Greenlee t, george s, pickens b, rhon d

Abstract accepted for oral presentation at the Symposium of the International Musculoskeletal, Mental, and Social Health (I-MESH) Consortium

A recent trial in the Military Health System (MHS) found risk-stratified care not superior to usual care for low back pain (LBP) for a primary outcome of self-reported disability. Because risk-stratified care follows a biopsychosocial framework and aims to target maladaptive beliefs, the question remains whether the intervention adequately addresses pain attitudes and maladaptive beliefs. We aimed to compare improvements in (1) pain attitudes related to harm and (2) pain knowledge and beliefs in patients with LBP based on assigned intervention (riskstratified versus usual care).

Risk-stratified care significantly improved maladaptive attitudes and beliefs about pain at six weeks compared to usual care. An attenuated treatment effect, regardless of treatment, was seen in high or medium versus low-risk patients. Although these changes did not translate to better clinical outcomes in the clinical trial, they reflect short-term success of risk-stratified care in decreasing maladaptive attitudes and beliefs about pain.

Rhon d, Arden n, motte s, fallowfield j, fisher b, bullock g

Abstract accepted for oral presentation at the 2024 ICMM World Congress on Military Medicine.

Musculoskeletal injuries are a significant threat to military readiness; sustained by over half of individuals in many military units each year. These injuries threaten mission capabilities through reduced workforce. Mitigating injury risk requires accurate representation of the problem and adequate data to properly inform decisions. Additionally, the ability to aggregate data and make valid comparisons across settings, military branches, populations and nations is only possible when the same data elements exist. The purpose of this project was to reach international consensus on the minimum core data elements that should be collected and reported when conducting musculoskeletal injury surveillance in military settings.

Consensus was reached for two data principles and 33 minimal data elements. These elements include demographics, health behaviors, service branch, health history, exposure, and injury characteristics. This core checklist can be leveraged by clinicians, researchers and stakeholders working in military settings when comparing and harmonizing data across studies, military service branches, and countries. Ultimately, this will lead to better synthesis of evidence-based practice and ability to generate a greater number of useful prognostic models in the future.

Juman L, Schneider E, Clifton D, Koehlmoos T

Injuries are the leading cause of medical encounters with over 2 million medical encounters for musculoskeletal (MSK) conditions and over 700,000 acute injuries per year. Musculoskeletal injuries (MSKIs) are by far the leading health and readiness problem of the U.S. Military. The Proceedings of the International Collaborative Effort on Injury Statistics published a list of 12 data elements deemed necessary for injury prevention in the civilian population; however, there are no standardized list of common data elements (CDEs) across the DoD specifically designed to study MSKIs in the Military Health System (MHS). This study aims to address this gap in knowledge by defining CDEs across the DoD for MSKIs, establishing a CDE dictionary, and compiling other necessary information to quantify MSKI disease burden in the MHS.

Luke Juman, Eric B Schneider, Dan Clifton, Tracey Perez Koehlmoos, Common Data Elements and Databases Essential for the Study of Musculoskeletal Injuries in Military Personnel, Military Medicine, 2024;, usae241, https://doi.org/10.1093/milmed/usae241

Galvin J, Patteron B, Bozoghlian m, nepola j, colburn z

A biorepository, also referred to as a “biobank,” is a collection of biologic samples that are stored for laboratory research. With the emergence of precision medicine, the importance of leveraging individual patient biomolecular signatures to improve diagnosis, prognosis, and treatment is becoming increasingly recognized. Successful development and sustainment of a biorepository provides the potential for transformative preclinical research. Establishing a biobank requires a team approach with involvement of the institutions' research laboratory team and regulatory body. Execution of research activities requires a coordinated team approach for case identification, consent process, data and specimen collection, specimen processing, and storage and archiving. The advancing fields of precision medicine and orthobiologics provide incredible opportunities for institutions to generate novel lines of inquiry in musculoskeletal diseases through a multiomics approach (genomic, transcriptomic, proteomic, microbiomic). In addition, a biobank is an important component of post-market surveillance for the rapidly emerging field of orthobiologics.

Galvin, Joseph W. DO; Patterson, Brendan M. MD, MPH; Bozoghlian, Maria MD; Nepola, James V. MD; Colburn, Zachary T. PhD, MBA, MS. Musculoskeletal Biorepository: Establishment, Sustainment, and Tips for Success. Journal of the American Academy of Orthopaedic Surgeons ():10.5435/JAAOS-D-24-00153, April 17, 2024. | DOI: 10.5435/JAAOS-D-24-00153

Galvin J, Milam R, Patterson B, nepola J, buckwalter j, wolf b, say f, free k, yohannes e

The incremental biological changes in the synovial microenvironment of the shoulder in acute and chronic instability that may contribute to joint degeneration are poorly understood. Proteomic analysis of synovial fluid in patients with shoulder instability may improve our understanding of proteins that are shed into shoulder synovial fluid after an injury.

Proteomic analysis enriched our understanding of proteins that were secreted into shoulder synovial fluid of patients with shoulder instability. The identification of POSTN, a proinflammatory catabolic protein involved with tissue remodeling and repair, as a significant target in anterior shoulder instability is a novel finding. Therefore, further study is warranted to determine the role that POSTN may play in the progression of bone loss and posttraumatic osteoarthritis.

Galvin JW, Milam RJ, Patterson BM, Nepola JV, Buckwalter JA 4th, Wolf BR, Say FM, Free KE, Yohannes E. Periostin Is a Biomarker for Anterior Shoulder Instability: Proteomic Analysis of Synovial Fluid. Am J Sports Med. 2024 May 4:3635465241246258. doi: 10.1177/03635465241246258. Epub ahead of print. PMID: 38702960.

dowe j, bradley m, leclere l, dickens j

Understanding the anatomical structure of a patient’s shoulder joint is essential in surgical decision-making, especially regarding glenohumeral bone loss. The use of various imaging techniques, such as magnetic resonance imaging (MRI) and computed tomography (CT), bring certain advantages and disadvantages in assessing joint structure.

The process of obtaining a 3D view of the shoulder joint from an MRI, although less common, can be completed effectively to assess bone loss while also solving some issues surrounding CT scans. By loading MRI datasets into an image-reformation program, such as 3D Slicer, the anatomical structures can be segmented to create realistic 3D models of the shoulder joint. Surgical direction can be determined after bone loss measurements and structural assessment of these models, without the need for CT scans. This technique can also be applied to other skeletal joints, in addition to the shoulder.

Dowe, J. N., Bradley, M. W., LeClere, L. E., & Dickens, J. F. (2024). Creating a Three-Dimensional Reconstruction of the Glenohumeral Joint From Magnetic Resonance Imaging to Assist in Surgical Decision-Making. Journal of Emerging Advanced Technology in Surgery, 1(1), 102972. https://doi.org/10.1016/j.eats.2024.102972

gailey r, kristal a, al muderis m, lucarevic j, clemens s, applegate b, isaacson b, pasquina p, symsack a, gaunaurd i

The literature comparing bone-anchored prosthesis (BAP) with socket prosthesis (SP) consistently reports improvement in physical health and quality of life using primarily patient-reported outcome measures (PROMs).

There were no statistically significant differences between the BAP and SP groups in temporal spatial gait parameters and prosthetic mobility as measured by the 10-meter walk test and component timed-up-and-go, yet large effect sizes were found for several variables. In addition, Activities-specific Balance Confidence Scale and Prosthetic Limb Users Survey of Mobility™ scores were not statistically different between the BAP and SP groups, yet a large effect sizes were found for both variables.

This study found that people with TFA who use a BAP can demonstrate similar temporal spatial gait parameters and prosthetic mobility, as well as self-perceived balance confidence and prosthetic mobility as SP users. Therefore, suggesting that the osseointegration reconstruction surgical procedure provides an alternative option for a specific population with TFA who cannot wear nor have limitations with a SP. Future research with a larger sample and other performance-based outcome measures and PROMs of prosthetic mobility and balance would further determine the differences between the prosthetic options.

Gailey, Robert S.1; Kristal, Anat1; Al Muderis, Munjed2; Lučarević, Jennifer3; Clemens, Sheila4; Applegate, E. Brooks5; Isaacson, Brad M.6,7; Pasquina, Paul F.6,8; Symsack, Allison7,8; Gaunaurd, Ignacio A.1,9. Comparison of prosthetic mobility and balance in transfemoral amputees with bone-anchored prosthesis vs. socket prosthesis. Prosthetics and Orthotics International 47(2):p 130-136, April 2023. | DOI: 10.1097/PXR.0000000000000189

rhon d, Drysdale l, radcliffe c, newman p

Stress fractures are common in military personnel, with training that often leads to overload and repetitive bone stress. These injuries limit duty, affect military readiness, and can end a military career. Injury mitigation is a high priority for military leadership and health, but risk profiles for stress fractures have not been fully explored. Many studies have evaluated risk factors, but meta-analyses of risk with aggregated study data are few. The purpose of this review was to conduct a systematic review of the literature to identify risk factors for stress fracture in military populations, and through meta-analysis, calculate aggregate risk profiles.

The search assessed studies published between January 1995 and September 2023 in PUBMed and CINAHL. Any study assessing risk factors for any type of stress fracture in a military population was considered, as long as an English translation was available. We excluded studies predicting disability, return to duty, or any variable not representing a stress fracture occurrence. When raw data were unavailable, we exported risk statistics as reported (e.g. risk ratios[RR], odds ratios[OR], hazard ratios [HR], rate ratios[RR]) as point estimates with 95% confidence intervals (CI) for categorical variables and means with standard deviations or 95% CI for continuous variables. We used imputation tools in Revman to estimate RR when values were not provided. We used the Prediction model Risk Of Bias ASsessment (PROBAST) Tool to assess methodological quality. We conducted a meta-analysis on unique predictor variables. We assessed heterogeneity of predictors using I2 statistics, and when heterogeneity was moderate to high (> 25%), we used a random effects model.

Despite the abundance of literature assessing risk factors for stress fractures, the variability in the capture and reporting of risk factors made data harmonization challenging. Only 3 factors were significantly associated with risk of developing a stress fracture: decreased bone mineral density in females, increased body weight, and female sex. Standardization of collecting and reporting risk factors is necessary in the future to improve the quality of meta-analysis and collective understanding or stress fracture risk factors.

rhon d, Davis A, Ali J, Brandt C, Burns A, Lucio W, Vining R, Young-mccaughan S

Pragmatic clinical trials (PCTs) often study interventions delivered within the context of standard clinical encounters with the overall goal of producing generalisable knowledge to inform implementation strategies and health policy. In reality, however, PCTs have a gradient of pragmatic and explanatory features, as described by the PRagmatic Explanatory Continuum Indicator Summary, 2nd edition (PRECIS-2) framework. To facilitate the process of iterative learning, PCTs and comparative effectiveness trials frequently test interventions shown to be effective in explanatory trials, the latter having more stringent entry criteria. PCTs are particularly valuable for assessing use of non-pharmacological interventions, such as those designed to manage pain. Conducted in settings involving a broad range of patients and delivered by a range of qualified clinicians that may or may not have a research background, PCTs can illuminate implementation barriers and practice variations affecting the delivery of clinical interventions that may or may not be widely supported by institutional culture.

The purpose of this manuscript is to clearly define and differentiate usual care and validated care, such that these terms can be considered generically as part of regulatory activities that affect PCTs.

Rhon DI, Davis AF, Ali J, et alAmbiguity in care delivery terminology: implications that affect pragmatic clinical trials using non-pharmacological interventionsBMJ Evidence-Based Medicine Published Online First: 21 November 2023. doi: 10.1136/bmjebm-2023-112547

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

Abstract accepted for poster presentation at the 2024 Arthroscopy Association of North America (AANA) 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.

Velasco t, Reilly n, Roberts k, Hulsopple c, Hoellen d, Wise S, Dickison c, Goss d, Leggit j

Abstract accepted for a poster presentation at the 2024 Alexander T. Augusta Military Medical Center (ATAMMC) Research Day

Chronic exertional compartment syndrome (CECS) is characterized by intense localized pain, weakness, or paresthesia in the lower limb muscles, exacerbated by running.1,2 This condition significantly impairs active-duty service members (ADSMs) who regularly engage in running activities. While surgical interventions have shown mixed results, the exploration of non-surgical and pharmaceutical options, particularly botulinum toxin A (BoNT-A) and gait retraining, has gained attention.2-5 The purpose of this case series was to examine the biomechanical gait patterns observed in ADSMs with CECS pre and post non-surgical treatment.

In this case serires, the administration of BoNT-A was shown to be associated with more positive outcomes on pain reduction during running without leading to the adoption of gait patterns associated with injury risk. More extensive research is warranted to examine the effectiveness of BoNT-A for CECS from longitudinal perspectives.

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

Abstract accepted for a poster presentation at the 2024 Madigan Research Day

Little is known about the pathobiology of unidirectional anterior and posterior shoulder instability. 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.

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

Abstract accepted for poster presentation at the 2024 Madigan Research Day

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.

Galvin J, Milam r, patterson b, mepola j, buckwalter j, wolf b, say f, free k, yohannes e

The incremental biological changes in the synovial microenvironment of the shoulder in acute and chronic instability that may contribute to joint degeneration are poorly understood. Proteomic analysis of synovial fluid in patients with shoulder instability may improve our understanding of proteins that are shed into shoulder synovial fluid after an injury.

Proteomic analysis enriched our understanding of proteins that were secreted into shoulder synovial fluid of patients with shoulder instability. The identification of POSTN, a proinflammatory catabolic protein involved with tissue remodeling and repair, as a significant target in anterior shoulder instability is a novel finding. Therefore, further study is warranted to determine the role that POSTN may play in the progression of bone loss and posttraumatic osteoarthritis.

Sheean a, defoor m, spindler k, arner j, athiviraham a, bedi a, defroda s, ernat j, frangiamore s, nuelle c

Interest in the relationship between psychology and the outcomes of anterior cruciate ligament (ACL) reconstruction (ACLR) continues to grow as variable rates of return to preinjury level of activity continue to be observed.

General mental health and wellbeing, in addition to a host of unique psychological traits (self-efficacy, resilience, psychological readiness and distress, pain catastrophizing, locus of control, and kinesiophobia) have been demonstrated convincingly to affect treatment outcomes. Moreover, compelling evidence suggests that a number of these traits may be modifiable. Although the effect of resilience on outcomes of orthopaedic surgical procedures has been studied extensively, there is very limited information linking this unique psychological trait to the outcomes of ACLR. Similarly, the available information related to other parameters, such as pain catastrophizing, is limited with respect to the existence of adequately sized cohorts capable of accommodating more rigorous and compelling analyses. A better understanding of the specific mechanisms through which psychological traits influence outcomes can inform future interventions intended to improve rates of return to preinjury level of activity after ACLR.

The impact of psychology on patients’ responses to ACL injury and treatment represents a promising avenue for improving low rates of return to preinjury activity levels among certain cohorts. Future research into these areas should focus on specific effects of targeted interventions on known, modifiable risk factors that commonly contribute to suboptimal clinical outcomes.

Sheean AJ, DeFoor MT, Spindler KP, Arner JW, Athiviraham A, Bedi A, DeFroda S, Ernat JJ, Frangiamore SJ, Nuelle CW. The Psychology of ACL Injury, Treatment, and Recovery: Current Concepts and Future Directions. Sports Health. 2024 Feb 19:19417381241226896. doi: 10.1177/19417381241226896. Epub ahead of print. PMID: 38374636.

Juman l, schneider e, koehlmoos t

Abstract accepted at the 2024 Association of Military Surgeons of the United States

The U.S. military consists of approximately 1.4 million active-duty personnel and is responsible for providing a combat-ready force to protect the nation. Deployment limiting medical conditions (DLMCs) affect up to 7% of the military’s total force. Musculoskeletal injuries (MSKIs) degrade the physical fitness of individual service members through lost duty time & reduced training. In 2018, MSKIs accounted for >2 million outpatient medical encounters among military service members & are the leading reason for lost training time among Army personnel. It has been estimated that MSKIs result in >25 million limited duty days annually across all the Services.

This research makes a first attempt at identifying a standardized set of common data elements for musculoskeletal injuries across the DoD. This list of common data elements will enhance the capabilities of the MHS to study MSKIs in hopes of empowering the research community to drive meaningful understandings of the epidemiology of MSKIs in the MHS.

Defoor m, cognetti d, bedi a, carmack d, arner j, defroda s, enrat j, frangiamore s, nuelle c, sheean a

To determine whether low resilience is predictive of worse patient-reported outcomes (PROs) or diminished improvements in clinical outcomes after joint preserving and arthroscopic surgery.

A comprehensive search of PubMed, Medline, Embase, and Science Direct was performed on September 28, 2022, for studies investigating the relationship between resilience and PROs after arthroscopic surgery in accordance with the Preferred Reported Items for Systematic Reviews and Meta-analyses guidelines.

Patient resilience is inconsistently demonstrated to affect clinical outcomes associated with joint preserving and arthroscopic surgery. However, substantial limitations in the existing literature including underpowered sample sizes, lack of standardization in stratifying patients based on pretreatment resilience, and inconsistent collection of PROs throughout the continuum of care, diminish the strength of most conclusions that have been drawn.

DeFoor MT, Cognetti DJ, Bedi A, Carmack DB Jr, Arner JW, DeFroda S, Ernat JJ, Frangiamore SJ, Nuelle CW, Sheean AJ. Patient Resilience Does Not Conclusively Affect Clinical Outcomes Associated With Arthroscopic Surgery but Substantial Limitations of the Literature Exist. Arthrosc Sports Med Rehabil. 2024 Feb 13;6(2):100812. doi: 10.1016/j.asmr.2023.100812. PMID: 38379604; PMCID: PMC10877194.

Persinger J, Hager N

The Incidence of stress fractures in military members has been reported to range from .8%-6.9% for men and from 3.4% - 21% for women.   The early identification is critical to optimizing treatment for bone stress injuries (BSI). The current gold standard for diagnosing BSI is either triple-phase, Bone scintigraphy technetium-99m, MRI or CT. Diagnostic, high frequency ultrasound (US) has been demonstrated to identify early periosteal changes in BSI.

This case report concluded that high frequency ultrasound is a relibale and accurate modality for early diagnosis of BSI and assiting with return to duty decision making. This diagnostic imaging tool for BSI is valuable, inexpensive, and easily accesible. Future studies are warranted to determine whether US could be a competitive screening tool vs MRI for initial BSI diagnosis

Persinger j, gabler g, hager n

Successful delivery of a Diagnostic Musculoskeletal US program requires a combination of hands-on experience with the ultrasound system, a thorough review of applicable, regional pathophysiology, and an overview of the technology aspects of the US acquisition system. Most often, these programs are delivered over several months in an in-person, academic setting that allows for student-educator, student-equipment, and student-patient interactions. During the initial COVID-19 outbreak and in response to campus policy and public mandates for distant learning, the Department of Physical Medicine and Rehabilitation at Uniformed Services University of the Health Sciences (USUHS) transformed a musculoskeletal (MSK) ultrasound clerkship into a virtual platform - training students deployed locally, nationally, and internationally. This modification of the educational approach allowed for delivering a high quality MSK Ultrasound Curriculum in a safe and often remote environment. Further, many of the successes gleaned from this experience during the pandemic enhanced future MSK educational programs for both medical students and physicians.

The implementation of the virtual MSK US clerkship at USUHS represents a paradigm shift for the department in providing training in hands-on skills for diagnostic sonography with direct application to clinical care. The ability to link students and instructors without geographical limitations provided a positive long-term impact on future similarly patterned courses. It also enabled this team to take lessons learned from the program and apply them to remote clinical education opportunities in the future.

Persinger J, Hager N, Grogan S, Mincey C

The Geneva Foundation (Tacoma, WA) in conjunction with Uniformed Services University of the Health Sciences (USUHS), and the Podiatry Clinic at Madigan Army Medical Center (MAMC) is conducting a research study to establish normative values for thickness and cross-sectional area (CSA), microvascular flow states, power Doppler flow states, and Young’s modulii in the posterior lower leg muscles (gastroc/soleus) and Achilles tendon. This study supports a concurrent study attempting to validate shear-wave elastography (SWE) and microvascular flow (MVF) as a novel, sensitive, and non-invasive means of determining the health and recovery state of the above structures.

Achilles tendinopathy, plantar fasciitis, and chronic exertional compartment syndrome (CECS) are commonly seen in the active-duty service member and military recruit population. These conditions are common contributors to significant warfighter disability, impacting operational readiness. Non-invasive technology such as microvascular flow and shear wave elastography may prove to be timely and cost effective.