PUBLICATIONS
Publication listing coming soon
ABSTRACTS
Abstract listing coming soon
2018 PROJECTS
Clinical Outcomes of Ultrasound Guided Carpal Tunnel Release (USCTR)
Evaluation of Video Telehealth Versus Standard Gait Retraining
Body-Worn Sensors for Risk of Injury Prediction during Military Training
Optimal Management of First-Time Traumatic Shoulder Instability
Registry Development and Non-Surgical Treatment Options for Chronic Exertional Compartment Syndrome
A Retrospective Study of Service Members Enrolled in the Warrior Care and Transition Program
Epidemiology of Musculoskeletal Injuries Trends in the MHS
EPIDEMIOLOGY OF MUSCULOSKELETAL INJURIES TRENDS IN THE MHS
MSI negatively affect military readiness, and accounted for 36.3% of all injury-related ambulatory visits in active duty service members in 2016. The high intensity of combat preparedness has elucidated that the greatest nonfatal threat to soldiers in non-deployed settings are MSI sprains, strains, and overuse injuries of the spine, back, and upper and lower extremities. In fact, the top five MSIs ranked by their contribution to the highest days of limited duty (DLD) contributed between 14 and 22 DLD per injury—or approximately 9 million DLD annually. While multiple epidemiological studies have been commissioned over the past 20 years to characterize the burden of specific MSIs in the MHS, information is fragmented and cannot be used to decrease DLD and predict the economic burden of MSIs in the MHS.
This study will provide critical MSI surveillance by developing a standardized, service-wide epidemiological report which will be used to understand the frequency and prevalence of injuries in the military. Data will be published quarterly and distributed to key stakeholders and sponsors to identify clinical and operational gaps in care.
A RETROSPECTIVE STUDY OF SERVICE MEMBERS ENROLLED IN THE WARRIOR CARE AND TRANSITION PROGRAM
Throughout the campaigns in Iraq and Afghanistan, the Army has been determined to improve the health, welfare, and preparedness of wounded soldiers. The Warrior Care and Transition Program (WCTP) was established in 2004 and subsequently expanded and formalized in 2007 to serve as a comprehensive clinical rehabilitation program for the U.S. Army’s ill and/or injured soldiers. The primary focus of the WCTP is to fulfill the Army’s goal of enhancing wounded soldiers’ transitions back into the fighting force or into a veteran’s status, with full reintegration into the community. Since the WCTP’s inception in 2004, more than 77,000 soldiers have transitioned through the WCTP, and over 30,000 have returned to military duty. The program is designed to provide robust social and clinical care to active and reserve soldiers who require significant support, including case management, social work, and/or transition assistance. While entrance criteria have changed over the duration of the WCTP program, soldiers are generally required to have complex medical needs that will require significant care for a period of at least 3-6 months.
To meet the goal of comprehensive care, warrior transition units (WTU) integrate a diverse staff of primary care physicians, nurse case managers, rehabilitation specialists (OT/PT), social workers, counselors, and others. In addition to assistance with soldier transition, WTU programs also offer mental health and occupational therapy programs (Erickson, 2008). Coordinating efforts across all staff members is important to ensure the delivery of quality patient care. Recently, the Recovering Warrior Task Force, established by Congress in 2010, evaluated DoD wounded warrior services across the military. They synthesized 87 recommendations, which included efforts to better coordinate continuity of care in ways such as integrating IT systems and implementing more user-friendly electronic health records. At WTUs, a large amount of attention is placed on properly managing each patient’s electronic health record to maintain compliance.
WTU patient populations have changed in response to the nature of modern warfare and its intrinsic risks. As the needs of the Army and active combat operations have evolved over the past 10 years, the types of injuries and illnesses sustained by soldiers entering the WCTP have also changed, with the majority of entrants now falling into a disease NBI category. At present, there are fourteen WTUs co-located with MTFs, which reflects a >40% reduction in WTUs from the height of the program. Although military operations in Iraq and Afghanistan have declined significantly, resulting in fewer wounded warriors returning home and a decline of the WCTP population (currently around 2,600 soldiers), the Army is committed to supporting and caring for transitioning soldiers and their families, and remains flexible to changes in the future population.
To the best of our knowledge, this is the first study of its kind to characterize the patient population within the WCTP. Despite the WCTP’s focus on effectively coordinating efforts, there has been minimal systematic research on the WCTP, and the potential exists to identify relevant trends and anomalies that may inform decision-makers within the medical command (MEDCOM) and WCTP. Certain patterns and anomalies may even prove relevant to other military medical efforts and highlight clinical gaps. There are several large, well-maintained databases that track WCTP patients and are available for records-based research (provided the requisite data use agreements and institutional oversight), but this must be evaluated by MIRROR.
A RANDOMIZED PLACEBO-CONTROLLED TRIAL OF PLATELET RICH PLASMA (PRP) INJECTION IN A MILITARY POPULATION WITH FACET MEDIATED LUMBAR LOW BACK PAIN
Low back pain (LBP) is both the single most common cause of disability and the leading cause of visits to primary care doctors. Not surprisingly, the direct and indirect costs of low back pain accounts for approximately $88 billion of health care expenditure—barely trailing the cost of care for diabetes and heart disease. In order to reduce the large financial and personal cost, clinical studies must be designed to treat LBP.
Peer-reviewed literature has shown that the incidence of lumbar facet mediated pain ranges from 15-45% among patients with LBP. Some of the challenge to diagnosing facet mediated pain is based on poor correlation of abnormal imaging findings to patient’s symptoms. Not only is there a high prevalence of abnormalities on magnetic resonance imaging (MRI) of asymptomatic population, advanced imaging such as computed tomography (CT) scans fail to show an association between facet joint pain and degenerative changes seen within CT. It is due to such poor correlation of image findings to patient’s symptoms that medial branch block (MBB) has become the standard to diagnose facet joint pain.
Once facet joint pain has been diagnosed clinically, the current interventional treatment options for prolonged relief includes corticosteroid (CSI) injection of the facet joint or radiofrequency ablation of the medial branch nerves. There are variable evidence to the effectiveness of the corticosteroid injection of the lumbar facet joints, with a systemic review showing Level III evidence of trials with short term effectiveness less than 6 months. The evidence for radiofrequency ablation is more robust with Level 1 evidence for effectiveness less than 6 month and Level 2 evidence for effectiveness greater than 6 months (Manchikanti L. et al. Pain Physician Jul/Aug 2015; 19:E535-582; Rajni Vekaria et al. Eur Spine J 2016 25:1266-1281). There are also studies that have suggested similar effectiveness of intra-articular facet joint injection and radiofrequency ablation. Other clinical providers have evaluated autologous use of biological material to treat facet mediated pain including platelet rich plasma (PRP), to accelerate healing of a degenerative tissue. (Wu J et al. Pain Physician 2016 Nov-Dec 19; 19(8); 617- 625). A new techniques for the treatment of lumbar facet joint syndrome using intra-articular injection with autologous platelet rich plasma.
Novel treatment methods for treating facet pain are sorely needed since CSI treatments have reported risks associated with injection, osteoporosis, accelerated degeneration, avascular necrosis, and suppression of endogenous corticosteroid production. Further, the long-term consequence of ongoing radiofrequency ablation treatment has not been fully elucidated. While radiofrequency ablation (RFA) temporarily denervates the medial branch that provides the sensation to the facet joint, RFA also denervates parts of paraspinal muscles, which can potentially cause weakness and further slow rehabilitation.
The use of orthobiologics and concepts behind regenerative therapy has gained increased traction as a way to treat musculoskeletal issues. PRP is an autologous source of blood product that contains higher platelet concentration after being prepared in a centrifuge. It is thought that the higher level of growth factors (such as PDGF, TGF-B, VEGF< EGF, bFGF< IGF-1) and cytokines released by the platelets promote a healing cascade. Preclinical and clinical studies have investigated use of PRP on treating various structures including tendons, ligaments and joints. While these trials have shown promising results there continues to be lack of high quality studies.
In order to improve the rehabilitation of service members with LBP, novel trials that include PRP must be studied. Although early clinical evidence suggests that PRP therapy may improve outcomes without destruction of tissues, to date, no randomized single blinded placebo-controlled study to look at the effectiveness of PRP injection for lumbar facet mediated joint pain exists.
The study will provide evidence-based medicine on a new regenerative medicine treatment option that may affect significant military personnel with LBP. PRP may offer alternate treatment methods that may help preserve the facet joint structures, improve pain and function without causing destructive lesions or worsening degenerative joints. This healing process may favor improved participation with rehabilitation therapy and ultimately improve return to duty status. This study will also assess the effectiveness of point of care generated PRP, as a minimally invasive treatment option for treating lumbar facet pain. Specifically, PRP effectiveness will be compared to injecting placebo control when injected into facet joints.
RANDOMIZED, COMPARATIVE-EFFECTIVENESS STUDY OF INTRADISCAL AUTOLOGOUS STEM CELLS VERSUS INTRADISCAL CORTICOSTEROID FOR CHRONIC DISCOGENIC LOW BACK PAIN
Discogenic pain accounts for 20-45% of cases of mechanical low back pain and is more common in younger and middle-aged adults.{Manchikanti, 2000 #134} Diagnosis can be made on the basis of a combination of symptoms and exam findings, imaging lack of improvement with facet injections sacroiliac injections and epidural steroid injections, and concordant pain relief with provocative discography. Surgical treatments may include spinal fusion or artificial disc replacement. A systematic review of fusion to non-surgical treatment in patients with more than one year of moderate to serve low back pain found only a 35% improvement in the surgical group and 20% improvement in the non-surgical group. Various injectables, including corticosteroids and tumor necrosis factor, have been investigated for the treatment of discogenic low back pain.. In a study of 120 patients randomized to receive intradiscal corticosteroid or saline, Cao et al found a significant improvement in pain and function at 3 and 6 months in the corticosteroid group. In Cohen’s placebo-controlled study of 36 patients, intradiscal etanercept did not seem to improve outcomes. There is growing interest in the use of cell therapy, primarily mesenchymal stem cells, for the regeneration of intervertebral disc cells thought to contribute to disc degeneration and discogenic pain.66. Pettine treated 26 patients with intradiscal autologous mesenchymal stem cells and reported an average percentage of visual analog score reduction of 64%, 64%, and 57% and Oswestry Disability Index (ODI) reduction of 58%, 55%, and 57% at 3, 6, and 12 months respectively. There are other published case series showing similar benefit, but there are no controlled trials evaluating stem cells for discogenic pain. It is not clear whether the stem cells, extracellular matrix, or other factors contribute to the improvement observed in these cases.
REGISTRY DEVELOPMENT AND NON-SURGICAL TREATMENT OPTIONS FOR CHRONIC EXERTIONAL COMPARTMENT SYNDROME
Chronic exertional compartment syndrome (CECS) is a debilitating disorder affecting mostly an active population. The proposed pathophysiology is increased pressure in muscle compartments causing pain, paresthesia, and inability to tolerate exercise in the affected fascial compartment. CECS involves the lower extremities, primarily affects young active adults, and limits running and/or endurance activities. While the incidence of CECS in the general population is unknown, the prevalence in the military population has been found to be 0.49 cases per 1000 patient-years.
The current standard for definitive treatment of CECS is surgical fasciotomy of the involved compartments. According to a 2016 systematic review, surgical intervention for CECS is successful in only 66% of those affected, with 13% of patients reporting complications from surgery, and 6% needing a repeat procedure. A 2014 retrospective review of military members showed that only 59% of patients who underwent elective fasciotomy for CECS were able to return to full duty while 22% of the patients that were treated with fasciotomy were eventually medically discharged. One of the reasons for the limited success rate, is an incomplete understanding of the pathophysiology coupled with proper patient selection.
Gait retraining is an attractive alternative to fasciotomy. It aims to influence the effect of foot contact and running kinematics to reduce leg compartment pressures which relieves pain. Diebal et al. published a case series of 10 military members with CECS who underwent a gait retraining program that emphasized forefoot running. At six-weeks and one-year post-intervention, running distance, pain, and performance all significantly improved. Despite high rates of success in limited case studies, real world application of gait retraining has limitations. Many patients struggle to make and/or sustain adaptations in their running style. Some patients have severe pain with exercise which limits efforts at effective gait re-training.
A newer proposed treatment is the intramuscular administration of onabotulinumtoxin A, also known as botulinum toxin A or BoNT-A into the muscles of the involved compartment(s). One case series studying botulinum toxin injections for CECS demonstrated normalized intramuscular pressure up to nine months post-injection in 87.5% (14/16) of patients, and exertional pain was completely eliminated in 94% (15/16) of patients.81 Eleven patients experienced reduced muscle strength that was without functional consequences and transient, with only 1 of the 16 patients who complained of new posterior leg pain that did not appear to be related to BoNT-A injections. There were no other adverse effects reported.
Military sports medicine clinics at Fort Belvoir Community Hospital (FBCH) and USU have been utilizing BoNT-A injections for the non-surgical treatment of CECS. A retrospective review of patients with CECS treated with BoNT-A at FBCH Sports Medicine Clinic from 2014 to 2017 provided data on twenty-nine patients who were treated with BoNT-A for CECS. Prior to treatment, none of the 29 patients were able to perform their desired activity and 24% were unable to run one mile without severe leg pain. After botulinum injections, these numbers improved to 66% and 72% respectively. Sixty-nine percent of patients reported that they were satisfied or somewhat satisfied with their treatment, twelve patients continued to have sustained relief by the time they were contacted, and seven patients experienced a recurrence of symptoms. In those with recurrence, the mean duration of improvement was 7.8 months. Of note, 11 patients received both BoNT-A and fasciotomy during their treatment course. Only one patient reported a favorable response to fasciotomy and failure with BoNT-A, suggesting that BoNT-A injections might be predictive of success with fasciotomy.
BoNT-A is FDA approved for intramuscular, intradetrusor, or intradermal use for muscle spasticity, migraine headaches, detrusor instability and severe forehead lines, lateral canthal lines, and glabellar lines in adults. To avoid side effects and predict treatment success, a recent published case review of pre-treatment with xylocaine injections prior to proposed BoNT-A injection for frontalis and glabellar rhytides was issued. Further, a yet unpublished case using the pre-treatment xylocaine protocol was conducted at FBCH. The subject improved her running symptoms with the xylocaine injection and subsequently underwent BoNT-A treatment. One month after the BoNT-A she is able to now walk/run up to 1 mile with no exertional symptoms.
The purpose of this grant application is to create a registry across all MTFs for CECS to compare diagnostic and therapeutic data. We will simultaneously assess the effectiveness of non-surgical treatments options for chronic exertional compartment syndrome as well as test the use of xylocaine injections to predict success for non-surgical or surgical options at selected sites. This study will also determine if successful gait retraining, either home based or supervised, is essential to positive results Furthermore this study will also determine if BoNT-A injections plus gait retraining is better than either treatment alone. Finally, this study would determine if xylocaine injections could predict who will benefit from BoNT-A injections or fasciotomy.
OPTIMAL MANAGEMENT OF FIRST-TIME TRAUMATIC SHOULDER INSTABILITY
Military service members are the most at-risk population for shoulder instability and 80% of these individuals have a re-injury (recurrent instability). Of particular concern are military trainees who are 40X more likely to have a shoulder instability event than their civilian counterparts. The spectrum of shoulder instability includes shoulder subluxations (transient instability that maintains glenohumeral continuity) and frank dislocations (complete glenohumeral disassociation requiring reduction). Following a first-time shoulder instability event, both operative and non-operative management are routinely employed. Both treatment approaches yield outcomes that span the spectrum from complete success (no future instability events) to complete failure (recurrent instability events). Furthermore, there is no evidence to guide the optimal rehabilitation strategy (supervised versus self-managed rehabilitation). Thus, there is no clear indication for what treatment approach is superior and should be employed across the military. The ramifications of incorrect acute management of shoulder instability, will likely have long-term consequences for the individual. Improperly managed shoulders may lead to progressive articular cartilage damage, loss of humeral head or glenoid osseous support and labral-ligamentous injury. Collectively, these progressive sequelae increase the risk for recurrent shoulder instability events. Chronic recurrent instability results in increasing bone loss, higher surgical failure rates, and post-traumatic osteoarthritis. Conversely, immediate surgical stabilization following a single instability event may result in unnecessary surgery that could have been successfully managed with non-operative treatment. Due to the dearth of definitive evidence for the optimal initial method of treatment (operative versus non-operative), a large-scale trial is needed to optimize the outcomes for these most readiness-impairing and burdensome injuries. The findings of this study will inform military specific clinical practice guidelines (CPGs) that will lead to optimized management of shoulder instability in a young, physically active military population. Optimal management of shoulder instability will result in improved patient outcomes, maximize warfighter return to duty/activity (RTD/A) and mitigate re-injury in Service Members with shoulder instability. Collectively, the results of this study will result in improved Force medical readiness. This proposal also directly responds to the surgical and rehabilitation techniques and outcomes for soft tissue trauma of common musculoskeletal injuries for enhanced RTD/A techniques and outcomes for soft tissue trauma of common musculoskeletal injuries for enhanced RTD/A.
BODY-WORN SENSORS FOR RISK OF INJURY PREDICTION DURING MILITARY TRAINING
More than 800,000 military service members are injured each year, leading to an estimated 25 million days of limited duty annually.90 Musculoskeletal injuries are the greatest threat to force readiness during both peacetime and combat operations. Although the more severe injuries during combat can lead to a significant loss of military personnel, even seemingly mild injuries during sport and exercise could contribute to a lack of readiness and poorer overall fitness.91 Furthermore, noncombat MSI (during physical training, tactical training, recreational activity, and sport) are endemic within the military population accounting for 85% of all MSI among United States (U.S.) military personnel. Athletic injuries are also the leading cause of disability discharge among service members (SM) in the U.S. Army, according to Physical Evaluation Board data.Thus, prevention and care of these sports and physical training injuries are top priorities for leaders in the DoD.
Most sports-related MSI affect the lower limb. Forty percent of these injuries occur at the knee, making it the most common site of musculoskeletal injury. Specifically, soft tissue injuries are the most frequently encountered and represent 47% of all knee injuries. In the U.S., fibrocartilage, ligamentous, and tendinous integrity compromise about the knee can lead to joint instability. Knee joint instability can have short-term and/or long-term negative effects, affecting force readiness and return-to-duty/return-to-sport (RTD/RTS) decisions. Objective measures of knee stability could be used to determine those at risk for injury thus decreasing the rate of injury. In addition, objective measures of knee stability could be used throughout the rehabilitation process to determine healing and neuroadaptation of soft tissue and surrounding contractile musculature, respectively, enabling the SM to RTD/RTS without fear of re-injury and with a greater potential to achieve their pre-injury level of performance.
Effective measures of injury risk and function are urgently needed in the military and athletic populations. Traditional functional assessment tests such as the hop test and vertical drop jump tests are currently used to determine time of return to pre-operative physical activity level following knee injury and used as a clinical screening tool for ACL injury, respectively. However, the sensitivity for detecting functional weaknesses regarding, i.e. single-leg hop test for distance, is reported to be between 38-52%. It was also recently reported that none of the vertical drop jump test variables were associated with increased ACL injury risk in a cohort study of 710 athletes. Often, by the time the test results are known the functional status of the healing individual has changed or the individual has made the decision to return to activity.
THE IMPACT OF A UNIQUE SPORTS MEDICINE MODEL ON READINESS IN THE ARMY: A PROSPECTIVE COHORT ANALYSIS ON THE DURATION OF HEALTHCARE MANAGEMENT AND THE INCIDENCE OF RE-INJURY WITHIN 24 MONTHS
Training room clinical models have been in use in sport at all levels for generations. This approach employs rapid initial assessment and triage by highly trained MSI treatment and rehabilitation experts (e.g. Athletic Trainers, Physical Therapists, Orthopedic surgeons and Sports Medicine physicians). These skilled providers work in concert to mitigate the secondary effects of injury and return athletes to activities as quickly/safely as possible. Traditional sports medicine models revolve around quick access to multi-disciplinary care teams including allied health providers with unique expertise in sports nutrition, strength and conditioning, and sports psychology.
In the current standard of care, healthcare providers organize operationally to allow for more patients to be seen in a shorter period of time. This model allows a multidisciplinary team to treat patients simultaneously during designated clinic hours and consult with one another on diagnoses and treatment plans—this is highly efficient for both the patient and the organization. The Sports Medicine Model is equally focused on primary injury prevention, because primary prevention is the best way to keep athletes on the field and in the game.
In contrast, the military medicine model, outside of trained combat medics who provide pre-hospital battlefield trauma care and resuscitation at point of injury during field training and combat, provides traditional problem-based clinic visits for MSI of active duty service members. Providers outside of the primary MTFs who most typically are not specialized in MSI, evaluate patients and refer them to an appropriate consultant such as a physical therapist, radiology, sports medicine trained family physician, or orthopedic surgeon. Inherent time lags between providers often delays care, which is suboptimal when treating MSI. For active duty members, these delays may result in disbarment or failures from training schools, missed deployments, and decreases in medical readiness for deployable units.
EVALUATION OF VIDEO TELEHEALTH VERSUS STANDARD GAIT RETRAINING
Telehealth-based gait retraining has the potential to improve outcomes for Warfighters recovering from running related injuries in remote and austere environments. Since 1992 the U.S. military has valued the use of telehealth to meet its unique obligations and missions. The goal of telehealth is to provide seamless communication of medical information between a patient and medical provider. Studies have shown statistically significant improvement in healthcare endpoints in the military as a direct result of telehealth care. Through the use of telehealth, it is possible to monitor, train, consult and inform end users in their deployed environment. It enables healthcare professionals to maintain or even improve an end user’s condition and quality of life, and at the same time reduce in-hospital and travel costs.
Forty-five percent of physical training and sports-related injuries in the military are due to running. Nearly all military service members run for physical training. Annual running injury incidence has recently been reported between 19-79%.141 While running-related injuries are multifactorial, average vertical loading rate has been the variable most linked to running related injury.19,142,143 Approximately 80% of runners use a rearfoot strike (RFS) pattern whereby the heel hits the ground first on each step. Runners using a RFS pattern have been shown to have up to 3.4 times greater risk of sustaining a running-related injury compared to runners who use a non-rearfoot strike (NRFS). Alterations in running gait, to include foot strike pattern may reduce injuries
Recently, running with biofeedback in a lab setting has been used effectively for rehabilitation of runners recovering from patellofemoral knee pain (PFPS) and for reducing stress fracture risk. Florkiewicz et al. trained nine runners recovering from various lower-extremity injuries in 8 sessions over 10 weeks to increase cadence and transition from a RFS to a (NRFS) pattern. While gait retraining in a lab setting has been successful with the use of real-time in-clinic biofeedback, to our knowledge, this is the first research project that uses gait retraining via video telehealth to modify gait of previously injured runners.
CLINICAL OUTCOMES OF ULTRASOUND GUIDED CARPAL TUNNEL RELEASE (USCTR)
Carpal tunnel syndrome (CTS) is the most common peripheral entrapment neuropathy and affects 3-6% of adults in the United States at a total annual cost of over 2 billion dollars. In patients with severe or refractory symptoms, carpal tunnel release (CTR) represents the definitive management option, and over 500,000 CTRs are performed annually in the United States with over 90% of patients reporting clinical improvement. Although initially performed via a large palmar incision (3-5 cm), CTR techniques have continually evolved to reduce surgical trauma with the goal of improving cosmesis, reducing post-operative pain, and promoting faster recovery. Currently available CTR techniques include mini-open CTR via a single, 1-3 cm palmar incision (mOCTR), endoscopic CTR via one (wrist) or two (wrist and palm) 1-2 cm incisions (ECTR), and ultrasound guided CTR via a single < 1 cm wrist or palmar incision (USCTR).
According to Defense Medical Epidemiology Database information, in 2016, there were 16,823 active duty service members, across the Army, Navy, Air Force and Marines diagnosed with carpal tunnel syndrome. This amounts to approximately 13/1000 service members a year. The ability to have adequate numbers of orthopedic providers to conduct the necessary carpal tunnel release surgeries to meet this demand can be limited for various reasons such as a remote location or general lack of specialty care at the MHS Site. As described above, point-of-care musculoskeletal providers now have the capability to conduct these procedures outside of the operating room environment. Further, early evidence of USCCTR vs. traditional mOCTR indicates a more rapid recovery and likely quicker return to duty.
Regardless of technique, the primary goal of CTR is to transect the transverse carpal ligament (TCL) while avoiding injury to nearby neurovascular structures. Although ECTR may promote a faster recovery compared to mOCTR, concerns have been raised regarding the potential for increased complications due to limited visualization of surrounding structures during TCL transection. USCTR techniques combine a single small incision with direct visualization of at-risk structures such as the median nerve and its thenar motor ranch/recurrent motor branch, ulnar vessels, and superficial palmar arterial arch. To date, over 630 cases of USCTR have been reported in the peer-reviewed literature with a >98% success rate and no documented neurovascular injuries. Furthermore, a recently published, single surgeon, prospective randomized clinical trial comparing mOCTR to USCTR reported that patients treated with USCTR experienced significantly faster recovery with respect to functional scores, pain reduction, and pain medication discontinuation
USE OF MICRO-FRAGMENTED, AUTOLOGOUS ADIPOSE TISSUE TO TREAT MENISCAL INJURIES IN ACTIVE-DUTY MILITARY PERSONNEL
Meniscus tears are among the most common knee injuries in both general and military populations. This is not surprising, as military training and deployments often expose soldiers to high physical demands that can affect the knee. A 2012 study found an meniscal tear incidence rate of 8.3 per 1,000 person-years among active-duty service members, compared with about 0.61 per 1,000 in the general population. Incidence increased with age; however, incidence in the youngest members (<20 years old) was 3.0 per 1,000, a 5-fold increase compared to the general population. Soldiers who were in the enlisted ranks, were men, and served in the Army and Marines had the highest incidence of meniscal tears.
Non-battle musculoskeletal injuries are the leading cause of medical evacuation among deployed solders, and are derived from injuries caused by physical training and sports. During a 15-month period, 1.0% of lower extremity non-battle injuries in an Army Brigade Combat Team (Operation Iraqi Freedom) were related to the meniscus. Goodman et al. found that 19.3% of soldiers who had not been medically evaluated during combat consulted an orthopedic surgeon upon return for a musculoskeletal complaint. Of these consultations, a staggering 20.8% of lower extremity procedures were meniscal debridement or repair.
While the immediate consequences of meniscal injuries can be troublesome, long-term effects may be devastating to the soldier and the military at large. Galvin, et al. reported that out of 178 individuals who received meniscal repairs, 18.5% were separated from the military for an average time of 29 months while 28% required a permanent activity limiting duty profile. Meniscal tears may also increase the risk for other knee injuries such as osteoarthritis (OA), which is one of the most common medical reasons for discharge from active duty service. In a 2017 study, 23% of soldiers who were diagnosed with meniscal injuries ultimately received total knee replacements as a result of OA. Out of 14 subjects who were interviewed by the Army Physical Evaluation Board, 11 were medically discharged because of OA and/or their total knee replacement. It is imperative to evaluate alternative rehabilitative treatments that limit the negative outcomes, discharge rates, and time of separation associated with meniscal injuries.
IMPLEMENTING A BIOPSYCHOSOCIAL MODEL FOR MUSCULOSKELETAL INJURIES AT POINT OF CARE IN THE OUTPATIENT CLINIC TO OPTIMIZE REHABILITATION, EFFICIENT RETURN TO DUTY, AND DIMINISH ATTRITION
In civilian research, it has been shown that psychosocial and motivational elements play an important role in musculoskeletal outcomes. In occupational medicine the implementation of a biopsychosocial model can be utilized as a predictor for return-to-work among employees with low back injuries. The State of Colorado’s Division of Workers Compensation (DOWC) has recently ruled that outcomes incorporating a biopsychosocial model, when appropriately interpreted by the clinician who have been trained and accredited by QPOP (Quality Performance and Outcomes Payments), are reimbursable utilizing specifically designated Z-codes. Their rationale is that patient derived outcomes create better shared decision making and return to work capacity between the practitioner and patient. Issues such as expectations, anxiety, and motivation measured at the same time as the musculoskeletal injury, affords more appropriate utilization of services in a patient centered care model.
The Comprehensive Outcomes Management Technologies (COMT) platform is an endorsed system by the DOWC. The COMT platform demonstrated that distress was an important predictor for recovery following rotator cuff repair. Caragee et al. utilized the psychological component of the system and showed that it was a better predictor than magnetic resonance injury (MRI) for lumbar spine surgery. The system integrates a distress risk and assessment scale with the patient’s perception of their function given the injured body part. Specific functional measurements are for: Spine, Knee, Shoulder, Hip, Ankle, Hand/Wrist, and Elbow. Thus, the combination of the distress risk and assessment method (DRAM) and the musculoskeletal measurements create a true biopsychosocial model. Returning to work is analogous to returning to military duty. Although, the stressors are different but it still holds true that musculoskeletal pain and loss of function is a multifactorial problem. A typical phenomenon experienced by many clinicians is that patients who seem to have a similar diagnosis, capacity and social situation have remarkably different outcomes after rehabilitation. These challenges appear to be components in military recruits and other military personnel throughout the DoD.
What is particularly promising about the COMT system is that it has shown to change not only the patient’s behavior, but also that of the clinician. One of the critical aspects of clinical medicine is the shared decision making between the clinician and the patient. It is a fairly straight forward interaction to discuss bloodwork, imaging, or biopsy results. This interaction creates a shared treatment partnership via shared goals and expectation management. Since the patient is self-reporting their biopsychosocial and functional status via the COMT platform, it enables the patient and the physician to review the data together in a more objective manner and effectively establish the treatment partnership. Other members of the rehabilitation team have the ability to analyze the patient’s self-reported data when using the COMT approach; thus creating a team-oriented patient centered model. The integrated biopsychosocial system optimizes efficiencies of care via motivational interviewing with data. This encourages the patient to be included in their return to duty and training.
THE EFFECTIVENESS OF BATTLEFIELD ACUPUNCTURE (BFA) IN ADDITION TO STANDARD POST-SURGICAL SHOULDER PHYSICAL THERAPY
The opioid epidemic effects all walks of life in the United States, with the percentage of servicemen and women addicted to opioids higher than the general population. In 2016, opioids were involved in over 60% of drug overdose deaths. Use and abuse of prescribed opioids negatively impacts the deployment readiness of DoD service members. Side effects from narcotic pain medications directly increase duty limitations. There is a clear need for alternative and integrative methods of treating acute and chronic pain.
Battlefield Acupuncture (BFA) was developed by Dr. Richard Niemtzow in 2001 to treat acute and chronic pain in austere environments. Since its inception, BFA has been used in integrative medical treatments for a myriad of conditions. Medical providers and researchers have used BFA to treat neuropathic symptoms, sore throats, thoracic pain from chronic obstructive pulmonary disease, and post-surgical musculoskeletal pain.
BFA provides an integrative pain treatment option for Service members to decrease prescription medication usage. BFA research indicates clinically significant reduction in NSAID use, shorter admission times and greater perceived pain reduction (p <0.0001) within the first 24 hours of BFA treatment that persisted up to 48 hours. Cadets at the United States Military Academy are faced with the challenges of returning to academic classes as little as 2 days after orthopedic surgery often prior to controlling their post-operative pain. Collectively, current studies elicit short term reduction in pain medication use and perceived pain (up to 72 hrs) but show no significant difference at long term follow ups (up to 30 days post treatment) relative to perceived pain. To date, there are no studies investigating BFA’s effectiveness in reducing post-operative shoulder pain and pain medication use.
EFFICACY OF AN EVIDENCE-BASED TELEHEALTH INTERVENTION IN MODIFYING HEALTH BEHAVIORS ASSOCIATED WITH POST-TRAUMATIC OSTEOARTHRITIS
Compared to the general population, military service members are at increased risk for acute traumatic knee joint injury, such ACL rupture. Those who sustain these injuries are more likely to develop post-traumatic osteoarthritis (PTOA) during their military career. PTOA is a major source of disablement and discharge. Current recommendations for managing PTOA include weight management, low impact exercise to reduce load on the affected joint, biomechanical corrections, and education about joint health. Despite widespread agreement on these treatments, their implementation in current clinical medicine is sporadic at best. Thus, these strategies, although effective, are widely under-utilized. Furthermore, the diagnosis of PTOA in an individual service member is often made late in the clinical course of the disease, when these approaches are less effective. There is a need for a novel therapeutic intervention to address prevention of PTOA post-injury. Increasing patient self-efficacy for managing PTOA is a highly promising approach.
Traditionally, the management of acute traumatic knee joint injuries has terminated when service members are returned to duty. Treatment has simply focused on restoring anatomic structures and initial functional capabilities through surgical repair and a course of rehabilitation. Thus, patients are often fully discharged from follow-up care approximately 6 months post-surgery. However, there is strong evidence that severe knee injuries are the starting point for a cascade of progressive degenerative joint changes that, over the course of several years, lead to chronic pain and impaired function, resulting in physical limitations that affect performance of duties and activities of daily living. As a result of this major gap in clinical care, acute knee joint injuries frequently progress into PTOA, resulting in high rates of dysfunction and discharge among military service members.
To address this gap in clinical care, we have developed a mobile device telehealth platform for service members at risk of PTOA. The intervention is designed to facilitate behavior change through increased knowledge and patient self-efficacy, integrated quantitative tools that allow patients and healthcare providers to monitor their OA risk factors. The telehealth platform utilizes a set of novel, evidence-based behavioral intervention strategies. These behavioral intervention strategies address known risk factors associated with OA initiation and progression. The telehealth education is supplemented by quantitative tools for physical activity tracking and assessing biomechanics. By actively engaging patients in their own care through novel technologies and strategies, we aim to address this major gap in clinical care and prevent progression to PTOA following knee injury. This study examines the effect of this therapeutic intervention that delivers novel, evidence-based behavioral health strategies through an innovative clinical intervention platform. The intervention is designed to be a major disease-prevention therapeutic tool that greatly reduces the onset of progression of PTOA following knee injury by empowering military service members to manage, and seek care for, their personal risk factors for PTOA.