Designing and developing a nature-based virtual reality with heart rate variability biofeedback for surgical anxiety and pain management: evidence from total knee arthroplasty patients.

OBJECTIVES: Total knee arthroplasty (TKA) is one of the most common joint surgeries, with over a million procedures performed annually in the US. Over 70% of patients report moderate to high pain and anxiety surrounding TKA surgery, and 96% are discharged with an opioid prescription. This population requires special attention as approximately 90% of TKA patients are older adults and one of the riskiest groups prone to misusing opioids. This study aimed to develop and compare the efficacy of nature-based virtual reality (VR) with heart rate variability biofeedback (HRVBF) to mitigate surgical pain and anxiety. METHODS: This randomized control trial recruited 30 patients (mean age = 66.3 ± 8.2 years, 23 F, 7 M) undergoing TKA surgery and randomly assigned to a control, 2D video with HRVBF, or VR with HRVBF group. A visual analog scale (VAS) was used to measure pain levels before and after the intervention. In addition, a second VAS and the State-Trait Anxiety Inventory (STAI) were used to measure anxiety before and after the intervention. Electrocardiogram (ECG) was used to continuously measure HRV and respiration rate in preoperative and postoperative settings. RESULTS: VR and 2D-video with HRVBF decreased pain and anxiety post-intervention compared with the control group, p's <.01. On analyzing physiological signals, both treatment groups showed greater parasympathetic activity levels, and VR with HRVBF reduced pain more than the 2D video, p < .01. CONCLUSIONS: Nature-based VR and 2D video with HRVBF can mitigate surgical pain and anxiety. However, VR may be more efficacious than 2D video in reducing pain.

Primary mitochondrial disease in the US: Data from patients and physicians' perspective on health care delivery.

This article presents data that examine the patient's perception of health care delivery for mitochondrial disease in the US. It also presents the opinions of mitochondrial disease expert physicians about creating a specialised network of clinics to oversee the care of patients with this disease within the US. Two separate electronic surveys were developed; one for mitochondrial disease patients and their families ascertaining their satisfaction with their current health care and the challenges they face. The other for the physicians group assessing the usefulness, feasibility and readiness to develop specialized care clinics for mitochondrial disease in the US. Survey responses and descriptive analysis are presented here. The data in this article is supplemental, and supports the information presented in the research article "Harmonizing care for rare diseases: How we developed the mitochondrial care network in the United States." Karaa et al., 2019.

Harmonizing care for rare diseases: How we developed the mitochondrial care network in the United States.

The mitochondrial medicine society (MMS) has previously highlighted the clinical landscape and physician practice patterns of mitochondrial medicine in the US and attempted to develop consensus criteria for diagnosis and management to improve patient coordinated care. Most recently, and in collaboration with US-based patient advocacy groups, we developed a clinical care network to formally unify US-based clinicians who provide medical care to individuals with mitochondrial disease; to define, design and implement best practices in mitochondrial medicine building on the current consensus guidelines and to improve patients' clinical outcomes. Here we review the steps taken in collaboration with several stakeholders to develop goals and expectations for a mitochondrial care network (MCN), criteria for MCN site selection and formal launch of the network.

Body Mass Index and Type 2 Collagen Turnover in Individuals After Anterior Cruciate Ligament Reconstruction.

CONTEXT: Individuals with an anterior cruciate ligament reconstruction (ACLR) are at an increased risk of developing posttraumatic osteoarthritis. How osteoarthritis risk factors, such as increased body mass index (BMI), may influence early changes in joint tissue metabolism is unknown. OBJECTIVE: To determine the association between BMI and type 2 cartilage turnover in individuals with an ACLR. DESIGN: Cross-sectional study. SETTING: Research laboratory. PATIENTS OR OTHER PARTICIPANTS: Forty-five individuals (31 women, 14 men) with unilateral ACLR at least 6 months earlier who were cleared for unrestricted physical activity. MAIN OUTCOME MEASURE(S): Body mass index (kg/m2) and type 2 collagen turnover were the primary outcomes. Body mass index was calculated from objectively measured height and mass. Serum was obtained to measure type 2 collagen turnover, quantified as the ratio of degradation (collagen type 2 cleavage product [C2C]) to synthesis (collagen type 2 C-propeptide [CP2]; C2C : CP2). Covariate measures were physical activity level before ACLR (Tegner score) and current level of disability (International Knee Documentation Committee Index score). Associations of primary outcomes were analyzed for the group as a whole and then separately for males and females. RESULTS: Overall, greater BMI was associated with greater C2C : CP2 (r = 0.32, P = .030). After controlling for covariates (Tegner and International Knee Documentation Committee Index scores), we identified a similar association between BMI and C2C : CP2 (partial r = 0.42, P = .009). Among women, greater BMI was associated with greater C2C : CP2 before (r = 0.47, P = .008) and after (partial r = 0.50, P = .008) controlling for covariates. No such association occurred in men. CONCLUSIONS: Greater BMI may influence greater type 2 collagen turnover in those with ACLR. Individuals, especially women, who maintain or reduce BMI may be less likely to demonstrate greater type 2 collagen turnover ratios after ACLR.

Ankle Dorsiflexion displacement is associated with hip and knee kinematics in females following anterior cruciate ligament reconstruction.

The purpose of this study was to examine associations between ankle dorsiflexion (ankle-DF) displacement and knee and hip kinematics and kinetics during a jump-landing task in females following anterior cruciate ligament reconstruction (ACLR). Females (n = 23) with a history of unilateral ACLR (≥ 6-months post-ACLR) underwent a three-dimensional lower extremity biomechanical evaluation. Pearson Product Moment (r) correlations assessed associations between ankle-DF displacement and knee and hip kinematic and kinetic variables. On the involved-limb, individuals with lesser ankle-DF displacement demonstrated greater knee abduction displacement during the loading phase (r = -0.645, p = 0.001). On the uninvolved-limb, individuals with greater ankle-DF displacement demonstrated greater hip flexion displacement (r = 0.599, p = 0.003) and knee flexion displacement (r = -0.545, p = 0.007). There were no other significant associations between ankle-DF displacement and ankle, knee, or hip biomechanical variables on either limb (p > 0.05). Our findings demonstrate that reduced ankle-DF motion appears to share a different relationship between the involved- and uninvolved-limbs in females post-ACLR.

Peak knee biomechanics and limb symmetry following unilateral anterior cruciate ligament reconstruction: Associations of walking gait and jump-landing outcomes.

BACKGROUND: Aberrant walking-gait and jump-landing biomechanics may influence the development of post-traumatic osteoarthritis and increase the risk of a second anterior cruciate ligament injury, respectively. It remains unknown if individuals who demonstrate altered walking-gait biomechanics demonstrate similar altered biomechanics during jump-landing. Our aim was to determine associations in peak knee biomechanics and limb-symmetry indices between walking-gait and jump-landing tasks in individuals with a unilateral anterior cruciate ligament reconstruction. METHODS: Thirty-five individuals (74% women, 22.1 [3.4] years old, 25 [3.89] kg/m2) with an anterior cruciate ligament reconstruction performed 5-trials of self-selected walking-gait and jump-landing. Peak kinetics and kinematics were extracted from the first 50% of stance phase during walking-gait and first 100 ms following ground contact for jump-landing. Pearson product-moment (r) and Spearman's Rho (ρ) analyses were used to evaluate relationships between outcome measures. Significance was set a priori (P ≤ 0.05). FINDINGS: All associations between walking-gait and jump-landing for the involved limb, along with the majority of associations for limb-symmetry indices and the uninvolved limb, were negligible and non-statistically significant. There were weak significant associations for instantaneous loading rate (ρ = 0.39, P = 0.02) and peak knee abduction angle (ρ = 0.36, p = 0.03) uninvolved limb, as well as peak abduction displacement limb-symmetry indices (ρ= - 0.39, p = 0.02) between walking-gait and jump-landing. INTERPRETATION: No systematic associations were found between walking-gait and jump-landing biomechanics for either limb or limb-symmetry indices in people with unilateral anterior cruciate ligament reconstruction. Individuals with an anterior cruciate ligament reconstruction who demonstrate high-involved limb loading or asymmetries during jump-landing may not demonstrate similar biomechanics during walking-gait.

Quadriceps Neuromuscular Function and Jump-Landing Sagittal-Plane Knee Biomechanics After Anterior Cruciate Ligament Reconstruction.

CONTEXT: Aberrant biomechanics may affect force attenuation at the knee during dynamic activities, potentially increasing the risk of sustaining a knee injury or hastening the development of osteoarthritis after anterior cruciate ligament reconstruction (ACLR). Impaired quadriceps neuromuscular function has been hypothesized to influence the development of aberrant biomechanics. OBJECTIVE: To determine the association between quadriceps neuromuscular function (strength, voluntary activation, and spinal-reflex and corticomotor excitability) and sagittal-plane knee biomechanics during jump landings in individuals with ACLR. DESIGN: Cross-sectional study. SETTING: Research laboratory. PATIENTS OR OTHER PARTICIPANTS: Twenty-eight individuals with unilateral ACLR (7 men, 21 women; age = 22.4 ± 3.7 years, height = 1.69 ± 0.10 m, mass = 69.4 ± 10.1 kg, time postsurgery = 52 ± 42 months). MAIN OUTCOME MEASURE(S): We quantified quadriceps spinal-reflex excitability via the Hoffmann reflex normalized to maximal muscle response (H : M ratio), corticomotor excitability via active motor threshold, strength as knee-extension maximal voluntary isometric contraction (MVIC), and voluntary activation using the central activation ratio (CAR). In a separate session, sagittal-plane kinetics (peak vertical ground reaction force [vGRF] and peak internal knee-extension moment) and kinematics (knee-flexion angle at initial contact, peak knee-flexion angle, and knee-flexion excursion) were collected during the loading phase of a jump-landing task. Separate bivariate associations were performed between the neuromuscular and biomechanical variables. RESULTS: In the ACLR limb, greater MVIC was associated with greater peak knee-flexion angle ( r = 0.38, P = .045) and less peak vGRF ( r = -0.41, P = .03). Greater CAR was associated with greater peak internal knee-extension moment (ρ = -0.38, P = .045), and greater H : M ratios were associated with greater peak vGRF ( r = 0.45, P = .02). CONCLUSIONS: Greater quadriceps MVIC and CAR may provide better energy attenuation during a jump-landing task. Individuals with greater peak vGRF in the ACLR limb possibly require greater spinal-reflex excitability to attenuate greater loading during dynamic movements.

Associations Between Slower Walking Speed and T1ρ Magnetic Resonance Imaging of Femoral Cartilage Following Anterior Cruciate Ligament Reconstruction.

OBJECTIVE: To determine whether walking speed, collected at 6 and 12 months following anterior cruciate ligament reconstruction (ACLR), is associated with inter-extremity differences in proteoglycan density, measured via T1ρ magnetic resonance imaging, in tibiofemoral articular cartilage 12 months following ACLR. METHODS: Twenty-one individuals with a unilateral patellar-tendon autograft ACLR (10 women and 11 men, mean ± SD age 23.9 ± 2.7 years, mean ± SD body mass index 23.9 ± 2.7 kg/m2 ) were recruited for participation in this study. Walking speed was collected using 3-dimensional motion capture at 6 and 12 months following ACLR. The articular cartilage of the medial femoral condyle (MFC) and lateral femoral condyle and medial and lateral tibial condyles was manually segmented and subsectioned into 3 regions of interest (anterior, central, and posterior) based on the location of the meniscus in the sagittal plane. Inter-extremity mean T1ρ relaxation time ratios (T1ρ ACLR extremity / T1ρ contralateral extremity) were calculated and used for analysis. Pearson product-moment correlations were used to determine associations between walking speed and inter-extremity differences in T1ρ relaxation time ratios. RESULTS: Slower walking speed 6 months post-ACLR was significantly associated with higher T1ρ relaxation time ratios in the MFC of the ACLR extremity 12 months following ACLR (posterior MFC, r = -0.51, P = 0.02; central MFC, r = -0.47, P = 0.04). Similarly, slower walking speed at 12 months post-ACLR was significantly associated with higher T1ρ relaxation time ratios in the posterior MFC ACLR extremity (r = -0.47, P = 0.04) 12 months following ACLR. CONCLUSION: Slower walking speed at 6 and 12 months following ACLR may be associated with early proteoglycan density changes in medial femoral compartment cartilage health in the first 12 months following ACLR.

Automated Quantification of the Landing Error Scoring System With a Markerless Motion-Capture System.

CONTEXT: The Landing Error Scoring System (LESS) can be used to identify individuals with an elevated risk of lower extremity injury. The limitation of the LESS is that raters identify movement errors from video replay, which is time-consuming and, therefore, may limit its use by clinicians. A markerless motion-capture system may be capable of automating LESS scoring, thereby removing this obstacle. OBJECTIVE: To determine the reliability of an automated markerless motion-capture system for scoring the LESS. DESIGN: Cross-sectional study. SETTING: United States Military Academy. PATIENTS OR OTHER PARTICIPANTS: A total of 57 healthy, physically active individuals (47 men, 10 women; age = 18.6 ± 0.6 years, height = 174.5 ± 6.7 cm, mass = 75.9 ± 9.2 kg). MAIN OUTCOME MEASURE(S): Participants completed 3 jump-landing trials that were recorded by standard video cameras and a depth camera. Their movement quality was evaluated by expert LESS raters (standard video recording) using the LESS rubric and by software that automates LESS scoring (depth-camera data). We recorded an error for a LESS item if it was present on at least 2 of 3 jump-landing trials. We calculated κ statistics, prevalence- and bias-adjusted κ (PABAK) statistics, and percentage agreement for each LESS item. Interrater reliability was evaluated between the 2 expert rater scores and between a consensus expert score and the markerless motion-capture system score. RESULTS: We observed reliability between the 2 expert LESS raters (average κ = 0.45 ± 0.35, average PABAK = 0.67 ± 0.34; percentage agreement = 0.83 ± 0.17). The markerless motion-capture system had similar reliability with consensus expert scores (average κ = 0.48 ± 0.40, average PABAK = 0.71 ± 0.27; percentage agreement = 0.85 ± 0.14). However, reliability was poor for 5 LESS items in both LESS score comparisons. CONCLUSIONS: A markerless motion-capture system had the same level of reliability as expert LESS raters, suggesting that an automated system can accurately assess movement. Therefore, clinicians can use the markerless motion-capture system to reliably score the LESS without being limited by the time requirements of manual LESS scoring.

Biochemical markers of cartilage metabolism are associated with walking biomechanics 6-months following anterior cruciate ligament reconstruction.

The purpose of our study was to determine the association between biomechanical outcomes of walking gait (peak vertical ground reaction force [vGRF], vGRF loading rate [vGRF-LR], and knee adduction moment [KAM]) 6 months following anterior cruciate ligament reconstruction (ACLR) and biochemical markers of serum type-II collagen turnover (collagen type-II cleavage product to collagen type-II C-propeptide [C2C:CPII]), plasma degenerative enzymes (matrix metalloproteinase-3 [MMP-3]), and a pro-inflammatory cytokine (interleukin-6 [IL-6]). Biochemical markers were evaluated within the first 2 weeks (6.5 ± 3.8 days) following ACL injury and again 6 months following ACLR in eighteen participants. All peak biomechanical outcomes were extracted from the first 50% of the stance phase of walking gait during a 6-month follow-up exam. Limb symmetry indices (LSI) were used to normalize the biomechanical outcomes in the ACLR limb to that of the contralateral limb (ACLR/contralateral). Bivariate correlations were used to assess associations between biomechanical and biochemical outcomes. Greater plasma MMP-3 concentrations after ACL injury and at the 6-month follow-up exam were associated with lesser KAM LSI. Lesser KAM was associated with greater plasma IL-6 at the 6-month follow-up exam. Similarly, lesser vGRF-LR LSI was associated with greater plasma MMP-3 concentrations at the 6-month follow-up exam. Lesser peak vGRF LSI was associated with higher C2C:CPII after ACL injury, yet this association was not significant after accounting for walking speed. Therefore, lesser biomechanical loading in the ACLR limb, compared to the contralateral limb, 6 months following ACLR may be related to deleterious joint tissue metabolism that could influence future cartilage breakdown. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:2288-2297, 2017.

Benign Peripheral Nerve Sheath Tumor in a Distance Runner.

A 31-year-old female runner presented to physical therapy via direct access with an 8-month history of atraumatic left lateral calf pain. Following 1 month of physical therapy, the patient was referred to an orthopaedic sports medicine physician. Ultrasound imaging revealed a 2-cm hypoechoic mass with well-defined margins in the left proximal lateral soleus, while Doppler ultrasound demonstrated increased color flow surrounding the mass. Magnetic resonance imaging findings were consistent with a nerve sheath tumor, and ultrasound-guided tissue biopsy determined the mass to be a benign peripheral nerve sheath tumor. J Orthop Sports Phys Ther 2017;47(2):125. doi:10.2519/jospt.2017.6780.

CORRECTED ERROR VIDEO VERSUS A PHYSICAL THERAPIST INSTRUCTED HOME EXERCISE PROGRAM: ACCURACY OF PERFORMING THERAPEUTIC SHOULDER EXERCISES.

BACKGROUND AND PURPOSE: The accurate performance of physical therapy exercises can be difficult. In this evolving healthcare climate it is important to continually look for better methods to educate patients. The use of handouts, in-person demonstration, and video instruction are all potential avenues used to teach proper exercise form. The purpose of this study was to examine if a corrected error video (CEV) would be as effective as a single visit with a physical therapist (PT) to teach healthy subjects how to properly perform four different shoulder rehabilitation exercises. STUDY DESIGN: This was a prospective, single-blinded interventional trial. METHODS: Fifty-eight subjects with no shoulder complaints were recruited from two institutions and randomized into one of two groups: the CEV group (30 subjects) was given a CEV comprised of four shoulder exercises, while the physical therapy group (28 subjects) had one session with a PT as well as a handout of how to complete the exercises. Each subject practiced the exercises for one week and was then videotaped performing them during a return visit. Videos were scored with the shoulder exam assessment tool (SEAT) created by the authors. RESULTS: There was no difference between the groups on total SEAT score (13.66 ± 0.29 vs 13.46 ± 0.30 for CEV vs PT, p = 0.64, 95% CI [-0.06, 0.037]). Average scores for individual exercises also showed no significant difference. CONCLUSION/CLINICAL RELEVANCE: These results demonstrate that the inexpensive and accessible CEV is as beneficial as direct instruction in teaching subjects to properly perform shoulder rehabilitation exercises. LEVEL OF EVIDENCE: 1b.

Sagittal plane kinematics predict kinetics during walking gait in individuals with anterior cruciate ligament reconstruction.

BACKGROUND: Alterations in mechanical loading following anterior cruciate ligament reconstruction may lead to the development of knee osteoarthritis. Feedback that cues a change in knee kinematics during walking gait may influence mechanical loading, yet it remains unknown if knee kinematics predict kinetics during walking gait. Our aim was to determine if sagittal plane knee kinematics predict kinetics during walking gait in anterior cruciate ligament reconstructed individuals. METHODS: Forty-one individuals with a history of primary, unilateral anterior cruciate ligament reconstruction completed a motion capture walking gait analysis. Hierarchical linear regression analyses were used in order to determine the amount of variance in the kinetic variables of interest (peak vertical ground reaction force, instantaneous and linear vertical ground reaction force loading rate) that was individually predicted by the kinematic variables of interest (knee flexion angle at heelstrike, peak knee flexion angle, and knee flexion excursion). FINDINGS: Knee flexion excursion of the injured limb significantly predicted 11% of the variance in peak vGRF of the injured limb after accounting for gait speed and peak knee flexion angle (ΔR2=0.11, P=0.004). After accounting for gait speed and knee flexion angle at heelstrike, knee flexion excursion significantly predicted 16% of the variance in the injured limb peak vertical ground reaction force (ΔR2=0.16, P=0.001). No kinematic variable predicted vertical ground reaction force loading rate. INTERPRETATION: Altering knee flexion excursion may be useful as a future therapeutic target for modifying peak vertical ground reaction force during walking gait following anterior cruciate ligament reconstruction.

Sex Differences in the Incidence of Anterior Cruciate Ligament, Medial Collateral Ligament, and Meniscal Injuries in Collegiate and High School Sports: 2009-2010 Through 2013-2014.

BACKGROUND: Previous research has noted sex-based differences in anterior cruciate ligament (ACL) injury rates in young athletes, while little is known about medial collateral ligament (MCL) and meniscal injury rates in this population. The objective of this study was to compare injury rates for traumatic knee injuries (ie, ACL, MCL, and meniscal injuries) in collegiate and high school (HS) varsity student-athletes across multiple sports. HYPOTHESIS: Knee injury rates vary by sex and across different sports and levels of competition. STUDY DESIGN: Descriptive epidemiology study. METHODS: Injury and athlete-exposure data were utilized from the National Athletic Treatment, Injury and Outcomes Network (NATION) and National Collegiate Athletic Association (NCAA) Injury Surveillance Program (ISP) during the 2009-2010 to 2013-2014 academic years. Analyses focused on ACL, MCL, and meniscal injuries. Injury rates and injury rate ratios (IRRs) with 95% CIs were calculated for basketball, ice hockey, lacrosse, soccer, and baseball/softball. RESULTS: The ACL injury rate was higher for female than male athletes at the collegiate (IRR, 2.49; 95% CI, 1.81-3.41) and HS (IRR, 2.30; 95% CI, 1.67-3.18) levels. At the collegiate level, the highest ACL IRR comparing female to male athletes was reported in softball/baseball (IRR, 6.61; 95% CI, 1.48-29.55). At the HS level, the highest ACL IRR was reported in basketball (IRR, 3.68; 95% CI, 1.91-7.10). The MCL injury rate was higher for female than male athletes at the HS level (IRR, 2.11; 95% CI, 1.25-3.56) but lower for female than male athletes at the collegiate level (IRR, 0.73; 95% CI, 0.59-0.92). The meniscal injury rate was lower for female than male athletes at the HS level (IRR, 0.47; 95% CI, 0.31-0.71), while no differences by sex were seen at the collegiate level (IRR, 1.35; 95% CI, 0.90-2.02). CONCLUSION: Knee injury rates varied by sex across 5 different sports in the HS and collegiate settings. Female athletes sustained ACL injuries at a higher rate than male athletes at both the HS and collegiate levels in these 5 sports; however, there was not a distinct sex disparity in MCL and meniscal injuries. Future studies should examine the rates of concomitant and recurrent injuries to inform injury prevention and rehabilitation programs.

A quantitative approach to assessing the efficacy of occupant protection programs: A case study from Montana.

Quantitative evaluation of vehicle occupant protection programs is critical for ensuring efficient government resource allocation, but few methods exist for conducting evaluation across multiple programs simultaneously. Here we present an analysis of occupant protection efficacy in the state of Montana. This approach relies on seat belt compliance rates as measured by the National Occupant Protection Usage Survey (NOPUS). A hierarchical logistic regression model is used to estimate the impacts of four Montana Department of Transportation (MDT)-funded occupant protection programs used in the state of Montana, following adjustment for a suite of potential confounders. Activity from two programs, Buckle Up coalitions and media campaigns, are associated with increased seat belt use in Montana, whereas the impact of another program, Selective Traffic Enforcement, is potentially masked by other program activity. A final program, Driver's Education, is not associated with any shift in seat belt use. This method allows for a preliminary quantitative estimation of program impacts without requiring states to obtain any new seat belt use data. This approach provides states a preliminary look at program impacts, and a means for carefully planning future program allocation and investigation.

COMPARING THE IMPAIRMENT PROFILES OF OLDER DRIVERS AND NON-DRIVERS: TOWARD THE DEVELOPMENT OF A FITNESS-TO-DRIVE MODEL.

The purpose of this research effort was to compare older driver and non-driver functional impairment profiles across some 60 assessment metrics in an initial effort to contribute to the development of fitness-to-drive assessment models. Of the metrics evaluated, 21 showed statistically significant differences, almost all favoring the drivers. Also, it was shown that a logistic regression model comprised of five of the assessment scores could completely and accurately separate the two groups. The results of this study imply that older drivers are far less functionally impaired than non-drivers of similar ages, and that a parsimonious model can accurately assign individuals to either group. With such models, any driver classified or diagnosed as a non-driver would be a strong candidate for further investigation and intervention.

Ambulance Crash Characteristics in the US Defined by the Popular Press: A Retrospective Analysis.

Ambulance crashes are a significant risk to prehospital care providers, the patients they are carrying, persons in other vehicles, and pedestrians. No uniform national transportation or medical database captures all ambulance crashes in the United States. A website captures many significant ambulance crashes by collecting reports in the popular media (the website is mentioned in the introduction). This report summaries findings from ambulance crashes for the time period of May 1, 2007 to April 30, 2009. Of the 466 crashes examined, 358 resulted in injuries to prehospital personnel, other vehicle occupants, patients being transported in the ambulance, or pedestrians. A total of 982 persons were injured as a result of ambulance crashes during the time period. Prehospital personnel were the most likely to be injured. Provider safety can and should be improved by ambulance vehicle redesign and the development of improved occupant safety restraints. Seventy-nine (79) crashes resulted in fatalities to some member of the same groups listed above. A total of 99 persons were killed in ambulance crashes during the time period. Persons in other vehicles involved in collisions with ambulances were the most likely to die as a result of crashes. In the urban environment, intersections are a particularly dangerous place for ambulances.