cohen s, dohi t, munjupong s, qian c, chalermkitpanit p, pannangpetch p, noragrai k, wang e, williams k, christo p, euasobhon p, ross j, sivanesan e, ukritchon s, tontisirin n

The use of sedation during interventional procedures has continued to rise resulting in increased costs, complications and reduced validity during diagnostic injections, prompting a search for alternatives. Virtual reality (VR) has been shown to reduce pain and anxiety during painful procedures, but no studies have compared it to a control and active comparator for a pain-alleviating procedure. The main objective of this study was to determine whether VR reduces procedure-related pain and other outcomes for epidural steroid injections (ESI)

A randomized controlled trial was conducted in 146 patients undergoing an ESI at 6 hospitals in Thailand and the United States. Patients were allocated to receive immersive VR with local anesthetic, sedation with midazolam and fentanyl plus local anesthetic, or local anesthetic alone. The primary outcome was procedure-related pain recorded on a 0-10 scale. Other immediate-term outcome measures were pain from a standardized subcutaneous skin wheal, procedure-related anxiety, ability to communicate, satisfaction, and time to discharge. Intermediate-term outcome measures at 4 weeks included back and leg pain scores, function, and success defined as a ≥2-point decrease in average leg pain coupled with a score ≥5/7 on a Patient Global Impression of Change scale

Procedure-related pain scores with both VR (mean 3.7 (SD 2.5)) and sedation (mean 3.2 (SD 3.0)) were lower compared to control (mean 5.2 (SD 3.1); mean differences −1.5 (−2.7, −0.4) and −2.1 (−3.3, −0.9), respectively), but VR and sedation scores did not significantly differ (mean difference 0.5 (−0.6, 1.7)). Among secondary outcomes, communication was decreased in the sedation group (mean 3.7 (SD 0.9)) compared to the VR group (mean 4.1 (SD 0.5); mean difference 0.4 (0.1, 0.6)), but neither VR nor sedation was different than control. The trends favoring sedation and VR over control for procedure-related anxiety and satisfaction were not statistically significant. Post-procedural recovery time was longer for the sedation group compared to both VR and control groups. There were no meaningful intermediate-term differences between groups except that medication reduction was lowest in the control group.

Steven P. Cohen, Tina L. Doshi, COL Sithapan Munjupong, CeCe Qian, Pornpan Chalermkitpanit, Patt Pannangpetch, Kamolporn Noragrai, Eric J. Wang, Kayode A. Williams, Paul J. Christo, Pramote Euasobhon, Jason Ross, Eellan Sivanesan, Supak Ukritchon, Nuj Tontisirin. Multicenter, randomized, controlled comparative-effectiveness study comparing virtual reality to sedation and standard local anesthetic for pain and anxiety during epidural steroid injections. The Lancet Regional Health Southeast Asia.2024 Volume27:100437. https://doi.org/10.1016/j.lansea.2024.10043; ISSN 2772-3682.

Guastaldi f, monteiro j, giorgino r, tynan m, leartprapun n, nadkarni s, randolph m, redmond r

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

Articular cartilage and the meniscus are essential for smooth joint movements, but often degenerate due to trauma and overuse. Conventional repair methods like microfracture and autologous cell implantation frequently yield fibrocartilage instead of hyaline cartilage. Tissue engineering, exemplified by dynamic Self-Regenerating Tissue (dSRT), offers a promising solution by leveraging regenerative potential of cells. Fractional laser treatment, proven effective in skin regeneration, can be an adjunct for cartilage repair. This study evaluated the use of dSRT for cartilage and meniscus repair in a swine knee model. Laser Speckle Rheological Microscopy (SHEAR) was also employed to assess biomechanical properties.

dSRT displayed successful matrix formation, with good integration observed in laser-ablated channels in cartilage. This innovative approach holds promise for articular tissue resurfacing, albeit requiring further in vivo validation for knee meniscus repair.

giorgina r, rossi n, bejar-chapa m, monteiro j, guastaldi f, kostyra d, hussey m, tynan m, peretti g, randolph m, redmond r

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

Inflammation in shoulder and knee joints typically results in pain, stiffness and loss of function. Shoulder injuries in the military (rotator cuff tears, dislocations, etc) can lead to adhesive capsulitis ("frozen shoulder"). Similarly, arthritis involves inflammatory processes subsequent to injury. Both conditions are managed using non-steroidal anti- inflammatory drugs (NSAIDs), steroids, or surgery, with varying effectiveness and side effects. Photochemical tissue passivation (PTP) drastically reduces inflammation in wound healing and in this study we investigate PTP for reducing progressive inflammatory damage in both joints.

Reduced inflammation associated with frozen shoulder and knee osteoarthritis using PTP in rat models are highly encouraging. Findings highlight the important role of the joint capsule in frozen shoulder and the synovial tissue in the knee in the pathogenesis of arthritis.

giorgina r, monteiro j, guastaldi f, hussey m, tynan m, peretti g, randolph m, redmond r

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

Severe ligament injuries are associated with trauma involving excessive force to the knee joint, and are common in the military. Ligaments are fundamental for the structural and functional integrity of the knee and effective strategies for surgical repair are of paramount importance for return to active duty and long-term joint health. Photochemical tissue bonding (PTB) has good potential for treating complex orthopedic conditions, PTB using light and a photoinitiator to generate crosslinks between collagen molecules to augment mechanical strength. Advantages include focal precision, a barrier to adhesion between healing and surrounding tissues, and the ability to promote healing without foreign materials or invasive mechanical devices. In cases of complete injuries, the preferred treatment is generally surgical and reconstructive. In instances of isolated and non-complete injuries, non-operative treatment is indicated. However, partial ligament injuries pose a challenge as they often do not optimally respond to conservative treatments and can lead to long-term compromise of knee stability. This study examined the application of PTB in partial ligament injuries using the medial collateral ligament (MCL) in a swine model.

Self-healing of partial ligament injuries can lead to chronic instability, increased rupture risk, and early arthritis. Improvement of partial knee ligament repair with PTB would result in better outcomes through maintaining optimal biomechanical properties.

zhang h, schulz-hildebrandt h, domingue carrerra u, panikkar a, tearney g

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

Ultrasound guidance is essential for vascular access. However, ultrasound is limited by the unreliable visibility of the needle tip. To address this issue, our team developed a photoacoustic imaging device that differentiates between arteries and veins by inserting a fiber into the cannula for visualization. However, this technology required an external ultrasound system, which was not compatible for battlefield application. In this abstract, we report on our next generation needle tracking system that utilizes portable ultrasound to achieve robust needle tip tracking. These advances can potentially make accurate needle tip tracking practical on the battlefield. This needle tip tracking technology is based on Light- enhanced Ultrasound (LEUS) that integrates near-infrared light with ultrasound detection to enhance the capabilities of ultrasound in trauma care. LEUS features a novel photoacoustic mode that enables visualization of light-absorbing structures by detecting light-induced sound waves. Here, we utilize this effect to generate a photoacoustic beacon via fiber delivery. Specifically, we have designed a 130-um trench on the outer wall of a needle (800-um inside diameter) to contain the fiber, and we coated a 140- um photoacoustic beacon with a mixture of graphite and biocompatible epoxy at the tip of the fiber. Our coated beacon source emits the light-induced ultrasound signal with 5-mJ illumination. Additionally, we developed software to acquire ultrasound and photoacoustic signals simultaneously, enabling the real- time display of overlaid duplex images. We conducted testing by puncturing the smart beacon needle in a vascular access ultrasound phantom (VATA Inc.). In the pure Ultrasound B mode, the structure of the needle tip was challenging to discern. However, when switching to the LEUS system, the beacon signal consistently appeared as a red spot, clearly representing of the needle tip. Remarkably, the red spot remained visible at the maximum depth of 30 ± 0.23 mm. Throughout this depth range, the signal-to- noise ratio of the beacon signal remained constant at 15dB, demonstrating a stable signal suitable for vascular guidance. Here we show a portable LEUS-driven vascular access guidance system with greatly enhanced needle tip visualization. This technology has great potential for improving the accuracy of vascular access by emergency medical providers without extensive vascular training.

Metzger e, hager n, ory r, lucio w, mckee s, anders j, givens m, wagner l, isaacson b, pasquina p

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

Photobiomodulation (PBM) 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, to biologically modulate cellular activity to enhance healing. PBM treatment can enhance repair and regeneration of tissue, stimulate metabolism, and reduce inflammation and pain during injury recovery. We are investigating use of this modality to increase Warfighter quality of life, and improve operational readiness, focusing on musculoskeletal (MSK) injury, performance, recovery, self-reported behavioral health, wellness, and nerve, hearing, and wound healing.

The Defense Health Agency supported the creation of the Photomedicine to Enhance Military Readiness program. This portfolio utilizes 16 PBM studies - 7 basic science studies, 8 randomized-control clinical trials, 1 normative study - to assess and

Hollander M, hagen j, givens m, metzger e, anders j, wagner l, isaacson b, pasquina p, hager n

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

Photobiomodulation Therapy (PBMT) utilizes light sources such as LEDs in order to provide a noninvasive means to enhance performance and accelerate recovery. Currently, practitioners utilize photobiomodulation devices in musculoskeletal injury rehabilitation, physical performance enhancement, and cognitive optimization. This study intends to address a critical gap in the understanding of PBMT technologies by providing empirical validations of the spectral and irradiance outputs of commercially available PBM devices.

This study investigated full body photobiomodulation (PBM) light beds. The study team utilized a spectrometer to determine the respective wavelengths produced by each device. Irradiance measurements were determined using a power meter and a specific area of illumination. Measurements collected at consistent intervals along the X and Y axes of the devices investigated variability across the illuminated surfaces. Additional variability assessments were based on body placement, treatment distances, and comparisons of the top and bottom canopy of PBM light beds. In addition, irradiance variations over a day of treatments and during independent sessions were measured. Utilizing these repeated measurements, the impact of temperature on irradiance was determined.

The spectral and irradiance investigations highlight the distinct characteristics of each device and help inform ideal-use scenarios between the commercial PBMT devices. These preliminary findings offer a comprehensive understanding of irradiance variability in PBMT to help preface future clinical investigations on the use of this cutting-edge technology in military contexts.

Hughes n, cornell b, gabler g, rossi r, metzger e, hager n, wagner l, isaacson b, pasquina p

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

Special Operations Forces (SOF) train continually to maintain peak performance. Thus, they are nearly always in a state of recovery, and in need of noninvasive therapies to address the taxing workload. Photobiomodulation therapy (PBMT) is a noninvasive treatment where a low-level laser is applied to the body to enhance healing, recovery, and performance. Army Tactical Human Optimization Rapid Rehabilitation and Reconditioning (THOR3) provides a consistent avenue for implementation of PBMT as a modality. Studies in athletes have shown performance and recovery benefits with pre-and post-workout focal application of PBMT. While there is less evidence on the potential cognitive/behavioral effects of a systematic application of PBMT, self-reported fatigue has also been found to be significantly lower in groups with focal PBMT application as compared to placebo. Further, PBMT research in healthy military tactical athletes is limited. PBMT may be a promising tool for enhancing physical performance by accelerating musculoskeletal and psychological recovery in the SOF population. We aim to study the physiologic and behavioral effects of PBMT application post-exercise on performance in SOF Operators.

PBMT shows promise in accelerating musculoskeletal repair and psychological resilience, reducing injury risk, and enhancing performance in these domains. Potentially, this study may inform standards of training and care to maximize readiness among elite warfighting units.

Negri l, farinelli w, korupolu a, lee h, wang y, hui j, tam j, andy yun s, gelfand j

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

We developed an antimicrobial blue light (ABL) device prototype for treating skin wounds, an application for which no approved devices exist. The prototype was tested in a preclinical, in vivo porcine wound model, with partial-thickness wounds heavily infected with methicillin-resistant Staphylococcus aureus (MRSA), the leading antimicrobial resistant (AMR) wound pathogen isolated worldwide.

Our prototype reduced MRSA by 4.7 logs (>99.99%) compared to untreated wounds after only two simple, once-a-day treatments (p<0.0001). These proof-of-principal results suggest ABL could reduce the number of days, doses, and costs of antibiotics for skin wounds, reducing AMR and costs of care. As a stand-alone treatment, or in combination with antimicrobials, these preclinical results support a potential role for our ABL device prototype in treating wound infections.

Karikari n, rossi r, gabler g, grogan s, schroeder j, free k, lopez p, dannenbaum j, hager n, metzger e, isaacson b, wagner l, pasquina p

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

Lower extremity musculoskeletal injuries (MSKIs) are the primary reason for limited duty in Active-Duty Service Members (ADSMs). MSKIs account for 60% of limited duty days and 65% of medical nondeployability in ADSMs. Knee Osteoarthritis (KOA) - a degenerative joint disease resulting in cartilage loss due to wear and tear or by a force applied to the knee - is frequent in the United States Military with over 20,000 cases detected in ADSMs over a 10-year period. Photobiomodulation (PBM) and Platelet-rich Plasma (PRP) have both emerged as promising treatments for boosting knee function and decreasing stiffness and pain. Ideal PBM dosage, optimal PRP treatment, and the biological cascade of each treatment as well as the potential additive treatment of PRP and PBM together merits further investigation. This study aims to assess the effect PBM has on PRP injections for KOA treatment through evaluations of synovial and serum inflammatory and reparative biomarkers. The treatments are compared through four arms: Physical Therapy (PT) vs PT + PRP vs PT + PBM vs PT + PRP + PBM. The relationship between pain, function and treatment is analyzed in addition to the biomarkers obtained from participant biologics. These aims seek to inform KOA treatment practices and improve ADSMs return to duty.

All participants completed a blood draw and knee joint aspiration at the baseline and again at 6-weeks post-baseline. Each participant was randomized to PT, + PBM, +PRP, or + PRP + PBM. PBM was delivered three times a week for three weeks. PRP was injected at the baseline. Further data collection was completed through the Defense and Veteran’s Pain Rating Scale, Single Assessment Numeric Evaluation, Knee Injury and Osteoarthritis Outcome Score, The Veterans RAND 12 Item Health Survey questionnaires and activity logs to monitor participant progression. Participants completed the study at 6 weeks and provided a second blood draw and knee aspiration at that time

Both PRP and PBM have shown promise in aiding healing and slowing the progression of KOA. When applied together, these interventions may improve outcomes for ADSMs suffering from KOA. This has the potential to positively impact the health and performance of our warfighters.

Rossi r, gabler g, persinger j, karikari n, mckee s, schroeder j, grogan s, hager n, metzger e, isaacson b, wagner l, pasquina p

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

Non-insertional Achilles Tendinopathy (AT) is a common overuse injury in active and sedentary adults. In the military, overuse injuries of the lower extremity (e.g., AT) are the most common category of disability and are most prevalent in the Army. Research studying the sub-population of AT amongst active duty (AD) personnel is scant and warrants analysis given its high prevalence. Current laser-induced photobiomodulation (PBMT) studies demonstrate increased cell proliferation and metabolism, which may aid the tendon repair and remodeling process. Extracorporeal shockwave therapy (SWT) is a process that delivers energy to the muscles or tendons for pain relief and to enhance tissue repair.  by stimulating an inflammatory response and healing cascade.Studies support ESWT as an effective treatment for AT when combined with eccentric strengthening (ECC). The addition of PBMT may enhance these effects by increasing cellular function and optimizing the cascade. Thus, the combination of modalities should be investigated. The primary aim of our trial is to evaluate the effects of four randomized treatment groups in the management of AT: Physical Therapy (PT), PT with SWT, PT with PBMT, and PT combined with SWT and PBMT.

Participants receive self-guided ECC PT. The PT/SWT arm receives weekly SWT for three weeks. The PT/PBMT arm receives twice weekly PBMT for three weeks. The PT/SWT/PBMT arm receives both interventions. Baseline, three-month, and six-month intervals assess ultrasound measures (cross-sectional area, width/degree of thickening within the tendon at the site of maximal circumference/maximal pain, neovascularity, and elastography), quantitative function in heel raises to fatigue, ankle strength, and ROM are assessed at baseline, three months, and six months. The following surveys are collected: Victorian Institute of Sports Assessment–Achilles, Patient-Reported Outcomes Measurement Information System, The University of Wisconsin Running Injury and Recovery Index, Defense and Veteran’s Pain Rating Scale, and Lower Extremity Functional Scale.

PBMT and SWT are effective tendinopathy treatments. Combining both modalities may elicit synergistic structural changes and modulate AT pain. This study can potentially promote positive change in the management of AT, which adversely affects the military population, by promoting novel treatment options for our warfighters.

Persinger j, mincey c, gabler g, rossi r, grogan s, hager n, schroeder j, metzger e, isaacson b, wagner l, pasquina p

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

Musculoskeletal injuries are commonly found in active-duty service members and military recruits. The use of new non-invasive ultrasound technologies, such as microvascular flow (MVF) and shear wave elastography (SWE), may prove to be appropriate and cost effective in the early diagnosis of these injuries. The Geneva Foundation in conjunction with Uniformed Services University of the Health Sciences, and the Madigan Army Medical Center is conducting a research study to establish normative values for thickness, MVF, Power Doppler (PD), and Young’s modulii in the posterior lower leg. 

Ultrasound evaluations are conducted utilizing a Samsung RS-85 Prestige with shear wave elastography and microvascular flow capabilities.  The TeleRay Remote cloud-based platform is utilized for secure storage and ultrasound image review with the additional capacity to allow remote observation. By study completion, 206 ultrasound examinations will be conducted on asymptomatic participants by a Registered Musculoskeletal Sonographer (RMSKS) credentialed provider. Image acquisition is standardized using EZ Exam. Imaging is obtained from the Achilles insertion to the gastroc-soleus complex with stop points at the calcaneal insertion, avascular zone, gastroc-soleus junction, gastrocnemius, and soleus.  Measurements are obtained in orthogonal planes to obtain the width and height at each of the sites. Using a system preset optimized for low-flow states Power Doppler and MVF evaluation is conducted at each point with comments noting the number vessels in the region of interest. SWE interrogation is conducted utilizing a system preset optimized for tendon elastography.

MVF has been shown to be more sensitive than PD (19 instances of flow vs 3).  Further evaluation with SWE will continue to provide the normal range of values in this application. 

Fellin c, steiner r, buchen j, woodle s, yuan x, anders j,

jariwala s

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

The most severe case of peripheral nerve injury (PNI) involves complete transection of the nerve. One therapeutic approach uses nerve guidance conduits (NGCs) to facilitate nerve regeneration. Recently, three-dimensional (3D) bioprinting has been adopted for the fabrication of biomimetic conduits. However, many of these NGC therapies fail to achieve full reinnervation making it necessary to employ a combinatorial approach that incorporates treatments in conjunction with 3D printed conduits. Photobiomodulation Therapy (PBMT) utilizes electromagnetic energy to achieve beneficial therapeutic outcomes. Most notably, exposure to near-infrared light (700 - 1100 nm) has been shown to reduce inflammation and improve neural regeneration. Herein, we investigate whether the use of a novel 3D printed NGC in conjunction with PBMT (980 nm) will improve nerve regeneration when used as a combinatorial approach in a rodent sciatic nerve transection model.

The tissue of conduit-repaired rodents displayed no sign of foreign-body reaction, inflammation, or macrophage infiltration. The conduits remained sutured to the nerve stumps and displayed a high degree of ECM integration and neovascularization. Histological analysis indicates new nerve tissue present inside the conduit lumen with typical axon and vasculature anatomical features. Rodents treated with PBMT displayed significantly more regenerating nerve tissue within the conduit.

The results of this study demonstrate successful implantation of the DLP 3D printed NGC with no observable foreign-body reaction, a high degree of ECM integration, and neovascularization. Nerve regeneration was detected within the conduit and improved with the addition of PBMT. These findings support the use of PBMT as a combinatorial approach to conduit-based peripheral nerve repair.

Shaw k, wido d, smith m, miller m

Abstract accepted at American Association of Neuromuscular and Electrodiagnostic Medicine 2024

Electrodiagnostic studies and diagnostic ultrasound evaluation are vital tools for the management of CTS. Aberrant anatomy is an important consideration for surgical disposition. Berrettini anastomosis is an interneural communication between common palmar digital sensory branches from the median and ulnar nerves. Here, we report a unique case of a patient with moderate carpal tunnel syndrome and concomitant Berrettini anastomosis, highlighting preoperative value of ultrasound in the EDX clinic in avoidance of iatrogenic injury. 

Ultrasound is an important adjunct to EDX in the preoperative stage of carpal tunnel syndrome management. Identification of aberrant anatomy via ultrasound has the potential to minimize complications from carpal tunnel release (CTR). In this case, a Berrettini anastamosis was identified and rather than proceed with ultrasound-guided CTR, the patient was referred to Orthopedics for open CTR.

Rhon d, George s, parsons n, fritz j

Abstract accepted at the IASP 2024 World Congres on Pain.

Patients beliefs about low back pain can affect perceived harms and benefits of various treatment options. This can subsequently influence the patient’s level of engagement with interventions and the treatment effectiveness. When receiving care, a greater emphasis on the biomedical model could lead to surgery being seen as one of the only acceptable interventions. Similarly, from a biomedical perspective, exercise could be seen as potentially exacerbating rather than helping low back pain. In contrast, patients who don’t perceive surgery to be an effective solution or understand that exercise can help improve their symptoms, may engage at a higher level with evidence-based treatments. Therefore, the aim of this study was to assess the influence of healthy versus maladaptive beliefs about surgery and exercise as interventions for low back pain. Specifically, we aimed to assess the relationship between these beliefs and self-reported pain interference and physical function outcomes.

Maladaptive beliefs about treatment have the potential to adversely influence pain and physical function outcomes in the short term out to six months. Patients receiving care for low back pain who believed that surgery would be beneficial or that exercise would be harmful improved significantly less than patients who felt otherwise. The ability to better understand and address patient beliefs about treatment effectiveness may present an opportunity to improve engagement with interventions and subsequently treatment outcomes.

Rhon d, George s, parsons n, fritz j

Abstract accepted at the IASP 2024 World Congres on Pain.

Patients beliefs about low back pain can affect perceived harms and benefits of various treatment options. This can subsequently influence the patient’s level of engagement with interventions and the treatment effectiveness. When receiving care, a greater emphasis on the biomedical model could lead to surgery being seen as one of the only acceptable interventions. Similarly, from a biomedical perspective, exercise could be seen as potentially exacerbating rather than helping low back pain. In contrast, patients who don’t perceive surgery to be an effective solution or understand that exercise can help improve their symptoms, may engage at a higher level with evidence-based treatments. Therefore, the aim of this study was to assess the influence of healthy versus maladaptive beliefs about surgery and exercise as interventions for low back pain. Specifically, we aimed to assess the relationship between these beliefs and self-reported pain interference and physical function outcomes.

Maladaptive beliefs about treatment have the potential to adversely influence pain and physical function outcomes in the short term out to six months. Patients receiving care for low back pain who believed that surgery would be beneficial or that exercise would be harmful improved significantly less than patients who felt otherwise. The ability to better understand and address patient beliefs about treatment effectiveness may present an opportunity to improve engagement with interventions and subsequently treatment outcomes.

schermerhorn j, rich e, kazman j, clifton d, nelson a

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

Non-combat musculoskeletal (MSK) disorders are a major cause of morbidity in the U.S. Army. Physical fitness tests are required for training and readiness but they may be accompanied by injury risks. The Army recently transitioned from the Army Physical Fitness Test (APFT) to the Army Combat Fitness Test (ACFT). We hypothesize that this transition, and associated changes in individual and group training regimens, are associated with increased MSK diagnoses.

We conducted a retrospective review of recently enlisted active-duty Service Members from 2016 to 2022 and analyzed the incidence of MSK diagnoses within the first six months of military service.  The three cohorts were control APFT (2016–2019), COVID (2020–2021), and ACFT (April 2022–October 2022). All cohorts began in April. Survival analyses were used to compare ACFT and COVID cohorts with the control APFT.

Among new enlistees, risk for MSK conditions has fluctuated over years, likely in response to the introduction of the ACFT in April 2022 and to COVID lockdowns. Consistent with much prior research, women had much higher rates of MSK conditions than men, which might mask trends over time (e.g., due to a ceiling effect). Continued monitoring of MSK trends over time and practices around the ACFT is necessary to maximize force readiness and minimize overall MSK disorder burden.

cohen s, li s, lester d, clark w, mcgee m, boggs j

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

Chronic low back pain (CLBP), including degenerative spine conditions such as spondylosis, is associated with debilitating pain and functional impairments and is a significant problem for US Service Members and Veterans. Percutaneous (60-day) peripheral nerve stimulation (PNS) is an opioid-free, non-destructive treatment that is commercially available, in use in the Military Health System, and has resulted in meaningful pain relief and functional improvement across various conditions. A large prospective multicenter trial previously presented at MHSRS revealed significant and sustained long-term relief of CLBP. The present analysis explores real-world outcomes for patients with a diagnosis of spondylosis, including a subset with reported ICD10 codes M47.816/M47.817 (lumbar/lumbosacral spondylosis without myelopathy or radiculopathy), to determine if real-world outcomes are consistent with the prospective study.

Data were retrospectively reviewed from a real-world database of patients who: previously received 60-day PNS targeting the lumbar medial branch nerve(s), were reported as having lumbar spondylosis without neuropathic symptoms, opted to provide anonymized data, and provided baseline and end of treatment (EOT) outcomes. A subset was analyzed in those with confirmed ICD-10 diagnosis codes M47.816 or M47.817. Responders were defined as patients who reported ≥50% pain relief and/or clinically meaningful improvement (≥1) in physical function as measured by the Patient Global Impression of Change. Safety was not analyzed in this retrospective review

Consistent with prospective trials, PNS targeting the lumbar medial branches produced significant improvements in real world outcomes of pain and physical function at EOT in the majority of patients with spondylosis. A follow-on DoD PRMRP-funded randomized controlled trial (the RESET Study) that compares 60- day PNS to standard interventional management for CLBP recently completed enrollment and primary endpoint results are expected in 2025. 60-day percutaneous PNS treatment is an opioid-free, non-destructive treatment option available for U.S. Service Members and Veterans with spondylosis without myelopathy or radiculopathy.

galvin j, johnson c, say f, free k, eichinger j, patterson b, nepola j, hogue j, dalgard c, colburn z

Abstract accepted at The Society of Military Orthopedic Surgeons 2024 Annual Meeting

Glenoid dysplasia is a rare pathology characterized by failure of development of the posterior glenoid, resulting in severe deformity and alteration of shoulder mechanics. It is largely asymptomatic until approximately 25 to 45 years of age. When patients develop pain, they typically already have severe posterior cartilage wear and early-onset osteoarthritis. Therefore, early detection of glenoid dysplasia may offer an opportunity to intervene in adolescence or counsel patients on their condition so they can modify their activities. The purpose of this study was to identify genetic variants associated with the diagnosis of severe glenoid dysplasia.

Three male patients (mean age: 40.3 yrs, range: 38-43) with severe glenoid dysplasia who underwent blood draw at the time of operative treatment were analyzed. High molecular weight genomic DNA was isolated from the stabilized whole blood before PCR-free sequencing libraries were generated with sufficient yield for downstream sequencing. Whole genome sequencing (WGS) was performed on all 3 patients with genomic data passing quality assessment (QA) after alignment and variant calling (mean coverage >30x, alignment >97%, percent bases 20x >92%). For variant priorization and interpretation, we utilized a phenotype-aware workflow, Genomizer, with the gene ontology HP:0006633 and the parent ontology of “abnormality of the glenoid fossa.” Additionally, we interpreted variants from genes within the American College of Medical Genetics and Genomics (ACMG) v3.2 list, to potentially report actionable secondary findings.

HOXA9,c.715G>A:p.(Val239Met) was identified as a candidate genetic variant in 1 of 3 patients with severe glenoid dysplasia. Prior evidence has implicated the HOX gene in the development of the inferior glenoid ossification center. This information may lead to future precision medicine approaches for early diagnosis and novel treatments. Future larger studies are needed to confirm these findings.

Yuan x, isaacson b

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

The MHS transitioned to the ICD10 coding scheme in October 2015 and began the rollout of a new electronic health record (EHR) system, MHS GENESIS, in October 2017. Both changes may have affected the observed prevalence and healthcare utilization associated with musculoskeletal injuries (MSKIs) in Service members. The purpose of this study was to 1) determine the effect of the ICD10 transition on the prevalence of select MSKI conditions and 2) describe MSKI-related healthcare utilization at military treatment facilities (MTFs) during the transition to GENESIS.

We calculated monthly prevalence rates for six diagnostic groupings of MSKIs from October 2011 to February 2020. To determine if the transition to ICD10 influenced prevalence rates, we performed an interrupted time series analysis (ITSA), using the ICD10 transition date (1 October 2015) as the interruption point. To assess trends in direct and private sector care encounters during the GENESIS transition, we calculated monthly MSKI-related encounters at four MTFs from 1 November 2015 through 30 September 2021.

Differences in prevalence of MSKIs could be due to changes in the amount and/or specificity of available codes in ICD10. Those involved in MSKI surveillance should exercise caution when evaluating periods that span the ICD10 transition. For analyses that span such a transition, ITSA is a viable approach to capturing MSKI rates. Changes in healthcare utilization patterns in two of four MTFs during their adoption of GENESIS suggest MSKI care may have shifted from direct to private sector care during this period.