Timothy C. Mauntel’s research while affiliated with Walter Reed National Military Medical Center and other places

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Publications (57)


Association between Pregnancy and Musculoskeletal Conditions in Active-Duty Military Service Members
  • Article

December 2024

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1 Read

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1 Citation

Journal of Athletic Training

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D Alan Nelson

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Christina M Koreerat

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[...]

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Timothy C Mauntel

Context: Non-combat musculoskeletal conditions are endemic among service members and disproportionately affect females. Pregnancy and childbirth contribute to lower physical fitness assessment scores and higher body mass index, both risk factors for musculoskeletal conditions, for up to one-year post-pregnancy. However, there is a paucity of information regarding the impact of pregnancy on musculoskeletal conditions. Objective: To explore the association between the post-pregnancy period and incident musculoskeletal conditions (MSK). Design: Retrospective, longitudinal cohort study. Setting: Medical and administrative data from the Medical Assessment and Readiness System. Other participants: Female military service members with and without a pregnancy. Main outcome measure(s): Months since pregnancy end, health history, and demographic and military service data were abstracted for each subject. Subsequent MSKs were identified with relevant ICD-10 codes. A multivariable logistic regression model assessed the association between the time since pregnancy end and MSK incidence. Results: A total of 298,607 female service members were identified, of which 19,980 had a pregnancy. A larger percentage of post-pregnancy service members (65.8%) had a MSK diagnosis as compared to the non-pregnant cohort (60.3%). Adjusting for covariates, the model suggests a temporal influence on post-pregnancy MSK incidence, such that service members 3- to 4-months and 5- to 6-months post-pregnancy were more likely to be diagnosed with a MSK as compared to the non-pregnant cohort. However, service members <2 months post-pregnancy were less likely to be diagnosed with an MSK, and the odds of an MSK beyond 6-months decreased out to 24-months post-pregnancy. Conclusions: Pregnancy may increase a service member's odds of sustaining an MSK 3- to 6- months post-pregnancy. Understanding the relationships between pregnancy and MSK risks may lead to changes in postpartum return-to-duty/activity policies, better enabling service members to care for themselves and their families.




Movement Clearing Screens for Service Member Musculoskeletal Injury Risk Identification

July 2024

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14 Reads

Journal of Athletic Training

Context Pain during movement screens is a risk factor for musculoskeletal injury (MSKI). Movement screens often require specialized/clinical expertise and large amounts of time to administer. Objective Evaluate if self-reported pain 1) with movement clearing screens is a risk factor for any MSKI, 2) with movement clearing screens is a risk factor for body region-specific MSKIs, and 3) with a greater number of movement clearing screens progressively increases MSKI risk. Design Retrospective cohort study. Setting Field-based. Participants Military Service members (n=4,222). Main Outcome Measures Active-duty Service members self-reported pain during movement clearing screens (Shoulder Clearing, Spinal Extension, Squat-Jump-Land). MSKI data were abstracted up to 180-days post-screening. A Traffic Light Model grouped Service members if they self-reported pain during 0 (Green), 1 (Amber), 2 (Red), or 3 (Black) movement clearing screens. Cox proportional hazards models adjusted for age, gender, body mass index, and prior MSKI determined the relationships between pain during movement clearing screens with any and body region-specific MSKIs. Results Service members self-reporting pain during the Shoulder Clearing (adjusted-Hazard Ratio and 95% confidence interval (HRadj [95%CI]) =1.58 [1.37, 1.82]), Spinal Extension (HRadj=1.48 [1.28, 1.87]), or Squat- Jump-Land (HRadj=2.04 [1.79, 2.32]) tests were more likely to experience any MSKI compared to Service members reporting no pain. Service members with pain during the Shoulder Clearing (HRadj=3.28 [2.57, 4.19]), Spinal Extension (HRadj=2.80 [2.26, 3.49]), or Squat-Jump-Land (HRadj=2.07 [1.76, 2.43]) tests were more likely to experience an upper extremity, spine, back, and torso, or lower extremity MSKI, respectively, compared to Service members reporting no pain. The Amber (HRadj=1.69 [1.48, 1.93]), Red (HRadj=2.07 [1.73, 2.48]), and Black (HRadj=2.31 [1.81, 2.95]) cohorts were more likely to experience an MSKI compared to the Green cohort. Conclusions Self-report movement clearing screens in combination with a Traffic Light Model provide clinician/non-clinician-friendly, expedient means to identify Service members at MSKI risk.


A machine learning framework to classify musculoskeletal injury risk groups in military service members
  • Article
  • Full-text available

June 2024

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26 Reads

Frontiers in Artificial Intelligence

Background Musculoskeletal injuries (MSKIs) are endemic in military populations. Thus, it is essential to identify and mitigate MSKI risks. Time-to-event machine learning models utilizing self-reported questionnaires or existing data (e.g., electronic health records) may aid in creating efficient risk screening tools. Methods A total of 4,222 U.S. Army Service members completed a self-report MSKI risk screen as part of their unit's standard in-processing. Additionally, participants' MSKI and demographic data were abstracted from electronic health record data. Survival machine learning models (Cox proportional hazard regression (COX), COX with splines, conditional inference trees, and random forest) were deployed to develop a predictive model on the training data (75%; n = 2,963) for MSKI risk over varying time horizons (30, 90, 180, and 365 days) and were evaluated on the testing data (25%; n = 987). Probability of predicted risk (0.00–1.00) from the final model stratified Service members into quartiles based on MSKI risk. Results The COX model demonstrated the best model performance over the time horizons. The time-dependent area under the curve ranged from 0.73 to 0.70 at 30 and 180 days. The index prediction accuracy (IPA) was 12% better at 180 days than the IPA of the null model (0 variables). Within the COX model, “other” race, more self-reported pain items during the movement screens, female gender, and prior MSKI demonstrated the largest hazard ratios. When predicted probability was binned into quartiles, at 180 days, the highest risk bin had an MSKI incidence rate of 2,130.82 ± 171.15 per 1,000 person-years and incidence rate ratio of 4.74 (95% confidence interval: 3.44, 6.54) compared to the lowest risk bin. Conclusion Self-reported questionnaires and existing data can be used to create a machine learning algorithm to identify Service members' MSKI risk profiles. Further research should develop more granular Service member-specific MSKI screening tools and create MSKI risk mitigation strategies based on these screenings.

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Self-reported musculoskeletal injury risk assessment.
Adjusted hazard ratios for the variables of interest.
Cox proportional regression models for each traffic light model.
Cont.
Musculoskeletal Injury Risk Stratification: A Traffic Light System for Military Service Members

June 2023

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133 Reads

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4 Citations

Healthcare

Risk factor identification is a critical first step in informing musculoskeletal injury (MSKI) risk mitigation strategies. This investigation aimed to determine if a self-reported MSKI risk assessment can accurately identify military service members at greater MSKI risk and determine whether a traffic light model can differentiate service members’ MSKI risks. A retrospective cohort study was conducted using existing self-reported MSKI risk assessment data and MSKI data from the Military Health System. A total of 2520 military service members (2219 males: age 23.49 ± 5.17 y, BMI 25.11 ± 2.94 kg/m2; and 301 females: age 24.23 ± 5.85 y, BMI 25.59 ± 3.20 kg/m2, respectively) completed the MSKI risk assessment during in-processing. The risk assessment consisted of 16 self-report items regarding demographics, general health, physical fitness, and pain experienced during movement screens. These 16 data points were converted to 11 variables of interest. For each variable, service members were dichotomized as at risk or not at risk. Nine of the 11 variables were associated with a greater MSKI risk and were thus considered as risk factors for the traffic light model. Each traffic light model included three color codes (i.e., green, amber, and red) to designate risk (i.e., low, moderate, and high). Four traffic light models were generated to examine the risk and overall precision of different cut-off values for the amber and red categories. In all four models, service members categorized as amber [hazard ratio (HR) = 1.38–1.70] or red (HR = 2.67–5.82) were at a greater MSKI risk. The traffic light model may help prioritize service members who require individualized orthopedic care and MSKI risk mitigation plans.


The association between kinesiophobia and functional limitations in service members with knee pain

May 2023

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17 Reads

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3 Citations

Musculoskeletal Science and Practice

Background: Knee diagnoses account for more than 50% of lower extremity musculoskeletal conditions in non-deployed US Service members. However, there is limited information regarding kinesiophobia in Service members with non-operative knee diagnoses. Hypotheses: The objectives of this study were to determine the prevalence of high levels of kinesiophobia in US military Service members with knee pain across different knee diagnoses, and to determine the relationships between kinesiophobia and lower extremity function and/or specific functional limitations in Service members with knee pain. It was hypothesized Service members with knee pain would exhibit high levels of kinesiophobia across all knee diagnoses examined, and higher levels of both kinesiophobia and pain would be associated with worse self-reported function in this population. It was also hypothesized higher levels of kinesiophobia would be associated with functional activities with high knee loading. Design: Retrospective cohort study. Level of evidence: IV. Methods: Sixty-five US Service members presenting to an outpatient physical therapy clinic were included in this study (20 females; age = 30.8 ± 7.7 years; height = 1.74 ± 0.9 m; mass = 80.7 ± 16.2 kg). Inclusion criterion was the presence of knee pain (duration = 50 ± 59 months); exclusion criterion was knee pain as a sequela of knee surgery. Data regarding demographic, pain chronicity, pain by Numeric Rating Scale (NRS), Tampa Scale of Kinesiophobia (TSK), and Lower Extremity Functional Scale (LEFS) were retrospectively obtained from patients' medical records. A high level of kinesiophobia was defined as a TSK score of greater than 37 points. Patient diagnoses included: osteoarthritis (n = 16); patellofemoral pain syndrome (n = 23); and other non-operative knee diagnoses (n = 26). Commonality analysis was utilized to determine the effects of age, height, mass, NRS, and TSK on LEFS score. Predictor values were interpreted as <1% = negligible, >1% = small; >9% = moderate, >25% = large. Additionally, exploratory item-specific analyses examined the strength of the relationships between kinesiophobia and LEFS item responses. Binary logistic regression determined if difficulty with an individual LEFS item could be predicted from either NRS or TSK score. Statistical significance was set at P < 0.05. Results: High levels of kinesiophobia were identified in 43 individuals (66%). NRS and TSK explained 19.4% and 8.6% of the unique variance in LEFS, and 38.5% and 20.5% of total variance, respectively. Age, height, and mass explained negligible to small proportions of the unique variance in LEFS. TSK and NRS were independent predictors for 13/20 individual LEFS items, with odds ratios ranging from 1.12 to 3.05 (P < 0.05). Conclusion: The majority of US Service members in this study exhibited high levels of kinesiophobia. Kinesiophobia was significantly related to self-reported functional scores and performance on individual functional tasks in Service members with knee pain. Clinical relevance: Treatment strategies addressing both fear of movement and pain reduction in patients with knee pain may help optimize functional outcomes.


Figure 1 Study flow diagram. mTBI, mild-traumatic brain injury; UGA, University of Georgia; WRNMMC, Walter Reed National Military Medical Center.
Investigating post-mild traumatic brain injury neuromuscular function and musculoskeletal injury risk: A protocol for a prospective, observational, case-controlled study in service members and active individuals

March 2023

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40 Reads

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1 Citation

BMJ Open

Introduction: Musculoskeletal injury (MSKI) risk is increased following mild traumatic brain injury (mTBI). Increased MSKI risk is present up to 2 years following post-mTBI return-to-duty/activity relative to both non-mTBI peers and to their pre-mTBI selves across a range of populations, including military service members, and professional, college and high school athletes. Despite the well documented increased post-mTBI MSKI risk, the underlying neuromuscular mechanisms contributing to this increased risk have yet to be definitively determined. A number of potential mechanisms have been suggested (eg, aberrant kinematics, dynamic balance impairments, lower voluntary muscle activation), but none have been confirmed with a comprehensive, prospective study. This study aims to: (1) elucidate the neuromuscular control mechanisms following mTBI that contribute to increased MSKI risk, and (2) prospectively track patient outcomes (up to 12 months; MSKI occurrences and patient-reported outcomes (PRO)). Methods and analysis: This is a multicentre prospective, case-matched control observational study to identify deficiencies in neuromuscular function following mTBI that may contribute to increased MSKI risk. Participants (aim to recruit 148, complete data collection on 124) will be classified into two cohorts; mTBI and control. All participants will undergo longitudinal (initial, 6 weeks post-initial, 12 weeks post-initial) comprehensive three-dimensional biomechanical (jump-landing; single leg hop; cut; gait), neuromuscular (interpolated twitch technique, muscular ramp contraction) and sensory (joint repositioning; light touch sensation) assessments to elucidate the underlying neuromuscular control mechanisms post-mTBI that may contribute to increased MSKI. Occurrences of MSKI and PROs (National Institutes of Health Patient-Reported Outcome Measurement Information System: Physical Function, Pain Interference, Depression, Anxiety; Brief Resilience Scale; Tampa Scale of Kinesiophobia), will be tracked monthly (up to 1 year) via electronic data capture platforms. Ethics and dissemination: The study received approval from the Walter Reed National Military Medical Center Institutional Review Board. Results will be made available to the associated funding agency and other researchers via conference proceedings and journal articles. Trial registration number: NCT05122728.


Hooks Versus Pedicle Screws at the Upper Instrumented Level: An In Vitro Biomechanical Comparison

February 2023

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19 Reads

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1 Citation

Spine

Study design: Controlled laboratory study. Objective: To compare motions at the upper instrumented vertebra (UIV) and supra-adjacent level (UIV+1) between two fixation techniques in thoracic posterior spinal fusion (PSF) constructs. We hypothesized there would be greater motion at UIV+1 after cyclic loading across all constructs and bilateral pedicle screws (BPS) with posterior ligamentous compromise would demonstrate the greatest UIV+1 range of motion (ROM). Summary of background data: Proximal junctional kyphosis (PJK) is a well-recognized complication following long thoraco-lumbar PSF, however its mechanism is poorly understood. Methods: Twenty-seven thoracic functional spine units (FSU) were randomly divided into three UIV fixation groups (n=9): (1) BPS, (2) bilateral transverse process hooks (TPH), and (3) BPS with compromise of the posterior elements between UIV and UIV+1 (BPS-C). Specimens were tested on a servohydraulic materials testing system in native state, following instrumentation, and after cyclic loading. FSUs were loaded in flexion-extension (FE), lateral bending (LB), and axial rotation (AR). Results: After cyclic testing, the TPH group had a mean 29.4% increase in FE ROM at UIV+1 versus 76.6% in the BPS group (P<0.05). The BPS-C group showed an increased FE of 49.9% and 62.19% with sectioning of the facet joints and interspinous ligament respectively prior to cyclic testing. Conclusion: Bilateral pedicle screws at the UIV led to greater motion at UIV+1 compared to bilateral TPH after cyclic loading. This is likely due to the increased rigidity of BPS compared to TPH leading to a "softer" transition between the TPH construct and native anatomy at the supra-adjacent level. Facet capsule compromise led to a 49.9% increase in UIV+1 motion, underscoring the importance of preserving the posterior ligamentous complex. Clinical studies that account for fusion rates are warranted to determine if constructs with a "soft transition" result in less PJK in vivo.


Survival of anterior cruciate ligament reconstructions in active-duty military populations

February 2023

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16 Reads

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2 Citations

Knee Surgery Sports Traumatology Arthroscopy

PurposeAnterior cruciate ligament tears and anterior cruciate ligament reconstruction (ACLR) are common in young athletes. The modifiable and non-modifiable factors contributing to ACLR failure and reoperation are incompletely understood. The purpose of this study was to determine ACLR failure rates in a physically high-demand population and identify the patient-specific risk factors, including prolonged time between diagnosis and surgical correction, that portend failure.MethodsA consecutive series of military service members with ACLR with and without concomitant procedures (meniscus [M] and/or cartilage [C]) done at military facilities between 2008 and 2011 was completed via the Military Health System Data Repository. This was a consecutive series of patients without a history of knee surgery for two years prior to the primary ACLR. Kaplan–Meier survival curves were estimated and evaluated with Wilcoxon test. Cox proportional hazard models calculated hazard ratios (HR) with 95% confidence intervals (95% CI) to identify demographic and surgical factors that influenced ACLR failure.ResultsOf the 2735 primary ACLRs included in the study, 484/2,735 (18%) experienced ACLR failure within four years, including (261/2,735) (10%) undergoing revision ACLR and (224/2,735) (8%) due to medical separation. The factors that increased failure include Army Service (HR 2.19, 95% CI 1.67, 2.87), > 180 days from injury to ACLR (HR 1.550, 95% CI 1.157, 2.076), tobacco use (HR 1.429 95% CI 1.174, 1.738), and younger patient age (HR 1.024, 95% CI 1.004, 1.044).Conclusion The overall clinical failure rate of service members with ACLR is 17.7% with minimum four-year follow-up, where more patients are likely to fail due to revision surgery than medical separation. The cumulative probability of survival at 4 years was 78.5%. Smoking cessation and treating ACLR patients promptly are modifiable risk factors impacting either graft failure or medical separation.Level of evidenceLevel III.


Citations (39)


... Identifying athletes who are at an elevated risk for MSK injuries is possible but challenging due to the extensive set of potential modifiable and non-modifiable risk factors; indeed, a recent military MSK review identified 950 potential variables. [27][28][29] A systematic review of extensive previous e!orts to develop MSK injury prediction models identifies some consistent risk factors, but results indicate generally limited success in overall prediction. [29,30] The combination of relatively large samples and the number of potential variables has motivated machine learning/artificial intelligence models to improve outcome prediction. ...

Reference:

A Machine Learning Model for Post-Concussion Musculoskeletal Injury Risk in Collegiate Athletes
Musculoskeletal Injury Risk Stratification: A Traffic Light System for Military Service Members

Healthcare

... 29,30 Subsequently, it may lead to even poorer recovery and more severe negative emotions, thus forming a vicious cycle. 31 We constructed a nomogram model based on identified independent influencing factors, which provides specific scores for each influencing factor. Subsequently, by adding up the scores of each influencing factor, the corresponding probability is obtained. ...

The association between kinesiophobia and functional limitations in service members with knee pain
  • Citing Article
  • May 2023

Musculoskeletal Science and Practice

... The main mechanism for regulating loads in standard physical therapy protocols is to change the sequence of basic exercises and increase quantitative indicators. However, these conditions do not consider the kinematic characteristics of the exercise technique and body position, considering the peculiarities of recruiting agonist, synergist, and stabilizer muscles (Hollman et al., 2021;Lynall et al., 2023). The calculation of load parameters is based only on subjective indicators, without a level of energy reserves and the percentage of active motor units involved. ...

Investigating post-mild traumatic brain injury neuromuscular function and musculoskeletal injury risk: A protocol for a prospective, observational, case-controlled study in service members and active individuals

BMJ Open

... This view was supported by our results, which showed that 64 of the 73 aircrews (87.7%) who underwent ACLR were medically cleared to return to work and only nine (12.3%) were permanently disqualified at the final medical evaluation. Anderson et al. (17) found that the cumulative probability of survival for service members with ACLR was 78.5% with at least four years of followup, which is slightly lower than our result. This may be due to the fact that Army soldiers are uniquely exposed to high physical demands, aggressive impacts, heavy loads, often on uneven terrain in suboptimal conditions compared to military aircrew. ...

Survival of anterior cruciate ligament reconstructions in active-duty military populations
  • Citing Article
  • February 2023

Knee Surgery Sports Traumatology Arthroscopy

... Thus, the long healing time combined with a high frequency of repeated injuries of the musculoskeletal system make them the main cause of work capacity loss and subsequent disability. Given this, there is a clinically justified need to accelerate the kinetics of tissue healing after open injuries [6]. The phase of muscle regeneration is complicated by a large amount of free radicals produced during the developed inflammatory process. ...

Repurposing existing products to accelerate injury recovery (REPAIR) of military relevant musculoskeletal conditions

... The absence of a unified approach for implementing an action plan during post-acute and long-term rehabilitation compli-cates the resolution of this issue. The opposing views between the multidisciplinary team and kinesiology specialists on the effectiveness of standard rehabilitation protocols for each phase contribute to the difficulty of the problem (Butowicz et al., 2022;Ladlow et al., 2022, Olkhovyi et al., 2020. The issues related to the servicemen's neuromuscular system readaptation using models to rehabilitate athletes after injuries are particularly acute (Keenan et al., 2017;Chernozub et al., 2023). ...

Pre-neuromusculoskeletal injury Risk factor Evaluation and Post-neuromusculoskeletal injury Assessment for Return-to-duty/activity Enhancement (PREPARE) in military service members: a prospective, observational study protocol

Journal of Translational Medicine

... One study showed that risk for MSK injury is greatest during the first 3 months after SRC (OR 5 2.48 [1.04-5.91]), 5 whereas others have shown that risk varies across time and/or depends on the type of sport. 6,7 Ample evidence indicates that clinical recovery precedes complete physiological recovery from SRC. 8 Subtle sensorimotor and neurocognitive deficits identified on balance 9 and dual-task 10 tests may persist beyond clinical resolution of concussion signs and symptoms, potentially explaining the increased risk of subsequent concussion and MSK injury. 11 A cross-sectional study of National Collegiate Athletic Association Division 1 American football and ice hockey athletes 12 found that athletes with a concussion within the past 2 years had dynamic balance deficits compared with nonconcussed athletes, suggesting that sensorimotor control deficits may persist beyond clinical recovery. ...

Lower Extremity Musculoskeletal Injuries After Concussion in Collegiate Student-Athletes

The American Journal of Sports Medicine

... Even IKDC, however, has been criticized for being lengthy and poorly representing the patient's quality of life [15,16]. The widespread use of IKDC, and the goal of trying to simplify and increase efficiency of clinics, were the reasons why it was used for the present study. ...

A High-Sensitivity International Knee Documentation Committee Survey Index From the PROMIS System: The Next-Generation Patient-Reported Outcome for a Knee Injury Population

The American Journal of Sports Medicine

... The advantage of the suture method in Group D is that it is a simple and straightforward fixation configuration in the clinical setting. Moreover, one could assume that the use of a stronger thread, such as a tape-type suture [20], may increase the biomechanical strength of the fixation configuration in Group D. Thus, a baseball suture tied directly to a suspensory button would be another option for soft-tissue QT graft fixation on the femoral side. ...

A Biomechanical Comparison of High-Tensile Strength Tape Versus High-Tensile Strength Suture for Tendon Fixation Under Cyclic Loading
  • Citing Article
  • April 2021

Arthroscopy The Journal of Arthroscopic and Related Surgery

... The measuring point is located on the front of the arm, almost midway between the shoulder and the elbow. Using a skinfold caliper, the skin was griped with the thumb and index finger approximately 1 centimeter above the specified location (Tenan et al., 2021). The subscapular skinfold is taken directly below the bottom point of the scapula, at a downward angle of around 45 degrees. ...

Generating the American Shoulder and Elbow Surgeons Score Using Multivariable Predictive Models and Computer Adaptive Testing to Reduce Survey Burden

The American Journal of Sports Medicine