Frequency, severity, and implications of shoulder pain in people with major upper limb amputation who use prostheses: Results of a National Study

BACKGROUND

People with upper limb amputation are potentially at increased risk of shoulder pain because they often perform compensatory movements to operate their prostheses and rely more heavily on their nonamputated limb for everyday activities.

OBJECTIVE

To describe the frequency, severity, associated factors, and implications of shoulder pain in people with unilateral major upper limb amputation who use prostheses.

DESIGN

Cross-sectional, observational design.

SETTING

National recruitment of people living in the community.

PARTICIPANTS

U.S. veterans and civilians (N = 107) with unilateral major upper limb amputation.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Shoulder pain (any, ipsilateral and contralateral to amputation), activity performance (Activities Measure for Upper Limb Amputation), health-related quality of life (Veterans RAND 12-Item Health Survey mental component summary [MCS] and physical component summary [PCS]), and disability (Quick Version of the Disabilities of the Arm, Shoulder and Hand Score [QuickDASH]).

RESULTS

All participants completed a comprehensive in-person assessment. Participants were 97% male with a mean age of 57.1 years and a mean time since amputation of 23.4 years. The prevalence of any shoulder pain was 30% (15% ipsilateral, 25% contralateral, 10% bilateral). Shoulder pain intensity (0 to 10 scale) was moderate for both ipsilateral (mean 4.9, SD 2.0) and contralateral (mean 4.2, SD 2.0) pain. No significant difference in shoulder pain frequency was observed by amputation level. The prevalence of any shoulder pain was greater in those using a body-powered prosthesis (38% compared to 18% in externally powered users). Each additional year since amputation was associated with an increased likelihood of having contralateral shoulder pain (odds ratio: 1.05, confidence interval: 1.01, 1.10). In linear regression models, those with contralateral shoulder pain had worse PCS (β = -7.07, p = .008) and worse QuickDASH (β = 18.25, p < .001) scores.

CONCLUSIONS

In our sample of predominantly male veterans with major upper limb amputation, shoulder pain was a common condition associated with functional and quality of life implications. Among prosthesis users, the shoulder contralateral to the amputation was at greatest risk, with risk increasing with every year since amputation.

Reintegrating Veterans with Polytrauma into the Community and Workplace

This article addresses employment as a critical part of community reintegration for polytrauma patients. Interdisciplinary polytrauma teams can work to effectively identify and eliminate known barriers to employment for veterans and offer continued support and guidance. This article discusses key themes pertinent to vocational reentry for service members/veterans, identifies evidenced-based employment models, highlights the essential role of everyday technology in meeting support needs, and describes 2 exemplar polytrauma models: the Louis Stokes Cleveland Veteran Affairs Medical Center in Cleveland, Ohio, and the Service member Transitional Advanced Rehabilitation (STAR) program at the Hunter Holmes McGuire Veterans Affairs Medical Center in Richmond, Virginia.

Department of Veterans Affairs Polytrauma Telerehabilitation: Twenty-First Century Care

The use of telehealth for the management of the polytrauma patient provides a unique opportunity to leverage technology to enhance care for a complex patient cohort, to assist in clinical care, and to enhance support for community reintegration for veteran patients. Telehealth connects experts to patients in remote or underserved areas, thereby decreasing a health care disparity. This is especially important when the rehabilitation team is multidisciplinary. The future of telerehabilitation is unknown and implementing virtual care into rehabilitation providers' standard practice will be impeded until state licensure and payment issues are resolved.

Prosthetic fitting, use, and satisfaction following lower-limb amputation: a prospective study

Providing a satisfactory, functional prosthesis following lower-limb amputation is a primary goal of rehabilitation. The objectives of this study were to describe the rate of successful prosthetic fitting over a 12 mo period; describe prosthetic use after amputation; and determine factors associated with greater prosthetic fitting, function, and satisfaction. The study design was a multicenter prospective cohort study of individuals undergoing their first major lower-limb amputation because of vascular disease and/or diabetes. At 4 mo, unsuccessful prosthetic fitting was significantly associated with depression, prior arterial reconstruction, diabetes, and pain in the residual limb. At 12 mo, 92% of all subjects were fit with a prosthetic limb and individuals with transfemoral amputation were significantly less likely to have a prosthesis fit. Age older than 55 yr, diagnosis of a major depressive episode, and history of renal dialysis were associated with fewer hours of prosthetic walking. Subjects who were older, had experienced a major depressive episode, and/or were diagnosed with chronic obstructive pulmonary disease had greater functional restriction. Thus, while most individuals achieve successful prosthetic fitting by 1 yr following a first major nontraumatic lower-limb amputation, a number of medical variables and psychosocial factors are associated with prosthetic fitting, utilization, and function.

Utilization of a lower extremity ambulatory feedback system to reduce gait asymmetry in transtibial amputation gait

The goal of our research is to augment gait rehabilitation for persons with gait asymmetry through a real-time feedback system that can be used independently by patients in the community. Our wireless, wearable, real-time gait asymmetry detection system called the lower extremity ambulatory feedback system (LEAFS) is a low-cost, in-shoe gait detection device that provides real-time auditory feedback based on the stance time symmetry ratio between the right and left limbs. This study evaluated the performance of the LEAFS in three study subjects with gait asymmetry secondary to unilateral transtibial amputation. Study subjects used the LEAFS for six 30-min training sessions under the supervision of a physical therapist. Two subjects demonstrated improved gait symmetry, with one subject reducing trunk sway by 85.5%, and the other subject reducing trunk sway by 16.0% and increasing symmetry ratio toward unity by 26.5%, as measured by a clinical motion analysis lab. The third subject did not demonstrate any objective improvements in gait symmetry or trunk sway. While testing with a larger number of subjects is necessary, this initial study using LEAFS with persons with transtibial amputations suggests that it can assist in improving gait symmetry in this population.

Prosthetic fitting, use, and satisfaction following lower-limb amputation: A prospective study

Providing a satisfactory, functional prosthesis following lower-limb amputation is a primary goal of rehabilitation. The objectives of this study were to describe the rate of successful prosthetic fitting over a 12 mo period; describe prosthetic use after amputation; and determine factors associated with greater prosthetic fitting, function, and satisfaction. The study design was a multicenter prospective cohort study of individuals undergoing their first major lower-limb amputation because of vascular disease and/or diabetes. At 4 mo, unsuccessful prosthetic fitting was significantly associated with depression, prior arterial reconstruction, diabetes, and pain in the residual limb. At 12 mo, 92% of all subjects were fit with a prosthetic limb and individuals with transfemoral amputation were significantly less likely to have a prosthesis fit. Age older than 55 yr, diagnosis of a major depressive episode, and history of renal dialysis were associated with fewer hours of prosthetic walking. Subjects who were older, had experienced a major depressive episode, and/or were diagnosed with chronic obstructive pulmonary disease had greater functional restriction. Thus, while most individuals achieve successful prosthetic fitting by 1 yr following a first major nontraumatic lower-limb amputation, a number of medical variables and psychosocial factors are associated with prosthetic fitting, utilization, and function.

The road to recovery and rehabilitation for injured service members with limb loss: a focus on Iraq and Afghanistan

Amputation of an extremity due to traumatic injury or a vascular occlusive disease is a life-altering event that occurs when limb salvage is not possible. While an amputation is viewed as a life saving procedure clinically, limb deficiency may result in an immediate loss in social, physical and financial well-being for the patient. Military personnel returning from Operation Enduring Freedom and Operation Iraqi Freedom face unique challenges due to short residual limbs, unplanned amputations, high incidences of multiple limb loss, and accustomed activity levels prior to an amputation. The primary rehabilitation goal for these individuals is to provide them with an expedited recovery and progressive reintroduction into the civilian or active duty population. It is the purpose of this review to discuss the most frequent rehabilitation hardships service members endure following combat related trauma and future of prosthetic limb technology.

Bioelectric analyses of an osseointegrated intelligent implant design system for amputees

The projected number of American amputees is expected to rise to 3.6 million by 2050. Many of these individuals depend on artificial limbs to perform routine activities, but prosthetic suspensions using traditional socket technology can prove to be cumbersome and uncomfortable for a person with limb loss. Moreover, for those with high proximal amputations, limited residual limb length may prevent exoprosthesis attachment all together. Osseointegrated implant technology is a novel operative procedure which allows firm skeletal attachment between the host bone and an implant. Preliminary results in European amputees with osseointegrated implants have shown improved clinical outcomes by allowing direct transfer of loads to the bone-implant interface. Despite the apparent advantages of osseointegration over socket technology, the current rehabilitation procedures require long periods of restrictive load bearing prior which may be reduced with expedited skeletal attachment via electrical stimulation. The goal of the osseointegrated intelligent implant design (OIID) system is to make the implant part of an electrical system to accelerate skeletal attachment and help prevent periprosthetic infection. To determine optimal electrode size and placement, we initiated proof of concept with computational modeling of the electric fields and current densities that arise during electrical stimulation of amputee residual limbs. In order to provide insure patient safety, subjects with retrospective computed tomography scans were selected and three dimensional reconstructions were created using customized software programs to ensure anatomical accuracy (Seg3D and SCIRun) in an IRB and HIPAA approved study. These software packages supported the development of patient specific models and allowed for interactive manipulation of electrode position and size. Preliminary results indicate that electric fields and current densities can be generated at the implant interface to achieve the homogenous electric field distributions required to induce osteoblast migration, enhance skeletal fixation and may help prevent periprosthetic infections. Based on the electrode configurations experimented with in the model, an external two band configuration will be advocated in the future.

Sprouty genes are expressed in osteoblasts and inhibit fibroblast growth factor-mediated osteoblast responses

Fibroblast growth factors (FGFs) and fibroblast growth factor receptors (FGFRs) are major regulators of skeletal growth and development. Signal transduction via FGFRs is complex and mediates proliferation, differentiation, or migration depending upon the cellular context. Members of the Spry gene family antagonize the FGFR signal transduction pathway and inhibit lung morphogenesis, angiogenesis, and chondrogenesis. We examined the expression of Spry2 in the osteoblastic MC3T3-E1 cell line. MC3T3-E1 cells express Spry2 in response to FGF1 stimulation. Treatment of MC3T3-E1 cells with FGF1 results in the expression of Spry2 in a manner consistent with an early response gene. Pharmacological inhibitors of mitogen-activated protein kinase activation inhibit FGF1-induced expression of Spry2 mRNA. Transient overexpression of Spry2 in MC3T3-E1 resulted in decreased FGF1-mediated extracellular signal-regulated kinase phosphorylation and FGF1-stimulated osteopontin promoter activity. Furthermore, we show that Spry2 interacts with Raf-1 in a glutathione-S-transferase pulldown assay and that this interaction may involve multiple sites. Finally, Spry2 expression precedes the onset of the expression of osteoblast differentiation markers in an in vitro assay of primary osteoblast differentiation. Taken together, these results indicate that Spry2 expression is an early response to stimulation by FGF1 in MC3T3-E1 cells and acts as a feedback inhibitor of FGF1-induced osteoblast responses, possibly through interaction with Raf1.

Research activities and perspectives of individuals completing a research enrichment program for physiatrists

OBJECTIVE

To investigate the research activity and perspectives, and the predictors and barriers to research activity, in a cohort of individuals completing a research enrichment program for physiatrists.

DESIGN

A retrospective cohort study design was utilized. Data collection was accomplished with a mailed survey, which was sent to 68 individuals who had completed the Research Enrichment Program for Physiatrists between 1991 and 1998. Data analysis was performed using both descriptive and inferential statistical methods.

RESULTS

Eighty-five percent (58 of 68) of surveys were completed and returned. The majority of respondents were in academic-based practice (83%) at the assistant professor level (59%). Sixty-nine percent of the group reported spending no time in research, and 64% reported having no "protected" time for research. The mean number of peer-reviewed journal publications was 2.4, and the average number of research grants was 1.6, with 57% of the cohort reporting no grant funding. Departmental PhD, statistical, and secretarial support for research were all noted to be inadequate or not available for >50% of the cohort. High demand for clinical productivity, lack of protected research time, and lack of research funding were all identified as major barriers to research activity. Cluster analysis found greater research time and support to be associated with measures of research productivity.

CONCLUSION

Long-term research success seems to require ongoing support, funding, and mentorship at the departmental and institutional level. Despite adequate training and motivation for research, research support was perceived as inadequate for many Research Enrichment Program graduates.

Sports and recreation for persons with limb deficiency

Opportunities for persons with limb deficiency to participate in sport and recreational activities have increased dramatically over the past 20 years. Various factors have contributed to this phenomenon, including an increased public interest in sports and fitness as well as improvements in disability awareness. An even more essential element has been a consumer-driven demand for advances in prosthetic technology and design. Whether the activity is a music performance, a friendly round of golf, or a high-level track-and-field competition, the benefits of participation in sports and recreation are numerous both at the individual and at the societal level. This article provides an overview of the development and scope of sport and recreational opportunities available to persons with limb deficiency. In addition, specific prosthetic considerations for several common sport and recreational activities are presented in a case-discussion format.

OVERALL ARTICLE OBJECTIVE

To review the development and scope of sport and recreational opportunities available to persons with limb deficiency.

Acquired limb deficiencies. 3. Prosthetic components, prescriptions, and indications

This self-directed learning module highlights indications for prosthetic components and prescription formulation for adults with acquired limb deficiency. It is part of the chapter on acquired limb deficiencies in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. Advantages and disadvantages of specific components of upper and lower limb prostheses are discussed, and a sample prescription sheet for upper limb devices is included. Recent innovations in terminal devices for upper limb prostheses are reviewed. Special considerations for the adult with acquired multilimb deficiency are also examined.

OVERALL ARTICLE OBJECTIVE

To describe indications for prosthetic components and prescription formulation for adults with acquired limb deficiency.

Sleep apnea in adults with traumatic brain injury: a preliminary investigation

OBJECTIVE

To determine the occurrence and nature of sleep-related breathing disorders in adults with traumatic brain injury (TBI).

DESIGN

Prospective, observational, consecutive sample enrollment of subjects admitted for rehabilitation after TBI.

SETTING

Inpatient rehabilitation and subacute rehabilitation units of a tertiary care university medical system.

PARTICIPANTS

Subjects (n = 28) included adults with TBI and a Rancho Los Amigos Scale level of 3 or greater who were less than 3 months postinjury and admitted for comprehensive inpatient rehabilitation.

INTERVENTIONS

Overnight sleep study using portable 6-channel monitoring system.

MAIN OUTCOME MEASURE

Respiratory disturbance index (RDI), which is the number of apneic and hypopneic episodes per hour of sleep.

RESULTS

Evidence of sleep apnea was found in 10 of 28 (36%) subjects as measured by a RDI level of 5 or greater and in 3 of 28 (11%) subjects as measured by a RDI level of 10 or greater. This rate of sleep apnea is significantly (p =.002) higher than would be predicted based on population norms. No correlation was found between the occurrence of significant sleep apnea and measures of TBI severity or other demographic variables. Sleep-related breathing disorders were primarily central though obstructive apneas were also noted.

CONCLUSION

In this preliminary investigation, sleep-related breathing disorders as defined by a respiratory disturbance index of 5 or greater appears to be common in adult subjects with TBI.

Primary adrenal insufficiency following traumatic brain injury: a case report and review of the literature

Primary adrenal insufficiency (PAI) is a relatively rare but serious condition that can lead to signs and symptoms ranging from mild generalized weakness and fatigue to fulminant shock and death. We present the case of a previously healthy 31-year-old man who developed PAI while undergoing rehabilitation after a severe traumatic brain injury (TBI). The patient suffered a TBI with comminuted skull fractures, bifrontal confusions, and bilateral epidural hematomas in a jet-ski accident. Acute hospitalization was prolonged by several medical complications, and the patient was admitted for subacute rehabilitation 1 month after his injury with cognitive deficits, persistent agitation, confusion, generalized weakness, and poor endurance for therapy. His weakness, fatigue, and orthostasis did not improve with attempts at gradual remobilization. The patient also had persistent anorexia, nausea, and hyponatremia despite various treatment regimens. Endocrinology workup showed normal anterior pituitary function but an abnormal response to adrenocorticotropic hormone (ACTH) stimulation, leading to the diagnosis of PAI. The patient was treated with prednisone and fludrocortisone, which resulted in improvement in clinical symptoms followed by rapid gains in all functional areas. No previous descriptions of PAI following head injury were found in the medical literature. It is important for physiatrists to be aware of this entity because symptoms of adrenal insufficiency can be similar to those commonly seen with TBI alone. PAI may also be confused with other endocrine disorders more frequently seen after TBI such as the syndrome of inappropriate antidiuretic hormone secretion. Recognition and appropriate management of adrenal insufficiency can lead to significant clinical and functional gains.

The Effect of Sublethal Heat Shock and Growth Atmosphere on the Heat Resistance of Listeria monocytogenes Scott A

Log phase cells of Listeria monocytogenes Scott A were heat shocked in Trypticase Soy + 0.6% yeast extract (TSYE) broth at 48°C for 10 min, followed by heating at 55°C for up to 50 min. Heat resistance was determined using nonselective (TSYE) and selective (McBride Listeria ) enumeration media which were incubated under aerobic and anaerobic environments. D₅₅°C-values for heat shocked cells were 2.1-fold higher than nonheat shocked cells (18.7 min vs. 8.89 min) when cells were enumerated on TSYE agar aerobically and 2.2-fold higher (26.4 min vs. 12.0 min) for cells enumerated anaerobically on TSYE agar. When cells were enumerated aerobically on McBride Listeria (ML) agar, D₅₅°C-values for heat shocked cells were 1.4-fold higher than nonheat shocked cells (9.55 min vs. 6.69 min). No growth was observed on ML agar anaerobically. The physiological condition of the microorganism, the enumeration medium, and the growth environment greatly affected the heat resistance of logphase cells of Listeria monocytogenes Scott A.

No basic rest-activity cycle in head, wrist or ankle

Kleitman's theory of a Basic Rest-Activity Cycle (BRAC) was tested by recording activity of the head, wrists, and left ankle from 10 healthy subjects. No 90-100 min rhythms in activity were found.

Naturalistic studies of human light exposure

For 24 h, 10 volunteers wore an apparatus that recorded their exposure to light at eye level and at the wrist. Activity was also recorded from the head, both wrists, and an ankle. Most of the subjects were exposed to daylight illumination intensities for only brief and scattered episodes during the 24 h. Some experienced the brightest illumination in the morning and others in the evening. Illuminations at eye level and at the wrist were correlated 0.76, while eye-level illumination was correlated 0.25, 0.44, 0.39, and 0.44 with head, wrists, and ankle activity, respectively. Because human biologic rhythms are probably well synchronized only by illumination approaching daylight intensities, inadequate illumination could be a source of sleep disturbance, chronobiologic disorders, or depression.

An activity-based sleep monitor system for ambulatory use

Wrist activity measured with a piezoceramic transducer was digitized and analyzed together with subjects' sleep/wake status to derive an optimal method for automatic computer sleep/wake scoring. Several algorithms for quantifying periods of activity were considered, and an algorithm that summed changes in activity level over a 2-s interval was found most sensitive. A computer program for scoring sleep/wake from the resulting digital activity records was then developed, and parameters derived by comparison with subjects' sleep/wake status as determined by EEG. EEG and activity sleep/wake scores agreed 94.46% of the time. A further prospective test of the automatic scoring system with new data yielded agreement of 96.02%. Finally, the data collection and recording functions were implemented in a wearable microprocessor-based digital activity monitor. The automatic scoring program was adjusted to use activity data collected by this monitor, and agreed 93.88% with EEG scoring. A prospective test with new data agreed 93.04% with EEG. Automatic scoring of activity data for sleep/wake is not only fast and accurate, but allows sleep to be monitored in non-laboratory situations. In addition, the score is objective and reliable, and free of scorer bias and drift.

Effects of Changing Compatibility Relationships on Reaction Time to the First Stimulus in a Double-Stimulation Task

This study investigated the effects of manipulating the response requirement to the second stimulus (S2) on reaction time (RT) to the first stimulus (S1) in a double-stimulation choice RT task. Forty subjects responded to the 100 msec presentation of a left or right light by pressing the key on the same or opposite side as the light. Treatment conditions included a single-stimulation control (no S2 presented), and two double-stimulation conditions each requiring two responses (R1 and R2) in close succession, in one of these latter conditions, the rule governing R2 was the same as that governing R1 while, in the other, the rule governing R2 changed. Results showed the typical double-stimulation effect; i.e., increased latency of R1 when it was followed by S2 - R2. More importantly, R1 latency was increased further when the rules governing R1 and R2 were different. Results are discussed in terms of divided preparation capacity as well as other theories of the psychological refractory period.