goss d, gaunaurd i, rochester k, helton m, marshall a, reilly n, melton c, gailey r

Abstract accepted for poster presentation at the 2024 Military Health System Research Symposium

Musculoskeletal injuries (MSI) are very common in the military population and even more common with very active and elite paratroopers in the 82nd Airborne Division.  Potter et al. published a one-year prospective cohort study in 2002 in Military Medicine outlining these injuries.  They followed 1,965 paratroopers in from Fort Bragg in 1996. These soldiers suffered 508 overuse injuries (including 38 stress fractures), 1,415 traumatic injuries (including 100 fractures), and 101 unclassified injuries. Injury rates were 6.8% per soldier per month for traumatic injury and 2.4% for overuse injury (totaling 1.2 injuries per soldier per year). Injuries resulted in 22,041 limited duty days, averaging 11 days per injury and 13 days per soldier (4.5% of total workdays). Fractures and stress fractures/reactions produced the most days lost per case. Most of these injuries resulted from military specific activities.

As part of a prospective injury prediction protocol involving knee sensors analyzing single leg stance and a side shuffle task, our Musculoskeletal Injury Rehabilitation Research for Optimal Readiness (MIRROR) team enrolled and screened 1183 soldiers from the 82nd Airborne Division at Fort Bragg/Liberty, NC from fall 2022 to fall 2023 with 6- month and 12-month MSI incidence evaluated in the electronic medical record (AHLTA and Genesis).

These results highlight the types of injuries an active group of soldiers from the 82nd Airborne Division are experiencing and can help to guide prevention and treatment strategies going forward.

foster k, wang-proce s, weber m, brizzolara k, yuan x, boeth r, rhon d

Abstract accepted for oral presentation at the 2024 Military Health System Research Symposium

Exercise is a treatment recommended in clinical practice guidelines for low back pain (LBP). The primary purpose was to determine the impact of receiving therapeutic exercise (TE) for the management of LBP on time-to occurrence of subsequent lower extremity (LE) injury within 1 year, in beneficiaries of the Military Health System (MHS). The secondary purpose was to examine the dosing impact (number of TE sessions) on time-to-occurrence of subsequent LE injury in beneficiaries who received TE.

Following LBP diagnosis, individuals wh did not recieve TE had an increased rish of subsequent LE injury in the year following the episode of LBP. Further, in individuals who did receive TE, the risk of subsequent LE injury significantly decreased with each additional session. The results of the study highlight the potential downstream impact and health, implications of LBP, as well as information to guide to treatment and return to duty decisions after LBP.

bradley m, sheean a

Abstract accepted for poster presentation at the 2024 Military Health System Research Symposium

Musculoskeletal injuries (MSKI) remain the largest source of disability, readiness impairment, non-deployable status, and separation within the US Military. Although MSKI are of such magnitude, severity, and cost, efforts to uniformly collect and evaluate outcomes following injury and treatment are lacking due to decentralized datasets and the migratory nature of military service members (SM). The Military Orthopaedics Tracking Injuries and Outcomes Network (MOTION) is addressing this issue by establishing a DoD-wide enterprise system for the reliable collection of validated health outcome measures related to MSKI that cause the greatest impact on readiness, disability, and well-being.

MOTION is an ongoing collection of patient-reported outcomes (PROs) and clinical provider assessments of patients who are receiving treatment of MSKI. The target population is active duty SM, retirees, and beneficiaries who receive various orthopaedic and rehabilitative treatment interventions on upper extremity, lower extremity, or spine MSKI. All patients are enrolled at the time of their initial presentation to the orthopaedic or allied health clinic. PROs are collected at the following time points: pre-operative visit, 6-weeks post-op, 6-months, 12 months, 2, 5, 10, 15, and 20 years.

MOTION will develop, conduct, and disseminate original and innovative military relevant clinical research focusing on outcomes and reducing time away from duty following MSKI. This research will result in the development and improvement of evidence-based clinical practice guidelines to improve military health and readiness, mitigate long-term physical detriments following injury, promote military career longevity, and improve post-military service quality of life. MOTION’s revolutionized MSKI care system will place the MHS at the forefront of MSKI care advancement and will result in a centralized, enterprise-wide MSKI care system for improving clinical best practices that is based in evidence, informed by data, and geared towards individualized therapeutic interventions.eatment.

Velasco t, reilly n, hulsopple c, roberts k, wise s, goss d, leggit, j

Abstract accepted for poster presentation at the 2024 Military Health System Research Symposium

Chronic exertional compartment syndrome (CECS) is a debilitating condition for runners, causing intense pain, paresthesia, and weakness in the lower limb muscles. This condition often affects active-duty service members (ADSMs) who engage in regular running and vigorous physical training. Although treatments like botulinum toxin A (BoTN-A) injections, structured running gait retraining, and fasciotomy exist, no single best approach exists, and outcomes may vary. This case study examines the running biomechanics and efficacy of a multimodal treatment approach for CECS in an ADSM.

A 27-year-old male ADSM presented with bilateral anterior and lateral CECS as defined by Pedowitz’s criteria. Baseline running assessments were performed utilizing instrumented pressure insoles (LoadSol, Novel USA, St. Paul, MN) to ascertain running mechanics, including cadence, loading rates, and peak ground reaction forces (GRF) incurred during running. The patient also reported subjective pain at cessation of running and functional scores via the University of Wisconsin Running Index (UWRI). The patient received BoTN-A injections to the 4 compartments, and completed a supervised gait retraining program as a non-surgical intervention. Running assessments and clinical outcomes were obtained at 6-weeks, 3, 6 and 12-months post-injection. The patient elected to undergo a bilateral fasciotomy following the 6-month visit.

This case study demonstrates how both surgical and non-surgical methods can influence the treatment of CECS and impact running biomechanics for an ADSM. In this case, non-surgical techniques resulted in more significant enhancements in running mechanics and clinical outcome scores. However, further data is required to ascertain the reliability of these results and to develop more efficacious treatment strategies for CECS

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

Abstract accepted for oral presentation at the 2024 Military Health System Research Symposium

Musculoskeletal injuries threaten military readiness. The ability to aggregate data and make valid comparisons across settings, military branches, and nations is only possible when data can be harmonized. The purpose was to reach international consensus on the minimum core data elements that should be collected and reported when conducting injury surveillance in military settings.

Steering committee members were selected to balance expertise across clinical and research backgrounds, country, and military branches, along with policy, implementation, or clinical/scientific investigation related to musculoskeletal injuries in military settings (n=45). Pertinent parties were engaged to improve the overall question, understand research implications, and facilitate knowledge translations. A synchronous mixed pertinent party meeting (n=62) was performed to explore level of agreement by experts who were identified through the closeness continuum. The moderator presented each statement with discussion prior to voting. Participants voted anonymously. Each statement was scored on a scale of 0-10, with 0 representing no importance and 10 representing maximum importance. Comments could be submitted to facilitate further discussion and elaboration. A majority was needed for inclusion. Dissenting opinions were discussed and included in the final consensus document.

33 minimal data elements were recommended when conducting surveillance and reporting of injuries. This core checklist can be leveraged by clinicians, researchers and stakeholders when comparing and harmonizing data across studies, military service branches, and countries.

Colahan c, pav v, yuan x, isaacson b, wagner l, hando b

Abstract accepted for oral presentation at the 2024 Military Health System Research Symposium

Musculoskeletal injuries (MSKIs) are highly prevalent and costly conditions among active duty Service members (ADSMs). Female Service members sustain MSKIs at higher rates than males. However, lack of female-specific MSKI research in the US Military has limited Department of Defense leaders from assessing and addressing their burden. The purposes of this study were to report the incidence, prevalence, and types of MSKIs sustained by female ADSMs across four Services in direct care (DC) and private sector care (PC) settings from fiscal years (FYs) 2016-21, and to quantify and describe MSKI-related healthcare utilization and private sector costs in females over the same period.

This retrospective, longitudinal population study included ADSMs from the Air Force, Army, Marine Corps, and Navy. Prevalence/incidence rates for Head/Neck, Upper Extremity (UE), Spine, and Lower Extremity (LE) MSKIs in female ADSMs, associated healthcare utilization, and PC costs were derived by querying electronic health records from the Military Health System (MHS) Data Repository from FY16-21. Utilization associated with MSKIs among females for each Body Region in DC and PC settings was classified into mutually exclusive outpatient encounter categories and acute inpatient stays. PC MSKI-associated costs in Service women were captured for each year, Service, Body Region, and setting.

This is the first population-level assessment of MSKI prevalence, incidence rates, healthcare utilization, and PC costs over a 6-year period for Service women in the MHS. Given the critical role of Service women in the military, MHS leaders, researchers, and public health officials should explore the underlying causes of these disparities in MSKI rates between the sexes, by expanding research efforts to all Services and military settings.

smith m, hogaboom n, dellanno r, st laurent m, yuan x,

nordstrom m

Abstract accepted for poster presentation at the 2024 Military Health System Research Symposium

Chronic neck pain impacts active duty Service Members (ADSMs) across all occupational specialties. Reduction of cervical lordosis in forward head posture (FHP) can lead to muscular imbalances, degenerative spinal changes, and increased neck pain. This study investigated the safety and efficacy of a novel, non-invasive therapy collar to improve FHP and neck pain among ADSMs.

Recent literature suggests current treatment strategies for neck pain may not be as effective for the active duty population, given their occupational, training, and external load carriage requirements. Therefore, evaluating the effects of a wearable, take-home device for neck pain due to FHP is highly relevant to ADSMs. Preliminary results suggest donning a non-invasive therapy collar for 6 weeks can yield pain reduction and postural improvement compared to conventional treatment.

blasini r, stewart e, smith m, kasuske a, bradley m, yuan x

Abstract accepted for oral presentation at the 2024 Military Health System Research Symposium

Musculoskeletal injuries (MSKI) affect 800,000 service members annually. Significant need exists to investigate strategies that impact the health, performance, and readiness of service members with MSKI. Platelet-rich plasma (PRP) offers a non-pharmacologic, minimally invasive approach to expedite tissue healing, recovery, and return to duty (RTD). Little is known on PRP outcomes in the military. The purpose of this practice improvement project is to evaluate outcomes following PRP injections at the Walter Reed National Military Medical Center Physical Medicine and Rehabilitation Clinic.

rhon d, greenlee t, lawson b, mccafferty r, gill n

To compare opioid use based on surgery intensity (low or high).

Higher-intensity procedures were associated with greater postoperative opioid use than lower-intensity procedures. Chronic opioid use was not significantly different between surgical intensity groups when considering only prior opioid use. Chronic opioid use was significantly higher among higher intensity procedures when accounting for surgical complications. The prresence of surgical complications is a stronger predictor of post-surgical long-term opioid use in high intensity surgeries than history of opioid use alone.

Rhon, Daniel I. PhD; Greenlee, Tina A. PhD; Lawson, Bryan MD; McCafferty, Randall MD; Gill, Norman W. DS. Assessment of Surgical Complications Strengthen the Relationship Between Spine Surgery Procedure Intensity and Chronic Opioid use After Surgery. Spine ():10.1097/BRS.0000000000005069, June 17, 2024. | DOI: 10.1097/BRS.0000000000005069

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.