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Pitkin M, Park H, Frossard L, Klishko AN, Prilutsky BI. Transforming the Anthropomorphic Passive Free-Flow Foot Prosthesis Into a Powered Foot Prosthesis With Intuitive Control and Sensation (Bionic FFF). Mil Med 2024; 189:439-447. [PMID: 39160882 DOI: 10.1093/milmed/usae149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 02/19/2024] [Accepted: 03/15/2024] [Indexed: 08/21/2024] Open
Abstract
INTRODUCTION Approximately 89% of all service members with amputations do not return to duty. Restoring intuitive neural control with somatosensory sensation is a key to improving the safety and efficacy of prosthetic locomotion. However, natural somatosensory feedback from lower-limb prostheses has not yet been incorporated into any commercial prostheses. MATERIALS AND METHODS We developed a neuroprosthesis with intuitive bidirectional control and somatosensation and evoking phase-dependent locomotor reflexes, we aspire to significantly improve the prosthetic rehabilitation and long-term functional outcomes of U.S. amputees. We implanted the skin and bone integrated pylon with peripheral neural interface pylon into the cat distal tibia, electromyographic electrodes into the residual gastrocnemius muscle, and nerve cuff electrodes on the distal tibial and sciatic nerves. Results. The bidirectional neural interface that was developed was integrated into the existing passive Free-Flow Foot and Ankle prosthesis, WillowWood, Mount Sterling, OH. The Free-Flow Foot was chosen because it had the highest Index of Anthropomorphicity among lower-limb prostheses and was the first anthropomorphic prosthesis brought to market. Conclusion. The cats walked on a treadmill with no cutaneous feedback from the foot in the control condition and with their residual distal tibial nerve stimulated during the stance phase of walking.
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Affiliation(s)
- Mark Pitkin
- Poly-Orth International, Sharon, MA 02067, USA
- Tufts University School of Medicine, Boston, MA 02111, USA
| | - Hangue Park
- Electrical and Computer Engineering, Texas A&M University, College Station, TX 77843, USA
- Biomedical Engineering, Sungkyunkwan University, Suwon 16419, South Korea
- Intelligent Prevision Healthcare Convergence, Sungkyunkwan University, Suwon 16419, South Korea
| | - Laurent Frossard
- Griffith University, Griffith Centre of Biomedical and Rehabilitation Engineering (GCORE), Southport, QLD 4215, Australia
- YourResearchProject Ptd Ltd, Brisbane, QLD 4065, Australia
| | - Alexander N Klishko
- School of Biological Sciences, Georgia Institute of Technology, Atlanta, GA 30332, USA
| | - Boris I Prilutsky
- School of Biological Sciences, Georgia Institute of Technology, Atlanta, GA 30332, USA
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Pursel A, Nichols R, Evans D, Lindquist K. The Exploration of the GWOT Combat Amputee's Experience With Longitudinal Care: A Qualitative Study. Mil Med 2023:usad490. [PMID: 38150398 DOI: 10.1093/milmed/usad490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 11/18/2023] [Accepted: 12/12/2023] [Indexed: 12/29/2023] Open
Abstract
INTRODUCTION Contemporary advances in combat medicine have allowed greater numbers of wounded service members to survive their injuries. An estimated 1,705 combat veterans sustained major lower or upper extremity amputations between 2001 and 2017 during the Global War on Terror. This study intends to answer the following question utilizing a qualitative study design: What were the common and abnormal experiences of the Global War on Terror combat amputees relative to their mechanism of injury, perception of injury, and systems of care utilized during their recovery and rehabilitation process?. METHODS During the months of December 2022 and January 2023, individual semi-structured interviews were conducted with U.S. Marines that served in the Global War on Terror (total n = 10). Deductive and inductive approaches were employed to identify codes, themes, and meta-themes in the data. RESULTS All participants deployed to Afghanistan between the years 2010 and 2014 and were assigned to the following military occupational specialties: Explosive Ordnance Disposal technicians (total n = 2); combat engineers (total n = 2); and infantrymen (total n = 6). Analysis of data collected from interviews highlighted these key observations: (1) Themes in the combat amputee experience include support, systems of care, and mindset and (2) the themes synergistically contribute to the meta-themes mental health and pain and vice versa. As all participants were subjected to a blast mechanism of injury, it is difficult to determine if this played a role in deviating rehabilitation and recovery processes. Perception of injury and how well participants adapted to their new lifestyle, meaning how optimistic they were, appeared to play a significant role in recovery. Participants had mixed feelings about the care they had received but generally spoke favorably of military hospitals and were frustrated with the Veteran Affairs, and there was no clear consensus on their relationship with civilian health care, though most participants chose to seek most of their care through the Veteran Affairs. CONCLUSION Based on the research question, this study found an intricate relationship between mental health, pain, and the experiences of the participants regarding their care and rehabilitation. However, the nature of qualitative research makes it impossible to determine generalizations that can be used to create meaningful change to address improving combat amputee veteran care. Further research into long-term health outcomes based on hypotheses not evaluated in existing literature would further improve the ability of health care providers to care for this unique patient population.
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Affiliation(s)
- Alexander Pursel
- Elson S Floyd College of Medicine, Washington State University, Spokane, WA 99202, USA
| | - Ryoma Nichols
- Elson S Floyd College of Medicine, Washington State University, Spokane, WA 99202, USA
| | - Dan Evans
- Elson S Floyd College of Medicine, Washington State University, Spokane, WA 99202, USA
| | - Kristina Lindquist
- Elson S Floyd College of Medicine, Washington State University, Spokane, WA 99202, USA
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Darter BJ, Hawley CE, Armstrong AJ, Avellone L, Wehman P. Factors Influencing Functional Outcomes and Return-to-Work After Amputation: A Review of the Literature. JOURNAL OF OCCUPATIONAL REHABILITATION 2018; 28:656-665. [PMID: 29397480 PMCID: PMC6076349 DOI: 10.1007/s10926-018-9757-y] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Purpose Amputation is a life changing event that can significantly impact an individual's physical and mental well-being. Our objective was to review literature exploring the impact of amputation upon a person's functioning and inclusion in the workplace. Methods Medline, CINAHL, and PsycINFO were searched using keywords related to amputation, employment and community reintegration. Eligible studies were published since 2000 and one of the following study designs: randomized controlled trial, non-randomized controlled trial, retrospective study, prospective study, concurrent cohort study, or cross sectional study. Studies for civilians with amputation as well as service members and Veterans with amputation were considered for inclusion. Results The search identified 995 articles, 25 of which met inclusion/exclusion criteria and were included in the review. While strong evidence for correlations and predictors of outcomes after amputation were limited, multiple factors were identified as contributing to physical functioning and employment after amputation. Conclusions Outcomes after amputation can vary widely with many potentially inter-related factors contributing. The factors identified may also serve to inform the development of interventions aiming to improve functional performance and reintegration after amputation. Furthermore, the review highlights the need for more high quality prospective studies.
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Affiliation(s)
- Benjamin J Darter
- Department of Physical Therapy, Virginia Commonwealth University, 1200 East Broad Street, Box 980224, Richmond, VA, 23298, USA.
- Department of Research, Hunter Holmes McGuire Veteran Affairs Medical Center, Richmond, VA, 23249, USA.
| | - Carolyn E Hawley
- Department of Rehabilitation Counseling, Virginia Commonwealth University, Richmond, VA, 23298, USA
| | - Amy J Armstrong
- Department of Rehabilitation Counseling, Virginia Commonwealth University, Richmond, VA, 23298, USA
| | - Lauren Avellone
- Rehabilitation Research and Training Center, Virginia Commonwealth University, Richmond, VA, 23284, USA
| | - Paul Wehman
- Department of Physical Medicine and Rehabilitation, Virginia Commonwealth University, Richmond, VA, 23284, USA
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Tennent DJ, Polfer EM, Sgromolo NM, Krueger CA, Potter BK. Characterization of disability following traumatic through knee and transfemoral amputations. Injury 2018; 49:1193-1196. [PMID: 29606330 DOI: 10.1016/j.injury.2018.03.029] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Revised: 03/20/2018] [Accepted: 03/26/2018] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The purpose of this study is to characterize through knee and transfemoral amputations following severe traumatic injuries. METHODS A retrospective review of all transfemoral and through knee amputations sustained by United States military service members from 1 October 2001 to 30 July 2011 was conducted. Data from the Department of Defense Trauma Registry, the Armed Forces Health Longitudinal Technology Application, inpatient medical records and the Physical Evaluation Board Liaison Offices were queried in order to obtain characteristics related to injury sustained, demographics, treatment, and disability/mental health outcome data. RESULTS A total of 1631 amputations in 1315 patients were identified. Of these there were 37 through knee and 296 were transfemoral amputations. Adequate records for detailed analysis were available on 140 and 25 transfemoral and through knee amputations respectively. There were no significant differences in demographic information, injury mechanism, initial injury severity score, or associated injuries, to include contralateral amputations. There was no significant difference in average disability rating (67.9% vs 78.3%, p = 0.46) or number of service members determined to be fully disabled (42.2% vs 28.6% p = 0.33) between the transfemoral and through knee amputation groups. Whereas there was no difference between groups preoperatively, the knee disarticulation group displayed a higher rate of mental health diagnoses post-amputation (96% vs 72%, p < 0.001) and a higher preponderance of anxiety related disorders than the transfemoral amputees (26.92% vs 12.96%, p = 0.0129). DISCUSSION/CONCLUSION Among this military amputee through knee and transfemoral amputees displayed similar physical disability profiles. However, the through knee amputees displayed a higher level of anxiety related disorders and mental health diagnosis overall. While we don't believe this relationship to be causal in nature, this finding reflects the importance of paying particular attention to mental health in the final disposition of traumatic lower extremity amputees.
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Affiliation(s)
- David J Tennent
- San Antonio Military Medical Center, Department of Orthopaedics, 3855 Roger Brooke Drive, Fort Sam Houston, TX 78234, United States.
| | - Elizabeth M Polfer
- William Beaumont Army Medical Center, Department of Orthopaedics, 5005 N Piedras St., El Paso, TX, 79920, United States.
| | - Nicole M Sgromolo
- San Antonio Military Medical Center, Department of Orthopaedics, 3855 Roger Brooke Drive, Fort Sam Houston, TX 78234, United States.
| | - Chad A Krueger
- Department of Orthopaedic Surgery and Rehabilitation, Womack Army Medical Center, Fort Bragg, NC, 28310, United States.
| | - Benjamin K Potter
- Walter Reed National Naval Military Medical Center, Department of Orthopaedics, WRNMMC 8901,Wisconsin Ave Fl America Building Bldg 19 2(nd), Bethesda, MD 20889, United States.
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Christensen J, Langberg H, Doherty P, Egerod I. Ambivalence in rehabilitation: thematic analysis of the experiences of lower limb amputated veterans. Disabil Rehabil 2017. [DOI: 10.1080/09638288.2017.1342281] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Jan Christensen
- Department of Occupational and Physiotherapy, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Public Health, Section of Social Medicine, Faculty of Health, CopenRehab, University of Copenhagen, Copenhagen, Denmark
| | - Henning Langberg
- Department of Occupational and Physiotherapy, Copenhagen University Hospital, Copenhagen, Denmark
| | | | - Ingrid Egerod
- Neurointensive Care Unit, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
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Abstract
Traumatic and trauma-related amputations represent unfortunate sequelae of severe injury, but should not be viewed as a treatment failure and may represent the best reconstructive option for some patients. Lessons from recent military conflicts have guided the evolution of modern surgical techniques and rehabilitation management of this challenging patient population, and treatment at a specialty center may improve patient outcomes. Despite appropriate management, however, surgical complications remain common and revision surgery is often necessary. Bridge synostosis procedures remain controversial, and clinical equipoise remains regarding their functional benefits. Based on European experience over the last 3 decades, osseointegration has evolved into a viable clinical alternative for patients unable to achieve acceptable function using conventional sockets, and several devices are being developed or tested in the United States. Targeted muscle reinnervation and advanced pattern recognition may dramatically improve the functional potential of many upper extremity amputees, and the procedure may also relieve neuroma-related pain. Furthermore, exciting new research may eventually facilitate haptic feedback and restore useful sensation for amputees. Natural disasters and global terrorism events, in addition to conventional trauma resulting in limb loss, make a working knowledge of current amputation surgical techniques essential to the practicing orthopaedic trauma surgeon.
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Affiliation(s)
- Scott M Tintle
- *Division of Orthopaedics, Uniformed Services University-Walter Reed National Military Medical Center Department of Surgery, Bethesda, MD; †Orthopaedic Trauma Service, R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD; and ‡Department of Orthopaedic Surgery, Johns Hopkins University, Baltimore, MD
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Comprehensive Rehabilitation Following Combat Extremity Trauma: Evolution and Its Impact on Outcomes. J Orthop Trauma 2016; 30 Suppl 3:S31-S33. [PMID: 27661425 DOI: 10.1097/bot.0000000000000672] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Recent military combat operations have resulted in a high burden of extremity-related long-term disability due to limb amputation and persistent deficits despite limb reconstruction. The US Army amputee care programs, established at focused centers with interdisciplinary care teams, have redefined the standard of how rehabilitation following limb loss is undertaken as the limb reconstruction is just one part of the entire patient's restoration of wellness and reintegration. Inspired by this approached, comprehensive rehabilitation programs designed for patients with limb reconstruction have also excelled rehabilitation following a spectrum of severe limb trauma. These programs, which include advances in orthotics and orthosis training, have improved function and military retention among the limb salvage patient population. Lessons learned from comprehensive rehabilitation efforts emphasize the value of highly skilled, interprofessional care teams and the overall wellness of the patients. Although this approach is resource intensive and not available in all health care systems, civilian trauma counterparts can learn from the example of holistic attention to the patient's recovery.
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Melcer T, Pyo J, Walker J, Quinn K, Lebedda M, Neises K, Nguyen C, Galarneau M. Rehabilitation and multiple limb amputations: A clinical report of patients injured in combat. ACTA ACUST UNITED AC 2016; 53:1045-1060. [PMID: 28355036 DOI: 10.1682/jrrd.2014.09.0219] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2014] [Revised: 06/07/2016] [Indexed: 11/05/2022]
Abstract
This clinical report describes the outpatient rehabilitation program for patients with multiple limb amputations enrolled in the Comprehensive Combat and Complex Casualty Care facility at the Naval Medical Center San Diego. Injury-specific data for 29 of these patients wounded by blast weaponry in Afghanistan in 2010 or 2011 were captured by the Expeditionary Medical Encounter Database at the Naval Health Research Center and were reviewed for this report. Their median Injury Severity Score was 27 (N = 29; range, 11-54). Patients averaged seven moderate to serious injuries (Abbreviated Injury Scale scores ≥2), including multiple injuries to lower limbs and injuries to the torso and/or upper limbs. All patients received care from numerous clinics, particularly physical therapy during the first 6 mo postinjury. Clinic use generally declined after the first 6 mo with the exception of prosthetic devices and repairs. The clinical team implemented the Mayo-Portland Adaptability Inventory, 4th Revision (MPAI-4) to assess functioning at outpatient program initiation and discharge (n = 23). At program discharge, most patients had improved scores for the MPAI-4 items assessing mobility, pain, and transportation, but not employment. Case reports described rehabilitation for two patients with triple amputations and illustrated multispecialty care and contrasting solutions for limb prostheses.
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Affiliation(s)
- Ted Melcer
- Department of Medical Modeling, Simulation, and Mission Support, Naval Health Research Center, San Diego, CA
| | - Jay Pyo
- Comprehensive Combat and Complex Casualty Care, Naval Medical Center San Diego, San Diego, CA
| | - Jay Walker
- Department of Medical Modeling, Simulation, and Mission Support, Naval Health Research Center, San Diego, CA
| | - Kimberly Quinn
- Department of Medical Modeling, Simulation, and Mission Support, Naval Health Research Center, San Diego, CA
| | - Martin Lebedda
- Department of Medical Modeling, Simulation, and Mission Support, Naval Health Research Center, San Diego, CA.,Comprehensive Combat and Complex Casualty Care, Naval Medical Center San Diego, San Diego, CA
| | - Kamaran Neises
- Department of Medical Modeling, Simulation, and Mission Support, Naval Health Research Center, San Diego, CA.,Comprehensive Combat and Complex Casualty Care, Naval Medical Center San Diego, San Diego, CA
| | - Christina Nguyen
- Department of Medical Modeling, Simulation, and Mission Support, Naval Health Research Center, San Diego, CA.,Comprehensive Combat and Complex Casualty Care, Naval Medical Center San Diego, San Diego, CA
| | - Michael Galarneau
- Department of Medical Modeling, Simulation, and Mission Support, Naval Health Research Center, San Diego, CA
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