Elevating Osteoarthritis

October 28, 2015 by JordanG
The November issue of the NATA News is focused on the research within the athletic training profession. One of the highlighted research groups is the Athletic Trainers' Osteoarthritis Consortium (ATOAC), who is working to raise awareness of osteoarthritis within sports medicine.

Many members of the ATOAC are gaining national recognition for the research they are conducting related to osteoarthritis. One of the most effective ways the consortium is moving the needle forward for OA awareness is by conducting quality research that influences best practices. The following researchers are just a sampling of the athletic trainers who are making strong contributions in this research field. We offer the following content below to compliment what was already included in the article, including descriptions of the studies and how each researcher became interested in osteoarthritis.

Troy Blackburn, PhD, ATC

University of North Carolina at Chapel Hill
Research grant received: $772,058 from the United States Department of Defense - Defense Medical Research and Development Program, Clinical and Rehabilitative Medicine Research Program, Neuromusculoskeletal Injuries Research Award
Research: Vibratory stimuli: A novel rehabilitation method for preventing post-traumatic knee osteoarthritis 

Blackburn explains: "Quadriceps dysfunction and compromised sensorimotor function following anterior cruciate ligament injury and surgical reconstruction are thought to contribute to development of post-traumatic knee osteoarthritis.  Vibratory stimuli have been demonstrated to enhance muscle function and proprioception.  This study will evaluate the effects of indirect (whole body vibration) and direct (local muscle vibration) vibratory stimuli on knee proprioception and gait biomechanics linked to cartilage degradation in individuals who have undergone anterior cruciate ligament reconstruction.

I became interested in osteoarthritis research because of personal experience with knee injury and the wealth of literature demonstrating the potential long-term negative effects on joint health. As athletic trainers, our primary goal is to treat and rehabilitate injuries for the immediate future so that athletes can return to participation.  However, this approach potentially sacrifices long-term joint health to achieve the short-term participation and performance goals.  This is particularly true in academic settings (e.g. high school and collegiate athletes) in which clinicians address the initial injury, but no longer serve as clinical providers after student-athletes matriculate.  However, athletic trainers are “on the front lines” with respect to post-traumatic osteoarthritis.  Signs of osteoarthritis have been identified as soon as 1-2 years following ACL injury, thus athletic trainers are the first line of defense in providing clinical care that could reduce the risk of osteoarthritis.  Therefore, it is vitally important that we continue to raise awareness of post-traumatic osteoarthritis among athletic trainers and support research efforts designed to develop treatment option."       


Michelle Boling, PhD, ATC

University of North Florida
Research grant received: $54,000 from the University of North Florida, Brooks College of Health, Dean’s Research Professorship Grant
Research:Patellofemoral Pain and Serum Biomarkers for Cartilage Turnover and Joint Metabolism: Implications for Future Development of Patellofemoral Osteoarthritis

Boling explains: My research agenda has always focused on risk factors for the development of patellofemoral pain and the treatment/management of individuals with patellofemoral pain. As I have worked with this patient population over the years, I began to wonder if these individuals are predisposed to the development of knee osteoarthritis later in life. I feel it is important for the sports medicine community to gain a better understanding of the relationship between prior knee injury and the subsequent development of knee osteoarthritis.

Kenneth Cameron, PhD, MPH, ATC

John A. Feagin Jr. Sports Medicine Fellowship, Keller Army Hospital
Research grant received: $749,807 from the Congressionally Directed Medical Research Program's (CDMRP) Peer Reviewed Orthopaedic Research Program (PRORP) U.S. Army Medical Research and Material Command (USAMRMC)
Research: Acute Changes in Biomarkers of Cartilage Turnover and Joint Metabolism Following Traumatic Knee Joint Injury

Cameron explains: The overall objective of the proposed study is to prospectively evaluate acute changes in biomarkers of cartilage turnover and joint metabolism following traumatic knee joint injury and surgical reconstruction, to better understand the impact of acute joint injury and whether these biomarkers can be used to detect people at risk for subsequent injury and the early onset of PTOA.
Research grant received: $249,596 from the Telemedicine and Advanced Technology Research Center (TATRC) AMEDD Advanced Medical Technology Initiative (AAMTI)
Research: Using a Telehealth Platform to Deliver Innovative Therapeutic Care for Military Service Members at High Risk for Post-traumatic Osteoarthritis

Cameron explains: The overall objective of this project is to facilitate appropriate ongoing follow-up in military service members who are at increased risk for post-traumatic OA due to a history of traumatic knee joint injury using a telehealth platform.

"I became interested in research related primarily to post-traumatic osteoarthritis (PTOA) because this is a leading cause of disability discharge in the military.  This is probably the result of the high incidence rates for acute traumatic joint injuries in this young and active population in combination with the repetitive loading that military service members experience through their training and occupational tasks.  Athletes are also at increased risk for PTOA following joint injury so these topics are naturally aligned with athletic training.  This is particularly important because PTOA in athletes and military service members can lead to advanced OA in patients as young as their late 20s and early 30s.  Our hope is that our research may someday allow us to identify those individuals who are at increased risk for the rapid progression of PTOA following joint injury earlier in their clinical course so that we can potentially develop interventions to alter the course of this debilitating disease."

Jeff Driban, PhD, ATC, CSCS

Tufts Medical Center
Research grant received: $1,485,568 from the National Institutes of Health (NIH) / National Institute of Arthritis and Musculoskeletal and Skin Disorders (NIAMS)
Research: Characterization of Rapidly Progressive Knee Osteoarthritis

Driban explains: Osteoarthritis is usually a slowly progressive disorder but some individuals develop end-stage disease in just a few years or even months.In this project, we hope to identify factors that differentiate or identify people with accelerated knee osteoarthritis so that eventually we could develop preventive strategies and uncover therapeutic targets.

"I became interested in OA when I was a graduate assistant for Temple University Hospital's orthopaedic department and I saw how OA impacted the lives of our patients. While many people think of OA as just a normal part of aging it is critical that clinicians recognize that some of our young athletes could be at risk for living over half their life with OA, which can be chronic, painful, disabling, and expensive disease. Our patients and members of their support system are often focused on the short-term goal of returning safely and quickly back to activity but sports medicine clinicians have an obligation to also consider the long-term health of our patients - after all, injury/illness prevention and wellness protection is an important domain of athletic training."

Chris Mendias, PhD, ATC

University of Michigan
Research grant received: $50,000 from the American Othopaedic Society for Sports Medicine
Research: Changes in biomarkers of cartilage degeneration and inflammation following arthroscopic decompression of femoroacetabular impingement (study conducted in collaboration with Asheesh Bedi, MD)

Mendias explains: For quite some time, we have not understood exactly what causes hip OA. We and many others in the field think that a condition called femoroacetabular impingement (FAI), in which there is a structural deformity in the hip joint that leads to cartilage damage and joint inflammation, is likely the primary causative factor that leads to the development of OA later in life. For athletes who have FAI and undergo surgery to correct the mechanical defect, we think that this will not only help to alleviate their pain and restore function in the short term, many in the field think that surgical correction of FAI is likely helpful in avoiding the development of hip OA later in life. The problem is that x-rays, which are most frequently used to diagnose OA, are not very sensitive to early changes in cartilage structure and function and we do not have any objective data to back-up the "hip preservation" effect of FAI surgery. So we used a combination of functional strength and stability measures, along with patient reported outcome scores and very sensitive and precise biochemical measures of cartilage degradation and inflammation obtained from blood samples of patients. We are in the final stages of the study, but so far it does look like that patients with FAI who undergo surgical repair of the defect and accelerated post-operative rehab are able to restore strength and function to their hip joint, and reduce inflammation and cartilage degeneration.

This study is being performed with my colleague Asheesh Bedi, MD. Dr. Bedi is an orthopaedic surgeon here at the University of Michigan, and is an assistant team physician for UM Athletics and the Detroit Lions. Dr. Bedi is also a world renowned hip surgeon and consults with several professional and collegiate sports teams throughout North America. For me, in addition to being an AT, I have my PhD in molecular biology and have a research program that looks at the cellular and molecular biology behind musculoskeletal tissue regeneration. Dr. Bedi and I collaborated on this study to combine our expertise in musculoskeletal medicine and molecular biology to try to determine whether surgical correction of FAI can protect cartilage from damage in the short term and perhaps avoid the development of OA or at least reduce its severity in the future.

Brian Pietrosimone, PhD, ATC

University of North Carolina at Chapel Hill
Research grant received: $20,000 from the NATA Research & Education Foundation, New Investigator Grant
Research: Establishing a Comprehensive Strategy to Evaluate Early Posttraumatic Osteoarthritis

Pietrosimone explains:  The study is designed to establish methods to measure early changes in cartilage health at twelve months post ACL reconstruction (ACL-R) measured with confirmed T1rho MRI methods, are associated with a comprehensive group of variables that evaluate changes in joint metabolism, inflammation and biomechanics at six and twelve months post ACL-R.
Research grant received: $275,000 from the National Institute of Arthritis, Musculoskeletal and Skin Disease
Research: Improving Disability in Knee Osteoarthritis by Targeting Neuromuscular Deficits

Pietrosimone explains: The study seeks to determine if a comprehensive rehabilitation strategy that targets neuromuscular activation deficits using Transcutaneous Electrical Nerve Stimulation (TENS) can enhance the effectiveness of previously described therapeutic exercise and aerobic walking rehabilitation interventions in patients with Knee Osteoarthritis.

Research grant received: $100,000 from the National Institute of Arthritis, Musculoskeletal and Skin Disease
Research: Posttraumatic Osteoarthritis: Establishing a Comprehensive Evaluation Strategy

Pietrosimone explains: The study seeks to establish methods to measure early changes in cartilage health at twelve months post ACL reconstruction (ACL-R) measured with confirmed T1rho MRI methods, are associated with a comprehensive group of variables that evaluate changes in joint metabolism, inflammation and biomechanics at six and twelve months post ACL-R.

"I’ve always been interested in developing new ways to keep people active throughout their lifespan.  Unfortunately lower extremity joint injury that occurs while we are young negatively affect how our joints age.  Athletic trainers are perfectly positioned to impact life-long joint health early after an injury allowing people to enjoy a healthy active lifestyle decades following a traumatic joint injury."


Timothy Tourville, PhD, ATC, CSCS

McClure Musculoskeletal Research Center
Research grant received: $589,494 from the NIH National Institute of Arthritis and Musculoskeletal and Skin Diseases, NIH Mentored Clinical Scientist Research Career Development Award (K08)
Research: Skeletal Muscle Size and Function after ACL Rupture: Predictors of OA Progression

Tourville explains: The pathophysiological factors that contribute to the initial onset and early progression of post-traumatic osteoarthritis (PTOA) following severe knee trauma, such as anterior cruciate ligament (ACL) rupture, are poorly understood. One factor that may predispose ACL-reconstructed patients to the onset and progression of PTOA is neuromuscular dysfunction of the quadriceps, which develops secondary to the combined catabolic sequelae produced by the index injury, subsequent surgery, and accompanying muscle disuse. Contrasting what is observed with models of uncomplicated disuse, muscular weakness and dysfunction following ACL-reconstruction are not completely remediated by strength training and orthopedic rehabilitation. This persistent muscle weakness is thought to predispose patients to PTOA by decreasing the ability of the quadriceps to attenuate shock during gait and maintain normal distribution of forces across the tibiofemoral joint. These biomechanical alterations can lead to abnormal contact stresses and loading within the knee, which provoke adaptations in cartilage metabolism that hasten its degradation and the onset and progression of PTOA.

Our goal is to address these neuromuscular maladaptations in their infancy through targeting of their root causes with therapeutic interventions. At present, however, the specific cellular and sub-cellular adaptations that occur in muscle to promote strength loss, the associated biomechanical gait alterations, and changes in articular cartilage composition have not been clearly defined. The purpose of this research project is to address this knowledge gap in three specific aims: 1) to determine the effects of acute ACL injury on skeletal muscle function, structure and protein expression at the molecular, cellular, tissue and whole body levels; 2) to define adaptations in gait biomechanics that result from muscle strength loss; and 3) to evaluate the loss of glycosaminoglycan and type-II collagen fibril disruption in the tibiofemoral articular cartilage. To accomplish these goals, we will study ACL-injured subjects with serial assessments of bilateral skeletal muscle strength and function as well as cartilage-specific MRI at pre-surgical baseline and 6-month follow up; and assess 3D gait kinematics at 6 months post-ACL-reconstruction. Results from these studies will advance knowledge by providing novel mechanistic information about the effect of ACL injury and subsequent surgical intervention on skeletal muscle size and function and its relationship to altered gait and cartilage biology in humans. These results have the potential to impact clinical care by informing the development of new interventions to specifically target the cellular and sub-cellular muscle adaptations that contribute to the pathoetiology of PTOA.

"Following the completion of my undergraduate AT degree at Keene State College I began practicing in Vermont as a licensed athletic trainer in an outpatient clinic, serving as the primary orthopedic rehabilitation provider for patients with a wide array of musculoskeletal maladies. In my clinical practice, I was surprised with the number of cases of post- traumatic osteoarthritis (PTOA) I was treating in otherwise healthy individuals following anterior cruciate ligament (ACL) injury. This clinical experience spurred me on to graduate school to obtain a masters degree with an emphasis in Exercise and Movement Science at the University of Vermont (UVM). I returned to the clinical orthopedic rehabilitation setting to resume my practice as an AT; however, as I continued to treat patients with OA, I found that I had even more questions regarding the pathoetiology and treatment of this disease, and a strong desire to pursue a career in academic research. This lead to my return to UVM graduate school and the clinical and translational science research setting to pursue doctoral, and post-doctoral training specific to primary and secondary (post-traumatic) OA, as well as cellular and molecular-level skeletal muscle physiology. I feel it is important to raise awareness about primary and post-traumatic OA in the sports medicine community, as AT’s are exceptionally well positioned to not only be on the cutting edge of high-quality, impactful clinical and translational research, but also on the front lines for the prevention and treatment of OA and PTOA through evidence-based practiced resulting from the exceptional research our profession is conducting."

Posted by NATA Communications Manager Jordan Grantham (jordang@nata.org).