Allen, C., Sheehan, R., Deyle, G., Wilken, J., & Gill, N. (2018). A manual physical therapy intervention for symptoms of knee osteoarthritis and associated fall risk: A case series of four patients. Physiotherapy Theory and Practice, 1-9.

Knee osteoarthritis is a common problem in active duty Service members and Veterans and symptoms associated with knee osteoarthritis correlate with fall risk.  This study provided evidence that a four-week manual physical therapy intervention of joint mobilization, manual muscle stretching and soft tissue mobilization, reduces pain and stiffness and improves function resulting in a secondary benefit of decreasing their overall fall risk.  This study suggests that targeting the underlying impairments rather than the fall risk may be an alternate approach to addressing increase fall risk.

Golyski, P. R., Bell, E. M., Husson, E. M., Wolf, E. J., & Hendershot, B. D. (2018). Modulation of vertical ground reaction impulse with real-time biofeedback: A feasibility study. Journal of Applied Biomechanics, 34(2), 134-140. doi: 10.1123/jab.2017-0004

Abnormal joint mechanics are often associated with an elevated risk for joint pathology.  Rehabilitation focused on gait modification has been used to control or alter mechanical loads during ambulation and minimize the risk for long-term complications.  This study evaluated the feasibility of a real-time gait modification paradigm intended to reduce loads on the lower limb.  This study supports the use of vertical ground reaction impulse (vGRI) as a real-time biofeedback variable toward the reduction of vertical loads applied to the limb while walking. Future studies are needed in this area.

Harper, N. G., Wilken, J. M., Neptune, R. R. (2018). Muscle function and coordination of stair ascent. Journal of Biomechanical Engineering, 140(1), 1-10. doi: 10.1115/1.4037791

Stair ascent is a critical task for independent daily living.  The more we understand about individuals living with an amputation and how they compensate for their losses to be able to perform a variety of critical tasks, the better an effective and targeted rehabilitation program can be developed.  This modeling study demonstrated that the hamstrings are utilized for propulsion after transtibial amputation and that rehabilitation should include strengthening and engaging these muscles to maximize outcomes.

Hendershot, B. D., Shojaei, I., Acasio, J. C., Dearth, C. L., & Bazrgari, B. (2017). Walking speed differentially alters spinal loads in persons with traumatic lower limb amputation. Journal of Biomechanics, 70, 249-254.

This study suggests that the rehabilitation team may need to consider the speed of walking and the increased forces within the lumbar spine during therapy to minimize back pain.  The authors reported that faster walking speeds results in larger forces within the lumbar spine in individuals with lower limb amputations compared to uninjured controls.  This study supported anecdotal evidence that individuals with unilateral lower limb amputation commonly report low back pain and perceive altered trunk motions during activities of daily living as a primary contributor to its onset and recurrence.

Hsieh, K. L., Sheehan, R. C., Wilken, J. M. & Dingwell, J. B. (2018). Healthy Individuals are more maneuverable when walking slower while navigating a virtual obstacle course. Gait and Posture, 61, 466-472. doi: 10.1016/j.gaitpost.2018.02.015

This study concluded that walking slower decreased stability but improved maneuverability and using a combination of walking strategies in therapy will improve how individuals modulate between stability and maneuverability allowing them to better navigate in the community.  When navigating in the community, it is important to be able to switch both walking speeds and strategies depending on the specific task.  Individuals, when negotiating obstacles, should slow their walking speed and plan the direction of their transitions to improve maneuverability.

Acasio, J. C., Butowicz, C. M., Golyski, P. R., Nussbaum, M. A., & Hendershot, B. D. (2018). Associations between trunk postural control in walking and unstable sitting at various levels of task demand. Journal of Biomechanics, 75, 181-185.

Physical pathologies including Lower limb loss and back pain, common injuries in our Service members, can adversely influence trunk postural control.  These results, along with the positive correlations among global trunk postural control measures in the study, establish a tentative relationship by which improvements in trunk postural control via unstable sitting may translate to other functional activities.  It is unclear if this relationship persists among individuals with impaired trunk postural control and future studies are needed.

Butowicz, C. M., Acasio, J. A., Dearth, C. L., & Hendershot, B. D. (2018). Trunk muscle activation patterns among persons with lower limb loss: Influences of walking speed. Journal of Electromyography and Kinesiology, 40, 48-55.

Low back pain is a common health condition secondary to lower limb amputation and gaining a better understanding of the mechanism of this pain will help guide effective rehabilitation.  Persons with lower limb amputation walk with altered trunk-pelvic motions.  The underlying trunk muscle activation patterns associated with these motions may provide insight into neuromuscular control strategies post lower limb amputation and the increased incidence of low back pain.  This study suggests that trunk neuromuscular control strategies secondary to lower limb amputation are driven by functional needs to generate torque proximally, to advance the affected limb during gait. This strategy may have unintended consequences such as increasing risk of low back pain.

Farrokhi, S., Mazzone, B., Schneider, M., Gombatto, S., Mayer, J., Highsmith, M. J., & Hendershot, B. (2017). Biopsychosocial risk factors associated with chronic low back pain after lower limb amputation. Medical Hypotheses, 108, 1-9. doi: 10.1016/j.mehy.2017.07.030

There is a high prevalence of unknown etiologies of low back pain in persons with a lower limb amputation making treatment of the low back pain challenging. The aim of this work was to organize data originating from prior studies of the biopsychosocial correlated of low back pain after lower limb amputation in a conceptual framework that could help generate new research questions and improve our understanding of low back pain after a lower limb amputation. The authors hypothesized that alterations in biological, psychological and social factors are related to the development of low back pain symptoms and disability after a lower limb amputation and should be considered during the clinical decision making process and for future research efforts to improve patient outcomes. The proposed biopsychosocial model could be useful in identifying risk factors for early identification of patients at risk for low back pain and testing the effectiveness of different approaches aimed at reducing chronic low back pain related disability after a lower limb amputation.

Farrokhi, S., Mazzone, B., Eskridge, S., Shannon, K., & Hill, O.T. (2018). Incidence of overuse musculoskeletal injuries in military service members with traumatic lower limb amputation. Archives of Physical Medicine and Rehabilitation, 99, 348-354.

This article highlights the importance of educating and training Service members with lower limb amputations on proper body mechanics and mitigation strategies to prevent secondary overuse musculoskeletal injuries.  The authors of this study reported that the overall one-year incidence of developing at least one musculoskeletal overuse injury after lower limb amputation was between 59% and 68%.  Furthermore, Service members with unilateral lower limb amputations were almost twice as likely to develop an overuse lower or upper limb injury.  It is suspected that this number may be higher in those who have longer prosthetic use.

Highsmith, M. J., Goff, L. M., Lewandowski, A. L., Farrokhi, S., Hendershot, B. D., Hill, O. T., Rabago C. A., Russell Esposito, E., Mayer, J. M. (2018). Low back pain in persons with lower extremity amputation: a systematic review of the literature. The Spine Journal. doi: 10.1016/j.spinee.2018.08.011

There is a higher incidence of low back pain in persons with lower extremity amputation compared to able-bodied persons. Understanding the relationships between lower extremity amputation and low back pain will allow rehabilitation teams to develop programs and focus therapy to ultimately decrease the incidence of low back pain in this population. The authors included 17 articles in their review and concluded that based on the state of the current evidence and appropriate preventative and treatment strategies to manage low back pain, that there is a significant knowledge gap in this area. This important systematic review highlights that effective interventions to manage low back pain with persons with a lower extremity amputation is a considerable knowledge gap and a much needed area of future study.

Krupenevich, R. L., Miller, R. H., Hendershot, B. D., Schnall, B. L., & Pruziner, A. L. (2018). Knee adduction moment peak and impulse do not change during the first six months of walking with a prosthesis. Gait and Posture, 63, 86-90. doi: 10.1016/j.gaitpost.2018.04.040.

The purpose of this study was to compare the intact knee joint kinetics of individuals with unilateral lower limb loss across three time points within the first six months after initial independent ambulation with a prosthesis.  The results of this study suggest that recently ambulatory individuals with lower limb loss do not change the major features of knee adduction and knee flexion of their intact knee joint over the first six months of independently walking with a prosthesis.

Morgenroth, D. C., Roland, M., Pruziner, A. L., & Czerniecki, J. M. (2018). Transfemoral amputee intact limb loading and compensatory gait mechanics during down slope ambulation and the effect of prosthetic knee mechanisms. Clinical Biomechanics, 55, 65-72.

Persons with a unilateral transfemoral amputation are at a higher risk of developing intact limb knee osteoarthritis thought to arise from altered/abnormal loads during locomotion.  However, there were no observable differences in intact limb loading when comparing persons with a transfemoral amputee during down slope ambulation and prosthetic knee type (PK versus C-leg) to able-bodied individuals.  This study suggests that transfemoral amputees may compensate by walking slower and taking shorter step length on the intact limb. These findings should be considered during rehabilitation and when designing prosthetic foot-ankle and knee components.

*Carey, S. L., Stevens, P. M., & Highsmith, M. J. (2017). Differences in myoelectric and body-powered upper-limb prostheses: Systematic literature review update 2013–2016. Journal of Prosthetics and Orthotics, 29(4S), 17-20. doi: 10.1682/JRRD.2014.08.0192

This systematic review compared the body powered and the myolelectric prostheses.  There is little evidence addressing functional capabilities of prostheses and even fewer studies providing a direct comparison of prostheses in a controlled setting.  This study demonstrates that there is a lack of empirical evidence regarding functional differences in upper-limb prostheses.  This study highlights that prosthetic selection should be based on a patient’s individual needs, personal preferences, prosthetic experience and functional needs.

*VA Article

Knight, A. D., Anderson, P. P., Beachler, M. D., Dearth, C. L., Hassinger, L. M., Hendershot, B. D., & Liacouras, P. C. (2018). Customized 3D-Printed Prosthetic Devices for Wounded Warriors. American Journal of Physical Medicine and Rehabilitation. doi: 10.1097/PHM.0000000000001047

Many traumatically injured Service members would like to continue to serve on active duty and participate in pre-injury activities.  These personal patient goals often challenge the rehabilitative team, to include customizing the assistive devices to increase function.  Commercially available prosthetic and orthotic devices are limited in their ability to allow these individuals to return to duty.  This article highlights the importance of using advanced technological approaches and customized 3D-printed prosthetics to provide individualized, custom devices to enhance functional capabilities and outcomes to allow traumatically injured Service members the ability to return to duty and continue to pursue high-performance activities, individualized to their own needs and desires.

*Klenow, T. D., Kahle, J. T., Fedel, F., Ropp, J., & Highsmith, M. J. (2017). Comparative efficacy of transfemoral prosthetic interfaces: Analysis of gait and perceived disability. Journal of Prosthetics and Orthotics, 29(3), 130-136

There have been a myriad of innovations in the field of prosthetic interfaces and one such technology is the High-Fidelity interface. The purpose of this study was to measure the effects of the High Fidelity interface system on gait and perceived disability compared with a traditional socket design in a subject with a transfemoral amputation. The results of this study demonstrated some biomechanical advantages, which may allow for increased stability with use of the High-Fidelity interface and an improvement in perceived disability. Future research with a larger sample size is needed.

* VA Article

Koehler-McNicholas, S. R., Nickel, E. A., Barrons, K., Blaharski, K. E., Dellamano, C. A., Ray, S. F., Hendershot, B. D., & Hansen, A. H. (2018). Mechanical and dynamic characterization of prosthetic feet for high activity users during weighted and unweighted walking. PLoS One, 13(9), 1-16. doi: 10.1371/journal.pone.0202884

A goal of rehabilitation is to return Service members and Veterans to duty or to meaningful activity.  Many Service members and Veterans with lower-limb amputations would like to resume physically demanding occupations that require them to carry heavy loads. However, it is currently unclear which prosthetic feet best accommodate heavy load carriage while also providing good overall function and mobility during un-weighted activities.  The results of this study suggest that prosthetic ankle-foot systems with compliant forefoot heel structures may better accommodate weighted walking by reducing the metabolic cost of physically demanding activities.  However, the rehabilitation team must also consider other factors, such as the residual-limb strength of the user and the overall stiffness profile of the prosthetic feet.

*Lura, D. J., Wernke, M. W., Carey, S. L., Kahle, J. T., Miro, R. M., & Highsmith, M. J. (2017). Crossover study of amputee stair ascent and descent biomechanics using Genium and C-Leg prostheses with comparison to non-amputee control. Gait and Posture, 58, 103-107.

Transfemoral amputees typically have difficulty ascending and descending stairs affecting their ability to comfortably navigate in the community.  This study compared the Genium to the C-Leg and reported that for stair descent there were no differences between the prostheses.  For stair ascent, the Genium decreased deficiency in gait patterns and demonstrated a more symmetric gait relative to the C-Leg.

*VA Article

Resnik, L. J., Acluche, F., Borgia, M. L., Cancio, J. M., Latlief, G. & Sasson, N. (2018). Function, quality of life, and community integration of DEKA Arm users after discharge from prosthetic training: Impact of home use experience. Prosthetics and Orthotics International, 42(6), 571-582. doi: 10.1177/0309364618774054

This study demonstrated that the majority of upper limb amputees, using the DEKA arm, discharged from prosthetic training and rehabilitation continue to improve in function with home use.  However, some upper limb amputees experience a decline in function and greater perceived disability after home use, suggesting that some patients will need continued therapy after intensive prosthetic training ends, in conjunction with home use.

Resnik, L. J., Borgia, M. L., Acluche, F., Cancio, J. M., Latlief, G. & Sasson, N. (2018). How do the outcomes of the DEKA Arm compare to conventional prostheses? PLoS One, 13(1), 1-18.

As the field moves toward more advanced upper limb prostheses and the promise of what these devices can offer, the need for clinical studies evaluating and comparing the effectiveness of these devices is needed.  This study expanded on previous research by comparing outcomes after several months of home use.  This study compared self-reported function, dexterity, activity performance, quality of life and community integration of the Gen 3 DEKA Arm to a conventional prosthesis and examined differences in outcomes by conventional prosthesis type, terminal deice and by DEKA Arm configuration level.  The authors reported that clients using the DEKA Arm had less perceived disability and more engagement of the prosthesis in everyday tasks. Furthermore, after home use with the DEKA Arm, activity speed was equivalent to using conventional prosthesis suggesting that home use after completion of formal prosthetic training program may lead to better function.

Russell Esposito, E., & Miller, R. H. (2018). Maintenance of muscle strength retains a normal metabolic cost in simulated walking after transtibial limb loss. PLoS One, 19(1), 1-19. doi: 10.1371/journal.pone.0191310

A goal in rehabilitation for the patient with an amputation is to optimize gait patterns.  The results of this study suggest that an increase in the metabolic cost of walking is not an inevitable consequence of unilateral transtibial limb loss; an increase in metabolic cost may be driven more by the loss of strength in the remaining muscles rather than loss of the limb.  Targeted rehabilitation care after the amputation is essential for maintaining muscle strength in the remaining muscles and contributes to normal gait patterns.  This study also supports that a modeling approach may serve as the basis for future investigations.

Russell Esposito, E., Lipe, D. H., & Rábago, C. A. (2018). Creative prosthetic foot selection enables successful ambulation in stiletto high heels. Prosthetics and Orthotics International, 42(3), 344-349. doi: 10.1177/0309364617741937

In rehabilitation, goals must be client-centered.  One goal for individuals who wear a prosthetic is the ability to wear a variety of footwear.  This article demonstrated that for one patient, returning to wearing footwear with high heels might be an option using creativity in prosthetic foot selection.  However, it should be noted that special attention to gait mechanics should be closely assessed to insure patient safety.  Rehabilitation professionals must continue to assess and train on a variety of footwear to ensure patients safety and to reach client’s goals.

Shaw, E. P., Rietschel, J. C., Hendershot, B. D., Pruziner, A. L., Miller, M. W., Hatfield, B. D., & Gentili, R. J. (2018). Measurement of attentional reserve and mental effort for cognitive workload assessment under various task demands during dual-task walking. Biological Psychology, 134, 39-51.

The aim of this study was to examine changes in cognitive workload through a combined assessment of electroencephalography as individuals were seated or walking while concurrently performing a cognitive task under various levels of challenge within an ecologically valid environment.  The results of this study demonstrated that as the difficulty of the cognitive task increased from easy to hard during both the seated and walking condition, there was a diminution of attentional reserve and elevation of cognitive effort.  This important work provides data supporting that attentional reserve and mental effort can collectively index cognitive workload under varying demands due to changes in task difficulty or performance.  This approach allows the rehabilitation team to perform cognitive workload assessment in patient populations with gait deficiencies, to include lower limb loss.

Spahn K., Wyatt, M. P., Julianne, S. M., Mazzone, B. N., Yoder, A. J., & Kuhn, K. M. (2018). Do gait and functional parameters change after transtibial amputation following attempted limb preservation in a military population? Clinical Orthopaedics and Related Research, 1-7 [e-pub ahead of print].

At times, surgeons and rehabilitative teams attempt limb preservation strategies for military personnel who have sustained severe lower extremity trauma.  Some of these patients will undergo a number of procedures and will still be left with a painful, poorly functioning extremity.  This study demonstrated that elective late transtibial amputation after attempted limb preservation in a young, motivated group of Service members may be successful in decreasing pain and narcotic use, minimizing the need for assistive devices and increasing activity levels, improving gait mechanics and allowing for high-level functional activities.

Sposato, L., Yancosek, K., & Cancio, J. (2017). Psychosocial reactions to upper extremity limb salvage: A case series. Journal of Hand Therapy. doi: 10.1016/j.jht.2017.09.003

This study highlighted the need for clinicians to address the physical and psychosocial needs of the patient who has undergone upper extremity limb salvage.  This case series article addresses an area of study that is limited in the current literature, the psychosocial adaptations after upper extremity limb salvage. It is important to consider the psychosocial aspect of the patient in all aspects of rehabilitation care specifically, pain management, ensure client centered goals and interventions and social support when treating patients with an upper extremity limb salvage.

Rose, L. F., Wolf, E. J., Brindle, T., Cernich, A., Dean, W. K., Dearth, C. L., Grimm, M., Kusiak, A., Nitkin, R., Potter, K., Randolph, B. J., Wang, F., & Yamaguchi, D. (2018). The convergence of regenerative medicine and rehabilitation: Federal perspectives. Regenerative Medicine, 3(1), 1-7.

This article provides information on federal agencies’ perspective on regenerative medicine and rehabilitation.  Federal government agencies have been investing in research and clinical efforts focused on regenerative medicine (NIH, NSF, VA and DoD), rehabilitation sciences (VA, NIH, NSF, DoD) and more recently, regenerative rehabilitation (NIH and VA).  This article encourages clinicians and researchers from multiple disciplines to work collaboratively and synergistically to maximize restoration of function and quality of life for disabled and or injured patients, including Service members and Veterans.  In addition, this article provides the federal agencies research interest and contact information—important information for researchers or clinicians who are interested in funding or working in this field of study.

*Highsmith, J. T., Highsmith, M. J., & Monheit, G. D. (2017). Histologic accuracy of Mohs Micrographic Surgery. Dermatologic Surgery, 44(3), 350-353.

Mohs micropgraphic surgery enables the surgeon to maximize tumor removal while minimizing the amount of tissue being removed using advanced mapping techniques combed with microscopy and is the treatment of choice in skin cancers that demand tissue preservation.  Interpretation of frozen sections slides is vital to the success of Mohs micrographic surgery.  This study demonstrated agreement between the interpretation of histologic frozen section slides when evaluated by fellowship-trained Mohs surgeons and dermatopatholgists for Mohs micrographic surgery. These findings support current literature.

*VA Article

Klenow, T. D., Stevens, P. M., Rabago, C. A., Hill, O. T., Latlief, G. A., Ruiz-Gamboa, R., & Highsmith, M. J. (2018). The role of exercise testing in predicting successful ambulation with a lower extremity prosthesis: A systematic literature review and clinical practice guideline. Journal of Neuroengineering and Rehabilitation, 15(S1), 1-10. doi: 10.1186/s12984-018-0401-z

The authors of this study conducted a systematic review of the literature regarding the use of exercise testing in treatment of the population with limb loss. The ability to sustain an exercise intensity of ≥50% of a predicted VO2 max value in single leg cycle ergometry testing and achievement of a sustained workload of 30 W in upper extremity ergometry testing were found to be the strongest correlates to successful ambulation with a prosthesis.  VO2 values were found to increase in amputee subjects following a six-week exercise program.

Farrokhi, S., Perez, K., Eskridge, S., & Clouser, M. (2018). Major deployment-related amputations of lower and upper limbs, active and reserve components, U.S. Armed Forces, 2001-2017. Medical Surveillance Monthly Report, 25(7), 10-16.

Major limb amputations are a life threatening and life-altering event for Service members injured in combat.  Limb loss can often result in immediate and long-term decline in physical, social, and financial well-being of the injured Service member.  Additionally, caring for Service members with limb loss places a tremendous burden on their families, as well as the Departments of Defense and Veteran Affairs health systems.  From 2001 to 2017 a total of 1,705 Service members sustained a deployment-related amputation.  Of those 1,705 Service members, 1,496 sustained lower limb amputations and 284 sustained upper limb amputations.  The majority of injured were serving in the active component of the U.S. Army or U.S. Marine Corps and were enlisted.  The most frequent cause of limb amputation was a blast injury (1,545; 91%).  A better understanding of the size and characteristics of the combat-injured amputee population is critical to formulate sound strategies for current and future policy, healthcare needs, research focus areas and resource allocation decisions.