Acasio, J. C., Butowicz, C. M., Dearth, C. L., Bazrgari, B., & Hendershot, B. D. (2022). Trunk muscle forces and spinal loads while walking in persons with lower limb amputation: Influences of chronic low back pain. Journal of Biomechanics, 135(2022). doi: 10.1016/j.jbiomech.2022.111028

Lower back pain is a common problem facing individuals with lower limb loss. To further identify potential risk for lower back pain after amputation, the contribution of increased physical loads on the spine was evaluated. Contrary to what was expected, this study did not find a correlation between increased spinal loads and lower back pain. While several study limitations were noted (such as the inability to evaluate temporal relationships), the investigators hypothesized that gait modulation may be partly responsible for lower back pain in individuals with lower limb loss.

Acasio, J. C., Tullos, M. L., Mahon, C. E., Khatri, B. R., Kaufman, K. R., Dearth, C. L., & Hendershot, B. D. (2022). A single-subject comparison of functional outcomes between lower limb salvage versus transtibial amputation through sequential participation in a fall-prevention program. Prosthetics and Orthotics International, 46(4), 614-618. doi: 10.1097/PXR.0000000000000156

This case study is the first to prospectively compare functional and subjective outcomes for an individual with transtibial amputation after prolonged limb salvage. This study further supports earlier retrospective studies that show that delayed or late transtibial amputation in some cases may improve outcomes and reduce the risk of falling.

Adusei, K. M., Ngo, T. B., Alfonso, A. L., Lokwani, R., DeStefano, S., Karkanitsa, M., Spathies, J., Goldman, S. M., Dearth, C. L., & Sadtler, K. N. (2022). Development of a high-color flow cytometry panel for immunologic analysis of tissue injury and reconstruction in a rat model. Cells Tissues Organs, 212(1), 84-95. doi: 10.1159/000524682

Studying immune responses in rat models is hampered by the lack of sufficient materials to properly identify specific populations of immune cell types as well as their functional state. This study capitalizes on the full spectrum of light emission captured by flow cytometry to identify unique sub-populations of immune cells in a rat volumetric muscle loss model. This study adds additional tools and information that can be used to further understand the role of the immune system in volumetric muscle loss injuries.

Baumann, M., Price, C., Brousseau, L., Loftsgaarden, M., Powell, J., Sanders, J., & Childers, W. L. (2022). The relationship between residual limb health, motion within the socket, and prosthetic suspension. Physical Medicine and Rehabilitation, 15 September 2022. doi: 10.1002/pmrj.12899

This review examines residual limb movement within the prosthetic socket in relation to limb health. Direct studies comparing residual limb health and motion are limited, however, the literature suggests that elevated vacuum suspension systems resulted in both improved residual limb health compared to passive suction and pin-lock systems and had decreased motion compared to passive suction, pin-lock, knee sleeve, and anatomical suspension systems. Further investigation into the role of residual limb motion within the prosthetic socket and skin health are warranted.

Butowicz, C. M., Yoder, A. J., Farrokhi, S., Mazzone, B., & Hendershot, B. D. (2022). Low back pain influences lumbar-lower limb joint coordination and balance control during standing in persons with lower limb loss. Clinical Biomechanics, 92(2022). doi: 10.1016/j.clinbiomech.2022.105580

With eyes closed, persons with lower limb loss and low back pain demonstrated altered balance strategies between the trunk and lower limb. These strategies were not present in volunteers with lower back pain when their eyes were open or in the control group that lacked lower back pain.  This study reinforces the importance of the visual field in maintaining balance in individuals with lower limb loss.

Chang, E. S., Le, A.H., Looney, A. M., Colantonio, M. D. F., Roach, C. W. B., Helgeson, C. M. D., Clark, D M., Fredericks, D. R., & Nagda, S. H. (2021). Biomechanical comparison of anatomic restoration of the ulnar footprint vs traditional ulnar tunnels in ulnar collateral ligament reconstruction. The American Journal of Sports Medicine, 50(5), 1375-1381. doi: 10.1177/03635465211054475

Traditional Ulnar Collateral Ligament reconstruction primarily uses the docking technique. To investigate potential improvements of this technique, a series of biomechanical studies were conducted in cadaveric elbows using alternate (anatomical) tunnel locations. In cadaveric elbows, the anatomical technique had similar biomechanical properties of the docking technique and may provide greater area for tendon bone healing, easier visualization of the graft and decreasing risk of ulnar nerve injury. 

Cooper, K. J., Fain, A., & Childers, W. L. (2022). Back squat mechanics in persons with a unilateral transtibial amputation: A case study. Prosthetics and Orthotics International, 46(1), 50-53. doi: 10.1097/PXR.0000000000000058

Back squats are a widely used in rehabilitation treatment programs and may provide insight into compensatory mechanisms used by lower extremity amputees. In this report, a participant with a transtibial amputation was monitored using motion capture with reflective markers. While the individual used a hip-dominate strategy in both the amputated and sound limb, the study suggests that prosthetic foot energy storage and return could aid in the performance of tasks with similar movement characteristics.

Crunkhorn, A., Andrews, E., Fantini, C., Highsmith, M. J., Loftsgaarden, M., Randolph, B., Sall, J., & Webster, J. (2022). The management of upper limb amputation rehabilitation: Synopsis of the 2022 U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guideline for Acquired Amputation. American Journal of Physical Medicine & Rehabilitation, 102(3), 245-253. doi: 10.1097/PHM.0000000000002164

This paper describes the guidelines and processes used for updating the Clinical Practice Guidelines for upper extremity amputation within the VA and DOD in 2022. The focus was to identify new clinical recommendations using evidence-based criteria (GRADE methodology) versus expert opinion. The CPG evolved from 27 expert opinion clinical recommendations to four evidence based clinical recommendations. The CPG can be accessed at https://www.healthquality.va.gov/guidelines/rehab/ula/.

Dolan, C. P., Clark, A. R., Motherwell, J. M., Janakiram, N. B., Valerio, M. S., Dearth, C. L., & Goldman, S. M. (2022). The impact of bilateral injuries on the pathophysiology and functional outcomes of volumetric muscle loss. NPJ Regenerative Medicine, 7(1), 59. doi: 10.1038/s41536-022-00255-2

The pathophysiology of unilateral versus bilateral volumetric muscle loss and the efficacy of minced muscle autograph were evaluated. While rats with bilateral volumetric muscle loss had comparable systemic immune responses to rats with a unilateral injury, bilateral injured rats had better functional outcomes then rats with unilateral injury and minced muscle autograph resulted in no significant improvement in rats with bilateral injury. This study demonstrates the complexity in comparing injury severity and treatment efficacy. 

Dolan, C. P., Dearth, C. L., Corona, B. T., & Goldman, S. M. (2022). Retrospective characterization of a rat model of volumetric muscle loss. BMC Musculoskeletal Disorders, 23(1), 814. doi:10.1186/s12891-022-05760-5  

This paper retrospectively evaluates rat volumetric muscle loss studies of the tibialis anterior. The researchers found that the 6 mm biopsy punch was consistent and reproducible across numerous studies and can serve as an excellent animal model for volumetric muscle loss.

Dolan, C. P., Motherwell, J. M., Franco, S. R., Janakiram, N. B., Valerio, M. S., Goldman, S. M., & Dearth, C. L. (2022). Evaluating the potential use of functional fibrosis to facilitate improved outcomes following volumetric muscle loss injury. Acta biomaterialia, 140, 379-388. doi: 10.1016/j.actbio.2021.11.032 

Fibrosis is a common finding in volumetric muscle loss and has been typically viewed as a negative consequence following these injuries. However, some studies have shown that fibrosis leads to improved muscle function. This has been referred to as function fibrosis. To study this phenomenon, fibrosis was intentionally induced in rats which led to improved muscle function. While the mechanism remains unclear, this study demonstrates that fibrosis can result in improved muscle function.

Gunterstockman, B. M., Knight, A. D., Mahon, C. E., Childers, W. L., Cagle, T., Hendershot, B. D., & Farrokhi, S. (2022). Relationship between phantom limb pain, function, and psychosocial health in individuals with lower limb loss. Prosthetics and Orthotics International, 10-1097. doi: 10.1097/PXR.0000000000000191

Phantom limb pain is a common issue among amputees, but its impact on quality-of-life remains poorly characterized. In this study even though phantom limb pain was prevalent in young to middle-aged amputees, phantom limb pain did not interfere with activity levels or other measured clinical or quality-of life measures.

Janakiram, N. B., Motherwell, J. M., Goldman, S. M., & Dearth, C. L. (2022). Efficacy of non-surgical interventions for promoting improved functional outcomes following acute compartment syndrome: A systematic review. Plos one, 17(9): e0274132. doi: 10.1371/journal.pone.0274132

In this systematic review, potential non-surgical approaches to improve outcomes following acute compartment syndrome were investigated. Of note there were no clinical trials identified (all were pre-clinical animal studies). This review demonstrates a critical need for advanced research in this area.

Janakiram, N. B., Valerio, M. S., Goldman, S. M., & Dearth, C. L. (2021). The role of the inflammatory response in mediating functional recovery following composite tissue injuries. International journal of molecular sciences, 22(24), 13552. doi:10.3390/ijms222413552

This review provides and overview of the role of different immune cells and inflammatory signals on wound healing and functional recovery following severe composite tissue injury.

Kerns, R. D., Burgess, D. J., Coleman, B. C., Cook, C. E., Farrokhi, S., Fritz, J. M., Goertz, C., Heapy, A., Lisi, A. J., Rhon, D. I., & Vining, R. (2022). Self-management of chronic pain: Psychologically guided core competencies for providers. Pain Medicine, 23(11), 1815-1819. doi: 10.1093/pm/pnac083

Management of chronic pain is a personal experience and is unique to the individual. This commentary focuses on provider competencies necessary to support individualized patient education and self-management of chronic pain.

Ali, J., Antonelli, M., Bastian, L., Becker, W., Brandt, C. A., Burgess, D. J., Burns, A., Cohen, S. P., Davis, A. F., Dearth, C. L., Dziura, J., Edwards, R., Erdos, J., Fritz, J., Geda, M., George, S. Z., Goertz, C., Goodie, J., Farrokhi, S., Hastings, S. N., Heapy, A., Ilfeld, B. M., Katsovich, L., Kerns, R. D., Kyriakides, T. C., Lee, A., Long, C. R., Luther, S. L., Martino, S., Matheny, M. E., McGeary, D., Midboe, A., Pasquina, P., Peduzzi, P., Raffanello, M., Rhon, D., Rosen, M., Esposito, E. R., Scarton, D., Hastings, S. N., Seal, K., Silliker, N., Taylor, S., Taylor, S. L., Tsui, M., Wright, F. S., & Zeliadt, S. (2021). Optimizing the impact of pragmatic clinical trials for veteran and military populations: Lessons from the Pain Management Collaboratory. Military Medicine, 187(7-8), 179-185. doi: 10.1093/milmed/usab458

This study describes the development of a strategy to optimize Pragmatic Clinical Trials from the Pain Management Collaboratory team. The goal of pragmatic clinical trials, versus explanatory trials, is to evaluate interventions in real-world clinical practice settings. In this trial, the effectiveness and implementation of non-pharmacological approaches to pain management are being studied. Work groups were established within the Pain Management Collaboratory team to quickly communicate across the different agencies, and the structure, challenges and success of this structure are discussed.

Knight, A. D., Bass, S. R., Elrod, J. M., Hassinger, L. M., Dearth, C. L., Gonzalez-Vargas, J., Hendershot, B. D., & Han, Z. (2022). Toward developing a powered ankle-foot prosthesis with electromyographic control to enhance functional performance: A case study in a U.S. Service member. Military Medicine, 2022; usac038. doi: 10.1093/milmed/usac038

This case study describes the evaluation of improvements made to a commercially available powered ankle-foot prosthesis to allow Service members to complete military relevant tasks. The improved device, known as the Warrior Ankle, include increased weight capacity to accommodate body worn loads, increased angular range of motion, improved power and torque, and utilization of neuromuscular control to improve user intent. The Warrior Ankle performed better in complex terrain than the predicate device, however, weight, battery life, durability and control remain areas for improvement.

Knight, A. D., Hendershot, B. D., Sleeman, T. J., Dearth, C. L., Starker, F., Schneider, U., & Hansen, A.H. (2022). Toward improving residual limb climate within prostheses for persons with lower limb loss: A technical note. Prosthetics and Orthotics International, 46(2), 202-205. doi: 10.1097/PXR.0000000000000085

The trapping of heat and moisture in prosthetic sockets is a significant issue leading not only to discomfort, but skin problems that require clinical treatment. This technical report describes the process a multi-disciplinary team of DOD/VA clinicians and industry used to develop a passively ventilated socket liner protype. Future work will examine flexibility and integrity of the prototype.

Knight, A. D., Jayaraman, C., Elrod, J. M., Schnall, B. L., McGuire, M., Sleeman, T., Hoppe-Ludwig, S., Dearth, C. L., Hendershot, B. D., & Jayaraman, A. (2022). Functional performance outcomes of a powered knee-ankle prosthesis in Service members with unilateral transfemoral limb loss. Military Medicine, (2022); usac231. doi: 10.1093/milmed/usac231

An evaluation of powered knee and ankle prothesis was performed in a cohort of 3 Service members with lower limb loss. While Service members became proficient faster than an earlier study of civilians with lower limb loss, Service members exhibited larger alterations in body mechanics when using the powered knee and ankle prosthesis. These findings highlight the importance of including Service members in studies to identify and capture unique requirements of military members suffering from limb loss.

Mahon, C. E., & Hendershot, B. D. (2022). Biomechanical accommodation to walking with an ankle–foot prosthesis: An exploratory analysis of novice users with transtibial limb loss within the first year of ambulation. Prosthetics and Orthotics International, 46(5), 452-458. doi: 10.1097/PXR.0000000000000124

Adaptation to ankle-foot prosthesis was evaluated in 22 transtibial amputates using repeated biomechanical gait evaluations at five time points within the first year of independent ambulation (0, 2, 4, 6, 12 months). While more study is recommended, biomechanical adaptation to their prothesis, defined as a plateau in outcomes, occurred approximately 4 months after initial ambulation with an ankle-foot prosthesis.

Rhon, D. I., Fritz, J. M., Kerns, R. D., McGeary, D. D., Coleman, B. C., Farrokhi, S., Burgess, D., Goertz, C., Taylor, S., & Hoffman, T. (2022). TIDieR-Telehealth: Precision in reporting of telehealth interventions used in clinical trials - unique considerations for the Template for the Intervention Description and Replication (TIDieR) Checklist. BMC Medical Research Methodology, 22(1), 1-11. doi: 10.1186/s12874-022-01640-7

With the increased reliance on telehealth, guidance and standardization are necessary to ensure consistent high-quality health care as well as incorporating telehealth interventions into reproducible and translatable clinical trials. This work expands on the TIDieR checklist with a series of guidelines that were developed to clarify and aid clinicians in translating telehealth research. 

Roach, M. H., Aderman, M. J., Gee, S. M., Peck, K. Y., Roach, S. P., Goss, D. L., Posner, M. A., Haley, C. A., Svoboda, S. J., & Cameron, K. L. (2022). Influence of graft type on lower extremity functional test performance and failure rate after anterior cruciate ligament reconstruction. Sports Health, (2022). doi: 10.1177/19417381221119420

This study compared anterior cruciate ligament repair graft types in a military population. While hamstring autografts outperformed bone-patella tendon-bone (BTB) autografts and allografts in some lower extremity functional measures (Lower Quarter Y-Balance Test Posteromedial Direction and Single-Leg Hop Test), the graft failure rate for hamstring autografts was 9.8 times that of BTB autografts. This study underscores the importance of weighing patient activity levels and outcomes when selecting graft types.

Russell Esposito, E., Farrokhi, S., Shuman, B. R., Sessoms, P. H., Szymanek, E., Hoppes, C. W., Halle, R., Bechard, L., King, D., & Fraser, J. J. (2022). Uneven treadmill training for rehabilitation of lateral ankle sprains and chronic ankle instability: Protocol for a pragmatic randomized controlled trial. JMIR Research Protocols, 11(6): e38442. doi: 10.2196/38442

This paper describes the protocol for a randomized clinical trial to study the impact of using uneven treadmill training during rehabilitation to improve chronic ankle instability and reduce the risk of future lateral ankle sprains. Results of the trial are expected to be released in 2024.

Wasser, J. G., Acasio, J. C., Miller, R. H., & Hendershot, B. D. (2022). Lumbopelvic coordination while walking in Service members with unilateral lower limb loss: Comparing variabilities derived from vector coding and continuous relative phase. Gait & Posture, 92, 284-289. doi: 10.1016/j.gaitpost.2021.11.032

While both methods can detect gait induced variability in a lower limb loss population, continuous relative phase variability may be more sensitive than coupling angle variability detecting compensatory lumbopelvic movements.

Wasser, J. G., Acasio, J. C., Miller, R. H., & Hendershot, B. D. (2021). Overall greater demands on the musculoskeletal system at multiple walking speeds in Service members with lower limb loss. Journal of Applied Biomechanics, 37(6), 522-530. doi: 10.1123/jab.2020-0287

The effect of lower limb loss on full-body movement and trunk, pelvis and knee loading were examined at three different walking speeds in 38 males (23 transtibial and 15 transfemoral). Individuals with lower limb loss exhibited increased trunk motion in the frontal and transverse planes. Transfemoral amputees exhibited increased pelvic motion which was not observed in transtibial amputees. This study supports the concept that clinical practice should focus significant effort on strengthening the core and trunk of individuals to improve balance, decrease aberrant movements, and reduce risk of secondary musculoskeletal conditions.

Wasser, J. G., Hendershot, B. D., Acasio, J. C., Krupenevich, R. L., Pruziner, A. L., Miller, R. H., Goldman, S. M., Valerio, M. S., Senchak, L., Murphey, M. D., Heltzel, D. A., Fazio, M. G., Dearth, C. L., & Hager, N. A. (2022). A comprehensive, multidisciplinary assessment for knee osteoarthritis following traumatic unilateral lower limb loss in Service members. Military Medicine, 2022; usac203. doi: 10.1093/milmed/usac203

Thirty-eight individuals with unilateral limb loss (23 transtibial and 15 transfemoral) were prospectively enrolled to characterize and evaluate osteoarthritis of the knee and establish a baseline for future studies. Thirty-two were cleared for participation with 37.5% showing signs of osteoarthritis at the tibiofemoral joint. However, 72.7% demonstrated patellofemoral degeneration which suggest that this joint may be more susceptible to degeneration than the tibiofemoral joint in the lower limb loss population.

Yoder, A. J., Petrella, A. J., & Farrokhi, S. (2021). Sensitivity of a subject-specific ankle sprain simulation to extrinsic versus intrinsic biomechanical factors. Frontiers in Bioengineering and Biotechnology, 9(2021). doi: 10.3389/fbioe.2021.765331

This report describes the development of an open-source simulation of lateral ankle sprains with the goal of accelerating the development of solutions to prevent these injuries.

Zhao Dubuc, Y., Mazzone, B., Yoder, A. J., Esposito, E. R., Kang, T. H., Loh, K. J., & Farrokhi, S. (2022). Ankle sprain bracing solutions and future design consideration for civilian and military use. Expert Review of Medical Devices Journal, 19(2), 113-122. doi: 10.1080/17434440.2022.2039622

Ankle sprains are common in military environments and can result in serious operational impacts. This review examines commercially available braces and their impact on performance and ankle injuries. Options to improve ankle bracing are also discussed.