Following is a summary of published results in FY17 for several key research initiatives and focused research efforts.
Advanced Rehabilitation Sciences
Novel Rehabilitation Strategies
Functional outcomes of Service members with bilateral transfemoral and knee disarticulation amputations resulting from trauma
Schnall,B. L., Chen, Y. T., Bell, E. M., Wolf, E. J., & Wilken, J. M. (2016). Functional outcomes of Service members with bilateral transfemoral and knee disarticulation amputations resulting from trauma. Military Medicine, 181(S4), 55-60. doi: 10.7205/MILMED-D-15-00546
It is important to quantify performance
measures during rehabilitation in an effort to determine reasonable
expectations and trends that may influence the rehabilitation process. A study
was pursued to observe changes in function over the rehabilitation period in
patients in patients with transfemoral amputation and knee
disarticulation. Over the rehabilitation
period from date of independent ambulation to discharge (median 135 days)
patients were able to achieve functional community ambulation skills, were able
to cover a greater distance during a 6-minute walk test, and exhibited higher
confidence scores during stair ambulation. The change in scores for stair
ascent and descent did not change significantly. These results show that while
stair negotiation appears to plateau early, confidence builds despite absence
of functional gains over time, suggesting that clinicians can realign
rehabilitation paradigms to shift focus towards community distance ambulation
once safe stair ascent and descent is achieved.
Blood flow restriction training after knee arthroscopy: A randomized controlled pilot study
Tennent,D. J., Hylden, C. M., Johnson, A. E., Burns, T. C., Wilken, J. M., & Owens, J. G. (2017). Blood flow restriction training after knee arthroscopy: A randomized controlled pilot study. Clinical Journal of Sports Medicine, 27(3), 245-252. doi: 10.1097/JSM.0000000000000377
Blood flow restriction training is a method used within a rehabilitation environment to partially
restrict blood flow during exercises, which is theorized to increase
improvements in muscle size and strength.
In a novel study, our team evaluated the effects of blood flow restriction
training following knee arthroscopy and observed improvements in strength,
muscular hypertrophy, function, and patient-reported measures when compared
with the same exercise program performed without blood flow restriction.
Further study will determine if
this rehabilitation intervention can benefit patients who have sustained severe
extremity trauma.
Prosthesis thesis: A task oriented approach to motor learning
Oliver, R., Schoonover, C., Tu, T., Turner, S., Cancio, J., & Yancosek, K. (2017). Prosthesis thesis: A task oriented approach to motor learning. OT Practice, 22(8), 14-16
When
undertaking a new activity the brain and body adapt to the use of new motor
patterns inherent in that activity. As
such, one goal of therapy is for the body to incorporate the prosthesis into
any new movement strategies being learned. “Prosthesis thesis” is a
rehabilitation concept that allows the patient to create a meaningful project
over the course of therapeutic care.
Using the prosthesis thesis intervention occurs at a juncture of care to
help transition to the advanced phase of prosthetic training, where smoother,
more automatic, and well-coordinated movements are practiced. Case examples of successful outcomes
document how the principles of neuroplasticity are utilized within a clinical
setting to master desired functional skills.
Optimizing Gait Efficiency
Return to running following a knee disarticulation amputation: A case report
Diebal-Lee,
A. R., Kuenzi, R. S., & Rábago, C. A. (2017). Return to running following a
knee disarticulation amputation: A case report. International Journal of Sports
Physical Therapy, 12(4), 655-669
Rehabilitative training in proper running mechanics using advanced
prosthetic devices is an integral and essential aspect of a rehabilitation
intervention, and can effectively alter limb mechanics that improve performance
and prevent injury to the intact limb. A
three-week run training intervention for an individual with knee
disarticulation changed an asymmetrical foot strike pattern to a symmetrically
loaded non-rearfoot strike pattern.4This intervention enabled the patient to
double his pain-free run mileage from 5 km to 10 km and improve his run time,
contributing to his goal to participate in a triathlon. Additionally, the load placed on his intact
limb decreased to near normal, reducing additional load on the non-injured limb
that can lead to arthritic change over time.
Gait Training Interventions for Lower Extremity Amputees: A Systematic Literature Review
Highsmith MJ, Andrews CR,Millman C, Fuller A, Kahle JT, Klenow TD, Lewis KL, Bradley RC, Orriola JJ.Gait Training Interventions for Lower Extremity Amputees: A SystematicLiterature Review. Technology & Innovation 18(2), 99-113, 2016.
Therapeutic interventions using both
treadmill-based and overground training methods have been shown to be effective
at improving gait. These include
in-shoe auditory feedback, verbal and tactile cueing, early weight-bearing, the
use of walking aids, and combined physical therapy and psychological awareness
training. Gait lab analysis is an
integral part of documenting changes associated with these clinical
interventions that can assess energy efficiency, gait symmetry, and techniques
used to negotiate direction changes and uneven terrain.
The prevalence of gait deviations in individuals with transtibial amputation
Rabago, C. A. & Wilken,J. M. (2016). The prevalence of gait deviations in individuals withtrans-tibial amputation. Military Medicine, 11(12), 30-37. doi:10.1371/journal.pone.0166815
Patients with
transtibial amputation, who exhibit
decreased prosthetic ankle power generation during push off, do
not appear to elicit compensations in the intact limb, knee, and hip,
suggesting that interventions, such as powered prostheses, may not
greatly influence improved energy efficiency for these patients. These
individuals do, however, exhibit changes in knee and hip compensation in the
prosthetic limb that are typically used to control the knee during stance,
which may influence energy efficiency.
Can real-time visual feedback during gait retraining reduce metabolic demand for individuals with transtibial amputation?
RussellEsposito, E., Choi, H. S., Wilken, J. M., & Darter, B. J. (2017). Canreal-time visual feedback during gait retraining reduce metabolic demand forindividuals with transtibial amputation. Public Library of Science One, 12(2).doi:10.1371/journal.pone.0171786
An intervention effort using a
single-session of gait retraining through visual feedback in a computer-assisted
virtual reality environment successfully decreased center of mass sway and
quadriceps activity in a group of patients with transtibial
amputation. However these changes did
not significantly affect metabolic rate during walking, and metabolic rate was
not different than that of a control group.
Locomotor adaptability in persons with unilateral transtibial amputation
Darter,B. J., Bastian, A. J., Wolf, E. J., Husson, E. M., Labrecque, B. A., &Hendershot, B. D. (2017). Locomotor adaptability in persons with unilateraltranstibial amputation. PloS one, 12(7), e0181120. doi:10.1371/journal.pone.0181120
A follow-on study observed that reactive
changes and locomotor adaptation in response to a challenging and novel walking
condition utilizing a split-belt treadmill were similar in persons with
transtibial amputation compared to those without an amputation.
Overall, our results suggest persons with transtibial amputation have the
capacity to modify locomotor strategies to meet the demands of most ambulation
challenges imposed by an amputation and use of a prosthetic limb when the
individual is young, active, and/or has extensive access to rehabilitative
care.
The influence of traumatic transfemoral amputation on metabolic cost across walking speeds
RussellEsposito, E., Rábago, C. A., & Wilken, J. M. (2017). The influence oftraumatic transfemoral amputation on metabolic cost across walking speeds.Prosthetics and Orthotics International, (June). doi: 10.1177/0309364617708649
Interventions to lower metabolic costs of
walking may be more relevant in individuals with transfemoral and bilateral
lower-limb amputation as they utilize more pronounced biomechanical
compensations to ambulate, and compensations during gait produce increased
loads on the body that may reduce efficiency. Significantly decreased energy
efficiency was observed in a group of patients with transfemoral amputation,
even though they walked at a slower pace.
When compared to a control group, these individuals also exhibited a
44%-47% greater metabolic rate and cost, a 24-33% greater heart rate, and a
24%-35% greater perceived exertion. Of note, this transfemoral amputation group
was relatively young, physically fit, and had extensive access to
rehabilitative care. The metabolic
cost of walking fell within the ranges of an older or presumably less fit
group, suggesting that young, active individuals with transfemoral amputation
can benefit from prosthetic and other rehabilitative regimens designed to
improve energy efficiency.
Energy Costs & Performance of Transfemoral Amputees and Non-Amputees During Walking and Running: A Pilot Study
MengelkochLJ, Kahle JT, Highsmith MJ. Energy Costs & Performance of Transfemoral Amputees and Non-Amputees During Walking and Running: A Pilot Study. ProsthetOrthot Int, 2016;(epub ahead of print):1-8
To determine how different prosthetic
foot devices affect energy cost for patients with transfemoral amputation,
patients were tested with three prosthetic feet: a conventional foot (solid-ankle cushioned heel (SACH)); an energy storing and return foot (Renegade);
and a running-specific energy storing and return foot (Nitro). Energy costs were greater and ambulatory performance was lower for transfemoral amputees compared to matched,
non-amputee controls and did not differ between prosthetic foot conditions.
Constituent Lower Extremity Work (CLEW) approach: A novel tool to visualize joint and segment work
Ebrahimi,A., Goldberg, S. R., Wilken, J. M., & Stanhope, S. J. (2017). Constituent Lower Extremity Work (CLEW) approach: A novel tool to visualize joint andsegment work. Gait Posture, 56(Jul), 49-53. Doi
The use of gait evaluation to assess a patient’s response to training following injury can be an integral part of
developing an individualized therapeutic program. New avenues are being developed for how gait
evaluation can enhance the clinical information gained during a gait
assessment. One example can be found in the
Constituent Lower Extremity Work (CLEW) approach, a novel tool developed to visualize and interpret cyclic tasks
performed by the lower extremity, taking into account movements at the hip,
knee, ankle, and distal foot to come up a mechanical cost of transport.
How humans use visual optic flow to regulate stepping during walking
Salinas, M. M., Wilken, J.M., & Dingwell, J. B. (2017). How humans use visual optic flow to regulatestepping during walking. Gait Posture, 57(Sep), 15-20.doi:10.1016/j.gaitpost.2017.05.002
Gait analysis and training
within a laboratory environment is challenged by lack of a “real world”
environment in which to assess a patient’s ability to navigate obstacles
encountered in daily life. When a
patient pays attention to walking, as in a therapeutic or laboratory
environment, they are less distracted, which doesn’t accurately reflect the
patient’s ability to ambulate safely when everyday distractions are
present. Treadmill analysis within a
virtual reality environment has the advantage of being able to create a moving
visual surrounding that more accurately resembles a real world
environment. To assess the contribution
of “optic flow” researchers utilized a virtual reality environment to assess
gait reactions during walking under five conditions: blank screen, static screen, or three speeds
with a moving screen. When visual information was removed, individuals appeared to walk more
cautiously. Optic flow influenced both
how quickly humans corrected stride speed deviations and how successful they
were at minimizing stride speed and treadmill position variability. These
findings provide greater understanding of how advanced technologies can be used
to create clinical interventions that more accurately resembles a real world
situation.
A comparison of kinematic-based gait event detection methods in a self-paced treadmill application
Hendershot,B. D., Mahon, C. E., & Pruziner, A. L. (2016). A comparison ofkinematic-based gait event detection methods in a self-paced treadmillapplication. Journal of Biomechanics, 49(16), 4146-4149. doi:10.1016/j.jbiomech.2016.10.046
Finally, the use of self-paced treadmills
is allowing for a more individualized method of training on a treadmill within
rehabilitation clinics. To assure
methodologies used in biomechanical analyses during treadmill ambulation are
applicable to self-paced treadmills a study was pursued to validate
kinematic-based algorithms currently being used in our laboratories. Results indicate that common kinematic-based gait event
detection methods are applicable to self-paced treadmill applications and may
be robust for both asymptomatic and pathological gait patterns.
A computational algorithm for classifying step and spin turns using pelvic center of mass trajectory and foot position
Golyski,P. R., & Hendershot, B. D. (2017). A computational algorithm forclassifying step and spin turns using pelvic center of mass trajectory and footposition. Journal of Biomechanics, 54, 96-100. doi:10.1016/j.jbiomech.2017.01.02
Less than optimal turning strategies used by a patient may predispose
an individual to stumbles or falls during walking activities. Turning transitions are difficult to assess,
and are typically observed through subjective and time consuming visual
ratings. A novel biomechanical analysis using
pelvic center of mass trajectory (pCOM) and time-distance parameters
was developed to quantitatively identify turning strategies during gait. This assessment can be implemented in place of
time-consuming and subjective visual observations, and provides a new platform
for classifying and possibly optimizing turning strategies used by patients
during walking transitions.
The Effect of Transfemoral Interface Design On Gait Speed and Risk of Falls
KahleJT, Klenow TD, Sampson W, Highsmith MJ. The Effect of Transfemoral InterfaceDesign On Gait Speed and Risk of Falls. Technology & Innovation, 18(2),167-173, 2016.
To begin a strength and walking program,
the use of an effective prosthesis is imperative. There is collective agreement
that ongoing research is needed to develop appropriate intervention strategies
that can decrease fall risk, however these interventions should also consider
the impact of the prosthetic interface.
This is particularly important in individuals with transfemoral amputation,
where walking capacity and balance confidence are especially compromised. Researchers have found that a
high-fidelity interface socket improved walking capacity and balance confidence
in higher-functioning patients with transfemoral amputation when compared with
use of an ischial ramus containment socket. These
results suggest that the less cumbersome walls and subischial trimlines of a
high-fidelity interface socket might optimize freedom of movement and improved
walking capacity that may lead to a decreased risk for falls.
Mitigating Secondary Health Effects
Core temperature in service members with and without traumatic amputations during a prolonged endurance event
Andrews,A. M., Pruziner, A. L., Deehl, C., & Rogers, R. L. (2016). Core temperaturein service members with and without traumatic amputations during a prolongedendurance event. Military Medicine, 181(S4), 61-65. doi:10.7205/MILMED-D-15-00515
Many active duty service members return
to combat operations that take place in harsh environmental conditions. Anecdotal information from patients
suggested that individuals with amputation reported feeling hotter and
experiencing more profuse sweating during activity. Researchers postulated that the decreased
body surface area and increased energy needs during running and other athletic
activities may increase heat production and risk of heat injury for individuals
with amputations. To address these
possible health safety concerns a series of studies was undertaken to compare
core temperature changes between individuals with and without amputation during
strenuous military activities. One such
study monitored core body temperature during the Bataan Memorial Death March, a
26.2 mile road march that mimics the extended marching frequently performed by
many operational military forces. No
significant differences in core temperature were noted, nor did any subjects
reach the threshold for increased risk of heat stroke. The pace selected by those individuals with
amputation was slower, and may have attenuated core temperature increases.
Muscle Function and Coordination of Stair Ascent
Harper, N., Wilken, J. M.,& Neptune, R. (2017). Muscle Function and Coordination of Stair Ascent.Journal of Biomechanics. (Aug). doi: 10.1115/1.4037791
Stair ascent is an activity of daily living and necessary for maintaining
independence in community environments. Navigating stairs, particular during ascent, has traditionally been a
challenge for individuals following amputation or severe extremity trauma. Numerous muscle groups are involved in
successful stair climbing, to include the knee extensors, ankle plantarflexors,
hip extensors, and hip abductors. If an injury affects one of more of these
muscle groups, compensatory movements occur that can lead to secondary
musculoskeletal injury.
Rehabilitation and multiple limb amputations: A clinical report of patients injured in combat
Melcer,T., Pyo, J., Walker, J., Quinn, K., Lebedda, M., Neises, K., Nguyen, C., &Galarneau, M. (2017). Rehabilitation and multiple limb amputations: A clinicalreport of patients injured in combat. JRRD, 53(6), 1045-1060
Rehabilitation programs for service members with amputation and
extremity trauma are comprehensive. In a
subset of patients who obtained their care at a military amputee care center,
patients engaged in daily rehabilitation therapy, particularly for the six to
nine month period immediately following injury, and continued on a several
times a week basis for an average of 18 months. Functional outcomes assessments documented
the program’s effectiveness in improving physical and psychosocial functioning.
Impact of Traumatic Lower Extremity Injuries Beyond Acute Care: Movement-Based Considerations for Resultant Longer Term Secondary Health Conditions
Butowicz,C. M., Dearth, C. L., & Hendershot, B. D. (2017). Impact of Traumatic LowerExtremity Injuries Beyond Acute Care: Movement-Based Considerations forResultant Longer Term Secondary Health Conditions. Advances in Wound Care,6(8), 269-278, doi: 10.1089/wound.2016.0714
Of particular importance and relevance to
the long-term care of our young patients is the need to understand and
ultimately eliminate the secondary health complications that our patients are
at a pronounced and progressively increased risk for developing. There is a limited, but growing, body of evidence
relating movement abnormalities to altered musculoskeletal demands that may
lead to the development of longer term secondary conditions in this
population. Especially
important from a research and therapeutic intervention perspective is
determining the impact of altered movement patterns and other modifiable risk
factors that can increase mechanical loading of the spine and lower
extremities, potentially resulting in cumulative effects over time. Therefore,
developing effective early
intervention strategies that can prevent or minimize these deleterious
secondary health effects is critical to the program of care of individuals with
limb loss.
A narrative review of the prevalence and risk factors associated with development of knee osteoarthritis after traumatic unilateral lower limb amputation
Farrokhi,S., Mazzone, B., Yoder, A., Grant, K., & Wyatt, M. (2016). A narrativereview of the prevalence and risk factors associated with development of kneeosteoarthritis after traumatic unilateral lower limb amputation. MilitaryMedicine, 181(S4), 38-44. doi: 10.7205/MILMED-D-15-00510
Evidence compiled in a recent review
supports that young military Service members with traumatic unilateral lower
limb amputations may be at increased risk for developing knee osteoarthritis
(OA) compared to nonamputees. Potential
risk factors include chronic knee pain, obesity, abnormal knee joint mechanics,
muscle weakness, prior knee trauma, and altered activity levels. Therefore,
preservation of intact limb function through prevention of factors that place
an individual at risk for development of OA is an important component of
rehabilitative care.
A comparison of four-year health outcomes following combat amputation and limb salvage
Melcer, T., Walker, J.,Bhatnagar, V., Richard, E., Sechriest, V. F. II, & Galarneau, M. (2017). Acomparison of four-year health outcomes following combat amputation and limbsalvage. PLOS ONE, 12(1), e0170569. doi: 10.1371/journal.pone.0170569
A four-year study in service members showed a small but significant increase in
the prevalence of osteoarthritis one to two years after traumatic extremity
injury, with no additional change during years three and four. Approximately 20% of the late amputation and
limb salvage groups in the present study, however, had an osteoarthritis
diagnosis by age 25 to 35 years, compared to about 14% of individuals age 25-65
without amputation. These data suggest that extremity trauma
patients may be at increased risk for OA as they age.
Medial Knee Joint Contact Force in the Intact Limb during Walking in Recently Ambulatory Service Members with Unilateral Limb Loss: A Cross-sectional Study
Miller,R. H., Krupenevich, R. L., Pruziner, A. L., Wolf, E. J., & Schnall, B. L.(2017). Medial Knee Joint Contact Force in the Intact Limb during Walking inRecently Ambulatory Service Members with Unilateral Limb Loss: A Cross-sectionalStudy. PeerJ, 5, e2960. doi: 10.7717/peerj.2960
Knee joint forces and loading rates in the intact limb of individuals with above knee and
below knee amputations are significantly greater during walking than are the
limbs of individuals without amputation.
As walking reflects joint loading experienced in daily life, this
supports a “mechanical overloading'' hypothesis for the risk of developing knee
OA in the intact limb of limb loss subjects.
Knee Joint Loading during Single-Leg Forward Hopping
Krupenevich,R. L., Pruziner, A. L., & Miller, R. H. (2017). Knee Joint Loading duringSingle-Leg Forward Hopping. Medicine and science in sports and exercise, 49(2),327-332. doi: 10.1249/MSS.0000000000001098
Individuals with unilateral amputation often hop on the intact limb to maneuver over very
short distances. There is a substantial
increase in knee joint loading during hopping, suggesting that, overtime, these
high
impact loads could potentially increase knee osteoarthritis risk.
Biopsychosocial risk factors associated with chronic low back pain after lower limb amputation
Farrokhi,S., Mazzone, B., Schneider, M., Gombatto, S., Mayer, J., Highsmith, M. J.,& Hendershot, B. (2017). Biopsychosocial risk factors associated withchronic low back pain after lower limb amputation. Medical Hypotheses, 108,1-9. doi: 10.1016/j.mehy.2017.07.030
The biopsychosocial model of low back pain is likely influenced or
amplified by lower limb amputation.
Components of this model that are supported by the literature include
biological (i.e. increased pain sensitivity), psychological (i.e. ineffective
coping strategies, pain catastrophizing), and social (i.e. smoking, alcohol
consumption) factors. There are also
other contributors to low back pain that include biomechanical (i.e.
increased spinal loading) and lifestyle (i.e. weight gain, physical activity
level) factors that might be modifiable with targeted rehabilitation
interventions.
Concurrent Validity of the Continuous Scale-Physical Functional Performance
HighsmithMJ, Kahle JT, Miro RM, Cress ME, Quillen WS, Carey SL, Dubey RV, MengelkochLJ. Concurrent Validity of theContinuous Scale-Physical Functional Performance -10 (CS-PFP-10) Test inTransfemoral Amputees. Technology & Innovation 18(2), 185-191, 2016.
The Continuous Scale-Physical Functional Performance-10 (CS-PFP-10) test consists
of 10 standardized daily living tasks that evaluate overall physical functional
performance and performance in functional domains that include upper body
strength, upper body flexibility, lower body strength, balance and
coordination, and endurance. A study was
pursued to determine the concurrent validity of the CS-PFP-10 test and its
lower extremity functional domains in comparison to measures that have
established validity for use in persons with transfemoral amputation. Results showed that the lower limb and balance domains of
the CS-PFP-10 are valid measures to assess the physical functional performance
of TFA patients.
Psychometric Evaluation of the Hill Assessment Index (HAI) and Stair Assessment Index (SAI) in High-Functioning Transfemoral Amputees
HighsmithMJ, Kahle JT, Kaluf B, Miro RM, Mengelkoch LJ, Klenow TD. PsychometricEvaluation of the Hill Assessment Index (HAI) and Stair Assessment Index (SAI)in High-Functioning Transfemoral Amputees. Technology & Innovation 18(2),193-201, 2016.
The hill assessment index and stair assessment index were developed to objectively
evaluate ramp and stair gait. A study was
pursued to determine the validity and reliability of these tests in a sample of
persons with unilateral transfemoral amputation using microprocessor prosthetic
knee systems. The hill assessment index
showed moderate to excellent sensitivity and specificity, and good to adequate
reliability. The stair assessment index showed excellent to good reliability, suggesting that these clinical
assessments are reliable outcome measures for assessing ambulation on ramps and
stairs.
Assessment of disability related to femoroacetabular impingement syndrome by use of the Patient-Reported Outcome Measure Information System (PROMIS) and objective measures of physical performance
Sheean,A. J., Schmitz, M. R., Ward, C. L., Barrow, A. E., Tennent, D. J., Roach, C.J., Burns, T. C., & Wilken, J. M. (2017). Assessment of disability relatedto femoroacetabular impingement syndrome by use of the Patient-Reported OutcomeMeasure Information System (PROMIS) and objective measures of physicalperformance. American Journal of Sports Medicine, 45(11), 2476-2482. doi:10.1177/0363546517708793
Assessment tools need to be sensitive enough to detect changes in function in individuals
with lower limb pathology. The
Patient-Reported Outcomes Measurement System (PROMIS) was developed to
characterize outcomes among patients with specific musculoskeletal
conditions. In determining the
assessment capability of this tool researchers used the PROMIS to assess
differences between patients with femoroacetabular impingement and asymptomatic
controls. The PROMIS self-report
assessment was responsive to FAI-associated debility and may be used to
objectively assess surgical or other rehabilitative outcomes. These results suggest that the PROMIS might
be a way to practically and quickly incorporate this self-assessment tool into
routine clinical practice.
Systematic review of measures of physical function and activity limitation for persons with limb trauma and amputation
Resnik, L., Borgia. M.,Silver, B., & Cancio, J. (2017). Systematic review of measures of physicalfunction and activity limitation for persons with limb trauma and amputation.Archives of Physical Medicine and Rehabilitation, (17). doi10.1016/j.apmr.2017.01.015
There are numerous tools utilized to assess functional outcomes following injury of the
upper extremity. A systematic review was
pursued to identify outcome measures used in studies of persons with traumatic
upper limb injury and/or amputation, and to evaluate the focus, content, and
psychometric properties of each measure. The mostly highly rated performance
measures included 2 amputation-specific measures: the Activities Measure for
Upper Limb Amputees, and the University of New Brunswick Test of Prosthetic
Function skill and spontaneity subscales.
In addition 2 non-amputation-specific measures – the Box and Block Test
and modified Jebsen-Taylor Hand Function Test were highly rated. The most highly-rated self-report measures
were: Disabilities of the Arm, Shoulder and Hand; Patient Rated Wrist
Evaluation; QuickDASH; Hand Assessment Tool; International Osteoporosis
Foundation Quality of Life Questionnaire; and Patient Rated Wrist Evaluation
functional recovery subscale. While the self-assessment tools were not
amputation specific, all were considered suitable for both an
amputee and non-amputee population.
The Suitcase Packing Activity: A new evaluation of hand function
Baumann,M. L., Cancio, J. M., & Yancosek, K. E. (2017). The Suitcase PackingActivity: A new evaluation of hand function. Journal of Hand Therapy, (17).doi: 10.1016/j.jht.2017.02.002
Another potential tool is the suitcase packing activity, which was developed to provide
a measure of bimanual and unilateral hand function. Conceptualized to be occupation
based, the tool allows for assessment of hand function by participation in the
goal-directed activity of packing a suitcase.
As study evaluating the psychometric properties of this assessment tool
demonstrated good to excellent interrater reliability, good to excellent
test-retest reliability, and acceptable concurrent validity when compared
against other currently utilized assessment tools. These results show that the
suitcase packing assessment tools is a simple, low-cost, valid, and reliable
tool for assessing bimanual and unilateral hand function, and shows
promise in contributing to evidence-based practice by providing a quality,
composite measure of hand function.
Functional capacity evaluation-military: Program description and case series
Cancio,J., Oliver, R. M., & Yancosek, K. E. (2017). Functional capacityevaluation-military: Program description and case series. Military Medicine,182(1), 1658-1664. doi: 10.7205/MILMED-D-16-00072
A functional capacity evaluation quantifies an individual’s capacity to perform
activities related to employment.
Military activities differ significantly from typical activities
encountered in civilian jobs. To address
this need, a functional capacity evaluation was developed for use in a military
population, and included seventeen activities such as shooting, dragging,
pushing, lifting, high/low crawling, and other military relevant tasks. These tasks were assessed in 3 individuals
with limb reconstruction who were using an ankle foot orthosis to assist with
lower extremity function. The Functional
Capacity Evaluation – Military (FCE-M) is fully described in this
article, and provides a systematic method to assess performance of military tasks.66
Follow-on research is planned to standardize and perform psychometric testing,
with hopes that in the future this tool can provide a means of assessing a Service
member’s ability to return to full duty.
Psychosocial reactions to upper extremity limb salvage: A cross-sectional study
Sposato,L., Yancosek, K., Lospinoso, J. & Cancio, J. (2017). Psychosocial reactionsto upper extremity limb salvage: A cross-sectional study. Journal of HandTherapy. S0894-1130(17):30151-5. doi: 10.1016/j.jht.2017.05.020
Available studies indicate that individuals with lower extremity limb
salvage are at risk for poor psychosocial outcomes. In an initial study investigating outcomes
related to upper extremity limb salvage researchers observed similar
outcomes. Worse psychosocial adaptation was
associated with lower education, being less than 6 months post-injury, being
older than 23 years, and having more pain. Dominant hand injuries were
found to influence poor adaptation on the Reactions to Impairment and
Disability Inventory subscale. Studies assessing outcomes following limb
salvage procedures, particularly psycho-social factors that can affect
successful reintegration into the community, are needed.
Combat amputees' health-related quality of life and psychological outcomes: A brief report from the Wounded Warrior Recovery Project
Woodruff,S., Galarneau, M., Sack, D., McCabe, C., & Dye, J. (2017). Combat amputees'health-related quality of life and psychological outcomes: A brief report fromthe Wounded Warrior Recovery Project. Journal of trauma and acute care surgery,82(3), 592-595.
Conversely, a recent study in an amputee population suggests that when
assessed over 5 years postinjury, on average, amputees have unique physical and
functional limitations, yet do not report greater depression or PTSD symptoms
than others seriously injured in combat. These findings suggest that
state-of-the-art integrated amputee care that includes support networks and
emphasis on adjustment and psychological health following an amputation
procedure may increase successful coping and adjustment. The reasons behind differing psycho-social
outcomes between amputation and limb salvage procedures may be due to the
delays experienced in returning to the fullest level of function possible, and
deserves further study.
Advanced Prosthetics and Orthotics
Descriptive characteristics and amputation rates with use of Intrepid Dynamic Exoskeleton Orthosis
HillO, Bulathsinhala L, Eskridge SL, Quinn K, Stinner DJ. (2016). Descriptivecharacteristics and amputation rates with use of Intrepid Dynamic ExoskeletonOrthosis. Military Medicine, 181, 77-80.
High level functional activities are
often challenging for individuals with amputation and/or severe limb
trauma. Individuals who choose limb
preservation surgery are often prescribed ankle-foot orthoses (AFOs) to decrease pain and improve ambulatory function on level ground,
uneven surfaces, and slopes and stairs.
An advanced orthotic bracing solution, the “Intrepid Dynamic Exoskeletal
Orthosis” (IDEO), was developed by a CFI prosthetist specifically for young,
active military patients who have undergone limb preservation. The most common injury for which 624 Service
members were prescribed an IDEO between 2009 and 2014 occurred at or
surrounding the ankle joint, and over 80% avoided amputation within a one-year
time period.
Outcomes Associated With the Intrepid Dynamic Exoskeletal Orthosis (IDEO): A Systematic Review of the Literature
HighsmithMJ, Nelson LM, Carbone NT, Klenow TD, Kahle JT, Hill OT, Maikos JT, Kartel MS,Randolph BJ. Outcomes Associated With the Intrepid Dynamic Exoskeletal Orthosis(IDEO): A Systematic Review of the Literature. Military Medicine.181(11/12):69-76, 2016.
Modification to existing orthoses, such
as the IDEO, may optimize functional outcomes. Evidence collected during a
systematic literature review supports this, suggesting that strut stiffness is
a patient preference that should be considered during the orthotic prescription
process. Another factor that might affect orthotic performance is the location of the bending axis on the
strut. With this in mind, several
studies were pursued to compare functional outcomes of three AFO designs that
differed in location of the bending axis of the strut (high, middle, low). Building on
previous work that assessed function related to bending axis location during
walking, participants ran overground while wearing a passive-dynamic AFO with
posterior struts manufactured with central (middle) and off-centered (high and
low) bending axes. Half of
patients preferred the middle bending axis, four preferred low and two
preferred high, suggesting that individual preferences and abilities should be
considered when fabricating an AFO.
The effect of ankle foot orthosis alignment on walking in individuals treated for traumatic lower extremity injuries
Brown,S. E., Russell Esposito, E., & Wilken, J. M. (2017). The effect of anklefoot orthosis alignment on walking in individuals treated for traumatic lowerextremity injuries. Journal of Biomechanics, 16(61), 51-57. doi:10.1016/j.jbiomech.2017.06.037
An additional aspect of orthotic design
related to patient comfort appears to be the degree of flexion built into the
orthosis. Plantar flexion alignment of
the AFO (compared to neutral and dorsiflexed) resulted in earlier center of
pressure progression and a resulting decrease in both internal knee extensor
moment and quadriceps and soleus muscle activity, with 8/12 patients
preferring this plantar flexion alignment.
Effects of altering heel wedge properties on gait with the Intrepid Dynamic Exoskeletal Orthosis
Ikeda,A. J., Fergason, J. R., & Wilken, J. M. (2017). Effects of altering heelwedge properties on gait with the Intrepid Dynamic Exoskeletal Orthosis. Prosthetics and Orthotics International,(Sep). doi: 10.1177/0309364617728116
Patients walked over level ground in the
IDEO and six different heel wedges (soft or firm durometer, and 1, 2, or 3 cm
height), which also incorporate a slight degree of plantar flexion. Patients
preferred durometer and height that produced mechanics similar to able-bodied
individuals. Changing wedge
height and durometer is a simple, straightforward way to alter loading of the foot
with great potential to improve an individual’s gait.
Patient Response to an Integrated Orthotic and Rehabilitation Initiative for Traumatic Injuries: The PRIORITI-MTF Study
Hsu,J. R., Owens, J. G., DeSanto, J., Fergason, J. R., Kuhn, K. M., Potter, B. K.,Stinner, D. J., Sheu, R. G., Waggoner, S. L., Wilken, J. M., Huang, Y.,Scharfstein, D. O., & MacKenzie, E. J. (2017). Patient Response to anIntegrated Orthotic and Rehabilitation Initiative for Traumatic Injuries: ThePRIORITI-MTF Study. Journal ofOrthopaedic Trauma, 31(1), 56-62. doi: 10.1097/BOT.0000000000000795
Evidence supports that use of the IDEO, combined with the Return to Run physical therapy
program, can decrease pain, improve agility, power, and speed, and may allow
return to duty in a population of high-functioning patients. The
successful outcomes observed in a series of clinical studies led
to a prospective multi-site clinical trial, as described in this
publication. It is our hope that this study will eventually provide
generalizable outcomes for this unique program, and evidence-based support for
implementing this multidisciplinary intervention across the nation.
Interventions to Manage Residual Limb Ulceration Due To Prosthetic Use in Individuals with Lower Extremity Amputation: A Systematic Review of the Literature
HighsmithMJ, Kahle JT, Klenow TD, Andrews CR, Lewis KL, Bradley RC, Ward JM, Orriola JJ,Highsmith JT. Interventions to Manage Residual Limb Ulceration Due ToProsthetic Use in Individuals with Lower Extremity Amputation: A SystematicReview of the Literature. Technology & Innovation 18(2), 115-123, 2016.
Ulcers or pressure sores are among the more common skin
conditions in prosthetic users. This can
occur from shear forces, humidity, and moisture at the skin-socket
interface. Prevention is key, however
evidence from a meta-analysis suggests that continued prosthetic use is a
viable option to manage a residual limb with minor early stage ulceration in a
compliant patient lacking comorbidities that may delay healing. Conversely,
prosthetic discontinuance is also a viable method of residual limb ulcer
healing in the presence of multiple comorbidities that may delay healing.31
Therefore, it is clinically important to study factors within a socket that can
prevent detrimental movement that can lead to skin damage.
Comparative Effectiveness of an Adjustable Transfemoral Prosthetic Interface Accommodating Volume Fluctuation: Case Study
KahleJT, Klenow TD, Highsmith MJ. Comparative Effectiveness of an AdjustableTransfemoral Prosthetic Interface Accommodating Volume Fluctuation: Case Study.Technology & Innovation, 18(2), 167-173, 2016.
The standard of care socket interface doesn’t offer inherent adjustability. A case
analysis compared a non-adjustable transfemoral socket to a novel adjustable transfemoral
socket interface, and noted that the adjustable socket produced superior
subjective and performance outcomes. There is a critical need for
further study into advanced technologies that might optimize the stump-socket
interface.
Crossover study of amputee stair ascent and descent biomechanics using Genium and C-Leg prostheses with comparison to non-amputee control
LuraDJ, Wernke MW, Carey SL, Kahle JT, Miro RM, Highsmith MJ. Crossover study ofamputee stair ascent and descent biomechanics using Genium and C-Leg prostheseswith comparison to non-amputee control. Gait Posture. 58, 103-107, 2017.
The Genium knee offers a more advanced
sensor array than the C-leg, and improvements in perceived function have been
observed. When comparing the two knee
systems during stair ascent the Genium knee decreased deficiency in gait
patterns by enabling gait patterns that more closely resembled non-amputees.
Further comparative studies will
contribute greatly to understanding how a particular prosthetic device responds
to specific physical challenges, leading to optimized prosthetic prescription
for our patients.
Segmental contributions to sagittal-plane whole-body angular momentum when using powered compared to passive ankle-foot prostheses on ramps
Pickle,N. T., Silverman, A. K., Wilken, J. M., & Fey, N. P. (2017). Segmentalcontributions to sagittal-plane whole-body angular momentum when using poweredcompared to passive ankle-foot prostheses on ramps. IEEE InternationalConference on Rehabilitation Robotics, (Jul), 609-1614. doi:10.1109/ICORR.2017.8009478
The contributions of individual body segments to overall whole body mechanics throughout the gait cycle may yield further insights, specifically for people with
transtibial amputation using powered prostheses. When comparing passive with powered ankle prostheses, a powered prosthesis generated more normative
biomechanics in the trunk during prosthetic leg push-off when negotiating
inclines, and resembles more closely the biomechanical function of the soleus
muscle. There was little or no difference, however, between the passive and powered prostheses at declines of
-5° and -10°, suggesting that neither passive nor active prostheses replicate soleus
function on declines.
Evaluation of a powered ankle-foot prosthesis during slope ascent gait
Rabago,C. A., Whitehead, J. M., & Wilken, J. M. (2016). Evaluation of a poweredankle-foot prosthesis during slope ascent gait. Public Library of Science One,181(S4), 30-37. doi: 10.1671/journal.pone.0166815
An additional study comparing powered and passive ankle prostheses on knee
mechanics when walking up an incline found that use of a powered ankle
prosthesis increased ankle plantarflexion and push-off power when transitioning
off the prosthetic limb. This contributed to decreased intact limb knee
extensor power production, lessening demand on the intact limb knee.
Effects of the Genium Microprocessor Knee System on Knee Moment Symmetry During Hill Walking
HighsmithMJ, Klenow TD, Kahle JT, Wernke MW, Carey SL, Miro RM, Lura DJ. Effects of theGenium Microprocessor Knee System on Knee Moment Symmetry During Hill Walking.Technology & Innovation 18(2), 151-157, 2016.
Use of the Genium microprocessor knee system by individuals with transfemoral
amputation reportedly improves knee kinematics during walking on both flat
surfaces and hills. Given the improved kinematics associated with hill walking, researchers sought to assess the
impact of the Genium on knee mechanics. When ambulating on a five degree ramp, the Genium knee system improved
knee moment symmetry during both incline and decline walking compared with
C-Leg. Results of this work suggest that the Genium microprocessor knee
system may be a desirable intervention for patients with transfemoral limb loss
who range in function from high-functioning community ambulators to older
amputees who walk slower and require more consistent knee performance.
Predicting Walking Ability Following Lower Limb Amputation: An Updated Systematic Literature Review
KahleJT, Highsmith MJ, Schaepper H, Johannesson A, Orendurff MS, Kaufman K. Predicting Walking Ability Following Lower Limb Amputation: An UpdatedSystematic Literature Review. Technology & Innovation 18(2), 125-137, 2016.
Determining the appropriate prosthetic prescription and functional level potential is an
important aspect of care for patients with amputation. Little is known about which factors might
best predict the best outcomes when prescribing a prosthesis. In a recent meta-analysis moderate to
strongly supported predictive factors of prosthetic candidacy were determined to be
etiology, physical fitness, pre-amputation living status, amputation level,
age, physical fitness, and comorbidities. These factors are supported
in an earlier literature review and should be strongly considered in a complete
history and physical examination by a multidisciplinary team.
Economic Evaluations of Interventions for Transtibial Amputees: A Scoping Review of Comparative Studies
HighsmithMJ, Kahle JT, Lewandowski A, Klenow TD, Orriola JJ, Miro RM, Hill OT,Raschke SU, Orendurff MS, Highsmith JT,Sutton BS. Economic Evaluations of Interventions for Transtibial Amputees: AScoping Review of Comparative Studies. Technology & Innovation 18(2),85-98, 2016.
As the cost of prosthetic devices becomes higher with increasing technology,
economic analyses of prosthetic interventions are needed in order to determine
value related to device provision and maintenance, outcomes, and health. A recent review sought to formulate evidence
statements related to prosthetic interventions for persons with transtibial
amputation from an economic evaluation perspective based solely on comparative
studies. The findings concluded with moderate confidence that specific
weight-bearing and total-contact sockets for transtibial amputees are
functionally and economically equivalent in the short term when costs, delivery
time, and all stakeholder perspectives are considered. Long-term socket outcomes are relatively
unexplored, and further research in this area is needed to optimize prosthetic
prescription recommendations.
Functional performance differences between the Genium and C-Leg prosthetic knees and intact knees
HighsmithMJ, Kahle JT, Miro RM, Cress ME, Lura DJ, Quillen WS, Carey SL, Dubey RV,Mengelkoch LJ. Functional performance differences between the Genium and C-Legprosthetic knees and intact knees. J Rehabil Res Dev. 53(6), 753-766, 2016.
Engineering advancements incorporated into the Genium microprocessor knee include a
sagittal knee moment sensor, angle sensor, and gyroscope, which have the
potential to increasingly replicate normal knee motion. Comparisons were made to assess functional
outcomes between the advanced knee prosthesis Genium and the C-Leg, prescribed
frequently for our patients. Genium use improved upper-body flexibility, balance, and endurance domain scores compared
with the C-Leg. Only in the endurance
domain did Genium users score significantly lower than nonamputees. Regardless of knee condition, subjects with
transfemoral amputation did not equal or surpass nonamputees in any functional
domain, suggesting room for continued technological improvements in prosthetic
knee functional parameters.
Effects of the Genium Knee System on Functional Level, Stair Ambulation, Perceptive and Economic Outcomes in Transfemoral Amputees
HighsmithMJ, Kahle JT, Wernke MM, Carey SL, Miro RM, Lura DJ, Sutton BS. Effects of theGenium Knee System on Functional Level, Stair Ambulation, Perceptive andEconomic Outcomes in Transfemoral Amputees. Technology & Innovation 18(2),139-150, 2016.
This study noted that the laboratory determined
benefits of the Genium over the C-leg were supported by common clinical
benefits. Use of the Genium improved stair
walking performance, multi-directional stepping, functional level, and
perceived function. In this group of community ambulators with
transfemoral amputation the Genium was preferred, suggesting that while more
costly, the significant improvements in functional performance were worth the
additional cost.
Differences in Military Obstacle Course Performance Between Three Energy-Storing and Shock Adapting Prosthetic Feet in High-Functioning Transtibial Amputees: A Double-Blind, Randomized Control Trial
HighsmithMJ, Kahle JT, Miro RM, Lura DJ, Carey SL, Wernke MW, Kim SH, Quillen WS.Differences in Military Obstacle Course Performance Between ThreeEnergy-Storing and Shock Adapting Prosthetic Feet in High-FunctioningTranstibial Amputees: A Double-Blind, Randomized Control Trial. MilitaryMedicine. 181(11/12):45-54, 2016.
Military Service members with transtibial amputation function at a level beyond basic
ambulation. As many injured Service members would like to return to
high-performance activities commensurate with return to duty, efforts are
ongoing to demonstrate which prosthetic feet maximize this possibility. A
field-based study compared three prosthetic feet (Ossur Variflex, Endolite
Elite Blade, and Ossur Re-Flex Rotate) during performance on an obstacle
course. While no clear differences in
prosthetic feet emerged during obstacle course completion individual task
performance, perceived effort, and preference resulted in trends of slight performance
improvement with and preference for Elite Blade,42 a dual
function energy-storing and return foot combined with vertical shock
absorption. Controls completed the obstacle course faster and with less effort
than individuals with amputation regardless of prosthetic foot, suggesting
further advances in prosthetic technologies are needed to optimize high level
performance activities.
Bioenergetic Differences During Walking and Running in Transfemoral Amputee Runners Using Articulating and Non-Articulating Knee Prostheses
HighsmithMJ, Kahle JT, Miro RM, Mengelkoch LJ. Bioenergetic Differences During Walkingand Running in Transfemoral Amputee Runners Using Articulating andNon-Articulating Knee Prostheses. Technology & Innovation, 18(2), 159-165,2016
Running is an activity that
is part of military service and, as such, is an important goal of many Service members. For transfemoral amputees running presents a
challenge in that they have lost knee function.
Some distance runners with transfemoral amputation prefer to run with a
prosthesis that has a non-articulating knee joint, as they feel that it
controls knee buckling that can occur with an articulating knee mechanism. A study comparing outcomes between
articulating and non-articulating running prostheses noted decreased energy
expenditure, lower perceived exertion, faster self-selected walking and running
speeds, and a subjective preference for the articulated knee condition. These
findings suggest that for trained runners with transfemoral amputation a
running prosthesis with an articulating knee may be preferred.
A Review of Unique Considerations for Female Veterans With Amputation
RandolphBJ, Nelson LM, Highsmith MJ. A Review of Unique Considerations for FemaleVeterans With Amputation. Military Medicine. 181(11/12):66-68, 2016.
Dissatisfaction with prosthetic fit and appearance tends to be higher in the female population
living with limb loss. A recent review provides an overview of considerations
unique to female Veterans with amputation.These include the need for smaller
componentry that suits a smaller frame size, a need to adapt to changes that
occur during pregnancy, and the higher occurrence of osteoporosis as a woman
ages. These factors need to be
taken into account if treatment strategies are to be successful and gaps in
commercially available products and research are going to be appropriately
identified. Defining the population of
women Veterans with amputation and their needs is the next step in generating
research priorities for this population.
Predictors of retention and attrition in a study of an advanced upper limb prosthesis: Implications for adoption of the DEKA Arm
Resnik,L., Cancio, J., Klinger, S., Latlief, G., Sasson, N., & Smurr-Walters, L.(2017). Predictors of retention and attrition in a study of an advanced upperlimb prosthesis: Implications for adoption of the DEKA Arm. Disability andRehabilitation Assistive Technology, (April), 1-5. doi:10.1080/17483107.2017.1304585
The DEKA Gen 3 arm is a novel
upper limb prosthesis recently approved by the Food and Drug Administration,
and features enhanced ability to perform the complex movements required to
increase dexterity and movement quality. As a step
to identify and target the most appropriate candidates for prescription of the DEKA
Arm prescription a home study was undertaken.
Results from this study, for which completion of the home use study was
a reasonable proxy for participant willingness to adopt the device, found that
those most likely to be successful adopters were already using a personal
prosthesis and were free of pre-existing musculoskeletal problems. Further work is ongoing to optimize function of the DEKA
arm and other available prosthetic devices for the upper extremity.
Medical/Surgical Interventions
Multimodality imaging approaches for evaluating traumatic extremity injuries: Implications for military medicine
Stacy,M. R., & Dearth, C. L. (2017). Multimodality imaging approaches forevaluating traumatic extremity injuries: Implications for military medicine.Advances in Wound Care, 6(7), 241-251, doi: 10.1089/wound.2016.0716
Traumatic extremity injuries require
rapid diagnosis and treatment to facilitate optimal patient outcomes. A variety of imaging modalities are available
for non-invasive assessment following extremity trauma, and include
ultrasound, computed tomography (CT),
magnetic resonance imaging (MRI), and radiotracer imaging with SPECT and PET. A
recent review describes the advantages and
disadvantages to each. Disadvantages
that include exposure to radiation, high cost, non-portability, long image
acquisition times, and other challenges support a continued clinical need for noninvasive quantitative imaging techniques that
are capable of providing rapid objective assessments of residual limb health at
the time of initial presentation, as well as after various forms of medical
treatment.
Gait biomechanics following lower extremity trauma: Amputation vs. reconstruction
RussellEsposito, E., Stinner, D. J., Fergason, J. R., & Wilken, J. M. (2017). Gaitbiomechanics following lower extremity trauma: Amputation vs. reconstruction.Gait Posture, 54(May), 167-173. doi: 10.1016/j.gaitpost.2017.02.016
Surgical advances have substantially improved outcomes for individuals who have
undergone limb reconstruction surgery, and there is a growing body of knowledge
to inform clinicians and patients on functional expectations when considering
amputation or limb reconstruction. A
recent study comparing functional outcomes between patients with amputation and
limb reconstruction found that the reconstruction group exhibited less
ankle power and range of motion while the amputee group exhibited lower knee
flexor and extensor moments and power generation.6 This
suggests that surgical interventions that preserve or improve ankle function
can play a role in the decision to choose limb preservation over amputation.
The influence of limb alignment and transfemoral amputation technique on muscle capacity during gait
Ranz,E. C., Wilken, J. M., Gajewski, D. A., & Neptune, R. R. (2017). Theinfluence of limb alignment and transfemoral amputation technique on musclecapacity during gait. Computer Methods in Biomechanical and BiomedicalEngineering, 20(11), 1167-1174. doi: 10.1080/10255842.2017.1340461
Advanced musculoskeletal modeling
techniques suggest that femur length may have little effect if surgical
procedures are employed that preserved muscle tension. In a musculoskeletal modeling study looking at
the influence of various surgical options, muscle wrap techniques had little effect on
muscle capacity, while muscle tension had the greatest influence. This
analysis suggests that myodesis stabilization, which allows for greater muscle
tension, may provide superior hip muscle balance and function compared to
myoplasty stabilization or when leaving muscles unattached.
The Effectiveness of the Bone Bridge Transtibial Amputation Technique: A Systematic Review of High-Quality Evidence
KahleJT, Highsmith MJ, Kenney J, Ruth T, Lunseth PA, Ertl J. The Effectiveness ofthe Bone Bridge Transtibial Amputation Technique: A Systematic Review ofHigh-Quality Evidence. Prosthet Orthot Int, 2016;(epub ahead of print):1-8
An ongoing debate exists as to whether
the ERTL bone bridging procedure, which creates a boney bridge between the
distal tibia and fibula following amputation, contributes to a more efficient
platform in the total-surface-bearing socket.
A comprehensive systematic review undertaken in FY17 reported that current
level III evidence supports a bone bridge technique as an equivalent option to
the non-bone bridge transtibial amputation technique, and suggests that
formal level I and II clinical trials will need to be undertaken to answer this
question sufficiently to make a recommendation that can guide clinical
practice.
Dermatologic Surgery: Improving Smartphone Use to Avoid Wrong-site Surgery
HighsmithJT, Weinstein DA, Highsmith MJ, Etzkorn JR. Biopsy 1-2-3 in DermatologicSurgery: Improving Smartphone Use to Avoid Wrong-site Surgery. Technology &Innovation 18(2), 203-206, 2016.
With the increasing need to provide care
for patients who are geographically dispersed, advanced communication
capabilities may increasingly provide a real-time universal “tele-health”
platform for interface between clinicians and patients. A case report described a step-by-step
procedure that a patient can use to relay photographic images related to their
care to their clinicians through use of a Smartphone.18 In this case the information was limited to
a potential biopsy site, however the potential exists to utilize photos sent by
the patient as requested by the provider to assist in the medical care of a
patient. It is possible that use of a
photo that would come from the patient’s own smartphone device may not violate
privacy acts and, as such, might facilitate care provided when patients are
remote from a clinic, and placed within the medical record to document care.
Radiographic Assessment of Extremity Osseointegration for the Amputee
AlMuderis M, Bosley BA, Florschutz AV, Lunseth PA, Klenow TD, Highsmith MJ, KahleJT. Radiographic Assessment of Extremity Osseointegration for the Amputee.Technology & Innovation 18(2), 211-216, 2016.
The current standard of care for persons
with limb loss is use of an artificial limb with a socket attached to
prosthetic limb components. Though
significant technological advances have been made in prosthetic technologies,
the stump-socket interface remains a clinical challenge. Problems include limb volume changes over
time and during activities, sweating, suspension techniques, pain, and skin
breakdown. The surgical practice of
osseointegration offers a new and exciting option for patients for whom the use
of an artificial limb is challenging.
This procedure is in its infancy, and offers a rich environment for
investigation that builds on previous work in the field of joint replacement
surgery.
A recent study utilized a modification of
the radiographic zonal analysis (Gruen zones) used in orthopedic intramedullary
implant evaluation to address the need for a common reference standard for
osseointegration in an amputated extremity.
This OGA Zonal analysis, developed by a team of clinicians in
Australia who are one of the pioneers of the osseointegration technique, provides
a method for observing changes in extremity bone resulting from an
osseointegrated implant.19
This provides a radiographic standard that can contribute to
optimizing this procedure, with the hopes that osseointegration might become as
successful for patients with amputation as intramedullary joint replacement has
for individuals with debilitating arthritic change.
Regenerative Medicine Interventions
Regenerative and rehabilitative medicine: A necessary synergy for functional recovery from volumetric muscle loss injury
Greising,S. M., Dearth, C. L., & Corona, B. T. (2016). Regenerative and rehabilitativemedicine: A necessary synergy forfunctional recovery from volumetric muscle loss injury. Cells Tissues Organs,202(3-4), 237-249. doi: 10.1159/000444673
Clinical observations and the existing literature suggests that
traditional physical therapy does not significantly restore muscle strength or
limb function in patients with volumetric muscle loss (VML). An emerging field
of research, “regenerative rehabilitation”, is investigating the potential for
synergizing regenerative and rehabilitative therapies to restore limb and
muscle function following VML. Currently
there is no standard of care related to rehabilitative therapies for patients
with VML, though emerging therapies are in various stages of development or
clinical testing. A recent review highlighted current clinical strategies
of rehabilitation in patients with VML, and presented a summary of
generalizable preclinical findings that may lead to evidence-based
opportunities for multidisciplinary collaboration between these clinical and
research fields.
The effect of mechanical loading upon extracellular matrix bioscaffold-mediated skeletal muscle remodeling
Dziki,J. L., Giglio, R. M., Sicari, B. M., Wang, D. S., Gandhi, R. M., Londono, R.,Dearth, C. L. & Badylak, S. F. (2017). The effect of mechanical loadingupon extracellular matrix bioscaffold-mediated skeletal muscleremodeling. Tissue Engineering Part A. (epub ahead of print) doi:https://doi.org/10.1089/ten.tea.2017.0011
Mounting evidence suggests that site-appropriate loading of implanted extracellular
matrix (ECM) bioscaffolds and the surrounding skeletal muscle microenvironment
could enhance the development of functional muscle tissue. A mouse hind limb unloading VML model was
used to evaluate the effect of mechanical loading after ECM implantation, and
showed that myoblast chemotaxis and differentiation and isometric torque production
was positively influenced by mechanical loading.9 This work supports
the importance of incorporating a multidisciplinary approach that emphasizes
rehabilitation following surgical regenerative medicine interventions. Future
studies are planned to further explore these phenomenon and others, all in an
effort optimize the restoration of tissue form and function following extremity
trauma.