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Shuman BR, Hendershot BD, Morgenroth DC, Russell Esposito E. A patient-centered 'test-drive' strategy for ankle-foot orthosis prescription: Protocol for a randomized participant-blinded trial. PLoS One 2024; 19:e0302389. [PMID: 38696428 PMCID: PMC11065291 DOI: 10.1371/journal.pone.0302389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 03/31/2024] [Indexed: 05/04/2024] Open
Abstract
BACKGROUND Ankle-foot orthoses (AFOs) are commonly used to overcome mobility limitations related to lower limb musculoskeletal injury. Despite a multitude of AFOs to choose from, there is scant evidence to guide AFO prescription and limited opportunities for AFO users to provide experiential input during the process. To address these limitations in the current prescription process, this study evaluates a novel, user-centered and personalized 'test-drive' strategy using a robotic exoskeleton ('AFO emulator') to emulate commercial AFO mechanical properties (i.e., stiffness). The study will determine if brief, in-lab trials (with emulated or actual AFOs) can predict longer term preference, satisfaction, and mobility outcomes after community trials (with the actual AFOs). Secondarily, it will compare the in-lab experience of walking between actual vs. emulated AFOs. METHODS AND ANALYSIS In this participant-blinded, randomized crossover study we will recruit up to fifty-eight individuals with lower limb musculoskeletal injuries who currently use an AFO. Participants will walk on a treadmill with three actual AFOs and corresponding emulated AFOs for the "in-lab" assessments. For the community trial assessment, participants will wear each of the actual AFOs for a two-week period during activities of daily living. Performance-based and user-reported measures of preference and mobility will be compared between short- and long-term trials (i.e., in-lab vs. two-week community trials), and between in-lab trials (emulated vs. actual AFOs). TRIAL REGISTRATION The study was prospectively registered at www.clininicaltrials.gov (Clinical Trials Study ID: NCT06113159). Date: November 1st 2023. https://classic.clinicaltrials.gov/ct2/show/NCT06113159.
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Affiliation(s)
- Benjamin R. Shuman
- VA RR&D Center for Limb Loss and Mobility, VA Puget Sound Health Care System, Seattle, Washington, United States of America
- Department of Mechanical Engineering, University of Washington, Seattle, Washington, United States of America
- Seattle Institute for Biomedical and Clinical Research, Seattle, Washington, United States of America
| | - Brad D. Hendershot
- Extremity Trauma and Amputation Center of Excellence, Defense Health Agency, Falls Church, Virginia, United States of America
- Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, Maryland, United States of America
- Department of Physical Medicine & Rehabilitation, Uniformed Services University of the Health Sciences, Bethesda, Maryland, United States of America
| | - David C. Morgenroth
- VA RR&D Center for Limb Loss and Mobility, VA Puget Sound Health Care System, Seattle, Washington, United States of America
- Department of Rehabilitation Medicine, University of Washington, Seattle, Washington, United States of America
| | - Elizabeth Russell Esposito
- VA RR&D Center for Limb Loss and Mobility, VA Puget Sound Health Care System, Seattle, Washington, United States of America
- Department of Mechanical Engineering, University of Washington, Seattle, Washington, United States of America
- Extremity Trauma and Amputation Center of Excellence, Defense Health Agency, Falls Church, Virginia, United States of America
- Department of Physical Medicine & Rehabilitation, Uniformed Services University of the Health Sciences, Bethesda, Maryland, United States of America
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Gladish JR, Dearth CL, Beachler MD, Potter BK, Forsberg JA, Hendershot BD. Mechanical loading of bone-anchored implants during functional performance tests in service members with transfemoral limb loss. Front Rehabil Sci 2024; 5:1336115. [PMID: 38560026 PMCID: PMC10978646 DOI: 10.3389/fresc.2024.1336115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 03/06/2024] [Indexed: 04/04/2024]
Abstract
Introduction For individuals with limb loss, bone-anchored implants create a direct structural and functional connection to a terminal prosthesis. Here, we characterized the mechanical loads distal to the abutment during several functional performance tests in Service members with transfemoral (TF) limb loss, to expand on prior work evaluating more steady-state ambulation on level ground or slopes/stairs. Methods Two males with unilateral TF limb loss and two males with bilateral TF limb loss participated after two-stage osseointegration (24 and 12 months, respectively). Tri-directional forces and moments were wirelessly recorded through a sensor, fit distal to the abutment, during six functional tests: Timed Up and Go (TUG), Four Square Step Test (FSST), Six Minute Walk Test (6MWT), Edgren Side-Step Test (SST), T-Test (TTEST), and Illinois Agility Test (IAT). Additionally, participants performed a straight-line gait evaluation on a 15 m level walkway at a self-selected speed (0.93-1.24 m/s). Peak values for each component of force and moment were extracted from all six functional tests; percent differences compared each peak with respect to the corresponding mean peak in straight-line walking. Results Peak mechanical loads were largest during non-steady state components of the functional tests (e.g., side-stepping during SST or TTEST, standing up from the ground during IAT). Relative to walking, peak forces during functional tests were larger by up to 143% (anterior-posterior), 181% (medial-lateral), and 110% (axial); peak moments were larger by up to 108% (flexion-extension), 50% (ab/adduction), and 211% (internal/external rotation). Conclusions A more comprehensive understanding of the mechanical loads applied to bone-anchored implants during a variety of activities is critical to maximize implant survivability and long-term outcomes, particularly for Service members who are generally young at time of injury and return to active lifestyles.
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Affiliation(s)
- Jonathan R. Gladish
- Research & Surveillance Section, Extremity Trauma and Amputation Center of Excellence, Defense Health Agency, Falls Church, VA, United States
- Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, MD, United States
| | - Christopher L. Dearth
- Research & Surveillance Section, Extremity Trauma and Amputation Center of Excellence, Defense Health Agency, Falls Church, VA, United States
- Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, MD, United States
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD, United States
| | - Mark D. Beachler
- Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, MD, United States
| | - Benjamin K. Potter
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD, United States
- Department of Orthopaedics, Walter Reed National Military Medical Center, Bethesda, MD, United States
| | - Jonathan A. Forsberg
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD, United States
- Department of Orthopaedics, Walter Reed National Military Medical Center, Bethesda, MD, United States
- Orthopaedic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Brad D. Hendershot
- Research & Surveillance Section, Extremity Trauma and Amputation Center of Excellence, Defense Health Agency, Falls Church, VA, United States
- Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, MD, United States
- Department of Physical Medicine & Rehabilitation, Uniformed Services University of the Health Sciences, Bethesda, MD, United States
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Parr TE, Farrokhi S, Hendershot BD, Butowicz CM. Peak tibial axial acceleration during walking is related to intact-side lower limb pain in persons with unilateral transtibial amputation. Gait Posture 2024; 109:165-169. [PMID: 38310849 DOI: 10.1016/j.gaitpost.2024.01.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 11/16/2023] [Accepted: 01/25/2024] [Indexed: 02/06/2024]
Abstract
BACKGROUND Persons who undergo unilateral transtibial amputation are at an increased risk of secondary musculoskeletal joint pain and degeneration, which has been linked to excessive loading rates of the intact-side limb. Tibial axial acceleration, a feasible measure of loading rates with wearable sensors, would be clinically useful to relate to joint pain in persons with unilateral transtibial amputation. RESEARCH QUESTION What is the relationship between peak tibial axial accelerations and intact-side joint pain in persons with unilateral transtibial amputation during walking? METHODS Persons with unilateral transtibial amputation (n = 51) were separated into two groups based on the presence of intact-side limb pain (with pain: n = 16; without pain: n = 35). Tibial axial accelerations were measured with bilateral shank-mounted IMUs while participants completed three 10-meter walk tests. Peak tibial axial accelerations for each limb and between-limb symmetry were compared between groups using analysis of co-variance; significance was set at 0.05. RESULTS Between persons with vs. without intact-side limb pain, peak tibial axial accelerations were smaller on the prosthetic side (0.64 vs. 0.81 g; p = 0.04), similar on the intact side (0.82 vs. 0.79 g; p = 0.53), and more asymmetrical between sides (intact > prosthetic) (0.81 vs. 1.03 g; p = 0.01). SIGNIFICANCE Symmetry in peak tibial axial acceleration can assist with identifying preferential limb loading during walking and, with future research, could serve as a useful clinical target for intact-side limb unloading strategies to help mitigate secondary musculoskeletal pain in persons with unilateral transtibial amputation.
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Affiliation(s)
- Therese E Parr
- Oak Ridge Institute for Science and Education, Oak Ridge, TN, USA; Extremity Trauma and Amputation Center of Excellence, Defense Health Agency, Falls Church, VA, USA; Naval Medical Center San Diego, San Diego, CA, USA
| | - Shawn Farrokhi
- Extremity Trauma and Amputation Center of Excellence, Defense Health Agency, Falls Church, VA, USA; Naval Medical Center San Diego, San Diego, CA, USA; Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Brad D Hendershot
- Extremity Trauma and Amputation Center of Excellence, Defense Health Agency, Falls Church, VA, USA; Walter Reed National Military Medical Center, Bethesda, MD, USA; Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Courtney M Butowicz
- Extremity Trauma and Amputation Center of Excellence, Defense Health Agency, Falls Church, VA, USA; Walter Reed National Military Medical Center, Bethesda, MD, USA; Uniformed Services University of the Health Sciences, Bethesda, MD, USA.
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Butowicz CM, Golyski PR, Acasio JC, Hendershot BD. Comparing spinal loads in individuals with unilateral transtibial amputation with and without chronic low back pain: An EMG-informed approach. J Biomech 2024; 166:111966. [PMID: 38373872 DOI: 10.1016/j.jbiomech.2024.111966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 01/11/2024] [Accepted: 01/24/2024] [Indexed: 02/21/2024]
Abstract
Chronic low back pain (cLBP) is highly prevalent after lower limb amputation (LLA), likely due in part to biomechanical factors. Here, three-dimensional full-body kinematics and kinetics during level-ground walking, at a self-selected and three controlled speeds (1.0, 1.3, and 1.6 m/s), were collected from twenty-one persons with unilateral transtibial LLA, with (n = 9) and without cLBP (n = 12). Peak compressive, mediolateral, and anteroposterior L5-S1 spinal loads were estimated from a full-body, transtibial amputation-specific OpenSim model and compared between groups. Predicted lumbar joint torques from muscle activations were compared to inverse dynamics and predicted and measured electromyographic muscle activations were compared for model evaluation and verification. There were no group differences in compressive or anterior shear forces (p > 0.466). During intact stance, peak ipsilateral loads increased with speed to a greater extent in the cLBP group vs. no cLBP group (p=0.023), while during prosthetic stance, peak contralateral loads were larger in the no cLBP group (p=0.047) and increased to a greater extent with walking speed compared to the cLBP group (p=0.008). During intact stance, intact side external obliques had higher activations in the no cLBP group (p=0.039), and internal obliques had higher activations in the cLBP group at faster walking speeds compared to the no cLBP group. Predicted muscle activations demonstrated similar activation patterns to electromyographic-measured activations (r = 0.56-0.96), and error between inverse dynamics and simulated spinal moments was low (0.08 Nm RMS error). Persons with transtibial LLA and cLBP may adopt movement strategies during walking to reduce mediolateral shear forces at the L5-S1 joint, particularly as walking speed increases. However, future work is needed to understand the time course from pain onset to chronification and the cumulative influence of increased spinal loads over time.
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Affiliation(s)
- Courtney M Butowicz
- Research & Surveillance Section, Extremity Trauma and Amputation Center of Excellence, Defense Health Agency, Falls Church, VA 22042, United States; Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, MD 20889, United States; Department of Physical Medicine & Rehabilitation, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, United States.
| | - Pawel R Golyski
- Research & Surveillance Section, Extremity Trauma and Amputation Center of Excellence, Defense Health Agency, Falls Church, VA 22042, United States; Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, MD 20889, United States
| | - Julian C Acasio
- Research & Surveillance Section, Extremity Trauma and Amputation Center of Excellence, Defense Health Agency, Falls Church, VA 22042, United States; Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, MD 20889, United States
| | - Brad D Hendershot
- Research & Surveillance Section, Extremity Trauma and Amputation Center of Excellence, Defense Health Agency, Falls Church, VA 22042, United States; Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, MD 20889, United States; Department of Physical Medicine & Rehabilitation, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, United States
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Farrokhi S, Bechard L, Gorczynski S, Patterson C, Kakyomya J, Hendershot BD, Condon R, Perkins LTCM, Rhon DI, Delitto A, Schneider M, Dearth CL. The Influence of Active, Passive, and Manual Therapy Interventions for Low Back Pain on Opioid Prescription and Health Care Utilization. Phys Ther 2024; 104:pzad173. [PMID: 38112119 DOI: 10.1093/ptj/pzad173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 08/10/2023] [Accepted: 10/19/2023] [Indexed: 12/20/2023]
Abstract
OBJECTIVE The aim of this study was to explore associations between the utilization of active, passive, and manual therapy interventions for low back pain (LBP) with 1-year escalation-of-care events, including opioid prescriptions, spinal injections, specialty care visits, and hospitalizations. METHODS This was a retrospective cohort study of 4827 patients identified via the Military Health System Data Repository who received physical therapist care for LBP in 4 outpatient clinics between January 1, 2015 and January 1, 2018. One-year escalation-of-care events were evaluated based on type of physical therapist interventions (ie, active, passive, or manual therapy) received using adjusted odds ratios. RESULTS Most patients (89.9%) received active interventions. Patients with 10% higher proportion of visits that included at least 1 passive intervention had a 3% to 6% higher likelihood of 1-year escalation-of-care events. Similarly, with 10% higher proportion of passive to active interventions used during the course of care, there was a 5% to 11% higher likelihood of 1-year escalation-of-care events. When compared to patients who received active interventions only, the likelihood of incurring 1-year escalation-of-care events was 50% to 220% higher for those who received mechanical traction and 2 or more different passive interventions, but lower by 50% for patients who received manual therapy. CONCLUSION Greater use of passive interventions for LBP was associated with elevated odds of 1-year escalation-of-care events. In addition, the use of specific passive interventions such as mechanical traction in conjunction with active interventions resulted in suboptimal escalation-of-care events, while the use of manual therapy was associated with more favorable downstream health care outcomes. IMPACT Physical therapists should be judicious in the use of passive interventions for the management of LBP as they are associated with greater likelihood of receiving opioid prescriptions, spinal injections, and specialty care visits.
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Affiliation(s)
- Shawn Farrokhi
- Extremity Trauma and Amputation Center of Excellence, Defense Health Agency, Falls Church, Virginia, USA
- Department of Physical and Occupational Therapy, Naval Medical Center San Diego, San Diego, California, USA
- Department of Rehabilitation Medicine, Uniformed Services University of Health Sciences, Bethesda, Maryland, USA
| | - Laura Bechard
- Extremity Trauma and Amputation Center of Excellence, Defense Health Agency, Falls Church, Virginia, USA
- Department of Physical and Occupational Therapy, Naval Medical Center San Diego, San Diego, California, USA
- The Henry M. Jackson Foundation for the Advancement of Military Medicine Inc, Bethesda, Maryland, USA
| | - Sara Gorczynski
- Extremity Trauma and Amputation Center of Excellence, Defense Health Agency, Falls Church, Virginia, USA
- Department of Physical and Occupational Therapy, Naval Medical Center San Diego, San Diego, California, USA
- The Henry M. Jackson Foundation for the Advancement of Military Medicine Inc, Bethesda, Maryland, USA
| | - Charity Patterson
- Department of Physical Therapy, School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Joseph Kakyomya
- Department of Physical Therapy, School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Brad D Hendershot
- Extremity Trauma and Amputation Center of Excellence, Defense Health Agency, Falls Church, Virginia, USA
- Department of Rehabilitation Medicine, Uniformed Services University of Health Sciences, Bethesda, Maryland, USA
- Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Rachel Condon
- Army-Baylor Doctoral Program in Physical Therapy, Fort Sam Houston, Texas, USA
| | - L T C Matthew Perkins
- Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Daniel I Rhon
- Department of Rehabilitation Medicine, Uniformed Services University of Health Sciences, Bethesda, Maryland, USA
| | - Anthony Delitto
- Department of Physical Therapy, School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Michael Schneider
- Department of Physical Therapy, School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Christopher L Dearth
- Extremity Trauma and Amputation Center of Excellence, Defense Health Agency, Falls Church, Virginia, USA
- Department of Rehabilitation Medicine, Uniformed Services University of Health Sciences, Bethesda, Maryland, USA
- Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
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Wasser JG, Hendershot BD, Acasio JC, Krupenevich RL, Pruziner AL, Miller RH, Goldman SM, Valerio MS, Senchak LT, Murphey MD, Heltzel DA, Fazio MG, Dearth CL, Hager NA. A Comprehensive, Multidisciplinary Assessment for Knee Osteoarthritis Following Traumatic Unilateral Lower Limb Loss in Service Members. Mil Med 2024; 189:581-591. [PMID: 35803867 DOI: 10.1093/milmed/usac203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 06/16/2022] [Accepted: 06/22/2022] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION Knee osteoarthritis (KOA) is a primary source of long-term disability and decreased quality of life (QoL) in service members (SM) with lower limb loss (LL); however, it remains difficult to preemptively identify and mitigate the progression of KOA and KOA-related symptoms. The objective of this study was to explore a comprehensive cross-sectional evaluation, at the baseline of a prospective study, for characterizing KOA in SM with traumatic LL. MATERIALS AND METHODS Thirty-eight male SM with traumatic unilateral LL (23 transtibial and 15 transfemoral), 9.5 ± 5.9 years post-injury, were cross-sectionally evaluated at initial enrollment into a prospective, longitudinal study utilizing a comprehensive evaluation to characterize knee joint health, functionality, and QoL in SM with LL. Presences of medial, lateral, and/or patellofemoral articular degeneration within the contralateral knee were identified via magnetic resonance imaging(for medically eligible SM; Kellgren-Lawrence Grade [n = 32]; and Outerbridge classification [OC; n = 22]). Tri-planar trunk and pelvic motions, knee kinetics, along with temporospatial parameters, were quantified via full-body gait evaluation and inverse dynamics. Concentrations of 26 protein biomarkers of osteochondral tissue degradation and inflammatory activity were identified via serum immunoassays. Physical function, knee symptoms, and QoL were collected via several patient reported outcome measures. RESULTS KOA was identified in 12 of 32 (37.5%; KL ≥ 1) SM with LL; however, 16 of 22 SM presented with patellofemoral degeneration (72.7%; OC ≥ 1). Service members with versus without KOA had a 26% reduction in the narrowest medial tibiofemoral joint space. Biomechanically, SM with versus without KOA walked with a 24% wider stride width and with a negative correlation between peak knee adduction moments and minimal medial tibiofemoral joint space. Physiologically, SM with versus without KOA exhibited elevated concentrations of pro-inflammatory biomarker interleukin-7 (+180%), collagen breakdown markers collagen II cleavage (+44%), and lower concentrations of hyaluronic acid (-73%) and bone resorption biomarker N-telopeptide of Type 1 Collagen (-49%). Lastly, there was a negative correlation between patient-reported contralateral knee pain severity and patient-reported functionality and QoL. CONCLUSIONS While 37.5% of SM with LL had KOA at the tibiofemoral joint (KL ≥ 1), 72.7% of SM had the presence of patellofemoral degeneration (OC ≥ 1). These findings demonstrate that the patellofemoral joint may be more susceptible to degeneration than the medial tibiofemoral compartment following traumatic LL.
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Affiliation(s)
- Joseph G Wasser
- Research and Development Section, Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, MD 20814, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD 20817, USA
| | - Brad D Hendershot
- Research and Development Section, Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, MD 20814, USA
- Research & Surveillance Division, DoD-VA Extremity Trauma and Amputation Center of Excellence, Bethesda, MD 20814, USA
- Department of Rehabilitation Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Julian C Acasio
- Research and Development Section, Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, MD 20814, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD 20817, USA
| | - Rebecca L Krupenevich
- Research and Development Section, Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, MD 20814, USA
| | - Alison L Pruziner
- Research and Development Section, Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, MD 20814, USA
- Research & Surveillance Division, DoD-VA Extremity Trauma and Amputation Center of Excellence, Bethesda, MD 20814, USA
- Department of Rehabilitation Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Ross H Miller
- Department of Kinesiology, University of Maryland, College Park, MD 20742, USA
| | - Stephen M Goldman
- Research & Surveillance Division, DoD-VA Extremity Trauma and Amputation Center of Excellence, Bethesda, MD 20814, USA
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Michael S Valerio
- Research & Surveillance Division, DoD-VA Extremity Trauma and Amputation Center of Excellence, Bethesda, MD 20814, USA
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Lien T Senchak
- Department of Diagnostic Radiology, Walter Reed National Military Medical Center, Bethesda, MD 20814, USA
| | - Mark D Murphey
- Department of Diagnostic Radiology, Walter Reed National Military Medical Center, Bethesda, MD 20814, USA
- American Institute for Radiologic Pathology, Silver Spring, MD 20910, USA
| | - David A Heltzel
- Department of Diagnostic Radiology, Walter Reed National Military Medical Center, Bethesda, MD 20814, USA
| | - Michael G Fazio
- Department of Diagnostic Radiology, Walter Reed National Military Medical Center, Bethesda, MD 20814, USA
| | - Christopher L Dearth
- Research & Surveillance Division, DoD-VA Extremity Trauma and Amputation Center of Excellence, Bethesda, MD 20814, USA
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Nelson A Hager
- Department of Rehabilitation Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
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Maikos JT, Pruziner AL, Hendershot BD, Herlihy DV, Chomack JM, Hyre MJ, Phillips SL, Sidiropoulos AN, Dearth CL, Nelson LM. Effects of a Powered Ankle-Foot Prosthesis and Physical Therapy on Function for Individuals With Transfemoral Limb Loss: Rationale, Design, and Protocol for a Multisite Clinical Trial. JMIR Res Protoc 2024; 13:e53412. [PMID: 38277197 PMCID: PMC10858430 DOI: 10.2196/53412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 12/08/2023] [Accepted: 12/10/2023] [Indexed: 01/27/2024] Open
Abstract
BACKGROUND Powered ankle-foot prosthetic devices can generate net positive mechanical work during gait, which mimics the physiological ankle. However, gait deviations can persist in individuals with transfemoral limb loss because of habit or lack of rehabilitation. Prosthetic research efforts favor the design or evaluation of prosthetic componentry and rarely incorporate any type of rehabilitation, despite evidence suggesting that it is critical for minimizing gait imbalances. Given the accelerated rate of innovation in prosthetics, there is a fundamental knowledge gap concerning how individuals with transfemoral limb loss should learn to correctly use powered ankle-foot devices for maximum functional benefit. Because of the recent advances in prosthetic technology, there is also a critical unmet need to develop guidelines for the prescription of advanced prosthetic devices that incorporate both physical and psychological components to identify appropriate candidates for advanced technology. OBJECTIVE The primary goal of this investigation is to examine the roles of advanced prosthetic technology and a device-specific rehabilitative intervention on gait biomechanics, functional efficacy, and pain in individuals with transfemoral limb loss. The secondary goal is to develop preliminary rehabilitation guidelines for advanced lower limb prosthetic devices to minimize gait imbalances and maximize function and to establish preliminary guidelines for powered ankle-foot prosthetic prescription. METHODS This prospective, multisite study will enroll 30 individuals with unilateral transfemoral limb loss. At baseline, participants will undergo a full gait analysis and assessment of function, neurocognition, cognitive load, subjective preferences, and pain using their current passive prosthesis. The participants will then be fitted with a powered ankle-foot device and randomized into 2 equal groups: a powered device with a device-specific rehabilitation intervention (group A) or a powered device with the current standard of practice (group B). Group A will undergo 4 weeks of device-specific rehabilitation. Group B will receive the current standard of practice, which includes basic device education but no further device-specific rehabilitation. Data collection procedures will then be repeated after 4 weeks and 8 weeks of powered ankle use. RESULTS This study was funded in September 2017. Enrollment began in September 2018. Data collection will conclude by March 2024. The initial dissemination of results is expected in August 2024. CONCLUSIONS The projected trends indicate that the number of individuals with limb loss will dramatically increase in the United States. The absence of effective, evidence-based interventions may make individuals with transfemoral limb loss more susceptible to increased secondary physical conditions and degenerative changes. With this expected growth, considerable resources will be required for prosthetic and rehabilitation services. Identifying potential mechanisms for correcting gait asymmetries, either through advanced prosthetic technology or rehabilitative interventions, can provide a benchmark for understanding the optimal treatment strategies for individuals with transfemoral limb loss. TRIAL REGISTRATION ClinicalTrials.gov NCT03625921; https://clinicaltrials.gov/study/NCT03625921. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/53412.
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Affiliation(s)
- Jason T Maikos
- Veterans Affairs New York Harbor Healthcare System, New York, NY, United States
| | - Alison L Pruziner
- Walter Reed National Military Medical Center, Bethesda, MD, United States
- Extremity Trauma and Amputation Center of Excellence, Falls Church, VA, United States
- National Veterans Sports Programs and Special Events, Department of Veterans Affairs, Washington, DC, United States
| | - Brad D Hendershot
- Walter Reed National Military Medical Center, Bethesda, MD, United States
- Extremity Trauma and Amputation Center of Excellence, Falls Church, VA, United States
- Uniformed Services University of the Health Sciences, Bethesda, MD, United States
| | - David V Herlihy
- The Narrows Institute for Biomedical Research and Education, Brooklyn, NY, United States
| | - John M Chomack
- The Narrows Institute for Biomedical Research and Education, Brooklyn, NY, United States
| | - Michael J Hyre
- The Narrows Institute for Biomedical Research and Education, Brooklyn, NY, United States
| | | | | | - Christopher L Dearth
- Walter Reed National Military Medical Center, Bethesda, MD, United States
- Extremity Trauma and Amputation Center of Excellence, Falls Church, VA, United States
- Uniformed Services University of the Health Sciences, Bethesda, MD, United States
| | - Leif M Nelson
- Veterans Affairs New York Harbor Healthcare System, New York, NY, United States
- Extremity Trauma and Amputation Center of Excellence, Falls Church, VA, United States
- National Veterans Sports Programs and Special Events, Department of Veterans Affairs, Washington, DC, United States
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Alshehri MA, Alzahrani H, van den Hoorn W, Klyne DM, Vette AH, Hendershot BD, Roberts BWR, Larivière C, Barbado D, Vera-Garcia FJ, van Dieen JH, Cholewicki J, Nussbaum MA, Madigan ML, Reeves NP, Silfies SP, Brown SHM, Hodges PW. Trunk postural control during unstable sitting among individuals with and without low back pain: A systematic review with an individual participant data meta-analysis. PLoS One 2024; 19:e0296968. [PMID: 38265999 PMCID: PMC10807788 DOI: 10.1371/journal.pone.0296968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 12/26/2023] [Indexed: 01/26/2024] Open
Abstract
INTRODUCTION Sitting on an unstable surface is a common paradigm to investigate trunk postural control among individuals with low back pain (LBP), by minimizing the influence lower extremities on balance control. Outcomes of many small studies are inconsistent (e.g., some find differences between groups while others do not), potentially due to confounding factors such as age, sex, body mass index [BMI], or clinical presentations. We conducted a systematic review with an individual participant data (IPD) meta-analysis to investigate whether trunk postural control differs between those with and without LBP, and whether the difference between groups is impacted by vision and potential confounding factors. METHODS We completed this review according to PRISMA-IPD guidelines. The literature was screened (up to 7th September 2023) from five electronic databases: MEDLINE, CINAHL, Embase, Scopus, and Web of Science Core Collection. Outcome measures were extracted that describe unstable seat movements, specifically centre of pressure or seat angle. Our main analyses included: 1) a two-stage IPD meta-analysis to assess the difference between groups and their interaction with age, sex, BMI, and vision on trunk postural control; 2) and a two-stage IPD meta-regression to determine the effects of LBP clinical features (pain intensity, disability, pain catastrophizing, and fear-avoidance beliefs) on trunk postural control. RESULTS Forty studies (1,821 participants) were included for the descriptive analysis and 24 studies (1,050 participants) were included for the IPD analysis. IPD meta-analyses revealed three main findings: (a) trunk postural control was worse (higher root mean square displacement [RMSdispl], range, and long-term diffusion; lower mean power frequency) among individuals with than without LBP; (b) trunk postural control deteriorated more (higher RMSdispl, short- and long-term diffusion) among individuals with than without LBP when vision was removed; and (c) older age and higher BMI had greater adverse impacts on trunk postural control (higher short-term diffusion; longer time and distance coordinates of the critical point) among individuals with than without LBP. IPD meta-regressions indicated no associations between the limited LBP clinical features that could be considered and trunk postural control. CONCLUSION Trunk postural control appears to be inferior among individuals with LBP, which was indicated by increased seat movements and some evidence of trunk stiffening. These findings are likely explained by delayed or less accurate corrective responses. SYSTEMATIC REVIEW REGISTRATION This review has been registered in PROSPERO (registration number: CRD42021124658).
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Affiliation(s)
- Mansour Abdullah Alshehri
- NHMRC Centre of Clinical Research Excellence in Spinal Pain, Injury & Health, School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Australia
- Physiotherapy Department, Faculty of Applied Medical Sciences, Umm Al-Qura University, Mecca, Saudi Arabia
| | - Hosam Alzahrani
- Department of Physical Therapy, College of Applied Medical Sciences, Taif University, Taif, Saudi Arabia
| | - Wolbert van den Hoorn
- NHMRC Centre of Clinical Research Excellence in Spinal Pain, Injury & Health, School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Australia
| | - David M. Klyne
- NHMRC Centre of Clinical Research Excellence in Spinal Pain, Injury & Health, School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Australia
| | - Albert H. Vette
- Department of Mechanical Engineering, Donadeo Innovation Centre for Engineering, University of Alberta, Edmonton, Canada
- Glenrose Rehabilitation Hospital, Alberta Health Services, Edmonton, Canada
| | - Brad D. Hendershot
- Extremity Trauma and Amputation Center of Excellence, Defense Health Agency, Falls Church, Virginia, United States of America
| | - Brad W. R. Roberts
- Department of Mechanical Engineering, Donadeo Innovation Centre for Engineering, University of Alberta, Edmonton, Canada
| | - Christian Larivière
- Institut de recherche Robert-Sauvé en santé et en sécurité du travail (IRSST), Montreal, Quebec, Canada
- Center for Interdisciplinary Research in Rehabilitation of Greater Montreal (CRIR), Montreal Rehabilitation Institute, Montreal, Quebec, Canada
| | - David Barbado
- Sport Research Centre, Department of Sport Sciences, Miguel Hernández University of Elche, Alicante, Spain
- Institute for Health and Biomedical Research (ISABIAL Foundation), Miguel Hernández University of Elche, Alicante, Spain
| | - Francisco J. Vera-Garcia
- Sport Research Centre, Department of Sport Sciences, Miguel Hernández University of Elche, Alicante, Spain
- Institute for Health and Biomedical Research (ISABIAL Foundation), Miguel Hernández University of Elche, Alicante, Spain
| | - Jaap H. van Dieen
- Department of Human Movement Sciences, Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam Movement Sciences, Amsterdam, Netherlands
| | - Jacek Cholewicki
- Center for Neuromusculoskeletal Clinical Research, Michigan State University, Lansing, Michigan, United States of America
- Department of Osteopathic Manipulative Medicine, Michigan State University, East Lansing, Michigan, United States of America
| | - Maury A. Nussbaum
- Virginia Tech-Wake Forest School of Biomedical Engineering and Sciences, Virginia Tech, Blacksburg, Virginia, United States of America
- Department of Industrial and Systems Engineering, Virginia Tech, Blacksburg, Virginia, United States of America
| | - Michael L. Madigan
- Virginia Tech-Wake Forest School of Biomedical Engineering and Sciences, Virginia Tech, Blacksburg, Virginia, United States of America
- Department of Industrial and Systems Engineering, Virginia Tech, Blacksburg, Virginia, United States of America
| | | | - Sheri P. Silfies
- Department of Exercise Science, University of South Carolina, Columbia, South Carolina, United States of America
| | - Stephen H. M. Brown
- Department of Human Health and Nutritional Sciences, University of Guelph, Guelph, Ontario, Canada
| | - Paul W. Hodges
- NHMRC Centre of Clinical Research Excellence in Spinal Pain, Injury & Health, School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Australia
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Farrokhi S, Gunterstockman BM, Hendershot BD, Russell Esposito E, McCabe CT, Watrous JR. Post-Traumatic Osteoarthritis, Psychological Health, and Quality of Life After Lower Limb Injury in U.S. Service Members. Mil Med 2023:usad475. [PMID: 38109721 DOI: 10.1093/milmed/usad475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 11/06/2023] [Accepted: 11/29/2023] [Indexed: 12/20/2023] Open
Abstract
INTRODUCTION The aims of this project were to assess (1) the prevalence and timing of post-traumatic osteoarthritis (PTOA) after a traumatic lower limb injury, (2) the risk of PTOA based on injury type, and (3) the association of PTOA with psychological health and quality of life (QoL). MATERIALS AND METHODS The Wounded Warrior Recovery Project (WWRP) database and the Expeditionary Medical Encounters Dataset were queried to identify service members injured during deployment. The Military Health System Data Repository was utilized to extract medical record data to identify individuals with PTOA. Data on PTSD, depression symptoms, and QoL were extracted from the WWRP. RESULTS Of the 2,061 WWRP participants with lower limb injuries, 124 (6%) were diagnosed with PTOA, with first PTOA diagnosis occurring 3.8 ± 3.1 years after injury. Of the injury categories identified, only fractures were associated with high odds of lower limb PTOA (adjusted odds ratio [OR] = 3.92, 95% confidence interval [CI]: 2.38, 6.44). Individuals with PTOA diagnoses reported lower QoL scores relative to those without PTOA (F(1,2057) = 14.21, B = -0.05, P < .05). Additionally, rates of PTSD and depression symptoms were high but not different between those with or without PTOA. CONCLUSIONS Despite a low prevalence of lower limb PTOA in our study, fractures increased the risk of PTOA after deployment-related injuries. Additionally, those with PTOA reported lower QoL scores relative to those without PTOA. The findings of this study highlight the personalized needs of patients with trauma beyond just the repair of the immediate injury.
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Affiliation(s)
- Shawn Farrokhi
- Department of Physical Therapy, Chapman University, Rinker Health Science Campus, Irvine, CA 92618, USA
| | - Brittney Mazzone Gunterstockman
- Doctor of Physical Therapy Program, Lincoln Memorial University, Debusk College of Osteopathic Medicine, Knoxville, TN 37932, USA
| | - Brad D Hendershot
- Extremity Trauma and Amputation Center of Excellence, Defense Health Agency, Falls Church, VA 22042, USA
- Department of Rehabilitation Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
- Department of Rehabilitation, Research and Development Section, Walter Reed National Military Medical Center, Bethesda, MD 20814, USA
| | - Elizabeth Russell Esposito
- Extremity Trauma and Amputation Center of Excellence, Defense Health Agency, Falls Church, VA 22042, USA
- Department of Rehabilitation Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
- Center for Limb Loss & MoBility (CLiMB), VA Puget Sound Health Care System, Seattle, WA 98108, USA
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10
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Wasser JG, Hendershot BD, Acasio JC, Dodd LD, Krupenevich RL, Pruziner AL, Miller RH, Goldman SM, Valerio MS, Senchak LT, Murphey MD, Heltzel DA, Fazio MG, Dearth CL, Hager NA. Exploring relationships among multi-disciplinary assessments for knee joint health in service members with traumatic unilateral lower limb loss: a two-year longitudinal investigation. Sci Rep 2023; 13:21177. [PMID: 38040780 PMCID: PMC10692131 DOI: 10.1038/s41598-023-48662-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Accepted: 11/29/2023] [Indexed: 12/03/2023] Open
Abstract
Motivated by the complex and multifactorial etiologies of osteoarthritis, here we use a comprehensive approach evaluating knee joint health after unilateral lower limb loss. Thirty-eight male Service members with traumatic, unilateral lower limb loss (mean age = 38 yr) participated in a prospective, two-year longitudinal study comprehensively evaluating contralateral knee joint health (i.e., clinical imaging, gait biomechanics, physiological biomarkers, and patient-reported outcomes); seventeen subsequently returned for a two-year follow-up visit. For this subset with baseline and follow-up data, outcomes were compared between timepoints, and associations evaluated between values at baseline with two-year changes in tri-compartmental joint space. Upon follow-up, knee joint health worsened, particularly among seven Service members who presented at baseline with no joint degeneration (KL = 0) but returned with evidence of degeneration (KL ≥ 1). Joint space narrowing was associated with greater patellar tilt (r[12] = 0.71, p = 0.01), external knee adduction moment (r[13] = 0.64, p = 0.02), knee adduction moment impulse (r[13] = 0.61, p = 0.03), and CTX-1 concentration (r[11] = 0.83, p = 0.001), as well as lesser KOOSSport and VR-36General Health (r[16] = - 0.69, p = 0.01 and r[16] = - 0.69, p = 0.01, respectively). This longitudinal, multi-disciplinary investigation highlights the importance of a comprehensive approach to evaluate the fast-progressing onset of knee osteoarthritis, particularly among relatively young Service members with lower limb loss.
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Affiliation(s)
- Joseph G Wasser
- Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, MD, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD, USA
- Department of Physical Medicine and Rehabilitation, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Brad D Hendershot
- Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, MD, USA.
- Department of Physical Medicine and Rehabilitation, Uniformed Services University of the Health Sciences, Bethesda, MD, USA.
- Research and Surveillance Section, Extremity Trauma and Amputation Center of Excellence, Research and Engineering Directorate, Defense Health Agency, Falls Church, VA, USA.
| | - Julian C Acasio
- Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, MD, USA
- Research and Surveillance Section, Extremity Trauma and Amputation Center of Excellence, Research and Engineering Directorate, Defense Health Agency, Falls Church, VA, USA
| | - Lauren D Dodd
- Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, MD, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD, USA
| | - Rebecca L Krupenevich
- Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Alison L Pruziner
- Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, MD, USA
- Department of Physical Medicine and Rehabilitation, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
- Research and Surveillance Section, Extremity Trauma and Amputation Center of Excellence, Research and Engineering Directorate, Defense Health Agency, Falls Church, VA, USA
| | - Ross H Miller
- Department of Kinesiology, University of Maryland, College Park, MD, USA
| | - Stephen M Goldman
- Research and Surveillance Section, Extremity Trauma and Amputation Center of Excellence, Research and Engineering Directorate, Defense Health Agency, Falls Church, VA, USA
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Michael S Valerio
- Research and Surveillance Section, Extremity Trauma and Amputation Center of Excellence, Research and Engineering Directorate, Defense Health Agency, Falls Church, VA, USA
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Lien T Senchak
- Department of Diagnostic Radiology, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Mark D Murphey
- Department of Diagnostic Radiology, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - David A Heltzel
- Department of Diagnostic Radiology, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Michael G Fazio
- Department of Diagnostic Radiology, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Christopher L Dearth
- Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, MD, USA
- Research and Surveillance Section, Extremity Trauma and Amputation Center of Excellence, Research and Engineering Directorate, Defense Health Agency, Falls Church, VA, USA
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Nelson A Hager
- Department of Physical Medicine and Rehabilitation, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
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11
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Butowicz CM, Helgeson MD, Pisano AJ, Cook JW, Dearth CL, Hendershot BD. Lumbar Degenerative Disease and Muscle Morphology Before and After Lower Limb Loss in Four Military Patients. Mil Med 2023; 188:e3349-e3355. [PMID: 36564935 DOI: 10.1093/milmed/usac399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 10/12/2022] [Accepted: 12/02/2022] [Indexed: 12/25/2022] Open
Abstract
INTRODUCTION Low back pain (LBP) is highly prevalent after lower limb amputation (LLA). Reports describing longitudinal changes in spine health before and after amputation are rare. This study describes lumbar spine pathology, muscle morphology, and the continuum of care for LBP before and after LLA. MATERIALS AND METHODS We queried electronic medical records of patients who sought care for LBP before and after unilateral LLA between January 2002 and April 2020 and who had documented lumbar imaging pre- and post-LLA. Patient demographics, muscle morphology, spinal pathology, premorbid and comorbid conditions, self-reported pain, and treatment interventions were assessed. RESULTS Four patients with LBP and imaging before and after LLA were identified. Intervertebral disc degeneration progressed after amputation in three patients, whereas facet arthrosis progressed in both female patients. The fat content of lumbar musculature generally increased after amputation. Conservative management of LBP before and after amputation was standard, with progression to steroidal injections. CONCLUSIONS Lumbar spine health may degrade after amputation. Here, lumbar muscle size did not change after LLA, yet the fat content increased in combination with increases in facet and intervertebral disc degeneration.
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Affiliation(s)
- Courtney M Butowicz
- Neuromusculoskeletal Outcomes Lead Walter Reed National Military Medical Center, Research and Surveillance Division, Extremity Trauma and Amputation Center of Excellence, Research & Engineering Directorate, Defense Health Agency, Building 19, Room B312, Bethesda, MD 20889, USA
- Department of Rehabilitation Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD 20889, USA
| | - Melvin D Helgeson
- Department of Surgery, Uniformed Services University of the Health Sciences-Walter Reed National Military Medical Center, Bethesda, MD 20889, USA
- Department of Orthopaedics, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA
| | - Alfred J Pisano
- Department of Surgery, Uniformed Services University of the Health Sciences-Walter Reed National Military Medical Center, Bethesda, MD 20889, USA
- Department of Orthopaedics, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA
| | - John W Cook
- Department of Orthopaedics, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA
| | - Christopher L Dearth
- Neuromusculoskeletal Outcomes Lead Walter Reed National Military Medical Center, Research and Surveillance Division, Extremity Trauma and Amputation Center of Excellence, Research & Engineering Directorate, Defense Health Agency, Building 19, Room B312, Bethesda, MD 20889, USA
- Department of Rehabilitation Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD 20889, USA
- Department of Surgery, Uniformed Services University of the Health Sciences-Walter Reed National Military Medical Center, Bethesda, MD 20889, USA
| | - Brad D Hendershot
- Neuromusculoskeletal Outcomes Lead Walter Reed National Military Medical Center, Research and Surveillance Division, Extremity Trauma and Amputation Center of Excellence, Research & Engineering Directorate, Defense Health Agency, Building 19, Room B312, Bethesda, MD 20889, USA
- Department of Rehabilitation Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD 20889, USA
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12
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Knight AD, Jayaraman C, Elrod JM, Schnall BL, McGuire MS, Sleeman TJ, Hoppe-Ludwig S, Dearth CL, Hendershot BD, Jayaraman A. Functional Performance Outcomes of a Powered Knee-Ankle Prosthesis in Service Members With Unilateral Transfemoral Limb Loss. Mil Med 2023; 188:3432-3438. [PMID: 35895305 DOI: 10.1093/milmed/usac231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 04/29/2022] [Accepted: 07/23/2022] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION Clinical knowledge surrounding functional outcomes of a powered knee-ankle (PKA) device is limited, particularly among younger and active populations with limb loss. Here, three service members (SM) with unilateral transfemoral limb loss received an optimally tuned PKA prosthesis and device-specific training. MATERIALS AND METHODS Once proficiency with the PKA device was demonstrated on benchmark activities, and outcomes with the PKA and standard-of-care (SoC) prostheses were obtained via a modified graded treadmill test, 6-minute walk test, and overground gait assessment. RESULTS All SM demonstrated proficiency with the PKA prosthesis within the minimum three training sessions. With the PKA versus SoC prosthesis, cost of transport during the modified graded treadmill test was 4.0% ± 5.2% lower at slower speeds (i.e., 0.6-1.2 m/s), but 7.0% ± 5.1% greater at the faster walking speeds (i.e., ≥1.4 m/s). For the 6-minute walk test, SM walked 83.9 ± 13.2 m shorter with the PKA versus SoC prosthesis. From the overground gait assessment, SM walked with 20.6% ± 10.5% greater trunk lateral flexion and 31.8% ± 12.8% greater trunk axial rotation ranges of motion, with the PKA versus SoC prosthesis. CONCLUSIONS Compared to prior work with the PKA in a civilian cohort, although SM demonstrated faster device proficiency (3 versus 12 sessions), SM walked with greater compensatory motions compared to their SoC prostheses (contrary to the civilian cohort). As such, it is important to understand patient-specific factors among various populations with limb loss for optimizing device-specific training and setting functional goals for occupational and/or community reintegration, as well as reducing the risk for secondary complications over the long term.
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Affiliation(s)
- Ashley D Knight
- Research & Surveillance Division, DoD-VA Extremity Trauma and Amputation Center of Excellence, Bethesda, MD 20889, USA
- Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA
- Department of Rehabilitation Medicine, Uniformed Services of the Health Sciences, Bethesda, MD 20814, USA
| | - Chandrasekaran Jayaraman
- Max Nader Lab for Rehabilitation Technologies and Outcomes Research, Center for Bionic Medicine, Shirley Ryan AbilityLab, Chicago, IL 60611, USA
- Department of Physical Therapy and Human Movement Sciences, Northwestern University, Chicago, IL 60611, USA
| | - Jonathan M Elrod
- Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD 20817, USA
| | - Barri L Schnall
- Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA
| | - Matt S McGuire
- Max Nader Lab for Rehabilitation Technologies and Outcomes Research, Center for Bionic Medicine, Shirley Ryan AbilityLab, Chicago, IL 60611, USA
| | - Todd J Sleeman
- Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA
| | - Shenan Hoppe-Ludwig
- Max Nader Lab for Rehabilitation Technologies and Outcomes Research, Center for Bionic Medicine, Shirley Ryan AbilityLab, Chicago, IL 60611, USA
| | - Christopher L Dearth
- Research & Surveillance Division, DoD-VA Extremity Trauma and Amputation Center of Excellence, Bethesda, MD 20889, USA
- Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA
- Department of Surgery, Walter Reed National Military Medical Center-Uniformed Services of the Health Sciences, Bethesda, MD 20814, USA
| | - Brad D Hendershot
- Research & Surveillance Division, DoD-VA Extremity Trauma and Amputation Center of Excellence, Bethesda, MD 20889, USA
- Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA
- Department of Rehabilitation Medicine, Uniformed Services of the Health Sciences, Bethesda, MD 20814, USA
| | - Arun Jayaraman
- Max Nader Lab for Rehabilitation Technologies and Outcomes Research, Center for Bionic Medicine, Shirley Ryan AbilityLab, Chicago, IL 60611, USA
- Department of Physical Therapy and Human Movement Sciences, Northwestern University, Chicago, IL 60611, USA
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Butowicz C, Yoder AJ, Hendershot BD, Gunterstockman B, Farrokhi S. Principal components analysis of postural sway in persons with unilateral lower limb amputation: A wearable sensor approach. J Biomech 2023; 158:111768. [PMID: 37625201 DOI: 10.1016/j.jbiomech.2023.111768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 07/23/2023] [Accepted: 08/16/2023] [Indexed: 08/27/2023]
Abstract
Standing sway assessments can detect sensory imbalances which compromise postural control. Persons with lower limb amputation (LLA) often demonstrate impaired postural control, increasing fall risk. Here, principal features of postural sway were identified in persons with unilateral LLA using a single, commercially available wearable sensor. Sixty-one persons with LLA (n = 44 transtibial; n = 17 transfemoral) stood on a firm surface with eyes open/closed while wearing a single accelerometer mounted over the sacrum. Common parameters quantified spatiotemporal and spectral features of sway in anterior-posterior (AP) and mediolateral (ML) directions. Principal component (PC) dimensionality reduction was applied and loadings inspected to identify a reduced, non-redundant set among 14 original variables capturing 90 % variance. Six PCs described ≥ 90 % variance, with the first 3 explaining 75 %. With eyes open and closed, PC1 was loaded by variables characterizing trajectory planar size: area, jerk (i.e., sway smoothness), AP/ML RMS path distance, and AP/ML path range. With eyes open, PC2 was loaded by variables characterizing direction and spectral features: ellipse rotation, AP centroidal frequency, and ML jerk. With eyes closed, PC2 spectral loadings increased: ML centroidal frequency, ML frequency dispersion, and AP centroidal frequency. With eyes open, PC3 was loaded by ellipse rotation, jerk, ML velocity, ML centroidal frequency. With eyes closed, PC3 was loaded by ellipse rotation, ML centroidal frequency, ML frequency dispersion, and AP path velocity, characterizing off-axis error/corrections. RMS of path distance, ellipse rotation, centroidal frequency, frequency dispersion, path velocity, and jerk are a concise parameter set, derived from an accelerometer, to capture principal sway features in persons with LLA during standing balance with visual perturbations.
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Affiliation(s)
- Courtney Butowicz
- Research & Surveillance Division, Extremity Trauma and Amputation Center of Excellence, Defense Health Agency, Falls Church, VA 22042, United States; Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, MD 20889, United States; Department of Physical Medicine & Rehabilitation, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, United States.
| | - Adam J Yoder
- Research & Surveillance Division, Extremity Trauma and Amputation Center of Excellence, Defense Health Agency, Falls Church, VA 22042, United States; Department of Physical & Occupational Therapy, Naval Medical Center, San Diego, CA 92134, United States
| | - Brad D Hendershot
- Research & Surveillance Division, Extremity Trauma and Amputation Center of Excellence, Defense Health Agency, Falls Church, VA 22042, United States; Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, MD 20889, United States; Department of Physical Medicine & Rehabilitation, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, United States
| | - Brittney Gunterstockman
- Research & Surveillance Division, Extremity Trauma and Amputation Center of Excellence, Defense Health Agency, Falls Church, VA 22042, United States; Department of Physical & Occupational Therapy, Naval Medical Center, San Diego, CA 92134, United States; Department of Physical Therapy, Lincoln Memorial University, Knoxville, TN 37932, United States
| | - Shawn Farrokhi
- Research & Surveillance Division, Extremity Trauma and Amputation Center of Excellence, Defense Health Agency, Falls Church, VA 22042, United States; Department of Physical Medicine & Rehabilitation, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, United States; Department of Physical & Occupational Therapy, Naval Medical Center, San Diego, CA 92134, United States
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14
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Monaghan PG, Knight AD, Brinkerhoff SA, Harrison KD, Dearth CL, Hendershot BD, Sefton JM, Zabala M, Vazquez A, Shannon D, Crumbley D, Roper JA. Characterization of initial ankle-foot prosthesis prescription patterns in U.S. Service members following unilateral transtibial amputation. Front Rehabil Sci 2023; 4:1235693. [PMID: 37691914 PMCID: PMC10485831 DOI: 10.3389/fresc.2023.1235693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 08/10/2023] [Indexed: 09/12/2023]
Abstract
Introduction The purpose of this study was to explore relationships between patient-specific characteristics and initial ankle-foot prosthesis prescription patterns among U.S. Service members with unilateral transtibial limb loss. Methods A retrospective review of health records identified 174 individuals with unilateral transtibial limb loss who received care at Walter Reed National Military Medical Center between 2001 and 2019. We examined patient-specific factors such as demographics, participant duty status at injury and amputation, amputation etiology, and timing between injury, amputation, and initial prescription. The type of first prescribed ankle-foot prosthesis was categorized as energy storing and return - nonarticulating, energy storing and return - articulating, or computer controlled. Results Sex, amputation etiology, time from injury to initial prescription, and time from amputation to initial prescription differed by type of initial ankle-foot prosthesis prescription. Service members with shorter intervals between injury-initial prescription and amputation-initial prescription, and those injured by combat blast, were more likely to receive a non-articulating device. Incorporating sex, time from injury-initial prescription, time from amputation-initial prescription, and amputation etiology as predictors of prosthesis type, we were able to correctly classify 72% of all first prostheses prescribed. Discussion Patient-specific characteristics such as sex, the time between injury-initial prescription, time from amputation-initial prescription and amputation etiology are essential characteristics that influence initial ankle-foot prosthesis prescription patterns in U.S. Service members.
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Affiliation(s)
| | - Ashley D. Knight
- Research & Surveillance Section, Extremity Trauma and Amputation Center of Excellence, Defense Health Agency, Falls Church, VA, United States
- Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, MD, United States
- Department of Physical Medicine & Rehabilitation, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | | | | | - Christopher L. Dearth
- Research & Surveillance Section, Extremity Trauma and Amputation Center of Excellence, Defense Health Agency, Falls Church, VA, United States
- Department of Surgery, Uniformed Services University of the Health Sciences—Walter Reed National Military Medical Center, Bethesda, MD, United States
| | - Brad D. Hendershot
- Research & Surveillance Section, Extremity Trauma and Amputation Center of Excellence, Defense Health Agency, Falls Church, VA, United States
- Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, MD, United States
- Department of Physical Medicine & Rehabilitation, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | | | - Michael Zabala
- Department of Mechanical Engineering, Auburn University, Auburn, AL, United States
| | - Adan Vazquez
- School of Kinesiology, Auburn University, Auburn, AL, United States
- Department of Prosthetics and Orthotics, Alabama State University, Montgomery, AL, United States
| | - David Shannon
- Department of Educational Foundations, Leadership, and Technology, Auburn University, Auburn, AL, United States
| | - David Crumbley
- School of Nursing, Auburn University, Auburn, AL, United States
| | - Jaimie A. Roper
- School of Kinesiology, Auburn University, Auburn, AL, United States
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15
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Mahon CE, Hendershot BD, Gaskins C, Hatfield BD, Shaw EP, Gentili RJ. A mental workload and biomechanical assessment during split-belt locomotor adaptation with and without optic flow. Exp Brain Res 2023:10.1007/s00221-023-06609-6. [PMID: 37358569 DOI: 10.1007/s00221-023-06609-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 03/27/2023] [Indexed: 06/27/2023]
Abstract
Adaptive human performance relies on the central nervous system to regulate the engagement of cognitive-motor resources as task demands vary. Despite numerous studies which employed a split-belt induced perturbation to examine biomechanical outcomes during locomotor adaptation, none concurrently examined the cerebral cortical dynamics to assess changes in mental workload. Additionally, while prior work suggests that optic flow provides critical information for walking regulation, a few studies have manipulated visual inputs during adaption to split-belt walking. This study aimed to examine the concurrent modulation of gait and Electroencephalography (EEG) cortical dynamics underlying mental workload during split-belt locomotor adaptation, with and without optic flow. Thirteen uninjured participants with minimal inherent walking asymmetries at baseline underwent adaptation, while temporal-spatial gait and EEG spectral metrics were recorded. The results revealed a reduction in step length and time asymmetry from early to late adaptation, accompanied by an elevated frontal and temporal theta power; the former being well corelated to biomechanical changes. While the absence of optic flow during adaptation did not affect temporal-spatial gait metrics, it led to an increase of theta and low-alpha power. Thus, as individuals adapt their locomotor patterns, the cognitive-motor resources underlying the encoding and consolidation processes of the procedural memory were recruited to acquire a new internal model of the perturbation. Also, when adaption occurs without optic flow, a further reduction of arousal is accompanied with an elevation of attentional engagement due to enhanced neurocognitive resources likely to maintain adaptive walking patterns.
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Affiliation(s)
- Caitlin E Mahon
- Research and Surveillance Section, Extremity Trauma and Amputation Center of Excellence, Defense Health Agency, Falls Church, VA, USA
- Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Brad D Hendershot
- Research and Surveillance Section, Extremity Trauma and Amputation Center of Excellence, Defense Health Agency, Falls Church, VA, USA
- Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, MD, USA
- Department of Physical Medicine and Rehabilitation, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Christopher Gaskins
- Cognitive Motor Neuroscience Laboratory, Department of Kinesiology, School of Public Health (Bldg #255), University of Maryland, room #2138, College Park, MD, 20742, USA
- Neuroscience and Cognitive Science Program, University of Maryland, College Park, MD, USA
| | - Bradley D Hatfield
- Cognitive Motor Neuroscience Laboratory, Department of Kinesiology, School of Public Health (Bldg #255), University of Maryland, room #2138, College Park, MD, 20742, USA
- Neuroscience and Cognitive Science Program, University of Maryland, College Park, MD, USA
| | - Emma P Shaw
- Cognitive Motor Neuroscience Laboratory, Department of Kinesiology, School of Public Health (Bldg #255), University of Maryland, room #2138, College Park, MD, 20742, USA.
- Neuroscience and Cognitive Science Program, University of Maryland, College Park, MD, USA.
| | - Rodolphe J Gentili
- Cognitive Motor Neuroscience Laboratory, Department of Kinesiology, School of Public Health (Bldg #255), University of Maryland, room #2138, College Park, MD, 20742, USA.
- Neuroscience and Cognitive Science Program, University of Maryland, College Park, MD, USA.
- Maryland Robotics Center, University of Maryland, College Park, MD, USA.
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16
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Maikos JT, Hendershot BD, Pruziner AL, Hyre MJ, Chomack JM, Phillips SL, Heckman JT, Sidiropoulos AN, Dearth CL, Nelson LM. Criteria for Advanced Prosthetic Foot Prescription: Rationale, Design, and Protocol for a Multisite, Randomized Controlled Trial. JMIR Res Protoc 2023; 12:e45612. [PMID: 37014672 PMCID: PMC10131701 DOI: 10.2196/45612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 01/31/2023] [Accepted: 01/31/2023] [Indexed: 04/05/2023] Open
Abstract
BACKGROUND The prescription of prosthetic ankle-foot devices is often based on the professional judgment of the limb loss care team or limited evidentiary research. Current prosthetic research efforts have focused on the design and development of prosthetic devices rather than on understanding which devices are the most appropriate to prescribe. This investigation will evaluate biomechanical, functional, and subjective outcome measures to help determine the optimal prescription parameters of prosthetic ankle-foot devices. OBJECTIVE This study aims to develop evidence-based guidelines for limb loss care teams for the appropriate prescription of commercially available prosthetic ankle-foot devices to improve function and satisfaction. METHODS This investigation will be a multisite, randomized, crossover clinical trial targeting the enrollment of 100 participants. Participants will use 3 different types of prosthetic devices (energy storing and returning, articulating, and powered) in random order. Participants will be fitted and trained with each device and then separately use each device for a 1-week acclimation period. Following each 1-week acclimation period, participants will be evaluated using several functional measures and subjective surveys. A random subset of participants (30/100, 30%) will also undergo full-body gait analysis, following each 1-week acclimation period, to collect biomechanical data during level ground and incline and decline walking. After all individual device evaluations, participants will be given all 3 prostheses concurrently for 4 weeks of home and community use to capture user preference. Activity monitoring and a guided interview will be used to determine overall user preference. RESULTS The study was funded in August 2017, and data collection began in 2018. Data collection is expected to be completed before July 2023. Initial dissemination of results is expected to occur in the winter of 2023. CONCLUSIONS By identifying biomechanical, functional, and subjective outcomes that are sensitive to differences in prosthetic ankle-foot devices, a benchmark of evidence can be developed to guide effective prosthetic prescription. TRIAL REGISTRATION ClinicalTrials.gov NCT03505983; https://clinicaltrials.gov/ct2/show/NCT03505983. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/45612.
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Affiliation(s)
- Jason T Maikos
- Veterans Affairs New York Harbor Healthcare System, New York, NY, United States
| | - Brad D Hendershot
- Walter Reed National Military Medical Center, Bethesda, MD, United States
- Extremity Trauma and Amputation Center of Excellence, Falls Church, VA, United States
- Uniformed Services University of the Health Sciences, Bethesda, MD, United States
| | - Alison L Pruziner
- Walter Reed National Military Medical Center, Bethesda, MD, United States
- Extremity Trauma and Amputation Center of Excellence, Falls Church, VA, United States
- National Veterans Sports Programs and Special Events, Department of Veterans Affairs, Washington, DC, United States
| | - Michael J Hyre
- The Narrows Institute for Biomedical Research and Education, Inc, Brooklyn, NY, United States
| | - John M Chomack
- The Narrows Institute for Biomedical Research and Education, Inc, Brooklyn, NY, United States
| | | | - Jeffrey T Heckman
- Veterans Affairs Puget Sound Healthcare System, Seattle, WA, United States
- Regional Amputation Center, Veterans Affairs Puget Sound Healthcare System, Seattle, WA, United States
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA, United States
| | | | - Christopher L Dearth
- Walter Reed National Military Medical Center, Bethesda, MD, United States
- Extremity Trauma and Amputation Center of Excellence, Falls Church, VA, United States
- Uniformed Services University of the Health Sciences, Bethesda, MD, United States
| | - Leif M Nelson
- Veterans Affairs New York Harbor Healthcare System, New York, NY, United States
- Extremity Trauma and Amputation Center of Excellence, Falls Church, VA, United States
- National Veterans Sports Programs and Special Events, Department of Veterans Affairs, Washington, DC, United States
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Colantonio DF, Le AH, Pisano AJ, Chung JM, Wagner SC, Fredericks DR, Roach WB, Schlaff C, Dill A, Mauntel TC, Hendershot BD, Helgeson MD. Hooks Versus Pedicle Screws at the Upper Instrumented Level: An In Vitro Biomechanical Comparison. Spine (Phila Pa 1976) 2023; 48:E94-E100. [PMID: 36745404 DOI: 10.1097/brs.0000000000004547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 11/12/2022] [Indexed: 02/07/2023]
Abstract
STUDY DESIGN Controlled laboratory study. OBJECTIVE The aim was to compare motions at the upper instrumented vertebra (UIV) and supra-adjacent level (UIV+1) between two fixation techniques in thoracic posterior spinal fusion constructs. We hypothesized there would be greater motion at UIV+1 after cyclic loading across all constructs and bilateral pedicle screws (BPSs) with posterior ligamentous compromise would demonstrate the greatest UIV+1 range of motion. SUMMARY OF BACKGROUND DATA Proximal junctional kyphosis is a well-recognized complication following long thoracolumbar posterior spinal fusion, however, its mechanism is poorly understood. MATERIALS AND METHODS Twenty-seven thoracic functional spine units were randomly divided into three UIV fixation groups (n=9): (1) BPS, (2) bilateral transverse process hooks (TPHs), and (3) BPS with compromise of the posterior elements between UIV and UIV+1 (BPS-C). Specimens were tested on a servohydraulic materials testing system in native state, following instrumentation, and after cyclic loading. functional spine units were loaded in flexion-extension (FE), lateral bending, and axial rotation. RESULTS After cyclic testing, the TPH group had a mean 29.4% increase in FE range of motion at UIV+1 versus 76.6% in the BPS group ( P <0.05). The BPS-C group showed an increased FE of 49.9% and 62.19% with sectioning of the facet joints and interspinous ligament respectively prior to cyclic testing. CONCLUSION BPSs at the UIV led to greater motion at UIV+1 compared to bilateral TPH after cyclic loading. This is likely due to the increased rigidity of BPS compared to TPH leading to a "softer" transition between the TPH construct and native anatomy at the supra-adjacent level. Facet capsule compromise led to a 49.9% increase in UIV+1 motion, underscoring the importance of preserving the posterior ligamentous complex. Clinical studies that account for fusion rates are warranted to determine if constructs with a "soft transition" result in less proximal junctional kyphosis in vivo .
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Affiliation(s)
- Donald F Colantonio
- Department of Orthopaedics, Walter Reed National Military Medical Center, Bethesda, MD
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Anthony H Le
- DoD-VA Extremity Trauma and Amputation Center of Excellence, Walter Reed National Military Medical Center, Bethesda, MD
| | - Alfred J Pisano
- Department of Orthopaedics, Walter Reed National Military Medical Center, Bethesda, MD
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Joon M Chung
- School of Medicine, Georgetown University, Washington, DC
| | - Scott C Wagner
- Department of Orthopaedics, Walter Reed National Military Medical Center, Bethesda, MD
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Donald R Fredericks
- Department of Orthopaedics, Walter Reed National Military Medical Center, Bethesda, MD
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD
| | - William B Roach
- Department of Orthopaedics, Walter Reed National Military Medical Center, Bethesda, MD
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Cody Schlaff
- Department of Orthopaedics, Walter Reed National Military Medical Center, Bethesda, MD
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Andrew Dill
- School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Timothy C Mauntel
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD
- DoD-VA Extremity Trauma and Amputation Center of Excellence, Womack Army Medical Center, Fort Bragg, NC
| | - Brad D Hendershot
- DoD-VA Extremity Trauma and Amputation Center of Excellence, Walter Reed National Military Medical Center, Bethesda, MD
- Department of Rehabilitation Medicine, Uniformed Services University of the Health Science, Bethesda, MD
| | - Melvin D Helgeson
- Department of Orthopaedics, Walter Reed National Military Medical Center, Bethesda, MD
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD
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18
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Gunterstockman BM, Knight AD, Mahon CE, Childers WL, Cagle T, Hendershot BD, Farrokhi S. Relationship between phantom limb pain, function, and psychosocial health in individuals with lower-limb loss. Prosthet Orthot Int 2023; 47:181-188. [PMID: 36637908 DOI: 10.1097/pxr.0000000000000191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 08/17/2022] [Indexed: 01/14/2023]
Abstract
INTRODUCTION The adverse influence of chronic pain on function and psychological health in the general population is well understood. However, the relationship between phantom limb pain (PLP) after limb loss with function and psychological health is less clear. The study purpose was to assess the influences of PLP presence and intensity on function and psychosocial health in individuals with lower-limb loss (LLL). METHODS One hundred two individuals with major LLL completed a study-specific questionnaire on the presence and intensity of their PLP. The Patient-Reported Outcomes Measurement Information System -29 questionnaire was also administered. RESULTS Of 102 participants, 64% reported PLP, with a mean intensity of 4.8 ± 2.3 out of 10. Individuals with vs. without PLP demonstrated significantly greater sleep disturbances ( p = 0.03), whereas the differences in function, fatigue, pain interference, depressive symptoms, anxiety, or ability to participate in social roles and activities were not statistically different between groups ( p > 0.05). Of note, mean scores for many of the Patient-Reported Outcomes Measurement Information System-29 short forms among the current sample were similar to the mean of the general population, minimizing the potential clinical impact of PLP on these domains. CONCLUSIONS Our findings indicate a lack of meaningful associations between PLP presence or intensity with function, and psychosocial health among individuals with LLL. These findings conflict with previous research suggesting an adverse relationship between PLP, function, and psychosocial health after limb loss.
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Affiliation(s)
- Brittney M Gunterstockman
- Doctor of Physical Therapy Program, Lincoln Memorial University, Knoxville, TN, USA
- Currently with Lincoln Memorial University, Harrogate, TN, USA
- Research & Surveillance Division, DoD-VA Extremity Trauma and Amputation Center of Excellence, San Diego, CA, USA
- Department of Physical & Occupational Therapy, Naval Medical Center San Diego, San Diego, CA, USA
| | - Ashley D Knight
- Research & Surveillance Division, DoD-VA Extremity Trauma and Amputation Center of Excellence, Bethesda, MD, USA
- Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Caitlin E Mahon
- Research & Surveillance Division, DoD-VA Extremity Trauma and Amputation Center of Excellence, Bethesda, MD, USA
- Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - W Lee Childers
- Research & Surveillance Division, DoD-VA Extremity Trauma and Amputation Center of Excellence, San Antonio, TX, USA
- Department of Rehabilitation Medicine, Center for the Intrepid, Brooke Army Medical Center, San Antonio, TX, USA
| | - Tyler Cagle
- Department of Rehabilitation Medicine, Center for the Intrepid, Brooke Army Medical Center, San Antonio, TX, USA
| | - Brad D Hendershot
- Research & Surveillance Division, DoD-VA Extremity Trauma and Amputation Center of Excellence, Bethesda, MD, USA
- Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, MD, USA
- Department of Rehabilitation Medicine, Uniformed Services University, Bethesda, MD, USA
| | - Shawn Farrokhi
- Research & Surveillance Division, DoD-VA Extremity Trauma and Amputation Center of Excellence, San Diego, CA, USA
- Department of Physical & Occupational Therapy, Naval Medical Center San Diego, San Diego, CA, USA
- Department of Rehabilitation Medicine, Uniformed Services University, Bethesda, MD, USA
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Lynall RC, Wasser JG, Brooks DI, Call JA, Hendershot BD, Kardouni JR, Schmidt JD, Mauntel TC. Investigating post-mild traumatic brain injury neuromuscular function and musculoskeletal injury risk: A protocol for a prospective, observational, case-controlled study in service members and active individuals. BMJ Open 2023; 13:e069404. [PMID: 36948547 PMCID: PMC10039998 DOI: 10.1136/bmjopen-2022-069404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/24/2023] Open
Abstract
INTRODUCTION Musculoskeletal injury (MSKI) risk is increased following mild traumatic brain injury (mTBI). Increased MSKI risk is present up to 2 years following post-mTBI return-to-duty/activity relative to both non-mTBI peers and to their pre-mTBI selves across a range of populations, including military service members, and professional, college and high school athletes. Despite the well documented increased post-mTBI MSKI risk, the underlying neuromuscular mechanisms contributing to this increased risk have yet to be definitively determined. A number of potential mechanisms have been suggested (eg, aberrant kinematics, dynamic balance impairments, lower voluntary muscle activation), but none have been confirmed with a comprehensive, prospective study. This study aims to: (1) elucidate the neuromuscular control mechanisms following mTBI that contribute to increased MSKI risk, and (2) prospectively track patient outcomes (up to 12 months; MSKI occurrences and patient-reported outcomes (PRO)). METHODS AND ANALYSIS This is a multicentre prospective, case-matched control observational study to identify deficiencies in neuromuscular function following mTBI that may contribute to increased MSKI risk. Participants (aim to recruit 148, complete data collection on 124) will be classified into two cohorts; mTBI and control. All participants will undergo longitudinal (initial, 6 weeks post-initial, 12 weeks post-initial) comprehensive three-dimensional biomechanical (jump-landing; single leg hop; cut; gait), neuromuscular (interpolated twitch technique, muscular ramp contraction) and sensory (joint repositioning; light touch sensation) assessments to elucidate the underlying neuromuscular control mechanisms post-mTBI that may contribute to increased MSKI. Occurrences of MSKI and PROs (National Institutes of Health Patient-Reported Outcome Measurement Information System: Physical Function, Pain Interference, Depression, Anxiety; Brief Resilience Scale; Tampa Scale of Kinesiophobia), will be tracked monthly (up to 1 year) via electronic data capture platforms. ETHICS AND DISSEMINATION The study received approval from the Walter Reed National Military Medical Center Institutional Review Board. Results will be made available to the associated funding agency and other researchers via conference proceedings and journal articles. TRIAL REGISTRATION NUMBER NCT05122728.
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Affiliation(s)
- Robert C Lynall
- Department of Kinesiology, University of Georgia, Athens, GA, USA
| | - Joseph G Wasser
- Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, MD, USA
- Henry M Jackson Foundation for the Advancement of Military Medicine, Inc, Bethesda, MD, USA
| | - Daniel I Brooks
- Clinical Quality Management, Defense Health Agency, Falls Church, VA, USA
| | - Jarrod A Call
- Department of Physiology and Pharmacology, University of Georgia, Athens, GA, USA
- Regenerative Bioscience Center, University of Georgia, Athens, GA, USA
| | - Brad D Hendershot
- Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, MD, USA
- Extremity Trauma and Amputation Center of Excellence, Defense Health Agency, Falls Church, VA, USA
- Department of Physical Medicine & Rehabilitation, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | | | | | - Timothy C Mauntel
- Extremity Trauma and Amputation Center of Excellence, Defense Health Agency, Falls Church, VA, USA
- Department of Clinical Investigations, Womack Army Medical Center, Fort Bragg, NC, USA
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
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Kaufman KR, Miller EJ, Deml CM, Sheehan RC, Grabiner MD, Wyatt M, Zai CZ, Kingsbury T, Tullos ML, Acasio JC, Mahon CE, Hendershot BD, Dearth CL. Fall Prevention Training for Service Members With an Amputation or Limb Salvage Following Lower Extremity Trauma. Mil Med 2023:usad005. [PMID: 36794799 DOI: 10.1093/milmed/usad005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 11/02/2022] [Accepted: 01/10/2023] [Indexed: 02/17/2023] Open
Abstract
INTRODUCTION Recent military conflicts have resulted in a significant number of lower extremity injuries to U.S. service members that result in amputation or limb preservation (LP) procedures. Service members receiving these procedures report a high prevalence and deleterious consequences of falls. Very little research exists to improve balance and reduce falls, especially among young active populations such as service members with LP or limb loss. To address this research gap, we evaluated the success of a fall prevention training program for service members with lower extremity trauma by (1) measuring fall rates, (2) quantifying improvements in trunk control, and (3) determining skill retention at 3 and 6 months after training. MATERIALS AND METHODS Forty-five participants (40 males, mean [±SD] age, 34 ± 8 years) with lower extremity trauma (20 with unilateral transtibial amputation, 6 with unilateral transfemoral amputation, 5 with bilateral transtibial amputation, and 14 with unilateral LP procedures) were enrolled. A microprocessor-controlled treadmill was used to produce task-specific postural perturbations which simulated a trip. The training was conducted over a 2-week period and consisted of six 30-minute sessions. The task difficulty was increased as the participant's ability progressed. The effectiveness of the training program was assessed by collecting data before training (baseline; repeated twice), immediately after training (0 month), and at 3 and 6 months post-training. Training effectiveness was quantified by participant-reported falls in the free-living environment before and after training. Perturbation-induced recovery step trunk flexion angle and velocity was also collected. RESULTS Participants reported reduced falls and improved balance confidence in the free-living environment following the training. Repeated testing before training revealed that there were no pre-training differences in trunk control. The training program improved trunk control following training, and these skills were retained at 3 and 6 months after training. CONCLUSION This study showed that task-specific fall prevention training reduced falls across a cohort of service members with diverse types of amputations and LP procedures following lower extremity trauma. Importantly, the clinical outcome of this effort (i.e., reduced falls and improved balance confidence) can lead to increased participation in occupational, recreational, and social activities and thus improved quality of life.
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Affiliation(s)
- Kenton R Kaufman
- Mayo Clinic, Motion Analysis Laboratory, Rochester, MN 55905, USA
| | - Emily J Miller
- Mayo Clinic, Motion Analysis Laboratory, Rochester, MN 55905, USA
| | - Christine M Deml
- Mayo Clinic, Motion Analysis Laboratory, Rochester, MN 55905, USA
| | - Riley C Sheehan
- Department of Rehabilitation Medicine, Center for the Intrepid-Brooke Army Medical Center, San Antonio, TX 78219, USA
- Department of Kinesiology and Nutrition/Bioengineering, University of Illinois-Chicago, Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD 20817, USA
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | | | - Marilynn Wyatt
- Naval Medical Center San Diego, Motion Analysis Laboratory, San Diego, CA 92134, USA
| | - Claire Z Zai
- Naval Medical Center San Diego, Motion Analysis Laboratory, San Diego, CA 92134, USA
| | - Trevor Kingsbury
- Naval Medical Center San Diego, Motion Analysis Laboratory, San Diego, CA 92134, USA
| | - Meghan L Tullos
- Department of Kinesiology and Nutrition/Bioengineering, University of Illinois-Chicago, Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD 20817, USA
- Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, MD 20814, USA
| | - Julian C Acasio
- Department of Kinesiology and Nutrition/Bioengineering, University of Illinois-Chicago, Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD 20817, USA
- Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, MD 20814, USA
| | - Caitlin E Mahon
- Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, MD 20814, USA
- DoD-VA Extremity Trauma and Amputation Center of Excellence, Joint Base San Antonio Fort Sam Houston, TX 78234, USA
| | - Brad D Hendershot
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
- Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, MD 20814, USA
- DoD-VA Extremity Trauma and Amputation Center of Excellence, Joint Base San Antonio Fort Sam Houston, TX 78234, USA
| | - Christopher L Dearth
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
- Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, MD 20814, USA
- DoD-VA Extremity Trauma and Amputation Center of Excellence, Joint Base San Antonio Fort Sam Houston, TX 78234, USA
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21
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Butowicz CM, Hendershot BD, Watson NL, Brooks DI, Goss DL, Whitehurst RA, Harvey AD, Helton MS, Kardouni JR, Garber MB, Mauntel TC. Pre-neuromusculoskeletal injury Risk factor Evaluation and Post-neuromusculoskeletal injury Assessment for Return-to-duty/activity Enhancement (PREPARE) in military service members: a prospective, observational study protocol. J Transl Med 2022; 20:619. [PMID: 36567311 PMCID: PMC9790128 DOI: 10.1186/s12967-022-03832-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 12/14/2022] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Non-battle related musculoskeletal injuries (MSKI) are one of the primary medical issues diminishing Service member medical readiness. The MSKI problem is challenging because it is difficult to assess all of the factors that increase MSKI risk and influence post-MSKI outcomes. Currently, there are no high-throughput, clinically-feasible, and comprehensive assessments to generate patient-centric data for informing pre- and post-MSKI risk assessment and mitigation strategies. The objective of the "Pre-neuromusculoskeletal injury Risk factor Evaluation and Post-neuromusculoskeletal injury Assessment for Return-to-duty/activity Enhancement (PREPARE)" study is to develop a comprehensive suite of clinical assessments to identify the patient-specific factors contributing to MSKI risks and undesired post-MSKI outcomes. METHODS This is a phased approach, multi-center prospective, observational study (ClinicalTrials.gov number: NCT05111925) to identify physical and psychosocial factors contributing to greater MSKI risk and undesired post-MSKI outcomes, and to identify and validate a minimal set of assessments to personalize risk mitigation and rehabilitation strategies. In Phase I, one cohort (n = 560) will identify the physical and psychosocial factors contributing to greater MSKI risks (single assessment), while a second cohort (n = 780) will identify the post-MSKI physical and psychosocial factors contributing to undesired post-MSKI outcomes (serial assessments at enrollment, 4 weeks post-enrollment, 12 weeks post-enrollment). All participants will complete comprehensive movement assessments captured via a semi-automated markerless motion capture system and instrumented walkway, joint range of motion assessments, psychosocial measures, and self-reported physical fitness performance and MSKI history. We will follow participants for 6 months. We will identify the minimum set of clinical assessments that provide requisite data to personalize MSKI risk mitigation and rehabilitation strategies, and in Phase II validate our optimized assessments in new cohorts. DISCUSSION The results of this investigation will provide clinically relevant data to efficiently inform MSKI risk mitigation and rehabilitation programs, thereby helping to advance medical care and retain Service members on active duty status. TRIAL REGISTRATION PREPARE was prospectively registered on ClinicalTrials.gov (NCT05111925) on 5 NOV 2021, prior to study commencement.
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Affiliation(s)
- Courtney M. Butowicz
- Research & Surveillance Division, Extremity Trauma and Amputation Center of Excellence, 4494 Palmer Rd N, Bethesda, MD 20814 USA ,grid.414467.40000 0001 0560 6544Research & Development Section, Department of Rehabilitation, Walter Reed National Military Medical Center, 4494 Palmer Rd N, Bethesda, MD 20814 USA ,grid.265436.00000 0001 0421 5525Department of Physical Medicine & Rehabilitation, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Rd, Bethesda, MD 20814 USA
| | - Brad D. Hendershot
- Research & Surveillance Division, Extremity Trauma and Amputation Center of Excellence, 4494 Palmer Rd N, Bethesda, MD 20814 USA ,grid.414467.40000 0001 0560 6544Research & Development Section, Department of Rehabilitation, Walter Reed National Military Medical Center, 4494 Palmer Rd N, Bethesda, MD 20814 USA ,grid.265436.00000 0001 0421 5525Department of Physical Medicine & Rehabilitation, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Rd, Bethesda, MD 20814 USA
| | - Nora L. Watson
- grid.414467.40000 0001 0560 6544Department of Research, Walter Reed National Military Medical Center, 4494 Palmer Rd N, Bethesda, MD 20814 USA
| | - Daniel I. Brooks
- grid.478868.d0000 0004 5998 2926Clinical Quality Management, Defense Health Agency, 7700 Arlington Blfd, Falls Church, VA 22042 USA
| | - Donald L. Goss
- grid.256969.70000 0000 9902 8484Department of Physical Therapy, High Point University, 1 N University Pkwy, High Point, NC 27268 USA
| | | | - Alisha D. Harvey
- grid.414467.40000 0001 0560 6544Physical Therapy Service, Department of Rehabilitation, Walter Reed National Military Medical Center, 4494 Palmer Rd N, Bethesda, MD 20814 USA
| | | | | | - Matthew B. Garber
- grid.253615.60000 0004 1936 9510Department of Health, Human Function and Rehabilitation Science, The George Washington University, 2200 Pennsylvania Ave NW, Washington, DC, 20006 USA
| | - Timothy C. Mauntel
- Research & Surveillance Divsion, Extremity Trauma & Amputation Center of Excellence, 2817 Reilly Rd, Fort Bragg, NC 28310 USA ,grid.265436.00000 0001 0421 5525Department of Surgery, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Rd, Bethesda, MD 20814 USA ,grid.417180.b0000 0004 0418 8549Department of Clinical Investigations, Womack Army Medical Center, 2817 Reilly Rd, Fort Bragg, NC 28301 USA
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22
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Sheehan RC, Guerrero N, Wilson JB, Zai CZ, Kingsbury TD, Tullos ML, Acasio JC, Mahon CE, Miller E, Hendershot BD, Dearth CL, Grabiner MD, Kaufman KR. Common fall-risk indicators are not associated with fall prevalence in a high-functioning military population with lower limb trauma. Clin Biomech (Bristol, Avon) 2022; 100:105774. [PMID: 36208575 DOI: 10.1016/j.clinbiomech.2022.105774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 06/29/2022] [Accepted: 09/27/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND Persons with lower limb trauma are at high risk for falls. Although there is a wide range of measures used to assess stability and fall-risk that include performance measures, temporal-spatial gait parameters, and nonlinear dynamic stability calculations, these measures are typically derived from fall-prone populations, such as older adults. Thus, it is unclear if these commonly used fall-risk indicators are effective at evaluating fall-risk in a younger, higher-functioning population of Service members with lower limb trauma. METHODS Twenty-one Service members with lower limb trauma completed a battery of fall-risk assessments that included performance measures (e.g., four-square-step-test), and gait parameters (e.g., step width, step length, step time) and dynamic stability measures (e.g., local divergence exponents) during 10 min of treadmill walking. Participants also reported the number of stumbles and falls over the previous 4 weeks. Negative Binomial and Quasibinomial Regressions were used to evaluate the strength of associations between fall-risk indicators and self-reported falls. FINDING Participants reported on average stumbling 6(4) times and falling 2(3) times in the previous 4 weeks. At least one fall was reported by 62% of the participants. None of the fall-risk indicators were significantly associated with fall prevalence in this population of Service members with lower limb trauma (p > 0.1). INTERPRETATION Despite the high number of reported falls in this young active population, none of the fall-risk indicators investigated effectively captured and quantified the fall-risk. Further research is needed to identify appropriate fall-risk assessments for young, high-functioning individuals with lower limb trauma.
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Affiliation(s)
- Riley C Sheehan
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA; Center for the Intrepid, Department of Rehabilitation Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, USA; Uniformed Services University of the Health Sciences, Bethesda, MD, USA.
| | - Noel Guerrero
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA; Center for the Intrepid, Department of Rehabilitation Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, USA
| | - Jonathan B Wilson
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA; Center for the Intrepid, Department of Rehabilitation Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, USA; Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Claire Z Zai
- Naval Medical Center San Diego, San Diego, CA, USA
| | | | - Meghan L Tullos
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA; Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Julian C Acasio
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA; Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Caitlin E Mahon
- DoD-VA Extremity Trauma and Amputation Center of Excellence, Fort Sam Houston, TX, USA; Walter Reed National Military Medical Center, Bethesda, MD, USA
| | | | - Brad D Hendershot
- Uniformed Services University of the Health Sciences, Bethesda, MD, USA; DoD-VA Extremity Trauma and Amputation Center of Excellence, Fort Sam Houston, TX, USA; Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Christopher L Dearth
- Uniformed Services University of the Health Sciences, Bethesda, MD, USA; DoD-VA Extremity Trauma and Amputation Center of Excellence, Fort Sam Houston, TX, USA; Walter Reed National Military Medical Center, Bethesda, MD, USA
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23
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Mahon CE, Hendershot BD. 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. Prosthet Orthot Int 2022; 46:452-458. [PMID: 35333820 DOI: 10.1097/pxr.0000000000000124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 02/15/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND The way in which a person with limb loss interacts with a prosthesis changes over time; however, there remains a lack of guidance for defining accommodation to walking with a prosthesis, limiting consistency and generalizability of research. OBJECTIVE To evaluate accommodations to walking with dynamic elastic response prosthetic ankle-foot devices among novice users with unilateral transtibial limb loss during the first year of ambulation. STUDY DESIGN This is a retrospective cohort study. METHODS Prosthetic and intact ankle-foot mechanical power profiles and mechanical work during step-to-step transitions were calculated using the Unified Deformable model for 22 male individuals with limb loss at five time points within the first year of independent ambulation (0, 2, 4, 6, and 12 months). Subjects walked at a self-selected walking velocity and controlled walking velocity (CWV). Subjective measures included the Prosthetic Evaluation Questionnaire and the 36-Item Short-Form Health Survey. RESULTS Self-selected walking velocity ranged from 1.24 ± 0.06 m/s at 0 month to 1.38 ± 0.04 m/s at 12 months, whereas CWV was 1.20 ± 0.02 m/s. At both velocities, positive work/peak power during prosthetic push-off trended upward until the 4-month time point. In addition, negative peak power during intact foot-strike seemed to qualitatively become less negative until 4 months. Positive work during intact push-off trended downward until 4 months at CWV, whereas positive peak power during intact push-off qualitatively became more positive at self-selected walking velocity. CONCLUSIONS These trends may partially indicate (biomechanical) accommodation to walking by appearance of a "plateau" at 4 months after initial ambulation with a prosthesis.
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Affiliation(s)
- Caitlin E Mahon
- Research & Surveillance Division, DoD-VA Extremity Trauma and Amputation Center of Excellence, Bethesda, MD, USA
- Research and Development Section, Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Brad D Hendershot
- Research & Surveillance Division, DoD-VA Extremity Trauma and Amputation Center of Excellence, Bethesda, MD, USA
- Research and Development Section, Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, MD, USA
- Department of Rehabilitation Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
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24
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Carver JL, Le AH, Colantonio DF, Roach WB, Tucker CJ, Dickens JF, Hendershot BD, Helgeson MD, Mauntel TC. Knee Joint Peak Contact Pressure Location Following ACL And Meniscus Injuries And Surgical Treatments. Med Sci Sports Exerc 2022. [DOI: 10.1249/01.mss.0000877604.88632.8f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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25
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Knight AD, Hendershot BD, Sleeman TJ, Dearth CL, Starker F, Schneider U, Koehler-McNicholas SR, Barrons K, Nickel E, Mion S, Ferguson J, Slater BS, Voss GO, Koester K, Hansen AH. Toward improving residual limb climate within prostheses for persons with lower limb loss: a technical note. Prosthet Orthot Int 2022; 46:202-205. [PMID: 34932513 DOI: 10.1097/pxr.0000000000000085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 11/01/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND Individuals with lower limb loss often wear a gel liner and enclosed socket for connecting to a terminal prosthetic device. Historically, a significant limitation to traditional liners and sockets is that they are thermal insulators, thereby trapping heat and moisture within, which can lead to numerous deleterious issues, including loss of suspension and residual limb skin problems, and, in turn, reductions in mobility, function, and overall quality of life. To mitigate these issues, new approaches are therefore needed to enhance the residual limb climate (e.g. breathability and air permeability), allowing the dispersal of heat and moisture from within the liner and socket. METHODS In this study, a multidisciplinary team sought to establish the feasibility of an innovative prosthetic liner-socket system, designed to improve residual limb climate by capitalizing on passive (i.e. nonpowered) ventilation to reduce temperature/moisture and improve socket comfort for persons with transtibial amputations. Focus group meetings, along with an iterative design approach, were implemented to establish innovative design and development concepts that led to a passively ventilated liner-socket system. CONCLUSIONS Ex vivo design has supported the feasibility of developing a passively ventilated liner-socket. To build on these successes, future development and human subjects testing are needed to finalize a commercially viable system. Implementing a passively ventilated liner-socket system that improves residual limb health and comfort, without compromising function or mobility of the user, into standard clinical care may encourage a more active lifestyle and enhance the quality of life for individuals after lower limb loss.
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Affiliation(s)
- Ashley D Knight
- Research & Surveillance Division, DoD-VA Extremity Trauma and Amputation Center of Excellence, Bethesda, MD
- Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, MD
- Department of Rehabilitation Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Brad D Hendershot
- Research & Surveillance Division, DoD-VA Extremity Trauma and Amputation Center of Excellence, Bethesda, MD
- Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, MD
- Department of Rehabilitation Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Todd J Sleeman
- Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, MD
| | - Christopher L Dearth
- Research & Surveillance Division, DoD-VA Extremity Trauma and Amputation Center of Excellence, Bethesda, MD
- Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, MD
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Felix Starker
- Department of Biomechatronic Systems, Fraunhofer Institute, Stuttgart, Germany
| | - Urs Schneider
- Department of Biomechatronic Systems, Fraunhofer Institute, Stuttgart, Germany
| | - Sara R Koehler-McNicholas
- Minneapolis Veterans Affairs Health Care System, Minneapolis, MN
- Department of Rehabilitation Medicine, University of Minnesota, Minneapolis, MN
| | - Kyle Barrons
- Minneapolis Veterans Affairs Health Care System, Minneapolis, MN
| | - Eric Nickel
- Minneapolis Veterans Affairs Health Care System, Minneapolis, MN
| | - Spencer Mion
- Minneapolis Veterans Affairs Health Care System, Minneapolis, MN
| | - John Ferguson
- Minneapolis Veterans Affairs Health Care System, Minneapolis, MN
- Department of Rehabilitation Medicine, University of Minnesota, Minneapolis, MN
| | | | - Gregory O Voss
- Minneapolis Veterans Affairs Health Care System, Minneapolis, MN
| | - Karl Koester
- Minneapolis Veterans Affairs Health Care System, Minneapolis, MN
| | - Andrew H Hansen
- Minneapolis Veterans Affairs Health Care System, Minneapolis, MN
- Department of Rehabilitation Medicine, University of Minnesota, Minneapolis, MN
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26
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Knight AD, Bass SR, Elrod JM, Hassinger LM, Dearth CL, Gonzalez-Vargas J, Hendershot BD, Han Z. Toward Developing a Powered Ankle-Foot Prosthesis With Electromyographic Control to Enhance Functional Performance: A Case Study in a U.S. Service Member. Mil Med 2022; 188:usac038. [PMID: 35234252 DOI: 10.1093/milmed/usac038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 01/26/2022] [Accepted: 02/04/2022] [Indexed: 11/14/2022] Open
Abstract
The only commercially available ankle-foot prosthesis with powered propulsion lacks ruggedization and other capabilities for service members seeking to return to duty and/or other physically demanding activities. Here, we evaluated a ruggedized powered ankle-foot prosthesis with electromyographic control ("Warrior Ankle"; WA) in an experienced male user of the predicate (Empower) prosthesis. The participant (age = 56 years, mass = 86.8 kg, stature = 173 cm) completed a 650 m simulated hike with varying terrain at a fixed, self-selected speed in the WA and predicate prosthesis, with and without a 22.8 kg weighted vest ("loaded" and "unloaded," respectively). Peak dorsiflexion and plantarflexion angles were extracted from each gait cycle throughout the simulated hike (∼500 prosthetic-side steps). The participant walked faster with the WA (1.15 m/s) compared to predicate (0.80 m/s) prosthesis. On the prosthetic side, peak dorsiflexion angles were larger for the WA (loaded: 27.9°; unloaded: 26.9°) compared to the predicate (loaded: 19.4°; unloaded: 21.3°); peak plantarflexion angles were similar between prostheses and loading conditions [WA (loaded: 15.5°; unloaded: 14.9°), predicate (loaded: 16.9°; unloaded: 14.8°). The WA better accommodated the varying terrain profile, evidenced by greater peak dorsiflexion angles, as well as dorsiflexion and plantarflexion angles that more closely matched or exceeded those of the innate ankle [dorsiflexion (WA: 31.6°, predicate: 27.5°); plantarflexion (WA: 20.7°, predicate: 20.5°)]. Furthermore, the WA facilitated a faster walking speed, suggesting a greater functional capacity with the WA prosthesis. Although further design enhancements are needed, this case study demonstrated feasibility of a proof-of-concept, ruggedized powered ankle-foot prosthesis with electromyographic control.
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Affiliation(s)
- Ashley D Knight
- Research and Surveillance Division, DoD-VA Extremity Trauma and Amputation Center of Excellence, Bethesda, MD 20889, USA
- Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA
- Department of Rehabilitation Medicine, Uniformed Services of the Health Sciences, Bethesda, MD 20814, USA
| | - Sarah R Bass
- Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA
- Department of Rehabilitation Medicine, Uniformed Services of the Health Sciences, Bethesda, MD 20814, USA
| | - Jonathan M Elrod
- Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD 20817, USA
| | - Louise M Hassinger
- Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA
| | - Christopher L Dearth
- Research and Surveillance Division, DoD-VA Extremity Trauma and Amputation Center of Excellence, Bethesda, MD 20889, USA
- Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA
- Department of Surgery, Uniformed Services University of the Health Sciences-Walter Reed National Military Medical Center, Bethesda, MD 20814, USA
| | | | - Brad D Hendershot
- Research and Surveillance Division, DoD-VA Extremity Trauma and Amputation Center of Excellence, Bethesda, MD 20889, USA
- Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA
- Department of Rehabilitation Medicine, Uniformed Services of the Health Sciences, Bethesda, MD 20814, USA
| | - Zhixiu Han
- Ottobock SE & Co. KGaA, Duderstadt 37115, Germany
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27
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Acasio JC, Butowicz CM, Dearth CL, Bazrgari B, Hendershot BD. Trunk Muscle Forces and Spinal Loads while Walking in Persons with Lower Limb Amputation: Influences of Chronic Low Back Pain. J Biomech 2022; 135:111028. [DOI: 10.1016/j.jbiomech.2022.111028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 02/24/2022] [Accepted: 02/25/2022] [Indexed: 10/19/2022]
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28
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Butowicz CM, Yoder AJ, Farrokhi S, Mazzone B, Hendershot BD. Low back pain influences trunk-lower limb joint coordination and balance control during standing in persons with lower limb loss. Clin Biomech (Bristol, Avon) 2022; 92:105580. [PMID: 35124535 DOI: 10.1016/j.clinbiomech.2022.105580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 01/07/2022] [Accepted: 01/13/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND Balance is sustained through multi-joint coordination in response to postural perturbations. Low back pain alters postural responses; however, it is unknown how coordination between the trunk and lower extremities affects center of mass control during standing balance among persons with limb loss, particularly those with back pain. METHODS Forty participants with unilateral lower limb loss (23 with back pain) stood with eyes open and closed on a firm surface, while wearing IMUs on the sternum, pelvis, and bilaterally on the thigh, shank, and foot. A state-space model with Kalman filter calculated sagittal trunk, hip, knee, and ankle joint angles. Fuzzy entropy quantified center of mass variability of sagittal angular velocity at the sacrum. Normalized cross-correlation functions identified coordination patterns (trunk-hip, trunk-knee, trunk-ankle). Multiple linear regression predicted fuzzy entropy from cross-correlation values for each pattern, with body mass and amputation level as covariates. FINDINGS With eyes open, trunk-lower limb joint coordination on either limb did not predict fuzzy entropy. With eyes closed, positive trunk-hip coordination on the intact limb predicted fuzzy entropy in the pain group (p = 0.02), but not the no pain group. On the prosthetic side, inverse trunk-hip coordination patterns predicted fuzzy entropy in pain group (p = 0.03) only. INTERPRETATION Persons with limb loss and back pain demonstrated opposing coordination strategies between the lower limbs and trunk when vision was removed, perhaps identifying a mechanism for pain recurrence. Vision is the dominant source of balance stabilization in this population, which may increase fall risk when visual feedback is compromised.
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Affiliation(s)
- Courtney M Butowicz
- Research & Surveillance Division, DoD-VA Extremity Trauma & Amputation Center of Excellence, Walter Reed National Military Medical Center, Bethesda, MD, USA.
| | - Adam J Yoder
- Research & Surveillance Division, DoD-VA Extremity Trauma & Amputation Center of Excellence, Naval Medical Center, San Diego, CA, USA
| | - Shawn Farrokhi
- Research & Surveillance Division, DoD-VA Extremity Trauma & Amputation Center of Excellence, Naval Medical Center, San Diego, CA, USA; Department of Rehabilitation Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Brittney Mazzone
- Research & Surveillance Division, DoD-VA Extremity Trauma & Amputation Center of Excellence, Naval Medical Center, San Diego, CA, USA; Department of Rehabilitation Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Brad D Hendershot
- Research & Surveillance Division, DoD-VA Extremity Trauma & Amputation Center of Excellence, Walter Reed National Military Medical Center, Bethesda, MD, USA; Department of Rehabilitation Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
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29
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Wasser JG, Acasio JC, Miller RH, Hendershot BD. Lumbopelvic coordination while walking in service members with unilateral lower limb loss: Comparing variabilities derived from vector coding and continuous relative phase. Gait Posture 2022; 92:284-289. [PMID: 34896840 DOI: 10.1016/j.gaitpost.2021.11.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 11/02/2021] [Accepted: 11/22/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND Continuous relative phase and vector coding are two common approaches for quantifying lumbopelvic coordination and variability. Evaluating the application of such methodologies to the lower limb loss population is important for better understanding reported asymmetrical movement dynamics of the lumbopelvic region. RESEARCH QUESTION How do coordination variabilities derived from trunk-pelvic coupling angles and continuous relative phases compare among individuals with and without unilateral lower limb loss walking at self-selected speeds? METHODS Full-body kinematics were obtained from thirty-eight males with unilateral lower limb loss (23 transtibial and 15 transfemoral) and fifteen males without limb loss while walking along a 15 m walkway. Coordination variabilities were derived from trunk-pelvic coupling angles and continuous relative phases and compared using a multivariate approach, as well as in unilateral outcome measures between control participants and participants with lower limb loss. RESULTS Overall, tri-planar measures of continuous relative phase variability were 19-43% larger compared to coupling angle variabilities for individuals without limb loss and individuals with transtibial limb loss. Individuals with transfemoral limb loss had 27% and 31% larger sagittal and transverse variabilities from continuous relative phases compared to coupling angles, respectively. During both prosthetic and intact limb stance, individuals with transtibial limb loss had 19-35% greater tri-planar measures of continuous relative phase variability compared to coupling angle variabilities. During intact stance phase, tri-planar measures of continuous relative phase variability were 27%- 42% larger compared to coupling angle variabilities for individuals without limb loss. SIGNIFICANCE While both methods provide valid estimates of lumbopelvic movement variability during gait, continuous relative phase variability may provide a more sensitive estimate in the lower limb loss population capturing velocity-specific motions of the trunk and pelvis.
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Affiliation(s)
- Joseph G Wasser
- Research and Development Section, Department of Rehabilitation, Walter Reed National Military Medical Center, 4494 Palmer Rd N, Bethesda 20814, USA; Henry M. Jackson Foundation, for the Advancement of Military Medicine, 6720A Rockledge Dr, Bethesda 20817, USA.
| | - Julian C Acasio
- Research and Development Section, Department of Rehabilitation, Walter Reed National Military Medical Center, 4494 Palmer Rd N, Bethesda 20814, USA; Henry M. Jackson Foundation, for the Advancement of Military Medicine, 6720A Rockledge Dr, Bethesda 20817, USA.
| | - Ross H Miller
- Department of Kinesiology, University of Maryland, 2351 SPH Building, 4200 Valley Dr, College Park 20742, USA; Neuroscience & Cognitive Science Program, University of Maryland, College Park, USA.
| | - Brad D Hendershot
- Research and Development Section, Department of Rehabilitation, Walter Reed National Military Medical Center, 4494 Palmer Rd N, Bethesda 20814, USA; DoD-VA Extremity Trauma & Amputation Center of Excellence, USA; Department of Rehabilitation Medicine, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Rd, Bethesda 20814, USA.
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30
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Acasio JC, Guerrero NA, Sheehan RC, Butowicz CM, Tullos ML, Mahon CE, Stewart JM, Zai CZ, Kingsbury TD, Grabiner MD, Dearth CL, Kaufman KR, Hendershot BD. Assessments of trunk postural control within a fall-prevention training program for service members with lower limb trauma and loss. Gait Posture 2022; 92:493-497. [PMID: 33663914 DOI: 10.1016/j.gaitpost.2021.02.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Revised: 01/20/2021] [Accepted: 02/17/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND Trunk postural control (TPC) is critical in maintaining balance following perturbations (i.e., avoiding falls), and impaired among persons with lower extremity trauma, contributing to elevated fall risk. Previously, a fall-prevention program improved TPC in individuals with unilateral transtibial amputation following trip-inducing perturbations. However, it is presently unclear if these improvements are task specific. RESEARCH QUESTION Do improvements to TPC gained from a fall-prevention program translate to another task which assesses TPC in isolation (i.e., unstable sitting)? Secondarily, can isolated TPC be used to identify who would benefit most from the fall-prevention program? METHODS Twenty-five individuals (21 male/4 female) with lower extremity trauma, who participated in a larger fall-prevention program, were included in this analysis. Trunk flexion and flexion velocity quantified TPC following perturbation; accelerometer-based sway parameters quantified TPC during unstable sitting. A generalized linear mixed-effects model assessed training-induced differences in TPC after perturbation; a generalized linear model assessed differences in sway parameters following training. Spearman's rho related training-induced changes to TPC following perturbation (i.e., the difference in TPC measures at pre- and post-training assessments) with pre- vs. post-training changes to sway parameters during unstable sitting (i.e., the difference in sway parameters at pre- and post-training assessments) as well as pre-training sway parameters with the pre- vs. post-training differences in TPC following perturbation. RESULTS Following training, trunk flexion angles decreased, indicating improved TPC; however, sway parameters did not differ pre- and post-training. In addition, pre- vs. post-training differences in TPC following perturbation were neither strongly nor significantly correlated with sway parameters. Moreover, pre-training sway parameters did not correlate with pre- vs. post-training differences in trunk flexion/flexion velocity. SIGNIFICANCE Overall, these results indicate that improvements to TPC gained from fall-prevention training are task-specific and do not translate to other activities. Moreover, isolated TPC measures are not able to identify individuals that benefit most from the fall-prevention program.
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Affiliation(s)
- Julian C Acasio
- Research and Development Section, Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, MD, USA; Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA
| | - Noel A Guerrero
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA; Department of Rehabilitation Medicine, Center for the Intrepid, Brooke Army Medical Center, San Antonio, TX, USA
| | - Riley C Sheehan
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA; Department of Rehabilitation Medicine, Center for the Intrepid, Brooke Army Medical Center, San Antonio, TX, USA; Department of Rehabilitation Medicine, Uniformed Service University of the Health Sciences, Bethesda, MD, USA
| | - Courtney M Butowicz
- Research and Development Section, Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, MD, USA; Research & Surveillance Division, DoD-VA Extremity Trauma & Amputation Center of Excellence, USA
| | - Meghan L Tullos
- Research and Development Section, Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, MD, USA; Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA
| | - Caitlin E Mahon
- Research and Development Section, Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, MD, USA; Research & Surveillance Division, DoD-VA Extremity Trauma & Amputation Center of Excellence, USA
| | - Julianne M Stewart
- Physical Therapy Department, Naval Medical Center San Diego, San Diego, CA, USA
| | - Claire Z Zai
- Physical Therapy Department, Naval Medical Center San Diego, San Diego, CA, USA
| | - Trevor D Kingsbury
- Physical Therapy Department, Naval Medical Center San Diego, San Diego, CA, USA
| | - Mark D Grabiner
- Department of Kinesiology and Nutrition, University of Illinois at Chicago, Chicago, IL, USA
| | - Christopher L Dearth
- Research & Surveillance Division, DoD-VA Extremity Trauma & Amputation Center of Excellence, USA; Department of Surgery, Uniformed Service University of the Health Sciences, Bethesda, MD, USA
| | - Kenton R Kaufman
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Brad D Hendershot
- Research and Development Section, Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, MD, USA; Department of Rehabilitation Medicine, Uniformed Service University of the Health Sciences, Bethesda, MD, USA; Research & Surveillance Division, DoD-VA Extremity Trauma & Amputation Center of Excellence, USA.
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Knight AD, Dearth CL, Hendershot BD. Deleterious Musculoskeletal Conditions Secondary to Lower Limb Loss: Considerations for Prosthesis-Related Factors. Adv Wound Care (New Rochelle) 2021; 10:671-684. [PMID: 32320367 PMCID: PMC8568798 DOI: 10.1089/wound.2019.1079] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Accepted: 02/23/2020] [Indexed: 11/13/2022] Open
Abstract
Significance: The intent of this work was to summarize the existing evidence of, and highlight knowledge gaps specific to, prosthetic devices/componentry and training regimes, particularly in the context of the human-device interaction and deleterious musculoskeletal conditions secondary to lower limb loss. Recent Advances: With the recent and evolving technological advancements in prostheses, there are numerous devices available to individuals with lower limb loss. Current literature demonstrates the importance of expanding the knowledge of all prosthetic device-specific factors and the significance of proper prescription, fit, and alignment, along with adequate device-/activity-specific training, to enhance human-device interaction, reduce gait abnormalities and compensatory motions, and as a result, mitigate risk for secondary musculoskeletal conditions. Critical Issues: Inadequate device prescription, fit, alignment, and training are evident owing to the lack of knowledge or awareness of the many device-specific properties and factors, leading to suboptimal use, as well as, biomechanical compensations, which collectively and adversely affect the function, activity level, and overall health of the prosthesis user. Future Directions: To maximize optimal outcomes after lower limb loss, it is essential to better appreciate the factors that affect both prosthesis use and satisfaction, particularly any modifiable factors that might be targeted in rehabilitation interventions such as device prescription, fit/alignment, and training regimes. A better understanding of such device-specific factors will help enhance the human-device interaction and resulting functional performance, thereby reducing secondary musculoskeletal conditions, allowing for the readiness of the fighting force (return-to-duty/redeployment) and/or improved reintegration into civilian society/work, and overall enhancing quality of life after lower limb loss.
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Affiliation(s)
- Ashley D. Knight
- DoD-VA Extremity Trauma & Amputation Center of Excellence, Bethesda, Maryland, USA
- Walter Reed National Military Medical Center, Bethesda, Maryland, USA
- Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Christopher L. Dearth
- DoD-VA Extremity Trauma & Amputation Center of Excellence, Bethesda, Maryland, USA
- Walter Reed National Military Medical Center, Bethesda, Maryland, USA
- Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Brad D. Hendershot
- DoD-VA Extremity Trauma & Amputation Center of Excellence, Bethesda, Maryland, USA
- Walter Reed National Military Medical Center, Bethesda, Maryland, USA
- Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
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Elrod JM, Schnall BL, Mauntel TC, Watson NL, Koehler-McNicholas SR, Nickel EA, Hansen AH, Dearth CL, Hendershot BD. Biomechanical characterization of the foot-ground interaction among Service members with unilateral transtibial limb loss performing unconstrained drop-landings: Effects of drop height and added mass. J Biomech 2021; 127:110701. [PMID: 34461366 DOI: 10.1016/j.jbiomech.2021.110701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 08/12/2021] [Accepted: 08/15/2021] [Indexed: 11/29/2022]
Abstract
There exist limited data to guide the development of methodologies for evaluating impact resilience of prosthetic ankle-foot systems, particularly regarding human-device interaction in ecologically valid scenarios. The purpose of this study was to biomechanically characterize foot-ground interactions during drop-landings among Service members with and without unilateral transtibial limb loss. Seven males with, and seven males without, unilateral transtibial limb loss completed six drop-landing conditions consisting of all combinations of three heights (20 cm, 40 cm, 60 cm) and two loads (with and without a 22.2 kg weighted vest). Peak ground reaction forces (GRF), vertical GRF loading rate and impulse, as well as ankle-foot, knee, and hip joint negative (absorption) powers and work were compared across groups (i.e., contralateral side and prosthetic side vs. uninjured controls) by height and load conditions. Loading occurred primarily in the vertical direction, and increased with increasing drop height and/or with added load. Vertical GRFs were overall ~ 15% smaller on the prosthetic side (vs. controls) with similar loading rates across limbs/groups. From the most challenging condition (i.e., 60 cm with 22 kg load), ankle-foot absorption energies on the prosthetic side were 64.6 (7.2) J; corresponding values were 187.4 (8.9) J for the contralateral limb and 161.2 (6.7) J among uninjured controls. Better understanding biomechanical responses to drop-landings in ecological scenarios will help inform future iterations of mechanical testing methodologies for evaluating impact resilience of prosthetic ankle-foot systems (enhancing prescription criteria and return-to-activity considerations) as well as identifying and mitigating risk factors for long-term secondary complications within the contralateral limb (e.g., joint degeneration).
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Affiliation(s)
- Jonathan M Elrod
- Research & Development Section, Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, MD, USA; The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD, USA
| | - Barri L Schnall
- Research & Development Section, Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Timothy C Mauntel
- Research & Surveillance Division, DoD-VA Extremity Trauma and Amputation Center of Excellence, Womack Army Medical Center, Fort Bragg, NC, USA; Department of Surgery, Uniformed Services University of the Health Sciences / Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Nora L Watson
- Department of Research Programs, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Sara R Koehler-McNicholas
- Minneapolis Department of Veterans Affairs Health Care System, Minneapolis, MN, USA; Division of Rehabilitation Sciences, Department of Rehabilitation Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Eric A Nickel
- Department of Research Programs, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Andrew H Hansen
- Minneapolis Department of Veterans Affairs Health Care System, Minneapolis, MN, USA; Division of Rehabilitation Sciences, Department of Rehabilitation Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Christopher L Dearth
- Research & Surveillance Division, DoD-VA Extremity Trauma and Amputation Center of Excellence, Walter Reed National Military Medical Center, Bethesda, MD, USA; Department of Surgery, Uniformed Services University of the Health Sciences / Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Brad D Hendershot
- Research & Development Section, Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, MD, USA; Research & Surveillance Division, DoD-VA Extremity Trauma and Amputation Center of Excellence, Walter Reed National Military Medical Center, Bethesda, MD, USA; Department of Rehabilitation Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA.
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Butowicz CM, Yoder AJ, Farrokhi S, Mazzone B, Hendershot BD. Lower limb joint-specific contributions to standing postural sway in persons with unilateral lower limb loss. Gait Posture 2021; 89:109-114. [PMID: 34271526 DOI: 10.1016/j.gaitpost.2021.06.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 05/20/2021] [Accepted: 06/24/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND Individuals with lower limb loss are at an increased risk for falls, likely due to impaired balance control. Standing balance is typically explained by double- or single-inverted pendulum models of the hip and/or ankle, neglecting the knee joint. However, recent work suggests knee joint motion contributes toward stabilizing center-of-mass kinematics during standing balance. RESEARCH QUESTION To what extent do hip, knee, and ankle joint motions contribute to postural sway in standing among individuals with lower limb loss? METHODS Forty-two individuals (25 m/17f) with unilateral lower limb loss (30 transtibial, 12 transfemoral) stood quietly with eyes open and eyes closed, for 30 s each, while wearing accelerometers on the pelvis, thigh, shank, and foot. Triaxial inertial measurement units were transformed to inertial anterior-posterior components and sway parameters were computed: ellipse area, root-mean-square, and jerk. A state-space model with a Kalman filter calculated hip, knee, and ankle joint flexion-extension angles and ranges of motion. Multiple linear regression predicted postural sway parameters from intact limb joint ranges of motion, with BMI as a covariate (p < 0.05). RESULTS With eyes open, intact limb hip flexion predicted larger sway ellipse area, whereas hip flexion and knee extension predicted larger sway root-mean-square, and hip flexion, knee extension, and ankle plantarflexion predicted larger sway jerk. With eyes closed, intact limb hip flexion remained the predictor of sway ellipse area; no other joint motions influenced sway parameters in this condition. SIGNIFICANCE Hip, knee, and ankle motions influence postural sway during standing balance among individuals with lower limb loss. Specifically, increasing intact-side hip flexion, knee extension, and ankle plantarflexion motion increased postural sway. With vision removed, a re-weighting of lower limb joint sensory mechanisms may control postural sway, such that increasing sway may be regulated by proximal coordination strategies and vestibular responses, with implications for fall risk.
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Affiliation(s)
- Courtney M Butowicz
- Research & Surveillance Division, DoD-VA Extremity Trauma & Amputation Center of Excellence, USA; Walter Reed National Military Medical Center, Bethesda, MD, USA.
| | - Adam J Yoder
- Research & Surveillance Division, DoD-VA Extremity Trauma & Amputation Center of Excellence, USA; Naval Medical Center, San Diego, CA, USA
| | - Shawn Farrokhi
- Research & Surveillance Division, DoD-VA Extremity Trauma & Amputation Center of Excellence, USA; Naval Medical Center, San Diego, CA, USA; Department of Rehabilitation Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Brittney Mazzone
- Research & Surveillance Division, DoD-VA Extremity Trauma & Amputation Center of Excellence, USA; Naval Medical Center, San Diego, CA, USA
| | - Brad D Hendershot
- Research & Surveillance Division, DoD-VA Extremity Trauma & Amputation Center of Excellence, USA; Walter Reed National Military Medical Center, Bethesda, MD, USA; Department of Rehabilitation Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
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34
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Le AH, Roach WB, Mauntel TC, Hendershot BD, Helgeson MD, Colantonio DF, Fredericks DR, Slaven SE, Pisano AJ, LeClere LE. A Biomechanical Comparison of High-Tensile Strength Tape Versus High-Tensile Strength Suture for Tendon Fixation Under Cyclic Loading. Arthroscopy 2021; 37:2925-2933. [PMID: 33901508 DOI: 10.1016/j.arthro.2021.04.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 03/16/2021] [Accepted: 04/14/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE To compare the biomechanical properties of high-tensile strength tape and high-tensile strength suture across 2 selected stitch techniques, the Krackow and whip stitch, in securing tendinous tissue during 5,000 cycles of nondestructive loading followed by a load to failure. METHODS Fourteen matched pairs each of cadaveric Achilles, quadriceps, and patellar tendons (n = 84) were randomly assigned to either Krackow or whip stitch and sutured with either 2-mm high-tensile strength tape or No. 2 high-tensile strength suture. Specimens were preloaded to 20 N, cyclically loaded from 20 to 200 N for 5,000 cycles at 2 Hz, and then loaded to failure at 200 mm/min. Linear mixed models evaluated the effects of suture material and stitch technique on cyclic normalized tendon-suture elongation, total normalized tendon-suture elongation at 5,000 cycles, and maximum load at failure. RESULTS Across all suture constructs, normalized elongation was greater during the initial 10 cycles, compared with all subsequent cycling intervals (all P < .001). There was less total normalized elongation (β = -0.239; P = .007) and greater maximum load at failure in tape (β = 163.71; P = .014) when used in the Krackow stitch compared with the whip stitch. CONCLUSIONS Our findings indicate that tape used in the Krackow stitch maintains the most favorable fixation strength after enduring cyclic loading, with greater maximum load at failure. In addition, overall normalized elongation during long-term cyclic loading was predominately affected by the stitch technique used, regardless of the suture material; however, tape allowed less normalized elongation during the initial loading cycles, especially when placed in the whip stitch. CLINICAL RELEVANCE Understanding the potential short- and long-term outcomes of suture material and stitch technique on securing tendinous tissue under repetitive stresses can help inform clinicians on optimal tendon fixation techniques for early postoperative activities.
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Affiliation(s)
- Anthony H Le
- DoD-VA Extremity Trauma and Amputation Center of Excellence, Walter Reed National Military Medical Center, Bethesda.
| | - William B Roach
- Department of Orthopaedics, Walter Reed National Military Medical Center, Bethesda
| | - Timothy C Mauntel
- DoD-VA Extremity Trauma and Amputation Center of Excellence, Walter Reed National Military Medical Center, Bethesda; Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda
| | - Brad D Hendershot
- DoD-VA Extremity Trauma and Amputation Center of Excellence, Walter Reed National Military Medical Center, Bethesda; Department of Rehabilitation Medicine, Uniformed Services University of the Health Science, Bethesda
| | - Melvin D Helgeson
- Department of Orthopaedics, Walter Reed National Military Medical Center, Bethesda; Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda
| | - Donald F Colantonio
- Department of Orthopaedics, Walter Reed National Military Medical Center, Bethesda
| | - Donald R Fredericks
- Department of Orthopaedics, Walter Reed National Military Medical Center, Bethesda
| | - Sean E Slaven
- Department of Orthopaedics, Walter Reed National Military Medical Center, Bethesda
| | - Alfred J Pisano
- Department of Orthopaedics, Walter Reed National Military Medical Center, Bethesda
| | - Lance E LeClere
- Department of Orthopaedic Surgery, Naval Health Clinic, United States Naval Academy, Annapolis, Maryland, U.S.A
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Motherwell JM, Hendershot BD, Goldman SM, Dearth CL. Gait biomechanics: A clinically relevant outcome measure for preclinical research of musculoskeletal trauma. J Orthop Res 2021; 39:1139-1151. [PMID: 33458856 DOI: 10.1002/jor.24990] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 12/01/2020] [Accepted: 01/11/2021] [Indexed: 02/04/2023]
Abstract
Traumatic injuries to the musculoskeletal system are the most prevalent of those suffered by United States Military Service members and accounts for two-thirds of initial hospital costs to the Department of Defense. These combat-related wounds often leave survivors with life-long disability and represent a significant impediment to the readiness of the fighting force. There are immense opportunities for the field of tissue engineering and regenerative medicine (TE/RM) to address these musculoskeletal injuries through regeneration of damaged tissues as a means to restore limb functionality and improve quality of life for affected individuals. Indeed, investigators have made promising advancements in the treatment for these injuries by utilizing small and large preclinical animal models to validate therapeutic efficacy of next-generation TE/RM-based technologies. Importantly, utilization of a comprehensive suite of functional outcome measures, particularly those designed to mimic data collected within the clinical setting, is critical for successful translation and implementation of these therapeutics. To that end, the objective of this review is to emphasize the clinical relevance and application of gait biomechanics as a functional outcome measure for preclinical research studies evaluating the efficacy of TE/RM therapies to treat traumatic musculoskeletal injuries. Specifically, common musculoskeletal injuries sustained by service members-including volumetric muscle loss, post-traumatic osteoarthritis, and composite tissue injuries-are examined as case examples to highlight the use of gait biomechanics as an outcome measure using small and large preclinical animal models.
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Affiliation(s)
- Jessica M Motherwell
- DoD-VA Extremity Trauma and Amputation Center of Excellence, Bethesda, Maryland, USA.,Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Brad D Hendershot
- DoD-VA Extremity Trauma and Amputation Center of Excellence, Bethesda, Maryland, USA.,Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, Maryland, USA.,Department of Rehabilitation Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Stephen M Goldman
- DoD-VA Extremity Trauma and Amputation Center of Excellence, Bethesda, Maryland, USA.,Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Christopher L Dearth
- DoD-VA Extremity Trauma and Amputation Center of Excellence, Bethesda, Maryland, USA.,Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, Maryland, USA
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Acasio JC, Nussbaum MA, Hendershot BD. Trunk-pelvic coordination during unstable sitting with varying task demand: A methodological study. J Biomech 2021; 118:110299. [PMID: 33581439 DOI: 10.1016/j.jbiomech.2021.110299] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 01/16/2021] [Accepted: 01/23/2021] [Indexed: 11/25/2022]
Abstract
Unstable sitting is used commonly to evaluate trunk postural control (TPC), typically via measures based on center-of-pressure (CoP) time series. However, these measures do not directly reflect underlying control/movement strategies. We quantified trunk-pelvis coordination during unstable sitting using vector coding (VC) and correlated such coordination with CoP-based outcomes across varying task demands. Thirteen uninjured individuals (11 male/2 female) sat on an unstable chair at four instability levels, in a random order, defined relative to the individual gravitational gradient (∇G): 100, 75, 60, and 45%∇G. VC assessed trunk-pelvic coordination, and coupling angles classified movements as: 1) anti-phase, 2) in-phase, 3) trunk-phase, or 4) pelvic-phase. With decreasing %∇G (i.e., increasing instability), we found: increased anti-phase movement in the sagittal and frontal planes; decreased in-phase movement in the sagittal and frontal planes; and increased in-phase and pelvic-phase movement in the transverse plane. In the sagittal and frontal planes, we observed significant weak-to-moderate correlations between anti-phase and in-phase movements (0.288 < |ρ| < 0.549). Correlations between CoP-based measures and pelvic-phase and trunk-phase movements were typically weak and/or non-significant (|ρ| < 0.318). VC techniques discriminated between levels of instability during unstable sitting, identifying in-phase coordination (stiffening strategy) at lower instability levels and anti-phase coordination at higher instability levels. Compared to CoP-based measures, trunk coordination outcomes during unstable sitting provide measures of TPC that more directly quantify underlying movement strategies. These results can also serve as a baseline for future work investigating populations with impaired TPC (e.g., individuals with low back pain or limb loss).
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Affiliation(s)
- Julian C Acasio
- Research & Development Section, Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, MD, USA; Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc, Bethesda, MD, USA
| | - Maury A Nussbaum
- Department of Industrial and Systems Engineering, Virginia Tech, Blacksburg, VA, USA
| | - Brad D Hendershot
- Research & Development Section, Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, MD, USA; Research & Surveillance Division, DoD-VA Extremity Trauma & Amputation Center of Excellence, USA; Department of Rehabilitation Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA.
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Farrokhi S, Russell Esposito E, McPherson D, Mazzone B, Condon R, Patterson CG, Schneider M, Greco CM, Delitto A, Highsmith MJ, Hendershot BD, Maikos J, Dearth CL. Resolving the Burden of Low Back Pain in Military Service Members and Veterans (RESOLVE): Protocol for a Multisite Pragmatic Clinical Trial. Pain Med 2020; 21:S45-S52. [PMID: 33313735 DOI: 10.1093/pm/pnaa367] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Physical therapy (PT) is frequently used for the management of low back pain (LBP) within the US Departments of Defense (DOD) and Veterans Affairs (VA). However, variations in PT practice patterns and use of ineffective interventions lower the quality and increase the cost of care. Although adherence to the clinical practice guidelines (CPGs) can improve the outcomes and cost-effectiveness of LBP care, PT CPG adherence remains below 50%. The Resolving the Burden of Low Back Pain in Military Service Members and Veterans (RESOLVE) trial will evaluate the effectiveness of an active PT CPG implementation strategy using an education, audit, and feedback model for reducing pain, disability, medication use, and cost of LBP care within the DOD and VA health care systems. DESIGN The RESOLVE trial will include 3,300 to 7,260 patients with LBP across three DOD and two VA medical facilities using a stepped-wedge study design. An education, audit, and feedback model will be used to encourage physical therapists to better adhere to the PT CPG recommendations. The Oswestry Disability Index and the Defense and Veterans Pain Rating Scale will be used as primary outcomes. Secondary outcomes will include the LBP-related medication use, medical resource utilization, and biopsychosocial predictors of outcomes. Statistical analyses will be based on the intention-to-treat principle and will use linear mixed models to compare treatment conditions and examine the interactions between treatment and subgrouping status (e.g., limb loss). SUMMARY The RESOLVE trial will provide a pragmatic approach to evaluate whether better adherence to PT CPGs can reduce pain, disability, medication use, and LBP care cost within the DOD and VA health care systems.
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Affiliation(s)
- Shawn Farrokhi
- DOD-VA Extremity Trauma and Amputation Center of Excellence, Falls Church, Virginia.,Naval Medical Center San Diego, San Diego, California
| | - Elizabeth Russell Esposito
- DOD-VA Extremity Trauma and Amputation Center of Excellence, Falls Church, Virginia.,Veterans Affairs Puget Sound Health Care System, Seattle, Washington.,Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Danielle McPherson
- Naval Medical Center San Diego, San Diego, California.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland
| | - Brittney Mazzone
- DOD-VA Extremity Trauma and Amputation Center of Excellence, Falls Church, Virginia.,Naval Medical Center San Diego, San Diego, California
| | - Rachel Condon
- Naval Medical Center San Diego, San Diego, California
| | | | | | | | | | - M Jason Highsmith
- US Department of Veterans Affairs, Tampa, Florida.,University of South Florida, Tampa, Florida
| | - Brad D Hendershot
- DOD-VA Extremity Trauma and Amputation Center of Excellence, Falls Church, Virginia.,Walter Reed National Military Medical Center, Bethesda, Maryland.,Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Jason Maikos
- US Department of Veterans Affairs New York Harbor Healthcare System, New York, New York, USA
| | - Christopher L Dearth
- DOD-VA Extremity Trauma and Amputation Center of Excellence, Falls Church, Virginia.,Walter Reed National Military Medical Center, Bethesda, Maryland.,Uniformed Services University of the Health Sciences, Bethesda, Maryland
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Wasser JG, Acasio JC, Hendershot BD, Miller RH. Single-leg forward hopping exposures adversely affect knee joint health among persons with unilateral lower limb loss: A predictive model. J Biomech 2020; 109:109941. [PMID: 32807307 DOI: 10.1016/j.jbiomech.2020.109941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 06/08/2020] [Accepted: 07/02/2020] [Indexed: 11/16/2022]
Abstract
Single-leg hopping is an atypical, yet convenient, method of ambulation for individuals who have sustained unilateral lower limb-loss. Hopping is generally discouraged by therapists but many patients report hopping, and the potential deleterious effects of frequent hopping on knee joint health remains unclear. Mechanical fatigue due to repeated exposures to increased or abnormal loading on the intact limb is thought to be a primary contributor to the high prevalence of knee osteoarthritis among individuals with unilateral lower limb amputation. We aimed to compare knee joint mechanics between single-leg hopping and walking at self-selected paces among individuals with unilateral lower limb-loss, and estimated the associated probability of knee cartilage failure. Thirty-two males with traumatic unilateral lower limb-loss (22 transtibial, 10 transfemoral) hopped and walked at a self-selected pace along a 15-m walkway. Peak knee moments were input to a phenomenological model of cartilage fatigue to estimate the damage and long-term failure probability of the medial knee cartilage when hopping vs. walking. We estimate that each hop accumulates as much damage as at least 8 strides of walking (p < 0.001), and each meter of hopping accumulates as much damage as at least 12 m of walking (p < 0.001). The 30-year failure probability of the medial knee cartilage exceeded a "coin-flip" chance (50%) when performing more than 197 hops per day. Although a convenient mode of ambulation for persons with unilateral lower limb-loss, to mitigate risk for knee osteoarthritis it is advisable to minimize exposure to single-leg forward hopping.
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Affiliation(s)
- Joseph G Wasser
- Research and Development Section, Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, MD, USA; Henry M. Jackson Foundation, for the Advancement of Military Medicine, Bethesda, MD, USA
| | - Julian C Acasio
- Research and Development Section, Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, MD, USA; Henry M. Jackson Foundation, for the Advancement of Military Medicine, Bethesda, MD, USA
| | - Brad D Hendershot
- Research and Development Section, Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, MD, USA; DoD-VA Extremity Trauma & Amputation Center of Excellence, USA; Department of Rehabilitation Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Ross H Miller
- Department of Kinesiology, University of Maryland, College Park, MD, USA; Neuroscience & Cognitive Science Program, University of Maryland, College Park, MD, USA.
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Mahon CE, Darter BJ, Dearth CL, Hendershot BD. The Relationship Between Gait Symmetry and Metabolic Demand in Individuals With Unilateral Transfemoral Amputation: A Preliminary Study. Mil Med 2020; 184:e281-e287. [PMID: 30690459 DOI: 10.1093/milmed/usy424] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Revised: 11/13/2018] [Accepted: 12/10/2018] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION Temporal-spatial symmetry allows for optimal metabolic economy in unimpaired human gait. The gait of individuals with unilateral transfemoral amputation is characterized by temporal-spatial asymmetries and greater metabolic energy expenditure. The objective of this study was to determine whether temporal-spatial asymmetries account for greater metabolic energy expenditure in individuals with unilateral transfemoral amputation. MATERIALS AND METHODS The relationship between temporal-spatial gait asymmetry and metabolic economy (metabolic power normalized by walking speed) was retrospectively examined in eighteen individuals with transfemoral amputation walking at a self-selected velocity overground. Pearson's product-moment correlations were used to assess the relationship between: (1) step time symmetry and metabolic economy and (2) step length symmetry and metabolic economy. The retrospective analysis of this data was approved by the Walter Reed National Military Medical Center Institutional Review Board and all individuals provided written consent. Additional insights on this relationship are presented through a case series describing the temporal-spatial and metabolic responses of two individuals with transfemoral amputation who completed a split-belt treadmill walking test. RESULTS For the cohort of individuals, there was no significant relationship between metabolic economy and either step time asymmetry or step length asymmetry. However, the case series showed a positive relationship between step length asymmetry and metabolic power as participants adapted to split-belt treadmill walking. CONCLUSION There is mixed evidence for the relationship between temporal-spatial asymmetries and metabolic energy expenditure. This preliminary study may suggest optimal metabolic energy expenditure in individuals with transfemoral amputation occurs at an individualized level of symmetry and resultant deviations incur a metabolic penalty. The results of this study support the idea that addressing only temporal-spatial gait asymmetries in individuals with transfemoral amputation through rehabilitation may not improve metabolic economy. Nevertheless, future prospective research is necessary to confirm these results and implications for clinical practice.
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Affiliation(s)
- Caitlin E Mahon
- DoD-VA Extremity Trauma and Amputation Center of Excellence, 8901 Wisconsin Ave. NW, Bethesda, MD.,Department of Rehabilitation, Walter Reed National Military Medical Center, 8901 Wisconsin Ave. NW, Bethesda, MD
| | - Benjamin J Darter
- Department of Physical Therapy, Virginia Commonwealth University, 1200 E. Broad St., Box 980224, Richmond, VA.,Department of Physical Medicine & Rehabilitation, Hunter Holmes McGuire VA Medical Center, 1201 Broad Rock Blvd., Richmond, VA
| | - Christopher L Dearth
- DoD-VA Extremity Trauma and Amputation Center of Excellence, 8901 Wisconsin Ave. NW, Bethesda, MD.,Department of Rehabilitation, Walter Reed National Military Medical Center, 8901 Wisconsin Ave. NW, Bethesda, MD.,Department of Surgery, Uniformed Services University of the Health Sciences & Walter Reed National Military Medical Center, Bethesda, MD
| | - Brad D Hendershot
- DoD-VA Extremity Trauma and Amputation Center of Excellence, 8901 Wisconsin Ave. NW, Bethesda, MD.,Department of Rehabilitation, Walter Reed National Military Medical Center, 8901 Wisconsin Ave. NW, Bethesda, MD.,Department of Rehabilitation Medicine, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Rd, Bethesda, MD
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Hendershot BD, Bazrgari B. Evolution of Fatigue Damage in the L5-S1 Intervertebral Disc Resulting from Walking Exposures Among Persons with Lower Limb Loss. Ann Biomed Eng 2020; 48:1678-1682. [PMID: 32112343 DOI: 10.1007/s10439-020-02481-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Accepted: 02/19/2020] [Indexed: 10/24/2022]
Abstract
The risk of fatigue damage within the L5-S1 spinal disc was calculated for a sample of 52 individuals with unilateral limb loss (26 transtibial; 26 transfemoral) and 26 uninjured controls using a non-linear multi-axial fatigue model of the spine motion segments. Time to complete damage was calculated for each participant and walking pace; the influences of walking activity were determined by varying daily step counts. Assuming similar activity across groups (10,000 steps per day), times to failure were not different between persons with and without limb loss (50 [23] vs. 46 [24] years, respectively); walking faster was associated with shorter times to failure. Greater daily step counts similarly decreased time to failure in all groups. While such a similarity in fatigue damage evolution does not necessarily downplay the role of biomechanical factors, it may highlight the important influences of psychosocial factors in the development of low back pain in persons with limb loss. Nevertheless, with additional work to include activities beyond walking, computational damage models can provide a predictive platform for evaluating specific clinical interventions (e.g., behavior modification, movement retraining, prosthetic devices) that are ultimately intended to mitigate physical risk factors for low back pain following limb loss.
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Affiliation(s)
- Brad D Hendershot
- DoD-VA Extremity Trauma and Amputation Center of Excellence, Bethesda, MD, 20889, USA. .,Walter Reed National Military Medical Center, 4954 N. Palmer Road, America Building (19), Room B320, Bethesda, MD, 20889, USA. .,Department of Rehabilitation Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, 20889, USA.
| | - Babak Bazrgari
- F. Joseph Halcomb III, M.D. Department of Biomedical Engineering, University of Kentucky, 514E Robotic and Manufacturing Building, Lexington, KY, 40506, USA.
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Schnall BL, Dearth CL, Elrod JM, Golyski PR, Koehler-McNicholas SR, Ray SF, Hansen AH, Hendershot BD. A more compliant prosthetic foot better accommodates added load while walking among Servicemembers with transtibial limb loss. J Biomech 2020; 98:109395. [PMID: 31668413 DOI: 10.1016/j.jbiomech.2019.109395] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Revised: 10/03/2019] [Accepted: 10/06/2019] [Indexed: 11/16/2022]
Abstract
Selecting an optimal prosthetic foot is particularly challenging for highly active individuals with limb loss, such as military personnel, who need to seamlessly perform a variety of demanding activities/tasks (often with and without external loads) while minimizing risk of musculoskeletal injuries over the longer term. Here, we expand on prior work by comparing biomechanical and functional outcomes in two prosthetic feet with the largest differences in mechanical response to added load (i.e., consistently "Compliant" and "Stiff" forefoot properties). In each foot, fourteen male Servicemembers with unilateral transtibial limb loss (from trauma) completed instrumented gait analyses in all combinations of two loading conditions (with and without 22 kg weighted vest) and two walking speeds (1.34 and 1.52 m/s), as well as the Prosthesis Evaluation Questionnaire. With the Stiff foot, sound limb peak loading was 2% smaller (p = 0.043) in the loaded versus unloaded condition, but similar between loading conditions in the Compliant foot (note, the Stiff foot was associated with larger loads, overall). Independent of load or walking speed, the Compliant (versus Stiff) foot provided 67.9% larger (p < 0.001) prosthetic push-off, 17.7% larger (p = 0.01) roll-over shape radii, and was subjectively favored by 10 participants. A more Compliant versus Stiff prosthetic foot therefore appears to better accommodate walking with and without added load, and reinforce the notion that mechanical properties of prosthetic feet should be considered for near-term performance and longer-term (joint) health.
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Affiliation(s)
- Barri L Schnall
- Research & Development Section, Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Christopher L Dearth
- Research & Development Section, Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, MD, USA; DoD-VA Extremity Trauma and Amputation Center of Excellence, Bethesda, MD, USA; Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Jonathan M Elrod
- Research & Development Section, Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Pawel R Golyski
- Research & Development Section, Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Sara R Koehler-McNicholas
- Minneapolis Department of Veterans Affairs Health Care System, Minneapolis, MN, USA; Division of Rehabilitation Science, Department of Rehabilitation Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Samuel F Ray
- Research & Development Section, Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Andrew H Hansen
- Minneapolis Department of Veterans Affairs Health Care System, Minneapolis, MN, USA; Division of Rehabilitation Science, Department of Rehabilitation Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Brad D Hendershot
- Research & Development Section, Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, MD, USA; DoD-VA Extremity Trauma and Amputation Center of Excellence, Bethesda, MD, USA; Department of Rehabilitation Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA.
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Butowicz CM, Krupenevich RL, Acasio JC, Dearth CL, Hendershot BD. Relationships between mediolateral trunk-pelvic motion, hip strength, and knee joint moments during gait among persons with lower limb amputation. Clin Biomech (Bristol, Avon) 2020; 71:160-166. [PMID: 31765911 DOI: 10.1016/j.clinbiomech.2019.11.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Revised: 07/24/2019] [Accepted: 11/12/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Repeated exposures to larger lateral trunk-pelvic motion and features of knee joint loading likely influence the onset of low back pain and knee osteoarthritis among persons with lower-limb amputation. Decreased hip abductor strength can also influence frontal plane trunk-pelvic motion and knee moments; however, it is unclear how these are inter-related post-amputation. METHODS Twenty-four participants with unilateral lower-limb amputation (14 transtibial; 10 transfemoral) and eight uninjured controls walked at 1.3 m/s while full-body biomechanical data were captured. Multiple linear regression and Cohen's f2 predicted (P < 0.05) the influences of mediolateral trunk and pelvic ranges of motion and angular accelerations, and bilateral isometric hip abductor strength on peak (intact) knee adduction moment and loading rate. FINDINGS There were no group differences in hip strength, peak knee adduction moment or pelvis acceleration (p > 0.06). The combination of hip strength, and mediolateral trunk and pelvic motion did not predict (F(5,29) = 2.53, p = 0.06, adjusted R2 = 0.27, f2 = 0.08) peak knee adduction moment. However, the combination of hip strength and trunk and pelvis acceleration predicted knee adduction moment loading rate (F(7,29) = 3.59, p = 0.008, adjusted R2 = 0.45, f2 = 0.25), with peak trunk acceleration (β = 0.72, p = 0.008) and intact hip strength (β = 0.78, p = 0.008) significantly contributing to the model. INTERPRETATION These data suggest increased hip abductor strength counteracts increased lateral trunk acceleration, concomitantly influencing the rate at which the ground reaction force vector loads the intact knee joint. Persons with lower-limb amputation perhaps compensate for increased intact limb loading by increasing trunk motion, thereby increasing demand on hip abductors to attenuate this preferential loading.
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Affiliation(s)
- Courtney M Butowicz
- Research and Development Section, Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Rebecca L Krupenevich
- Research and Development Section, Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, MD, USA; Department of Kinesiology, University of Maryland, College Park, MD, USA
| | - Julian C Acasio
- Research and Development Section, Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Christopher L Dearth
- Research and Development Section, Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, MD, USA; DoD-VA Extremity Trauma & Amputation Center of Excellence, USA; Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Brad D Hendershot
- Research and Development Section, Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, MD, USA; DoD-VA Extremity Trauma & Amputation Center of Excellence, USA; Department of Rehabilitation Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA.
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Yoder AJ, Silder A, Farrokhi S, Dearth CL, Hendershot BD. Author Correction: Lower Extremity Joint Contributions to Trunk Control During Walking in Persons with Transtibial Amputation. Sci Rep 2019; 9:16999. [PMID: 31719619 PMCID: PMC6851077 DOI: 10.1038/s41598-019-53340-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
- Adam J Yoder
- DoD-VA Extremity Trauma and Amputation Center of Excellence, Various locations, USA. .,Department of Physical & Occupational Therapy, Naval Medical Center, San Diego, CA, USA.
| | - Amy Silder
- DoD-VA Extremity Trauma and Amputation Center of Excellence, Various locations, USA.,Department of Physical & Occupational Therapy, Naval Medical Center, San Diego, CA, USA
| | - Shawn Farrokhi
- DoD-VA Extremity Trauma and Amputation Center of Excellence, Various locations, USA.,Department of Physical & Occupational Therapy, Naval Medical Center, San Diego, CA, USA
| | - Christopher L Dearth
- DoD-VA Extremity Trauma and Amputation Center of Excellence, Various locations, USA.,Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, MD, USA.,Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Brad D Hendershot
- DoD-VA Extremity Trauma and Amputation Center of Excellence, Various locations, USA.,Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, MD, USA.,Department of Rehabilitation Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
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Butowicz CM, Silfies SP, Vendemia J, Farrokhi S, Hendershot BD. Characterizing and Understanding the Low Back Pain Experience Among Persons with Lower Limb Loss. Pain Medicine 2019; 21:1068-1077. [DOI: 10.1093/pm/pnz293] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Abstract
Objective
This study preliminarily characterizes and compares the impact of lower limb loss and development of chronic low back pain (cLBP) on psychosocial factors, as well as the relationship between these factors and low back pain–related functional disability.
Design
Cross-sectional study.
Methods
Participants were adults, active duty or retired military, with traumatic lower limb loss with and without chronic low back pain. Psychosocial factors and low back pain–related functional disability were measured using common clinical self-report questionnaires. The presence of psychosocial factors was compared between those with and without cLBP using multivariate analysis of covariance (P < 0.05), and correlations determined relationships between psychosocial factors and cLBP-related functional disability.
Results
There were no statistically significant differences among psychosocial factors between those with vs without cLBP (F(4, 13) = 0.81, P = 0.54, η2= 0.19). Employment status (ρ = 0.43, P = 0.02), anxiety (ρ = 0.45, P = 0.04), and kinesiophobia (ρ = 0.47, P = 0.04) were moderately associated with low back pain–related disability.
Conclusions
Psychological (i.e., anxiety) and social (i.e., employment status) factors may influence how persons with traumatic lower limb loss respond to self-reported measures of low back pain–related disability. The findings suggest that the Modified Oswestry Disability Index identifies cLBP-related functional disability in the context of lower limb loss. These results support the interdependence among biological, psychological, and social factors, which should be collectively considered during the development of rehabilitative strategies to treat secondary musculoskeletal conditions within this population.
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Affiliation(s)
- Courtney M Butowicz
- Research and Development Section, Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, Maryland
- Henry M. Jackson Foundation, for the Advancement of Military Medicine, Bethesda, Maryland
- Departments of Exercise Science
| | | | | | - Shawn Farrokhi
- DoD-VA Extremity Trauma and Amputation Center of Excellence, Bethesda, Maryland
- Naval Medical Center San Diego, San Diego, California
| | - Brad D Hendershot
- Research and Development Section, Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, Maryland
- DoD-VA Extremity Trauma and Amputation Center of Excellence, Bethesda, Maryland
- Department of Rehabilitation Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
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Acasio JC, Shojaei I, Banerjee R, Dearth CL, Bazrgari B, Hendershot BD. Trunk-Pelvis motions and spinal loads during upslope and downslope walking among persons with transfemoral amputation. J Biomech 2019; 95:109316. [PMID: 31471112 DOI: 10.1016/j.jbiomech.2019.109316] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 07/28/2019] [Accepted: 08/14/2019] [Indexed: 11/27/2022]
Abstract
Larger trunk and pelvic motions in persons with (vs. without) lower limb amputation during activities of daily living (ADLs) adversely affect the mechanical demands on the lower back. Building on evidence that such altered motions result in larger spinal loads during level-ground walking, here we characterize trunk-pelvic motions, trunk muscle forces, and resultant spinal loads among sixteen males with unilateral, transfemoral amputation (TFA) walking at a self-selected speed both up ("upslope"; 1.06 ± 0.14 m/s) and down ("downslope"; 0.98 ± 0.20 m/s) a 10-degree ramp. Tri-planar trunk and pelvic motions were obtained (and ranges-of-motion [ROM] computed) as inputs for a non-linear finite element model of the spine to estimate global and local muscle (i.e., trunk movers and stabilizers, respectively) forces, and resultant spinal loads. Sagittal- (p = 0.001), frontal- (p = 0.004), and transverse-plane (p < 0.001) trunk ROM, and peak mediolateral shear (p = 0.011) and local muscle forces (p = 0.010) were larger (respectively 45, 35, 98, 70, and 11%) in upslope vs. downslope walking. Peak anteroposterior shear (p = 0.33), compression (p = 0.28), and global muscle (p = 0.35) forces were similar between inclinations. Compared to previous reports of persons with TFA walking on level ground, 5-60% larger anteroposterior and mediolateral shear observed here (despite ∼0.25 m/s slower walking speeds) suggest greater mechanical demands on the low back in sloped walking, particularly upslope. Continued characterization of trunk motions and spinal loads during ADLs support the notion that repeated exposures to these larger-than-normal (i.e., vs. level-ground walking in TFA and uninjured cohorts) spinal loads contribute to an increased risk for low back injury following lower limb amputation.
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Affiliation(s)
- Julian C Acasio
- Research and Development Section, Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, MD, USA; Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD, USA
| | - Iman Shojaei
- F. Joseph Halcomb III, M.D. Department of Biomedical Engineering, University of Kentucky, Lexington, KY, USA
| | - Rajit Banerjee
- University of Toledo College of Medicine and Life Sciences, Toledo, OH, USA
| | - Christopher L Dearth
- Research and Development Section, Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, MD, USA; DoD-VA Extremity Trauma & Amputation Center of Excellence, USA; Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Babak Bazrgari
- F. Joseph Halcomb III, M.D. Department of Biomedical Engineering, University of Kentucky, Lexington, KY, USA
| | - Brad D Hendershot
- Research and Development Section, Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, MD, USA; DoD-VA Extremity Trauma & Amputation Center of Excellence, USA; Department of Rehabilitation Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA.
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Yoder AJ, Silder A, Farrokhi S, Dearth CL, Hendershot BD. Lower Extremity Joint Contributions to Trunk Control During Walking in Persons with Transtibial Amputation. Sci Rep 2019; 9:12267. [PMID: 31439891 PMCID: PMC6706581 DOI: 10.1038/s41598-019-47796-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Accepted: 07/12/2019] [Indexed: 11/30/2022] Open
Abstract
Controlled trunk motion is crucial for balance and stability during walking. Persons with lower extremity amputation often exhibit abnormal trunk motion, yet underlying mechanisms are not well understood nor have optimal clinical interventions been established. The aim of this work was to characterize associations between altered lower extremity joint moments and altered trunk dynamics in persons with unilateral, transtibial amputation (TTA). Full-body gait data were collected from 10 persons with TTA and 10 uninjured persons walking overground (~1.4 m/s). Experimentally-measured trunk angular accelerations were decomposed into constituent accelerations caused by net joint moments throughout the body using an induced acceleration analysis. Results showed persons with TTA had similar ankle moment magnitude relative to uninjured persons (P > 0.05), but greater trunk angular acceleration induced by the prosthetic ankle which acted to lean the trunk ipsilaterally (P = 0.003). Additionally, persons with TTA had a reduced knee extensor moment relative to uninjured persons (P < 0.001), resulting in lesser sagittal and frontal induced trunk angular accelerations (P < 0.001). These data indicate kinetic compensations at joints other than the lumbar and hip contribute to altered trunk dynamics in persons with a unilateral TTA. Findings may inform development of new clinical strategies to modify problematic trunk motion.
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Affiliation(s)
- Adam J Yoder
- DoD-VA Extremity Trauma and Amputation Center of Excellence, Various locations, USA. .,Department of Physical & Occupational Therapy, Naval Medical Center, San Diego, CA, USA.
| | - Amy Silder
- DoD-VA Extremity Trauma and Amputation Center of Excellence, Various locations, USA.,Department of Physical & Occupational Therapy, Naval Medical Center, San Diego, CA, USA
| | - Shawn Farrokhi
- DoD-VA Extremity Trauma and Amputation Center of Excellence, Various locations, USA.,Department of Physical & Occupational Therapy, Naval Medical Center, San Diego, CA, USA
| | - Christopher L Dearth
- DoD-VA Extremity Trauma and Amputation Center of Excellence, Various locations, USA.,Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, MD, USA.,Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Brad D Hendershot
- DoD-VA Extremity Trauma and Amputation Center of Excellence, Various locations, USA.,Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, MD, USA.,Department of Rehabilitation Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
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Highsmith MJ, Goff LM, Lewandowski AL, Farrokhi S, Hendershot BD, Hill OT, Rábago CA, Russell-Esposito E, Orriola JJ, Mayer JM. Low back pain in persons with lower extremity amputation: a systematic review of the literature. Spine J 2019; 19:552-563. [PMID: 30149083 DOI: 10.1016/j.spinee.2018.08.011] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Revised: 08/14/2018] [Accepted: 08/20/2018] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Lower extremity amputation (LEA) is associated with an elevated risk for development and progression of secondary health conditions. Low back pain (LBP) is one such condition adversely affecting function, independence, and quality of life. PURPOSE The purpose of this study was to systematically review the literature to determine the strength of evidence relating the presence and severity of LBP secondary to LEA, thereby supporting the formulation of empirical evidence statements (EESs) to guide practice and future research. STUDY DESIGN/SETTING Systematic review of the literature. METHODS A systematic review of five databases was conducted followed by evaluation of evidence and synthesis of EESs. RESULTS Seventeen manuscripts were included. From these, eight EESs were synthesized within the following categories: epidemiology, amputation level, function, disability, leg length, posture, spinal kinematics, and osseointegrated prostheses. Only the EES on epidemiology was supported by evidence at the moderate confidence level given support by eight moderate quality studies. The four EESs for amputation level, leg length, posture, and spinal kinematics were supported by evidence at the low confidence level given that each of these statements had some evidence not supporting the statement but ultimately more evidence (and of higher quality) currently supporting the statement. The remaining three EESs that addressed function, disability and osseointegrated prosthetic use were all supported by single studies or had comparable evidence that disagreed with study findings rendering insufficient evidence to support the respective EES. CONCLUSIONS Based on the state of the current evidence, appropriate preventative and, particularly, treatment strategies to manage LBP in persons with LEA remain a knowledge gap and an area of future study.
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Affiliation(s)
- M Jason Highsmith
- Extremity Trauma & Amputation Center of Excellence (EACE), US Department of Veterans' Affairs, US Department of Defense, 13000 Bruce B. Downs Blvd., Tampa, FL, 33612, USA; School of Physical Therapy & Rehabilitation Sciences, Morsani College of Medicine, University of South Florida, 3515 E. Fletcher Ave. Tampa, FL, 33612, USA; 319th Minimal Care Detachment, U.S. Army Reserves, Pinellas Park, 2801 Grand Ave. Pinellas Park, FL, USA, 33782.
| | - Lisa M Goff
- Center of Innovation on Disability & Rehabilitation Research, James A. Haley Veterans' Administration Hospital, 8900 Grand Oak Ci, Tampa, FL, 33637, USA
| | | | - Shawn Farrokhi
- Extremity Trauma & Amputation Center of Excellence (EACE), US Department of Veterans' Affairs, US Department of Defense, 34800 Bob Wilson Dr. San Diego, CA, 92134, USA; The Department of Physical and Occupational Therapy, Naval Medical Center San Diego, San Diego, 34800 Bob Wilson Dr. San Diego, CA, 92134, USA
| | - Brad D Hendershot
- Extremity Trauma & Amputation Center of Excellence (EACE), US Department of Veterans' Affairs, US Department of Defense, Bethesda, 4494 North Palmer Rd, Bethesda, MD, 20889, USA; Department of Rehabilitation, Research and Development Section, Walter Reed National Military Medical Center, Bethesda, 4494 North Palmer Rd, Bethesda, MD, 20889, USA
| | - Owen T Hill
- Extremity Trauma & Amputation Center of Excellence (EACE), US Department of Veterans' Affairs, US Department of Defense, Ft. Sam Houston, 3851 Roger Brooke Dr, San Antonio, TX, 78234, USA
| | - Christopher A Rábago
- Extremity Trauma & Amputation Center of Excellence (EACE), US Department of Veterans' Affairs, US Department of Defense, Ft. Sam Houston, 3851 Roger Brooke Dr, San Antonio, TX, 78234, USA; Center for the Intrepid, Department of Rehabilitation Medicine, Brooke Army Medical Center, JBSA, Ft. Sam Houston, 3851 Roger Brooke Dr, San Antonio, TX, 78234, USA
| | - Elizabeth Russell-Esposito
- Extremity Trauma & Amputation Center of Excellence (EACE), US Department of Veterans' Affairs, US Department of Defense, Ft. Sam Houston, 3851 Roger Brooke Dr, San Antonio, TX, 78234, USA; Center for the Intrepid, Department of Rehabilitation Medicine, Brooke Army Medical Center, JBSA, Ft. Sam Houston, 3851 Roger Brooke Dr, San Antonio, TX, 78234, USA
| | - John J Orriola
- Shimberg Health Sciences Library, Morsani College of Medicine, University of South Florida, 12901 Bruce B. Downs Blvd., Tampa, FL, 33612
| | - John M Mayer
- U.S. Spine & Sport Foundation, 3760 Convoy St #101. San Diego, CA, 92111, USA
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Shojaei I, Hendershot BD, Acasio JC, Dearth CL, Ballard M, Bazrgari B. Trunk muscle forces and spinal loads in persons with unilateral transfemoral amputation during sit-to-stand and stand-to-sit activities. Clin Biomech (Bristol, Avon) 2019; 63:95-103. [PMID: 30851567 PMCID: PMC6503321 DOI: 10.1016/j.clinbiomech.2019.02.021] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Revised: 02/13/2019] [Accepted: 02/26/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Alterations and asymmetries in trunk motions during activities of daily living, involving lower extremities, are suggested to cause higher spinal loads in persons with unilateral lower limb amputation. Given the repetitive nature of most activities of daily living, knowledge of the amount of increase in spinal loads is important for designing interventions aimed at prevention of secondary low back pain due to potential fatigue failure of spinal tissues. The objective of this study was to determine differences in trunk muscle forces and spinal loads between persons with and without lower limb amputation when performing sit-to-stand and stand-to-sit tasks. METHODS Kinematics of the pelvis and thorax, obtained from ten males with unilateral transfemoral lower limb amputation and 10 male uninjured controls when performing sit-to-stand and stand-to-sit activities, were used within a non-linear finite element model of the spine to estimate trunk muscle forces and resultant spinal loads. FINDINGS The peak compression force, medio-lateral (only during stand-to-sit), and antero-posterior shear forces were respectively 348 N, 269 N, and 217 N larger in person with vs. without amputation. Persons with amputation also experienced on average 171 N and 53 N larger mean compression force and medio-lateral shear force, respectively. INTERPRETATION While spinal loads were larger in persons with amputation, these loads were generally smaller than the reported threshold for spinal tissue injury. However, a rather small increase in spinal loads during common activities of daily living like walking, sit-to-stand, and stand-to-sit may nevertheless impose a significant risk of fatigue failure for spinal tissues due to the repetitive nature of these activities.
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Affiliation(s)
- Iman Shojaei
- Department of Biomedical Engineering, F. Joseph Halcomb III, M.D. University of Kentucky, Lexington, KY 40506, USA
| | - Brad D. Hendershot
- DoD-VA Extremity Trauma and Amputation Center of Excellence, Bethesda, MD, USA,Department of Rehabilitation, Research and Development Section, Walter Reed National Military Medical Center, Bethesda, MD, USA,Department of Rehabilitation Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Julian C. Acasio
- Department of Rehabilitation, Research and Development Section, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Christopher L. Dearth
- DoD-VA Extremity Trauma and Amputation Center of Excellence, Bethesda, MD, USA,Department of Rehabilitation, Research and Development Section, Walter Reed National Military Medical Center, Bethesda, MD, USA,Department of Rehabilitation Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Matthew Ballard
- Department of Biomedical Engineering, F. Joseph Halcomb III, M.D. University of Kentucky, Lexington, KY 40506, USA
| | - Babak Bazrgari
- Department of Biomedical Engineering, F. Joseph Halcomb III, M.D. University of Kentucky, Lexington, KY 40506, USA
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Pruziner AL, Shaw EP, Rietschel JC, Hendershot BD, Miller MW, Wolf EJ, Hatfield BD, Dearth CL, Gentili RJ. Biomechanical and neurocognitive performance outcomes of walking with transtibial limb loss while challenged by a concurrent task. Exp Brain Res 2018; 237:477-491. [PMID: 30460393 DOI: 10.1007/s00221-018-5419-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Accepted: 10/26/2018] [Indexed: 01/19/2023]
Abstract
Individuals who have sustained loss of a lower limb may require adaptations in sensorimotor and control systems to effectively utilize a prosthesis, and the interaction of these systems during walking is not clearly understood for this patient population. The aim of this study was to concurrently evaluate temporospatial gait mechanics and cortical dynamics in a population with and without unilateral transtibial limb loss (TT). Utilizing motion capture and electroencephalography, these outcomes were simultaneously collected while participants with and without TT completed a concurrent task of varying difficulty (low- and high-demand) while seated and walking. All participants demonstrated a wider base of support and more stable gait pattern when walking and completing the high-demand concurrent task. The cortical dynamics were similarly modulated by the task demand for both groups, to include a decrease in the novelty-P3 component and increase in the frontal theta/parietal alpha ratio power when completing the high-demand task, although specific differences were also observed. These findings confirm and extend prior efforts indicating that dual-task walking can negatively affect walking mechanics and/or neurocognitive performance. However, there may be limited additional cognitive and/or biomechanical impact of utilizing a prosthesis in a stable, protected environment in TT who have acclimated to ambulating with a prosthesis. These results highlight the need for future work to evaluate interactions between these cognitive-motor control systems for individuals with more proximal levels of lower limb loss, and in more challenging (ecologically valid) environments.
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Affiliation(s)
- Alison L Pruziner
- DoD-VA Extremity Trauma and Amputation Center of Excellence, Bethesda, MD, USA. .,Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, MD, USA. .,Department of Rehabilitation Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA.
| | - Emma P Shaw
- Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, MD, USA.,Department of Kinesiology, School of Public Health, University of Maryland, College Park, MD, USA.,Neuroscience and Cognitive Science Program, University of Maryland, College Park, MD, USA
| | - Jeremy C Rietschel
- Department of Kinesiology, School of Public Health, University of Maryland, College Park, MD, USA.,Baltimore Veterans Administration Medical Center, Baltimore, MD, USA
| | - Brad D Hendershot
- DoD-VA Extremity Trauma and Amputation Center of Excellence, Bethesda, MD, USA.,Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, MD, USA.,Department of Rehabilitation Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Matthew W Miller
- Center for Neuroscience, School of Kinesiology, Auburn University, Auburn, AL, USA
| | - Erik J Wolf
- DoD-VA Extremity Trauma and Amputation Center of Excellence, Bethesda, MD, USA.,Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, MD, USA.,Department of Rehabilitation Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Bradley D Hatfield
- Department of Kinesiology, School of Public Health, University of Maryland, College Park, MD, USA.,Neuroscience and Cognitive Science Program, University of Maryland, College Park, MD, USA
| | - Christopher L Dearth
- DoD-VA Extremity Trauma and Amputation Center of Excellence, Bethesda, MD, USA.,Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, MD, USA.,Department of Rehabilitation Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA.,Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Rodolphe J Gentili
- Department of Kinesiology, School of Public Health, University of Maryland, College Park, MD, USA.,Neuroscience and Cognitive Science Program, University of Maryland, College Park, MD, USA.,Maryland Robotics Center, University of Maryland, College Park, MD, USA
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50
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Koehler-McNicholas SR, Nickel EA, Barrons K, Blaharski KE, Dellamano CA, Ray SF, Schnall BL, Hendershot BD, Hansen AH. Mechanical and dynamic characterization of prosthetic feet for high activity users during weighted and unweighted walking. PLoS One 2018; 13:e0202884. [PMID: 30208040 PMCID: PMC6135372 DOI: 10.1371/journal.pone.0202884] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Accepted: 08/12/2018] [Indexed: 11/19/2022] Open
Abstract
Many Service members and Veterans with lower-limb amputations have the potential for high function and the desire to resume physically demanding occupations that require them to carry heavy loads (e.g., military service, firefighters, farmers, ranchers, construction workers). However, it is currently unclear which prosthetic feet best accommodate heavy load carriage while also providing good overall function and mobility during unweighted activities. The main objective of this study was to investigate the ability of currently available prosthetic ankle-foot systems to accommodate weighted walking by examining the mechanical characteristics (i.e., forefoot stiffness) and dynamic function (i.e., rocker radius, effective foot length ratio, and late-stance energy return) of prosthetic feet designed for high activity users. Load versus deflection curves were obtained for nine prosthetic ankle-foot systems using a servohydraulic test frame and load cell. Effective roll-over shape characteristics and late-stance energy return measures were then obtained using quantitative gait analysis for three users with unilateral, transtibial amputation. Results from mechanical and dynamic testing showed that although forefoot stiffness varied across the nine feet investigated in this study, changes measured in roll-over shape radius and effective foot length ratio were relatively small in response to weighted walking. At the same time, prosthetic feet with more compliant forefoot keel structures appeared to provide more late-stance energy return compared to feet with stiffer forefoot keel structures. These results suggest that prosthetic ankle-foot systems with compliant forefoot keel structures may better accommodate weighted walking by reducing the metabolic cost of physically demanding activities. However, to more fully understand the biomechanical and functional implications of these results, other factors, such as the residual-limb strength of the user and the overall stiffness profile of the prosthetic foot, should also be considered.
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Affiliation(s)
- Sara R. Koehler-McNicholas
- Minneapolis Department of Veterans Affairs Health Care System, Minneapolis, Minnesota, United States of America
- * E-mail:
| | - Eric A. Nickel
- Minneapolis Department of Veterans Affairs Health Care System, Minneapolis, Minnesota, United States of America
| | - Kyle Barrons
- Minneapolis Department of Veterans Affairs Health Care System, Minneapolis, Minnesota, United States of America
| | - Kathryn E. Blaharski
- Minneapolis Department of Veterans Affairs Health Care System, Minneapolis, Minnesota, United States of America
| | - Clifford A. Dellamano
- Minneapolis Department of Veterans Affairs Health Care System, Minneapolis, Minnesota, United States of America
- Department of Biomedical Engineering, College of Engineering, University of Minnesota, Minneapolis, Minnesota, United States of America
| | - Samuel F. Ray
- Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, Maryland, United States of America
| | - Barri L. Schnall
- Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, Maryland, United States of America
| | - Brad D. Hendershot
- Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, Maryland, United States of America
- Department of Defense-Veterans Affairs Extremity Trauma and Amputation Center of Excellence, Bethesda, Maryland, United States of America
- Department of Rehabilitation Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, United States of America
| | - Andrew H. Hansen
- Minneapolis Department of Veterans Affairs Health Care System, Minneapolis, Minnesota, United States of America
- Program in Rehabilitation Science, Department of Rehabilitation Medicine, University of Minnesota, Minneapolis, Minnesota, United States of America
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