Acasio, J. C., Guerrero, N. A., Sheehan, R. C., Butowicz, C. M., Tullos, M. L., Mahon, C. E., Stewart, J. M., Zai, C. Z., Kingsbury, T. D., Grabiner, M. D., Dearth, C. L., Kaufman, K. R., & Hendershot, B. D. (2021). Assessments of trunk postural control within a fall-prevention training program for Service members with lower limb trauma and loss. Gait & Posture, 2021. doi: 10.1016/j.gaitpost.2021.02.020

Trunk postural control is critical in avoiding falls and is impaired among persons with lower extremity trauma, elevating their fall risk. Although, a fall-prevention program improves TPC in individuals with unilateral transtibial amputation following trip-inducing perturbations, the results of this study suggest that a fall prevention program is task specific and does not translate to another tasks such as unstable sitting. Twenty-five individuals with lower extremity trauma were included in this prospective study.

Acasio, J. C., Nussbaum, M. A., & Hendershot, B. D. (2021). Trunk-pelvic coordination during unstable sitting at varying task demand: A methodological study. Journal of Biomechanics, 118, Article #110299. doi: 10.1016/j.jbiomech.2021.110299

Unstable sitting is used commonly to evaluate trunk postural control, typically via measures based on center-of-pressure time series. Assessing thirteen uninjured individuals, the authors reported that vector coding techniques are able to discriminate between levels of instability during unstable sitting and, compared to traditional center-of-pressure based measures, serve as a unique TPC measure that is more directly indicative of underlying movement strategies. These results validate the feasibility for evaluating trunk-pelvic movement coordination strategies during unstable sitting.

Anderson, A. B., Tenan, M. S., MOTION Group (Mauntel, T. C.) & Dickens, J. F. (2021). Latent factor analysis of the PROMIS and single assessment numeric evaluation in patients undergoing shoulder surgery. Military Medicine, 2021, usab327. doi:10.1093/milmed/usab327

The purpose of this retrospective study (n=805) was to examine the relationship of the Single Assessment Numeric Evaluation (SANE) score and general constructs measured with the NIH Patient-Reported Outcomes Measurement Information System (PROMIS). The results of this study supports the use of the SANE as a valid single question to assess physical function providing similar information to the PROMIS in regard to measuring physical capabilities.

Butowicz, C. M., Acasio, J. C., & Hendershot, B. D. (2021). Trunk postural control strategies among persons with limb loss while walking and performing concurrent tasks. Journal of Applied Biomechanics, 37(2), 139-144. doi: 10.1123/jab.2020-0001

Altered trunk movements during gait in persons with lower-limb amputation are often associated with an increased risk for secondary health conditions. In this secondary analysis of 16 males with amputations and 8 uninjured males (controls) the authors reported that individuals with transfemoral amputation walked with wider strides compared with individuals with transtibial amputation and controls. Individuals with amputation demonstrated more trunk kinematic variability in the presence of wider strides, and performing a concurrent cognitive task while walking did not change trunk or gait mechanics.

Butowicz, C. M., Yoder, A. J., Mazzone, B., Farrokhi, S., & Hendershot, B. D. (2021). Lower limb joint-specific contributions to standing postural sway in persons with unilateral lower limb loss. Gait & Posture, 89, 109-114. doi: 10.1016/j.gaitpost.2021.06.020

Individuals with lower limb loss are at an increased risk for falls, likely due to impaired balance control. The authors explored to what extent do hip, knee, and ankle joint motions contribute to postural sway in standing among individuals with lower limb loss. Investigating 42 individuals with unilateral lower limb loss (30 transtibial, 12 transfemoral), authors reported hip, knee, and ankle motions influence postural sway during standing balance. Increasing intact-side hip flexion, knee extension, and ankle plantarflexion motion increased postural sway.

Cancio, J. M., Eskridge, S., Shannon, K., Orr, A., Mazzone, B., & Farrokhi, S. (2021). Development of overuse musculoskeletal conditions after combat-related upper limb amputation: A retrospective cohort study. Journal of Hand Therapy, 2021, ISSN 0894-1130. doi: 10.1016/j.jht.2021.05.003

The results of this retrospective cohort study demonstrated that the incidence of secondary overuse conditions is elevated in Service Members with upper limb loss. Specifically Service Members developing at least one musculoskeletal overuse condition after upper limb amputation was between 60% and 65%. The conditions included, overuse of the upper limb, neck and upper back, lower limb, and low back pain. One goal of rehabilitation should focus on prevention of secondary overuse conditions in this population. 

Colantonio, D. F., Le, A. H.,  Keeling, L. E., Slaven, S. E., Vippa, T. K., Helgeson, M. D., & Chang, E. (2021). Intramedullary unicortical button and all-suture anchors provide similar maximum strength for onlay distal biceps tendon repair. Arthroscopy: The Journal of Arthroscopic & Related Surgery, 2021, ISSN 0749-8063. doi: 10.1016/j.arthro.2021.06.036

The purpose of this study was to evaluate the biomechanical profile of onlay distal biceps repair with an intramedullary unicortical button versus all-suture anchors under cyclic loading and maximal load to failure. Twenty paired fresh-frozen human cadaveric elbows were randomized to onlay distal biceps repair with either a single intramedullary button or with two 1.35-mm all-suture anchors. The study suggests that all-suture anchors and unicortical intramedullary button have similar maximum strength at time zero. Both constructs provide suitable fixation for onlay distal biceps repair.

Dingwell, J. B., Cusumano, J. P., Rylander, J. H., & Wilken, J. M. (2020). How persons with transtibial amputation regulate lateral stepping while walking in laterally destabilizing environments. Gait and Posture, 83, 88-95. doi: 10.1016/j.gaitpost.2020.09.031

Persons with lower limb amputation often experience decreased physical capacity, difficulty walking, and increased fall risk and to prevent or recover from a loss of balance, they must regulate their stepping movements. Therefore, it is critical to identify how well persons with amputation regulate stepping. The objective of this study was to identify how persons with transtibial amputation (TTA) regulate lateral stepping while walking with and without lateral perturbations. Eight persons with unilateral TTA and thirteen able-bodied (AB) controls walked in a virtual environment under different conditions. Participants with TTA exhibited only a few minor differences from AB in lateral stepping regulation. Since control of stepping is intrinsically multi-objective, multi-objective approaches should be used when developing effective interventions to reduce fall risk in persons with amputation. 

Dolan, C. P., Valerio, M. S., Childers, W. L, Goldman, S. M., & Dearth, C. L. (2021). Prolonged field care for traumatic extremity injuries: Defining a role for biologically focused technologies. npj Regenerative Medicine, 6(1), 1-4. doi: 10.1038/s41536-020-00117-9

Duncan, J. C., Childers, W. L., & Pete, J. P. (2020). The effect of providing rehabilitation technology services through vocational rehabilitation in persons with amputation. Journal of Physical Medicine, Rehabilitation and Disability, 2020, 6: 060. doi: 10.24966/PMRD-8670/100060

The objective of this research was to define the effect of receiving rehabilitation technology through Vocational Rehabilitation services on employment outcomes. Individuals that had amputation listed as the primary impairment within 2007 and 2012 and used VR services were included in this study. Of 10,107 cases 65.7% achieved a positive employment outcome. Therefore, the results of this study suggest that providing rehabilitation technology significantly improved the odds of gaining employment. 

Elrod, J. M., Schnall, B. L., Mauntel, T. C., Watson, N. L., Koehler-McNicholas, S. R., Nickel, E. A., Hansen, A. H., Dearth, C. L., & Hendershot, B. D. (2021). Biomechanical characterization of the foot-ground interaction among Service members with unilateral transtibial limb loss performing unconstrained drop landings: Effects of drop height and added mass. Journal of Biomechanics, 127, Article 110701. doi: 10.1016/j.jbiomech.2021.110701

The purpose of this study was to biomechanically characterize foot–ground interactions during drop-landings among Service Members with and without unilateral transtibial limb loss. Seven males with, and seven males without, unilateral transtibial limb loss completed six drop-landing conditions consisting of all combinations of three heights (20 cm, 40 cm, 60 cm) and two loads (with and without a 22.2 kg weighted vest). Better understanding biomechanical responses to drop-landings in ecological scenarios will help inform future iterations of mechanical testing methodologies for evaluating impact resilience of prosthetic ankle–foot systems (enhancing prescription criteria and return-to-activity considerations) as well as identifying and mitigating risk factors for long-term secondary complications within the contralateral limb (e.g., joint degeneration).

Epperson, R. T., Isaacson, B. M., Rothberg, D. L., Olsen, R. E., Kawaguchi, B., Maxwell, J. M., Dickerson, M., Pasquina, P. F., Shero, J. C., & Williams, D. L. (2021). Developing a combat-relevant translatable large animal model of heterotopic ossification. Bone Reports, 15(2021), 101127, ISSN 2352-1872. doi: 10.1016/j.bonr.2021.101127

Of the 70% of war wounds involved the musculoskeletal system, heterotopic ossification (HO) is reported to occur in approximately 63%–65% of wounded warriors. The authors hypothesized that using a high-power blast of air and simulated battlefield trauma in a large animal model, HO would form and have similar morphology to ectopic bone observed in clinical samples. Initial radiographic and microcomputed tomography (CT) data demonstrated ectopic bone growth in sheep 24 weeks post-procedure. Advanced histological and backscatter electron (BSE) analyses showed that 5 out of 8 (63%) sheep produced HO with similar morphology to clinical samples. The authors concluded that not all ectopic bone observed by radiograph or micro-CT in animal models is HO. Advanced histological and BSE analyses may improve confirmation of HO presence and morphology, which was demonstrated in a large animal model.

Farrokhi, S., Russell Esposito, E., McPherson, D., Mazzone, B., Condon, R., Patterson, C. G., & Hendershot, B. D. (2020). Resolving the burden of low back pain in military service members and Veterans (RESOLVE): Protocol for a multisite pragmatic clinical trial. Pain Medicine, 21(2), S45-S52. doi: 10.1093/pm/pnaa367

The purpose of this manuscript is to describe the developing protocol titled, “Resolving the burden of low back pain in military service members and veterans (RESOLVE)”. The RESOLVE trial will provide a pragmatic approach to evaluate whether better adherence to PT CPGs can reduce pain, disability, medication use, and LBP care cost within the DOD and VA health care systems.

Fritz, J. M., Davis, A. F., Burgess, D. J., Coleman, B., Cook, C., Farrokhi, S., & Rhon, D. I. (2020). Pivoting to virtual delivery for managing chronic pain with nonpharmacological treatments: Implications for pragmatic research. Pain, 162(6), 1591-1596. doi: 10.1097/j.pain.0000000000002139

Goldman, S. M., Janakiram, N. B., Valerio, M. S., & Dearth, C. L. (2021). Evaluation of licofelone as an adjunct anti-inflammatory therapy to biologic scaffolds in the treatment of volumetric muscle loss. Cell Tissue Research, 385, 149–159. doi: 10.1007/s00441-021-03449-0

Biologic scaffolds (BS) are the most widely studied therapeutics for the treatment of volumetric muscle loss (VML), however, variability in reports on the nature of the immune response to their implantation suggests BS-associated inflammation may be limiting their regenerative efficacy. This study evaluated licofelone, as an anti-inflammatory adjunct therapy to a BS in the treatment of VML. Findings suggest that efforts related to modulating the wound healing environment of VML should focus on polypharmaceutical strategies that target multiple aspects of the early pathophysiology of VML to provide an environment that is sufficiently permissive for local regenerative therapies to promote restoration of myofiber number.

Le, A. H., Roach, W. B., Mauntel, T. C., Hendershot, B. D., Helgeson, M. D., Colantonio, D. F., Fredericks, D. R., Slaven, S. E., Pisano, A. J., & LeClare, L. E. (2021). A biomechanical comparison of high-tensile strength tape versus suture for tendon fixation under cyclic loading. Arthroscopy: The Journal of Arthroscopic & Related Surgery, 37(9), 2925-2933. doi: 10.1016/j.arthro.2021.04.016

The purpose of this study was to compare the biomechanical properties of high-tensile strength tape and high-tensile strength suture across 2 selected stitch techniques, the Krackow and whip stitch, in securing tendinous tissue loading followed by a load to failure. Fourteen matched pairs each of cadaveric Achilles, quadriceps, and patellar tendons (n ¼ 84) were randomly assigned to either Krackow or whip stitch.

The results indicate that tape used in the Krackow stitch maintains the most favorable fixation strength. In addition, overall normalized elongation during long-term cyclic loading was predominately affected by the stitch technique used, regardless of the suture material; however, tape allowed less normalized elongation during the initial loading cycles, especially when placed in the whip stitch. Understanding the potential short- and long-term outcomes of suture material and stitch technique on securing tendinous tissue under repetitive stresses can help inform clinicians on optimal tendon fixation techniques for early postoperative activities.

Lin, Y. A., Zhao, Y., Wang, L., Park, Y., Yeh, Y. J., Chiang, W. H., & Loh, K. J. (2021). Graphene k‐tape meshes for densely distributed human motion monitoring. Advanced Materials Technologies, 6(1), 1-9. doi: 10.1002/admt.202000861

This study complements the existing body of work and presents a flexible, self-adhering, fabric-based wearable sensor for measuring skin strains and human motions. Graphene nanosheet thin films are directly spray-coated onto kinesiology tape (K-Tape) to obtain a self-adhering strain sensor of high sensitivity and linearity. Their stable sensing performance and high repeatability are verified, while human subject tests confirm that they adequately capture muscle engagement during functional movements. The results show promise for using graphene K-Tape meshes to measure how specific major muscle groups engage during different physical activities.

Major, M. J., Hansen, A. H., & Esposito, E. R. (2021). Focusing research efforts on the unique needs of women prosthesis users. Journal of Prosthetics and Orthotics, 8 Jan 2021. doi: 10.1097/JPO.0000000000000353

Women with limb loss experience greater dissatisfaction with prosthetic fit, appearance, and types of footwear they can use. The purpose of this narrative review was to describe the considerations of lower-limb prosthesis prescription and use by women, and examples of current research to address these topics. Research efforts are beginning to explore factors that contribute to prosthetics prescription for women and to design creative prosthetics solutions to expand the range of available footwear options. 

Mazzone, B., Yoder, A., Condon, R., & Farrokhi, S. (2021). Clinical application of foot strike run retraining for military service members with chronic knee pain. BMJ Military Health, 25 May 2021. doi: 10.1136/bmjmilitary-2021-001789

The purpose of this report was to demonstrate that run retraining is beneficial as a clinical intervention for service members with knee pain. Sixteen service members with running-related chronic knee pain underwent run retraining that converted foot strike from a rearfoot to a non-rearfoot strike using real-time visual feedback. The authors reported Knee pain and function improved as a result of non-rearfoot strike run retraining, therefore, supporting the run retraining methods as a feasible intervention for chronic knee pain. 

Miller, R. H., & Esposito, E. R. (2021). Transtibial limb loss does not increase metabolic cost in three-dimensional computer simulations of human walking. PeerJ, 9, e11960. doi: 10.7717/peerj.11960

Loss of a lower limb below the knee and subsequently walking with a prosthesis, is generally thought to increase the metabolic cost of walking vs. able bodied controls. However, high-functioning individuals with limb loss such as military service members often walk with the same metabolic cost as controls. The purpose of this study was to investigate if transtibial limb loss in and of itself causes an increase in metabolic cost of walking. The results suggest that transtibial limb loss does not directly lead to an increase in metabolic cost, even when deviations from able-bodied gait mechanics are minimized. High metabolic costs observed in individuals with transtibial limb loss may be due to secondary changes in strength or general fitness after limb loss, modifiable prosthesis issues, or to prioritization of factors that affect locomotor control other than gait deviations and muscular effort.

Motherwell, J. M., Hendershot, B. D., Goldman, S. M., & Dearth, C. L. (2021). Gait biomechanics: A clinically relevant outcome measure for preclinical research of musculoskeletal trauma. Journal of Orthopaedic Research, 39, 1139–1151. doi: 10.1002/jor.24990

The objective of this review is to emphasize the clinical relevance and application of gait biomechanics as a functional outcome measure for preclinical research studies evaluating the efficacy of tissue engineering and regenerative medicine therapies to treat traumatic musculoskeletal injuries. This review used common musculoskeletal injuries including volumetric muscle loss, post-traumatic osteoarthritis, and composite tissue injuries to highlight the use of gait biomechanics as an outcome measure.

Pitkin, M., Cassidy, C., Shevtsov, M. A., Jarrell, J. R., Park, H., Farrell, B. J., Dalton, J. F., Childers, W. L., Kistenberg, R. S., Oh, K., Klishko, A. N., & Prilutsky, B. I. (2021). Recent progress in animal studies of the skin – and bone-integrated pylon with deep porosity for bone-anchored limb prosthetics with and without neural interface. Military Medicine, 186(S1), 688-695. doi: 10.1093/milmed/usaa445

This study investigated the improved titanium skin-bone integrated pylon to provide an infection-free and secure interface that can be used to route feedforward and feedback information to/from a powered prosthesis. The results showed that the use of the prosthesis increased vertical loading to nearly normal values and the dorsal implantation resulted in the infection-free deep ingrowth of skin into the skin- and bone-integrated pylon implants in cats.

Resnik, L., Borgia, M., Cancio, J., Heckman, J., Highsmith, J., Levy, C., Phillips, S., & Webster, J. (2020). Dexterity, activity performance, disability, quality of life, and independence in upper limb Veteran prosthesis users: A normative study. Disability and Rehabilitation, 2020 Oct 18;1-12. doi: 10.1080/09638288.2020.1829106

This study provides population-based, comparative data on dexterity, activity performance, disability, quality of life, and independence in upper limb prosthesis users. One hundred and twenty-seven individuals participated, 59% percent body-powered prostheses users. All measures of dexterity differed by amputation level and by laterality. All measures of activity differed by amputation level with the best scores in transradial amputation groups. Comparisons of body-powered users with transradial amputation found that dexterity was better for those with bilateral compared to unilateral amputation.

Resnik, L., Borgia, M., Ekerholm, S., Highsmith, M. J., Randolph, B. J., Webster, J., & Clark, M. A. (2021). Amputation care quality and satisfaction with prosthetic limb services: A longitudinal study of Veterans with upper limb amputation. Federal Practitioner, 38(3), 110-120. doi: 10.12788/fp.0096 

The purpose of this study was to measure and identify factors associated with satisfaction with care among veterans receiving prosthetic limb care at the US Department of Veterans Affairs (VA) and US Department of Defense (DoD) care settings and at community-based care providers. A longitudinal cohort of veterans with major upper limb amputation receiving any VA care from 2010 to 2015 were included in this study. Care satisfaction, client satisfaction survey, prosthesis satisfaction and care quality was measured. The study included 808 baseline participants and 585 follow-up participants. The authors reported that satisfaction with prosthetic limb care is associated with device satisfaction and receipt of care within the prior year. Veterans receiving amputation care within the VA or DoD received better care quality scores than those receiving prosthetic care outside of the VA or DoD. Satisfaction with care and quality of care were stable over the 12 months of this study.

Russell Esposito, E., Ruble, M. D., Ikeda, A. J., & Wilken, J. M. (2021). The effect of custom carbon ankle-foot orthosis alignment on roll-over shape and center of pressure velocity. Prosthetics Orthotics International, 45(2), 147-152. doi: 10.1177/0309364620971407

Maintaining an optimal rolling of the foot over the ground is thought to increase the stability and efficiency of pathologic gait. Ankle-foot orthoses are often prescribed to improve gait mechanics in individuals with lower extremity injuries; however, their design may compromise how the foot rolls over the ground. The aim of this study was to investigate the effects of the sagittal plane ankle-foot orthosis alignment on rollover shape and center of pressure velocity in individuals with lower limb reconstructions. Twelve individuals with lower limb reconstruction who used a custom carbon ankle-foot orthosis and 12 uninjured controls underwent gait analysis. The authors reported that the individuals using custom carbon ankle-foot orthoses can accommodate 3° alterations in the dorsiflexion or plantarflexion alignment; different alignments within this range do not impact roll-over shape during walking.

Sheehan, R. C., Fain, A. C., Wilson, J. B., Wilken, J. M., & Rabago, C. A. (2020). Inclusion of a military-specific, virtual reality-based rehabilitation intervention improved measured function, but not perceived function, in individuals with lower limb trauma. Military Medicine, 17 Nov 2020;usaa483. doi: 10.1093/milmed/usaa483

Military service places high physical demands on service members (SMs). Standard treatment interventions often fail to align with these unique demands. This study evaluated the effectiveness of military-specific VR based rehab intervention supplemental to standard care to improve performance in SMs with LE injuries. The authors reported that the inclusion of military specific treatment in a simulated VR environment improved activity tolerance in SMs with LE injuries. However, VR did not lead to improvements in stability or shooting performance.

Shuman, B. R., & Russell Esposito, E. (2021). Multiplanar stiffness of commercial carbon composite ankle-foot orthoses. Journal of Biomechanical Engineering, 144(1). doi: 10.1115/1.4051845

The mechanical properties of an ankle-foot orthosis can impact how a user’s movement is either restricted or augmented by the device. However, standardized methods for assessing stiffness properties of AFOs are lacking, posing a challenge for comparing between devices and across vendors. The purpose of this study was to quantify the rotational stiffness of thirteen commercial, nonarticulated, carbon composite ankle-foot orthoses. These results directly compare AFOs of different models and from different manufacturers using consistent methodology and can be a tool through which clinicians can apply their expertise in identifying appropriate AFOs for their patients.

Watrous, J. R., McCabe, C. T., Jones, G., Mazzone, B., Farrokhi, S., Eskridge, S. L., & Galarneau, M. R. (2021). The relationships between self-reported pain intensity, pain interference, and quality of life among injured U.S. Service members with and without low back pain. Journal of Clinical Psychology in Medical Settings, 28, 746–756. doi: 10.1007/s10880-020-09759-9

Low back pain is a prevalent military and veteran health problem. This study examined the prevalence of low back pain among individuals with deployment-related injuries, compared their self-reported pain intensity and interference ratings, and assessed the relationship between low back pain, self-reported pain ratings, and quality of life. The individuals with low back pain reported significantly higher intensity and interference due to their pain than individuals without low back pain. The results highlight the importance of patient-reported indicators of pain for assessing long-term quality of life.

Wilson, J. B., Rábago, C. A., Hoppes, C. W., Harper, P. L., Gao, J., & Russell Esposito, E. (2021). Should I stay or should I go? Identifying intrinsic and extrinsic factors in the decision to return to duty following lower extremity injury. Military Medicine, 186(1), 430-439. doi: 10.1093/milmed/usaa350

The purpose of this study was to identify the intrinsic and extrinsic factors influencing patients and clinicians decision to return to duty after severe lower extremity trauma. Thirty-two service members with severe lower extremity trauma and 30 providers with at least two years’ experience caring for SMs with similar injuries participated focus groups. The authors reported that individual (health condition, personal traits, and career consideration), interpersonal (clinician’s impact, family influence, and peer influence), healthcare system (systems of care, transdisciplinary rehabilitation, and innovation availability), and institutional (policy, benefits, and unit/commander) themes emerged amongst SM patients and clinicians. Service members placed less emphasis on severity of injury and greater emphasis on system and policy barriers than did clinicians. Understanding the characterization and classification of these clinician and SM that influence the decision to RTD after severe lower extremity trauma will improve the efficacy of future rehabilitation efforts and clinical practice guidelines by providing the clinical team the barriers to patient success.