Ikeda, A. J., Fergason, J. R., & Wilken, J. M. (2019). Clinical outcomes with the Intrepid Dynamic Exoskeletal Orthosis: A retrospective analysis. Military Medicine, 1: 2019. doi: 10.1093/milmed/usz004/5363847

The purpose of this retrospective study was to analyze outcomes on patients who were fitted with the Intrepid Dynamic Exoskeletal Orthosis (IDEO) over an 18-month period. Outcomes forms were completed by 99 patients with an average of 35 days from delivery. Overall, patients were comfortable in the IDEO and wore them most of the day. Patients reported a decrease in pain and an increase in function with wearing the IDEO.

Knight, A. D., Anderson, P. P., Beachler, M. D., Dearth, C. L., Hassinger, L. M., Hendershot, B. D., Sleeman, T. J., & Liacouras, P. C. (2019). Customized three-dimensional printed prosthetic devices for Wounded Warriors. American Journal of Physical Medicine & Rehabilitation, 98(4), e38-e39. doi: 10.1097/PHM.0000000000001047

This review highlights the importance of patient-specific designs and the future role of additive manufacturing in helping persons with limb loss to maximize function and increase quality of life. 3D printing allows for devices to be created from various materials with the use of CAD software and 3D scanning technology. The resources and capabilities of the Department of Defense allow for custom designs based on the preferences, abilities, and activity desires of each individual. Currently, more than 200 Service members with limb loss have benefited from customized 3D-printed devices. Examples include, a handgun holder, a fishing rod adaptor and rock and ice climbing attachments.

Mazzone, B., Farrokhi, S., Depratti, A., Stewart, J., Rowe, K., & Wyatt, M. (2019). High-level performance after the return to run clinical pathway in patients using the Intrepid Dynamic Exoskeletal Orthosis. Journal of Orthopaedic and Sports Physical Therapy, 49(7), 529-535. doi: 10.2519/jospt.2019.8763

This study assessed the effectiveness of the Return to Run Clinical Pathway (RTR) in returning patients with lower extremity fractures who utilize the Intrepid Dynamic Exoskeletal Orthosis (IDEO) to high-level mobility. Thirty Service members with lower extremity fractures who utilized the IDEO unilaterally and completed the RTR were included. The RTR led to improvements in high-level, multi-directional mobility in these patients.

Quacinella, M., Mazzone, B., Kuhn, K., & Wyatt, M., (2018). Use of the Intrepid Dynamic Exoskeletal Orthosis (IDEO) in the management of common peroneal nerve palsy after knee dislocation. Journal of Prosthetics and Orthotics, 31(1), 11-15. doi: 10.1097/JPO.0000000000000217

This case series of 2 Marines who sustained a peroneal nerve injury resulting in foot drop were prescribed an Intrepid Dynamic Exoskeletal Orthosis (IDEO). The combination of the IDEO and return to run clinical pathway allowed for these Marines with a common peroneal nerve palsy to return to high-level functioning. Both were cleared for active duty.

Schmidtbauer, K. A., Russell Esposito, E., & Wilken, J. M. (2019). Ankle-foot orthosis alignment affects running mechanics in individuals with lower limb injuries. Prosthetics and Orthotics International, 1-9; doi: 10.1177/0309364619826386

This study investigated how 3° changes in sagittal plane ankle-foot orthoses alignment affect running mechanics. Lower extremity running mechanics were assessed in 12 participants with unilateral lower limb injury running over ground. Participants wore their passive-dynamic ankle-foot orthoses in three alignments: 1) clinically fit neutral, 2) 3° plantarflexed from clinically fit neutral, and 3) 3° dorsiflexed from clinically fit neutral. Results showed that small changes in ankle-foot orthoses alignment significantly altered running mechanics, including footstrike angle, and knee extensor moments. Understanding how ankle-foot orthoses alignment impacts biomechanics should be a consideration when fitting passive-dynamic devices for higher impact activities, such as running. Individual running styles, including footstrike patterns, may be affected by small changes in alignment.

Shojaei, I., Hendershot, B. D., Acasio, J. C., Dearth, C. L., Ballard, M., & Bazrgari, B. (2019). Trunk muscle forces and spinal loads in persons with transfemoral amputation during sit-to-stand and stand-to-sit activities. Clinical Biomechanics, 63, 95-103. doi: https://doi.org/10.1016/j.clinbiomech.2019.02.021

Alterations and asymmetries in trunk motions during activities of daily living, involving lower extremities, are suggested to cause higher spinal loads in persons with unilateral lower limb amputation. Given the repetitive nature of most activities of daily living, knowledge of the amount of increase in spinal loads is important for designing interventions aimed at prevention of secondary low back pain due to potential fatigue failure of spinal tissues. The objective of this study was to determine differences in trunk muscle forces and spinal loads between persons with (n = 10) and without (n = 10) lower limb amputation when performing sit-to-stand and stand-to-sit tasks. Spinal loads were larger in persons with amputation, these loads were generally smaller than the reported threshold for spinal tissue injury. A small increase in spinal loads during common activities of daily living may impose a significant risk of fatigue failure for spinal tissues due to the repetitive nature of these activities.

Russell Esposito, E., Schmidtbauer, K. A., & Wilken, J. M. (2018). Experimental comparisons of passive and powered ankle-foot orthoses in individuals with limb reconstruction. Journal of Neuroengineering and Rehabilitation, 15, 111. doi: 10.1186/s12984-018-0455-y

This case series of 3 subjects with lower limb reconstruction, compared gait mechanics at a standardized speed in 4 AFO conditions: 1) None (shoes only), 2) Blue Rocker (BR, Allard, USA), 3) Intrepid Dynamic Exoskeletal Orthosis (IDEO), and 4) PowerFoot Orthosis (PFO BionX Medical Technologies, Inc.). The PFO was a custom, battery-powered device whose damping and power were capable to being tuned to meet patient needs. Subjects performed biomechanical gait analysis and metabolic testing at slow, moderate and fast speeds. Dependent variables included total limb power, mechanical work, mechanical efficiency, ankle motion, net metabolic cost across three speeds, and performance measures were calculated. Net positive work and efficiency were greatest in the PFO. There were large effects for between limb differences in positive work for all conditions except the PFO. The PFO normalized efficiency between the affected and unaffected limbs, whereas efficiency was less on the affected limb for all other conditions. Metabolic rate was not consistently lowest in any one AFO condition across speeds. Despite some positive results of the PFO, patient preferred their daily use AFO reporting that mass and size were concerns with using the PFO. Although the powered AFO provided some biomechanical benefits, further improvements are warranted to improve patient satisfaction.

Butowicz, C. M., Dearth, C. L., & Hendershot, B. D. Joint power distribution within the contralateral limb one does not change within one year after unilateral limb loss. Gait and Posture, 73, 8-13.

The purpose of this study was to investigate if lower limb joint kinetics change during the initial stages of independent ambulation among persons with lower-limb amputation. Nine males with unilateral lower-limb amputation completed instrumented gait analyses at 2 and 12-months post-independent ambulation. No differences existed between time points in total positive or negative work, at any joint in either plane and there were no differences in percent contribution by each joint to total average power by sagittal or frontal planes. The authors concluded that persons with unilateral lower-limb amputation do not alter power distribution among joints within the unaffected limb during initial independent ambulation. However, compared to previous cross-sectional reports, smaller peak powers in the unaffected hip and knee suggest mechanical work increases with time since amputation. Future research should monitor segment mechanics to determine when deleterious strategies develop, as these have implications for joint degeneration and pain.

Farrokhi, S., Mazzone, B., Moore, J., Shannon, K., & Eskridge, S. (2019). Physical therapy practice patterns for military Service members with lower limb loss. Military Medicine, 184(11-12), e907-e913. doi: https://doi.org/10.1093/milmed/usz107

The purpose of this study was to identify preferred PT practice patterns for military Service members with lower limb loss. This was a retrospective study, including 495 Service members with lower limb loss. A total of 86,145 encounters occurred during the first year after injury. Active treatments were included in 94% of all treatments, followed by manual therapy (15%), patient education (12%) and modalities (2%). The highest number of encounters, consisting of active and manual therapy, was received within the first 3 months by the patients with unilateral limb loss distal to the knee, while after the first 3 months, subjects with bilateral limb loss had higher encounters and received more active and manual therapy. Utilization of patient education was higher in the subjects with unilateral limb loss proximal to the knee and subjects with bilateral limb loss throughout the first year after injury. Service members with limb loss utilize PT services often within the first year after injury.

Mahon, C. E., Darter, B. J., Dearth, C. L., & Hendershot, B. D. (2019). The relationship between gait symmetry and metabolic demand in individuals with unilateral transfemoral amputation: A preliminary study. Military Medicine, 184(7-8), e281-e287. doi: https://doi.org/10.1093/milmed/usy424

The objective of this study was to determine whether temporal-spatial asymmetries account for greater metabolic energy expenditure in individuals with unilateral transfemoral amputation. The relationship between temporal-spatial gait asymmetry and metabolic economy (metabolic power normalized by walking speed) was retrospectively examined in 18 individuals with transfemoral amputation walking at a self-selected velocity overground. The relationship between: (1) step time symmetry and metabolic economy and (2) step length symmetry and metabolic economy were analyzed. The authors reported that there was no significant relationship between metabolic economy and either step time asymmetry or step length asymmetry.

Pickle, N. T., Silverman, A. K., Wilken, J. M., Fey, N. P. Statistical analysis of time series data reveals changes in 3D segmental coordination of balance in response to prosthetic ankle power on ramps. Scientific Reports, 9(1), 1272. doi: 10.1038/s41598-018-37581-9

How people regulate dynamic balance is different after amputation but it is not clear what underlining mechanisms drive those differences. This study analyzed the differences between active and passive prostheses and non-amputees, in coordination of balance throughout gait on ramps. Ten individuals with transtibial amputations and ten non-amputees were evaluated. This study identified significant changes in the mechanics of segmental coordination of balance during specific portions of the gait cycle, providing valuable biofeedback for targeted gait retraining.

Pruziner, A. L., Shaw, E. P., Rietschel, J. C., Hendershot, B. D., Miller, M. W., Wolf, E. J., Hatfield, B. D., Dearth, C.L., & Gentili, R. J. (2019). Biomechanical and neurocognitive performance outcomes of walking with transtibial limb loss while challenged by a concurrent task. Experimental Brain Research, 237(2), 477-491. doi: https://doi.org/10.1007/s00221-018-5419-8

The aim of this study was to concurrently evaluate temporospatial gait mechanics and cortical dynamics in a population with and without unilateral transtibial limb loss. Participants were asked to perform concurrent tasks of varying difficulty while seated and walking. All participants demonstrated a wider base of support and more stable gait pattern when walking and completing the high-demand concurrent task. These findings confirm and extend prior efforts indicating that dual-task walking can negatively affect walking mechanics and/or neurocognitive performance. These results highlight the need for future work to evaluation interactions between these cognitive-motor control systems for individual with more proximal levels of lower limb loss, and in more challenging environments. 

Quacinella, M., Bernstein, E., Mazzone, B., Wyatt, M., & Kuhn, K. (2018). Do spatiotemporal gait parameters improve after pilon fracture in patients who use the Intrepid Dynamic Exoskeletal Orthosis? Clinical Orthopaedics and Related Research, 477(4), 838-847. doi: 10.1097/CORR.0000000000000487

The purpose of this study was to determine whether the Intrepid Dynamic Exoskeletal Orthosis (IDEO) would improve gait parameters and decrease pain in patients with Pilon fractures. Seven subjects were evaluated. Authors reported, at selected walking speeds no clinically noted improvements in gait parameters or pain after application of the IDEO were observed.

Brown, S. E., Wilken, J. M., Russell Esposito, E., Fatone, S., & Ikeda, A. J. (2018). Evaluation of NU-FlexSIV socket performance for military Service members with transfemoral amputation. United States Army Medical Department Journal, 2018 Jul-Dec, 38-47.

The purpose of this study was to transfer the NU-FlexSIV Socket technique to military prosthetists and evaluate performance among Service Members with transfemoral amputation. Four subjects completed the study comparing the NU-FlexSIV Socket to the ischial containment socket. Gait kinematics, physical performance measures, limb-socket motion, and socket comfort were assessed after accommodation time in each socket. The NU-FlexSIV Socket provided greater hip motion across a variety of tasks without adversely affecting other movement mechanics but did not consistently improve socket comfort. Overall, the design was a viable alternative to traditional ischial containment sockets for some individuals with transfemoral amputation.

Schnall, B. L., Dearth, C. L., Elrod, J., Golyski, P. R., Ray, S. R., Koehler-McNicholas, S., Hansen, A. H., & Hendershot, B. D. (2019). A more compliant prosthetic foot better accommodates added load while walking among Service members with transtibial limb loss. Journal of Biomechanics. doi: https://doi.org/10.1016/j/jbiomech.2019.109395

Selecting an optimal prosthetic foot is challenging for highly active individuals with limb loss, who want to perform a variety of demanding activities while minimizing risk of musculoskeletal injuries. This study expanded on prior work by comparing biomechanical and functional outcomes in two prosthetic feet with the largest differences in mechanical response to added load (i.e., consistently “Compliant” and “Stiff” forefoot properties). In each foot, 14 male Service members with unilateral transtibial limb loss completed instrumented gait analyses in all combinations of two loading conditions and two walking speeds, and the Prosthesis Evaluation Questionnaire. The study found that the Stiff foot, sound limb peak loading was 2% smaller in the loaded versus unloaded condition, but similar between loading conditions in the Compliant foot. Independent of load or walking speed, the Compliant (versus Stiff) foot provided 67.9% larger prosthetic push-off, 17.7% larger roll-over shape radii, and was subjectively favored by 10 participants. A more Compliant versus Stiff prosthetic foot therefore appears to better accommodate walking with and without added load, and reinforce the notion that mechanical properties of prosthetic feet should be considered for near-term performance and longer-term (joint) health.

Nickel, E., Voss, G., Morin, S., Koehler-McNicholas, S., Hendershot, B. D., Schnall, B. L., Gravely, A., Barrons, K., Mion, S., & Hansen, A. H. (2019). Impact testing of prosthetic feet for high activity prosthesis users. Journal of Prosthetics and Orthotics, 31(3), 207-212. doi: 10.1097/JPO.0000000000000252

There are currently no accepted test standards for prosthetic feet to demonstrate durability to impact loading such as that encountered in physically demanding professions. The goal of the study was to build a system to pilot test the impact resilience of a selection of prosthetic feet marketed for high-activity prosthesis users. Three specimens each of nine prosthetic feet (n = 27 total) were selected. Maximum drop height without failure was used to assess impact resilience. The test system successfully measures impact resilience and is sensitive to foot type. Large effect sizes indicate substantial differences between prosthetic feet marketed for active prosthesis users.

Cancio, J. M., Edmondson, A., & Yancosek, K. E. (2018). Modified constraint-induced movement therapy for persons with unilateral upper extremity amputation: A case report. Journal of Hand Therapy, 31(1), 143-144. doi: 10.1016/j.jht.2017.11.005

Rates of prosthetic device abandonment are highest among persons with upper extremity (UE) amputation. Modified Constraint-Induced Movement Therapy (mCIMT), which has been extensively studied in patients with chronic, subacute, and acute stroke, is an under-utilized approach to treat persons with UE amputation. The purpose of this study was to present a  mCIMT intervention for prosthetic device training after unilateral UE amputation. Two subjects followed a standard UE amputation rehabilitation program in conjunction with a home training program using mCIMT. Both subjects exhibited an increase in observable and objective functional use with a UE prosthetic device. This case series suggests there may be a benefit to using mCIMT as an adjunct to traditional rehabilitation protocols.

Resnik, L. J., Frantzy, A., Borgia, M., Cancio, J. M., Latlief, F., Phillips, S., Sasson, N. (2018). EMG pattern recognition compared to foot control of the DEKA Arm. PLoS One. 2018 Oct 18;13(10):e0204854. doi:10.1371/journal.pone.0204854

EMG pattern recognition control (EMG-PR) is a promising option for control of upper limb prostheses with multiple degrees of freedom. The purposes of this study were to 1) evaluate outcomes of EMG-PR and inertial measurement units (IMU) control of the DEKA Arm as compared to personal prosthesis, and 2) compare outcomes of EMG-PR to IMU control of DEKA Arm. Thirty six subjects were non-randomized into two groups using two types of controls the EMG-PR and IMUs. The findings suggest that for persons with TR amputation, IMUs are a more effective control method for the DEKA Arm.

Cancio, J. M., Ikeda, A., Barnicott, S., Childers, W. L., Alderete, J., & Goff, B. (2019). Upper extremity amputation and prosthetics care across the active duty military and Veteran populations. Physical Medicine and Rehabilitation Clinics of North America, 30(1), 73-87. doi: 10.1016/j.pmr.2018.08.011.

Given the invaluable functions of the upper extremity in daily life, replacement of a missing limb through prosthetic substitution is challenging. This article provides an over-view of the care of the upper extremity amputee including surgical considerations, prosthetic design and fitting, and pre-prosthetic and post-prosthetic rehabilitation considerations. Because of the complexity of this area, patients are best served by centers with interdisciplinary teams experienced in UE amputation rehabilitation. Support (political, research funding, medical infrastructure, and emotional) for the combat injured continues to push innovations in UE amputation rehabilitation and these advances ultimately extend to the civilian health care sphere.

Acasio, J. C., Shojaei, I., Banerjee, R., Dearth, C. L., Bazrgari, B., & Hendershot, B.D. (2019). Trunk-pelvis motions and spinal loads during upslope and downslope walking among persons with transfemoral amputation. Journal of Biomechanics, 84, 67-72. doi: https://doi.org/10.1016/j.jbiomech.2019.109316

Larger trunk and pelvic motions in persons with lower limb amputation during activities of daily living (ADLs) adversely affect the mechanical demands on the lower back. This study characterized trunk-pelvic motions, trunk muscle forces, and resultant spinal loads among sixteen males with unilateral, transfemoral amputation (TFA) walking at a self-selected speed both up and down a 10-degree ramp. Compared to previous reports of persons with TFA walking on level ground, 5-60% larger anteroposterior and mediolateral shear observed here suggest greater mechanical demands on the low back in sloped walking, particularly upslope. Continued characterization of trunk motions and spinal loads during ADLs support the notion that repeated exposures to these larger-than-normal spinal loads contribute to an increased risk for low back injury following lower limb amputation.

Bhatnagar, V., Richard, E., Melcer, T., Walker, J., & Galarneau, M. (2019). Retrospective study of cardiovascular disease risk factors among a cohort of combat Veterans with lower limb amputation. Vascular Health and Risk Management, 15, 409-418

Veterans with either unilateral (n=442) or bilateral (n=146) lower limb amputation were compared to those with serious lower limb trauma without amputation (n=184) over an average of 8 years of follow-up. The results suggest that veterans with lower limb amputation have a higher risk for metabolic syndrome. Primary care interventions to manage weight, blood pressure, and lipid levels are fundamental in order to reduce cardiac risk in this relatively young cohort.

Butowicz, C. M., Acasio, J. C., Silfies, S., Nussbaum, M. A., & Hendershot, B. D. (2019). Chronic low back pain influences trunk neuromuscular control during unstable sitting among persons with lower-limb loss. Gait and Posture, 74, 236-241. doi: https://doi.org/10.1016/j.gaitpost.2019.09.019

Persons with unilateral lower-limb loss are at increased risk for developing chronic low back pain. However, it is unclear whether trunk postural control is associated with the presence or chronicity of low back pain within this population. Two groups of males with unilateral lower-limb loss (n = 18 with chronic low back pain; n = 13 without pain) performed an unstable sitting task. Trunk postural control was characterized using traditional and non-linear measures derived from center-of-pressure time series, as well as trunk kinematics and the ratio of lumbar to thoracic erector spinae muscle activations. The results suggest that persons with both lower-limb loss and chronic low back pain exhibit impaired trunk postural control compared to those with limb loss but without pain.

Mahon, C. E., Butowicz, C. M., Dearth, C. L., & Hendershot, B. D. (2019). Changes in trunk and pelvis motion among persons with unilateral limb loss during the first year of ambulation. Archives of Physical Medicine and Rehabilitation. doi: https://doi.org/10.1016/j.apmr.2019.08.476

The aim of this study was to retrospectively investigate trunk-pelvis kinematic outcomes among persons with unilateral transtibial and transfemoral limb loss with time from initial independent ambulation with a prosthesis, and describing self-reported presence and intensity of low pain. This study included 22 men with unilateral transtibial limb loss and 10 men with unilateral transfemoral limb loss. An interaction effect between time and group existed for sagittal and transverse continuous relative phase at self-selected walking velocity and transverse trunk range of motion and sagittal continuous relative phase at controlled walking velocity. Trunk range of motion decreased and trunk-pelvis coordination increased with increasing time after initial ambulation. Sagittal trunk and pelvis range of motion were always less and frontal trunk-pelvis coordination was always greater for persons with more distal limb loss. Low back pain increased for persons with transtibial limb loss and decreased for persons with transfemoral limb loss following the 4-month time point. Temporal changes (or lack thereof) in features of trunk-pelvis motions within the first year of ambulation help elucidate relationships between (biomechanical) risk factors for low back pain after limb loss.

Melcer, T., Walker, J., Sechriest II, V. F., Bhatnagar, V., Richard, E., Perez, K., & Galarneau, M. (2019). A retrospective comparison of five-year health outcomes following upper limb amputation and serious upper limb injury in the Iraq and Afghanistan conflicts. Physical Medicine and Rehabilitation Journal, 11(6), 577-589. doi: 10.1002/pmrj.12047

The purpose of this study was to compare health outcomes of 318 Service members, following serious upper limb injury during the first 5 years post injury. The authors reported a high prevalence of physical and psychological health diagnoses. The prevalence for nearly all wound complications and many physical and psychological disorders decreased substantially after post injury year 1. The prevalence of posttraumatic stress disorder increased significantly from post injury year 1 (20%) to year 3 (36%). Pain and psychological disorders ranged from 69% to 90% of patients during post injury year 1 and remained relatively high even post injury during year 5 (37%-53%). The results identify similarities and differences in clinical outcomes following combat-related upper limb amputation versus serious arm injury and can inform medical planning to improve rehabilitation programs and outcomes for these patients.

Rhon, D. I., Perez, K. G., & Eskridge, S. L. (2019). Risk of post‐traumatic knee osteoarthritis after knee injury in military service members. Musculoskeletal Care. 2019;1–7. doi: 10.1002/msc.1378

The aims of this study were: (a) to identify the incidence of osteoarthritis (OA) after a traumatic knee injury; (b) identify the risk of post-traumatic osteoarthritis (PTOA) based on the type of injury; and (c) identify the time from injury to OA diagnosis. A total of 345 (9.57%) of the 3,605 subjects were diagnosed with PTOA. The median time to diagnosis was 4.10 years. Four primary diagnoses remained significantly associated with PTOA after adjusting for age and injury severity score: fracture, sprain, dislocation and derangement. Subjects were significantly less likely to develop PTOA after a soft-tissue injury. A substantial number of individuals with a traumatic knee injury developed early PTOA (9.6%). Future studies should implement longer surveillance periods and identify other healthcare variables associated with the risk of developing PTOA, to include appropriate and timely interventions.

Yoder, A. J., Silder, A. B., Farrokhi, S., Dearth, C. L., & Hendershot, B. L. (2019). Lower extremity joint contributions to trunk control during walking in persons with transtibial amputation. Scientific Reports, 9, 12267. doi: 10.1038/s41598-019-47796-z

The aim of this work was to characterize associations between altered lower extremity joint moments and altered trunk dynamics in persons with unilateral, transtibial amputation (TTA). Full-body gait data were collected from 10 persons with TTA and 10 uninjured persons walking overground. Results showed persons with TTA had similar ankle moment magnitude relative to uninjured persons, but greater trunk angular acceleration induced by the prosthetic ankle which acted to lean the trunk ipsilaterally. Additionally, persons with TTA had a reduced knee extensor moment relative to uninjured persons, resulting in lesser sagittal and frontal induced trunk angular accelerations. These data indicate kinetic compensations at joints other than the lumbar and hip contribute to altered trunk dynamics in persons with a unilateral TTA. The findings may inform development of new clinical strategies to modify problematic trunk motion.

Shaw, E. P., Rietschel, J., Hendershot, B. D., Pruziner, A. L., Wolf, E. J., Dearth, C. L., Miller, M., Hatfield, B. D., & Gentili, R. J. (2019). A comparison of cognitive workload in individuals with transtibial and transfemoral lower limb loss during dual-task walking under varying demand. Journal of the International Neuropsychological Society, 25(9), 985-997. doi: https://doi.org/10.1017/S1355617719000602

The aim of this study was to evaluate the influence of lower limb loss (LL) on mental workload by assessing neurocognitive measures in individuals with unilateral transtibial (TT) versus those with transfemoral (TF) LL while dual-task walking under varying cognitive demand. Electroencephalography (EEG) was recorded as participants performed a task of varying cognitive demand while being seated or walking. The findings of this work suggests that both groups share some common but also different neurocognitive features during dual-task walking. Although all participants were able to recruit neural mechanisms critical for the maintenance of cognitive-motor performance under elevated cognitive or physical demands, the observed differences indicate that walking with a prosthesis, while concurrently performing a cognitive task, imposes additional cognitive demand in individuals with more proximal levels of amputation. This work can inform the development and assessment of rehabilitative interventions for individuals with lower extremity assistive devices such as prostheses and more generally populations whose control of posture or locomotion is compromised.

Cancio, J. M., & Rhee, P. (2018). Therapeutic management of the posttraumatic stiff elbow after open osteocapsular release. Techniques in Hand and Upper Extremity Surgery, 2018 Oct 8. doi: 10.1097/BTH.0000000000000207.

Postoperative management of the stiff elbow is challenging for both the surgeon and therapist. Effective communication between the referring surgeon and treating therapist is of utmost importance and will help establish functional goals and aid in developing a structured rehabilitative protocol that is individualized based on various patient factors. It is imperative the therapist perform an ongoing detailed assessment of function throughout the continuum of care and adjust the postoperative regimen as needed. The patient should be educated on the extensive nature of the rehabilitation process, specifically the home going program and orthosis wear schedule in order to achieve maximum elbow motion and functional potential. Although the surgical procedure for elbow osteocapsular release can result in marked improvement in elbow motion, post release rehabilitation is paramount to maintaining and even improving the gains achieved in surgery.

Cancio, J. M., Sgromolo, N. M., & Rhee, P. C. (2019). Blood flow restriction therapy after closed treatment of distal radius fractures. Journal of Wrist Surgery, 8(4), 288-294. doi: 10.1055/s-0039-1685455

This pilot study evaluated patient outcomes with a blood flow restricted (BFR) therapy program (n = 6) for closed management after a distal radius fracture compared to a traditional rehabilitation protocol (n = 7). The BFR group noted significantly greater reduction in pain with activity compared to the control group after 8 weeks of therapy. The two groups did not demonstrate any significant difference in radiographic outcomes. Larger studies are required to determine the efficacy and utility of adding this modality to a rehabilitation protocol in the upper extremity after a sustaining a distal radius fracture or other hand and wrist injuries.

Eskridge, S. L., Clouser, M. C., McCabe, C. T., Watrous, J. R., & Galarneau, M. R. (2019). Self-reported functional status in U.S. Service members after combat-related amputation. American Journal of Physical Medicine and Rehabilitation, 98, 631-635.

The objective of this study was to describe the functional status of Service members after combat-related amputation. The study sample included 82 Wounded Warriors with a combat-related lower extremity amputation who reported using a prosthetic device and completed the Orthotics and Prosthetics Users' Survey Lower Extremity Functional Status. Basic activities, such as walking indoors, getting on and off the toilet, and getting up from a chair, were reported by the majority of participants as "very easy/easy," whereas higher-level activities, such as climbing stairs, walking long distances, or running, were more often reported as "slightly difficult/very difficult" or "cannot do this activity." Functional status varied significantly by amputation site (unilateral below knee, unilateral above knee, or bilateral), with significantly better function reported in those with unilateral below knee than bilateral amputation. These findings highlight deficits in the functional status of US Service members with combat-related amputation. Self-reported functional status of daily activities may help target important activities for patient-centered goals.

Yoder, A., Mazzone, B., Miltenberger, R., & Farrokhi, S. (2019). Biomechanical improvements following foot strike biofeedback training for a patient using a passive dynamic ankle-foot orthosis during running. Prosthetics and Orthotics International, 43(4), 447-452. doi: https://doi.org/10.1177/0309364619851935

Passive dynamic ankle-foot orthoses have potential to facilitate return to running after a lower limb trauma. The purpose of this case study was to report biomechanical and functional outcomes for a patient utilizing a passive dynamic ankle-foot orthoses following completion of a session-based, midfoot strike run training program. After treatment, foot strike was changed from rearfoot to midfoot on the affected limb along with an 18% increase in mechanical work ratio of the ankle-foot-brace complex. Similar improvements were retained at one and five months following treatment. This report provides preliminary evidence that biofeedback-based foot strike training can enhance ankle-foot mechanical performance of patients using a passive dynamic ankle-foot orthoses to run. Therefore, patients using a passive dynamic ankle-foot orthoses to run following lower limb trauma, supplementing standard rehabilitation programs with biofeedback-based footstrike training may improve biomechanical performance and running capability.

Webster, J., Crunkhorn, A., Sall, J., Highsmith, M., Pruziner, A., & Randolph, B. (2019). Clinical practice guidelines for the rehabilitation of lower limb amputation: An update from the Department of Veterans Affairs and Department of Defense. American Journal of Physical Medicine and Rehabilitation. 2019 Sep; 98(9), 820-829. doi: 10.1097/PHM.0000000000001213

The US Department of Veterans Affairs and the US Department of Defense developed a clinical practice guideline for rehabilitation of lower limb amputation to address key clinical questions. This clinical practice guideline used the best available evidence from the past 10 years to provide key management recommendations to enhance the quality and consistency of rehabilitation care for persons with lower limb amputation. Recommendations include: 1) The importance of patient education across the continuum of care, 2) The performance of routine, periodic assessments during each phase of care that include inquiries into mental health concerns, social functioning, spiritual beliefs, and coping mechanisms 3) Pain should be assessed with standardized and validated tools, 4) Offer a multimodal, transdisciplinary individualized approach to pain management throughout all rehabilitation phases, 5) The patient's birth sex and self-identified sex identity should be considered in the development of treatment plans, 6) The early involvement of family members and contact with other patients with amputations is important for the patient's psychological adjustment 7) Before surgery the patient, caregiver and rehabilitation team engage in shared decision-making about residual limb length, amputation level, and rehabilitation goals and 8) Preoperative shared decision- making and a transdisciplinary team approach will help the clinical care team meet the goals of a well-shaped and well-healed postsurgical limb allowing for the initiation of prosthesis use.

Oliver, R. A., Cancio, J. M., Rábago, C. A., & Yancosek, K. E. (2019). Impact of firearms training in a virtual reality environment on occupational performance (marksmanship) in a polytrauma population. Military Medicine, 184(11-12), 832-838. doi: https://doi.org/10.1093/milmed/usz010

The purpose of this report is to describe marksmanship (shot grouping and weapon qualification) and return to duty outcomes following a course of Virtual Reality Environment based firearm training in 30 polytrauma patients. The results showed that the mean shot group sizes for the M9 and M4 weapon decreased between initial and post training time points for the M9 zero and M4 zero. There were no significant difference between initial and post training time points at the other shooting distances with either weapon. There was an 89% qualification rate for both the M9 and M4 weapons. The ability to correctly shoot a designated target depends on many cognitive and physical factors. Thus, the Service Member’s ability to utilize small arms weapons, performing an essential warrior task, may be considered when evaluating for return to duty.

Melcer, T., Walker, J., Bhatnagar, V., & Richard, E. (2019). Clinic use at the Departments of Defense and Veterans Affairs following combat related amputations. Military Medicine, 27 June, 2019. doi: 10.1093/milmed/usz149.

This was a retrospective analysis of 649 US Service members who sustained a single major limb amputation following injuries in the Iraq and Afghanistan conflicts, 2001-2008. The study indicated a gradual transition from DoD to VA only healthcare which extended across 5 years following combat related amputations. Patients with lower levels of amputation or early amputation generally transitioned earlier to VA only healthcare. These results can inform medical planning to support a timely and clinically effective transition from DoD to VA healthcare.

Kerns, R. D., Brandt, C. A., & Peduzzi, P. (2019). NIH-DoD-VA Pain Management Collaboratory. Pain Medicine, 20(12), 2336-2345. doi: https://doi.org/10.1093/pm/pnz186

This paper discusses the NIH-DoD-VA Pain Management Collaboratory (PMC). The PMC is focused on developing, implementing, and testing cost-effective, large-scale, real-world research on nonpharmacological approaches for management of pain and comorbid medical and mental health conditions in DoD and VA health care delivery organizations.

Rose, L. F., Wolf, E. J., Brindle, T., Cernich, A., Dean, W. K., Dearth, C. L., & Randolph, B. J. (2018). The convergence of regenerative medicine and rehabilitation: Federal perspectives. NPJ Regenerative Medicine, 3, 19. doi: https://doi.org/10.1038/s41536-018-0056-1

Encouraging clinicians and researchers from multiple disciplines to work collaboratively and synergistically will maximize restoration of function and quality of life for disabled and/or injured patients, including U.S. Veterans and Military Service members. Federal Government agencies have been investing in research and clinical care efforts focused on regenerative medicine (NIH, NSF, VA, and DoD), rehabilitation sciences (VA, NIH, NSF, DoD) and, more recently, regenerative rehabilitation (NIH and VA). As science advances and technology matures, researchers need to consider the integrative approach of regenerative rehabilitation to maximize the outcome to fully restore the function of patients. While regenerative medicine offers tremendous clinical promise, regenerative rehabilitation offers the opportunity to positively influence regenerative medicine by inclusion of principles from rehabilitation sciences. Regenerative medicine by itself may not be sufficient to ensure successful translation into improving function. Conversely, with a better understanding of regenerative medicine principals, rehabilitation researchers can better tailor rehabilitation efforts to accommodate and maximize the potential of regenerative approaches. Critical barriers in translating regenerative medicine techniques into humans may be difficult to overcome if preclinical studies do not consider outcomes that typically fall in the rehabilitation research domain, such as function, range of motion, sensation, and pain.