcriptomic data may assist in tracking GBL and injury progression in patients with recurrent anterior shoulder instability.

Galvin J, Rooney p, Egan a, say f, Grassbaugh j, Masini b, free k, bastian m, gillette l, colburn z

Abstracted accepted for a poster session at the 2023 Military Health System Research Symposium

The purpose of this study was to compare gene expression differences in the peripheral blood and capsular tissue of young patients with recurrent anterior shoulder instability and those patients with unidirectional posterior shoulder instability.

There are significant gene expression differences in the shoulder capsule of anterior and posterior shoulder instability patients. This transcriptomic data may provide an improved understanding of the pathobiology of various forms of shoulder instability which could lead to future precision medicine approaches to prevent the development of early glenohumeral osteoarthritis.

Cin H, Mincey C, Persinger J, Hager N, Yimyam C, Metzger E, Isaacson B, Wagner L, Pasquina P

Abstract accepted for a poster session at the 2023 Military Health System Research Symposium

Physical activity limiting conditions are incompatible with maintaining a fit and ready fighting force and improving the health and wellness of those entrusted to our care. This study may produce new scientific knowledge about optimal dosing parameters of PBMT to best reduce pain and improve function for those who are limited by PF. This innovative therapy has the potential to promote a fit and ready fighting force by returning service members to duty quickly, reducing health care costs, and promoting operational readiness. The long-term goals of this research team include: 1) developing PBMT protocols for broad application to other painful and duty-limiting conditions, and 2) exploring the application of this portable device in forward-deployed environments.

Cheema N, Nazarian A, Pham L, Ghag N, Fuchs C, Tam J, Anderson R

Abstract accepted for a poster session at the 2023 Military Health System Research Symposium

Fatigue is defined by the reduction of a muscle’s strength and performance during exercise, and it is affected by different parts of the motor pathway controlling muscle contractions. Fatigue can occur in the central nervous system and affects neuronal signaling to the muscle whereas peripheral fatigue affects the site of neuromuscular junctions present on the muscle. Fatigue limits performance and unless allowed to recover, continuous activity will result in muscle dysfunction and musculoskeletal injuries that are commonly observed in military personnel. Light therapy has been shown to have several beneficial physiologic effects in a wide range of tissues. The musculoskeletal system can be irradiated with wavelengths in red and near infrared (NIR) regions which penetrate deep into the body. Application of NIR light is a noninvasive procedure and there is minimal heat generated by the light emitting diodes (LEDs), making it an appealing therapeutic strategy for muscle damage. Recent studies are suggesting that photobiomodulation therapy (PBMT) can reduce pain, inflammation and enhance physical performance. However, the mechanism(s) of cellular responses by PBM in muscle is not clearly understood. There is no standardization in parameters for PBMT, with researchers and clinicians using a wide range of wavelengths, fluences, treatment duration/frequency, etc. in PBM applications. Therefore, the goal of this study is to improve our understanding of the mechanism(s) of action of PBM effects on the musculoskeletal system, ultimately to inform the choice of clinical treatment parameters. We investigate two wavelengths in NIR light, 980 nm and 810 nm, and their effect on fatigue induced in intense exercise in cells and mice.

Metzger E, Hager N, Wagner L, Isaacson B, Pasquina P

Abstract accepted for a poster session at the 2023 Military Health System Research Symposium

Noncombat, musculoskeletal injuries account for nearly 60% of warfighters’ limited duty days and 65% of warfighters on non-deployable status. Often the treatment and the rehabilitation modalities available for common musculoskeletal conditions have little impact on the progression of the condition. A safe, patient friendly, and effective modality that could advance the treatment of these conditions would be extremely impactful. Photobiomodulation (PBM) – (formerly known as low-power laser therapy or low-level laser therapy), involves applying non-ionizing forms of light from various sources including lasers, light-emitting diodes (LEDs), and broadband light, in the visible and near infrared spectrum, in order to biologically modulate cellular activity to enhance healing. Current research reveals that PBM treatment can influence repair and regeneration of several tissue lines, stimulate metabolism, and most importantly for the injured warfighter - reduce inflammation and pain while recovering from injury. The PBM research portfolio is investigating the influence of this modality as it serves to enhance human performance, recovery, operational readiness, and warfighter quality of life with guided research efforts into the following areas of interest and aimed outcomes:

1. Musculoskeletal (MSK) injury: increased function and decreased pain for issues such as knee osteoarthritis, plantar fasciitis, tendinopathy, and bone stress injury.

2. Performance: improved maximum isometric voluntary contraction, sprint time, and countermovement jump measures.

3. Recovery: decreased inflammatory and oxidative stress biomarkers, and physical activity disability.

4. Self-reported behavioral health: decreased delayed-onset muscle soreness, perceived exertion, fatigue, and mental athletic energy used, and increased sense of wellbeing.

5. Sleep: increased sleep efficiency and self-reported quality of sleep.

6. Nerve: increased nerve strength post-reparative common peripheral nerve surgery and comparative use of analogous, commercially available, or manufactured sealing mechanisms.

7. Hearing: preventative protective treatment to noise exposure.

8. Wound: increased reduction in pathogens during the healing process.

Bradley M, Yuan X

Abstract accepted for a poster session at the 2023 Military Health System Research Symposium

 This study demonstrates the influence of the APDACAP on the structure of the foot, particularly on talus positioning, for the first time in a large sample of humans and elucidates previously misunderstood concepts about pronation. We determined that the current, most widely used method for categorizing foot type (CIA) is not the most accurate for diagnostic screening. Instead, the investigators propose a new, more accurate categorization system for foot type, which includes the CIA’s three categories of low, medium, and high arch heights, and further stratifies to describe the wide spectrum of flexible and rigid foot types within each arch height category, by considering the degrees of APDACAP and TDA. Although the following still needs to be verified in a prospective trial, it is expected that the most often misdiagnosed/mistreated foot types are to be (1) low arch height yet rigid midfoot (i.e., low CIA & high APDACAP/TDA), (2) high arch height yet flexible midfoot (i.e., high CIA & low APDACAP/TDA), and (3) medium arch height with APDACAP/TDA values toward the outer extremes of the flexible/rigid continuums. The implications of the new categorization system will enable better awareness and care to prevent and treat lower extremity injuries.

Smith M, Yuan X, Smith J, Deal B, Nanos G, Tintle S, Reece D, Miller M

Abstract accepted for a poster session at the 2023 Military Health System Research Symposium

CTS is the most common peripheral entrapment neuropathy, impacting the health, performance, and readiness of Active Duty service members and military beneficiaries. Military occupations often require repetitive movements, forceful grip, and exposure to vibration, which are risk factors for CTS, illustrating the importance of access to novel CTR techniques that facilitate return to functional activity. Current barriers to CTS treatment within the MHS include limited access to subspeciality care in rural areas, lack of resources, and OR procedural costs and staffing requirements. Clinic-based procedures have demonstrated utility in decreasing costs and increasing access to care within the MHS. Preliminary data from this pragmatic randomized controlled feasibility trial at WRNMMC suggest that CTR-US can be performed by non-operative physicians with advanced training within a clinic environment and yield positive outcomes that compare favorably to the current SOC mOCTR approach. Outcomes of this trial comparing CTR-US and mOCTR at WRNMMC can further expand available CTS management options within the MHS, improving access to care, practice efficiency, operational readiness, and long-term functional outcomes for service members.

Goss D, Weart A, Miller E, McHenry P, Haltiwanger H, Gonnella M, Ford K, Reilly N, Crowell M

Abstract accepted for a breakout session at the 2023 Military Health System Research Symposium

By the nature of their work, active-duty service members (ADSMs) are exposed to greater risks of musculoskeletal injury in comparison to the general population. The prevalence of musculoskeletal injury presents significant financial and temporal strains on the Military Health System (MHS) as costs for treatment and collective time lost from active duty accumulate, respectively. As a result, one of every twenty-five ADSMs are unable to deploy or fulfill their duties due to injury at any given time. Despite the inherently dangerous nature of combat, the most prevalent cause of injury in the ADSM population is running. Effective treatments for running-related pain are needed that modify known risk factors for running-related knee pain (i.e., gait retraining to alter problematic movement patterns).” Previous research has identified numerous biomechanical parameters indicative of increased mechanical strain and corresponding increases in musculoskeletal injury risk.  Examples include, but are not limited to, greater peak vertical ground reaction forces (GRF), greater average vertical loading rates upon foot strike, and greater peak braking forces. Unfortunately, the ADSM population does not have ready access to the laboratory-grade facilities and analytical techniques (i.e., kinetics via force plates, kinematics via three-dimensional motion capture) often utilized to conduct traditional gait retraining assessments. As a result, gait kinetics are often not considered clinically when forming treatment plans following a running-related injury, leaving any underlying problematic mechanical patterns to persist following the resolution of the initial injury and predisposing the patient to an increased risk of a follow-up, potentially more severe injury. Recent advances in the capabilities of telehealth have expanded the spectrum of treatment modalities for a variety of pathologies. However, it has yet to be seen whether telehealth can be utilized effectively to treat running-related injuries based on targeted feedback stemming from biomechanical parameters associated with injury risk. To date, the use of telehealth to implement gait retraining to supplement clinical management plans and expedite the return-to-duty process in the ADSM population has been largely unexplored.

Gaunaurd I, Goss D, Helton M, Gonella M, Reilly N, Haltiwanger H, Mulier L, Gailey R

Musculoskeletal injuries (MSI) affect approximately 800,000 service members annually and 25 million days of limited duty. There is a need for quick screen 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 after performing sensors-based objective LE tests for static and dynamic stability. The number of Soldiers with prior lower limb MSI who had worse static and dynamic stability symmetry could be a concern for reinjury and/or less than ideal physical performance while on duty. The ability to identify the risk of injury in Soldiers, athletes or people with previous injuries may promote preventative interventions or pre-habilitation to reduce re-injury. 

Dowe JN, Bradley MW, Dickens JF

Abstracted accepted for a poster session at the 2023 Military Health System Research Symposium

Musculoskeletal injuries are some of the most prevalent issues in the military, being a significant contributor to functional limitations, duty restrictions, and impaired military readiness. In particular, shoulder instability events, such as dislocations and subluxations, are a disproportionately burdensome condition among military Service Members (SM), with SM being 20 times more likely to experience a shoulder instability event than their civilian counterparts. Furthermore, a common consequence of instability events is bone loss to the glenohumeral joint, which increases risk of re-injury (currently around 80% re-injury rate). As the amount of bone loss increases, so do the failure rates following nonoperative and operative treatment, leading to recurrent instability that contributes to inferior long-term outcomes and impaired biomechanics. With the military population being the most at-risk population for shoulder instability injuries, understanding the unique anatomical structure of a patient’s shoulder joint is essential in advancing treatment and surgical decision making. Additionally, the high costs associated with these injuries highlights the need for enhanced management and care. Imaging modalities, such as magnetic resonance imaging (MRI) and computed tomography (CT), are used to assess the extent of injury in patients who experience shoulder instability. These assessments help guide decisions regarding the direction of care for patients. However, these imaging modalities each have certain advantages and disadvantages in analyzing a patient’s joint structure. Currently, the closest to a gold standard for assessing bone loss in the shoulder is by obtaining a three-dimensional (3D) CT scan and then utilizing a 3D reconstruction. Though valuable, the current evaluation process can be improved to provide more efficiency and ease from both a clinician and patient perspective. The process of obtaining a 3D view of the shoulder joint from an MRI, although less common, can be completed to effectively assess bone loss and determine treatment, while also solving some of the issues associated with the use of CT.

Reilly N, Velasco T, Roberts K, Hulsopple C, Wise S, Goss D, Leggit J

Abstracted accepted for a poster session at the 2023 Military Health System Research Symposium

Active-duty service members (ADSMs) regularly run and perform vigorous physical activity per their training and physical fitness requirements. As such, ADSMs are at a higher risk of developing acute and persistent running-related musculoskeletal pathologies. As such, chronic exertional compartment syndrome (CECS) presents a significant clinical problem among the ADSM population. The condition impacts the ability to run as the repetitive mechanical strains incurred during gait result in localized pain, weakness, and/or paresthesia, predominantly in the musculature of the lower legs. Troublingly, the exact pathophysiology of CECS is not thoroughly understood, and surgical interventions to treat the condition (i.e., fasciotomy) have generally seen mixed outcomes regarding clinical success. As a result, alternative, non-surgical approaches have received increased attention. Two such approaches include 1) pharmaceutical interventions via botulinum toxin A (BoNT-A) to reduce lower limb pain and symptoms and perhaps reduce intramuscular compartment pressure, and 2) structured gait retraining to modify running mechanics (i.e., transition to forefoot strike pattern) to decrease skeletal muscle activity and stresses of the lower limbs. Prior research and case series utilizing each modality have reported promising results and clinical outcomes regarding pain and overall function during running. However, the implementation of these non-surgical interventions for patients with CECS has, to date, been limited in scope due to the availability of laboratory-grade equipment and analytical expertise for corresponding biomechanical gait data. The combination of these modalities on specific biomechanical gait parameters associated with injury risk in patients with CECS is mainly unexplored.

Rhon DI, Anderson DN, Konitzer LN, Pickens BB, Szymanek EB, Mayhew RJ, Laugesen MC, Greenlee TA

Physical therapy services delivered remotely are becoming more common. The purpose of this study was to summarize the acceptability and patient-centeredness of remotely delivered physical therapy. This was a survey study. Patients and clinicians from physical therapy clinics in the US Military Health System were asked to provide feedback at the conclusion of each remote visit. Platform, reason for care, components of physical therapy delivered and received, satisfaction, and perception of patient-centeredness were collected. Results were summarized as proportions and frequencies. Feedback was provided by physical therapists for 250 visits and from patients for 61 visits. Most visits were completed using audio only (n=172; 68.8%) while the rest integrated video capability (n=78; 31.2%). Overall patients perceived their care was patient-centered either completely or very much. Over 90% of visits were perceived by physical therapists as being highly patient centered. For 53.2% of visits, patients thought that same visit would have been even more impactful in person and for 52.4% of visits, physical therapists thought the visit would have been more impactful in person. In conclusion even though remotely provided physical therapy care was rated by patients to be patient-centered, approximately half of the patients responding felt the same physical therapy visit would have been more impactful in person. Similarly, physical therapists felt that their intervention would have been more impactful in person for approximately half of all visits. Physical therapy care delivered remotely was patient-centered and an acceptable alternative to in-person care for both patients and physical therapists.

Rhon, D.I., Anderson, D.N., Konitzer, L.N. et al. Patient-centeredness and acceptability of remotely delivered physical therapy care for musculoskeletal disorders in four large hospitals within the Military Health System. BMC Digit Health 1, 21 (2023). https://doi.org/10.1186/s44247-023-00017-0

Cohen SP, Doshi TL, Dolomisiewicz E, Reece DE, Zhao Z, Anderson- White M, Kasuske A, Wang EJ, Hsu A, Davis SA, Yoo Y, Pasquina PF, Youn Moon J

Non-organic signs have gained traction for identifying patients who may benefit from psychotherapy, decreasing the risk of treatment failure. In conjunction with other clinical factors, these signs may refine patient selection, but their association with clinical outcomes has not been studied for neck pain. Seventy-eight patients with cervical radiculopathy who received epidural steroid injection (ESI) were followed to determine the effects non-organic signs and other factors have on treatment outcome. A positive outcome was a > 2-point decrease in average arm pain, coupled with a score of 5 on a 7-point patient global impression of change scale. Nine tests in 5 categories (abnormal tenderness, regional disturbances deviating from normal anatomy, overreaction, discrepancies in exam findings with distraction, and pain during sham stimulation) were modified from previous studies and standardized. Other variables examined for their association with non-organic signs and outcomes included measures of disease burden, psychopathology, co-existing pain conditions, sleep dysfunction, imaging, and somatization.

Cohen, S. P., Doshi, T. L., Dolomisiewicz, E., Reece, D. E., Zhao, Z., Anderson-Whitle, M., Kasuke, A., Wang, E. J., Hsu, A., Davis, S. A., Yoo, Y., Pasquina, P. F., & Youn Moon, J. (2022). What is the Incidence of Subsequent Adjacent Joint Injury After Patellofemoral Pain? Mayo Clinical Proceedings, 98(6), 868-882. https://doi.org/10.1016/j.mayocp.2022.11.022

Rhon D, Sell T, Boeth R, Foster K, Greenlee T, Young J

Abstract presented at the World Physiotherapy Congress 2023 organized by World Confederation for Physical Therapy (WCPT)

Main outcome measures of study were frequency of adjacent joint injuries in the 2-year period after initial patellofemoral pain injury, and hazard ratios (HR) with 95% confidence interval (CI) and Kaplan–Meier survival curves for risk of adjacent joint injury based on receiving therapeutic exercise for the initial injury. After initial patellofemoral pain diagnosis, 42,983 (46.6%) individuals sought care for an adjacent joint injury. Of these, 19,587 (21.2%) were subsequently diagnosed with a lumbar injury, 2837 (3.1%) a hip injury, and 10,166 (11.0%) an ankle-foot injury. One in five (19.5%; n = 17,966) received therapeutic exercise which reduced the risk of having a subsequent lumbar (HR = 0.78, 95% CI 0.76–0.81), hip (HR = 0.93, 95% CI 0.87–0.98) or ankle-foot (HR = 0.86, 95% CI 0.83–0.90) injury.

Young J, Sell T, Boeth R, Foster K, Greenlee T, Rhon D

This retrospective cohort study was designed to investigate the incidence of subsequent lumbar spine, hip, and ankle-foot injuries after a diagnosis of patellofemoral pain. The results suggest that a high number of individuals with patellofemoral pain will sustain an adjacent joint injury within 2 years although causal relationships cannot be determined. Receiving therapeutic exercise for the initial knee injury reduced the risk of sustaining an adjacent joint injury. This study helps provide normative data for subsequent injury rates in this population and guide development of future studies designed to understand causal factors.

Young, J. L., Sell, T. C., Boeth, R., Foster, K., Greenlee, T. A., & Rhon, D. I. (2023). What is the Incidence of Subsequent Adjacent Joint Injury After Patellofemoral Pain? Clinical Rehabilitation. https://doi.org/10.1177/02692155231157177

Cohen SP, Doshi TL, Dolomisiewicz E, Reece DE, Zhao Z, Anderson- White M, Kasuske A, Wang EJ, Hsu A, Davis SA, Yoo Y, Pasquina PF, Youn Moon J

Neck pain is one of the top five leading causes of disability, with more than one-third being neuropathic in nature. Since 2000, the use of cervical epidural steroid injections has more than tripled, leading to increased scrutinization. The presence of nonorganic (Waddell) signs has been shown to be associated with treatment failure for back pain but has never been validated for neck pain. In a multicenter study, Waddell signs were adapted for cervical pain, with nine signs in five categories validated in a small pilot. Seventy-eight patients with cervical radiculopathy scheduled for epidural steroid injection were then evaluated with these signs for their association with outcome, with a positive outcome defined as a greater-than 2-point decrease in arm pain and a score greater than 5 on a 7-point improvement scale. Seventy-one percent had at least one nonorganic sign and 40% had at least one sign in three categories, with noncorrelative tenderness being most common (51%). Mean number of positive nonorganic categories was higher in individuals with negative outcomes (2.5 ± 1.8; 95% CI, 2.0 to 3.1) versus those with positive outcomes (1.1 ± 1.3; 95% CI, 0.7 to 1.5; P = 0.0002). Positive associations were noted between nonorganic signs and multiple pain (P = 0.011) and multiple psychiatric (P = 0.028) conditions.

Cohen, S. P., Doshi, T. L., Dolomisiewicz, E., Reece, D. E., Zhao, Z., Anderson-Whitle, M., Kasuke, A., Wang, E. J., Hsu, A., Davis, S. A., Yoo, Y., Pasquina, P. F., & Youn Moon, J. Science, Medicine, and the Anesthesiologist. Anesthesiology 2023; 138:A12–A15 doi: https://doi.org/10.1097/ALN.0000000000004586