Giordano, Kent, Mauntel, T.C., Dickens, Millington, & Highland (2020). A longitudinal comparison of Patient-Reported Outcomes Measurement Information System (PROMIS) to legacy scales in knee and shoulder arthroscopy patients. Arthroscopy, 37(1), 185-94. doi: 10.1016/j.arthro.2020.07.026– posted 20211215

The purpose of this prospective correlational study was to compare psychometric properties of the Defense and Veterans Pain Rating Scale (DVPRS) and Patient Reported Outcomes Measurement Information System (PROMIS) scales to traditional legacy scales over a longitudinal postoperative period in Military Health System patients undergoing arthroscopic knee and shoulder procedures. A total of 59 participants completed the scales preoperatively and postoperatively. PROMIS scales measuring physical function, pain presentations, and other health domains demonstrated acceptable concurrent validity with traditional legacy scales. By integrating the prospective collection of biopsychosocial PROMIS scales into practice it is possible for clinicians in orthopedic settings to assess changes in validated patient reported outcomes to inform patient centered care planning throughout postoperative recovery. This is an important first step in promoting the use of standardized patient reported outcome measures across musculoskeletal conditions within the DOD.

Resnik, L., Borgia, M., Ekerholm, S., Highsmith, J. M., Randolph, B. J., Webster, J., Clark, M. A. (2021). Amputation care quality and satisfaction with prosthetic limb services: A longitudinal study of Veterans with upper limb amputation. Federal Practitioner, 38(3), 110-120. https://doi.org/10.12788/fp.0096

The purpose of this longitudinal study was to measure and identify factors associated with satisfaction with care among veterans. The metrics were collected for those receiving prosthetic limb care at the US Department of Veterans Affairs (VA) and US Department of Defense (DOD) care settings and at community-based care providers. A cohort of veterans with major upper limb amputation were interviewed by phone twice, 1 year apart. Care satisfaction was measured by the Orthotics and Prosthetics User's Survey (OPUS) client satisfaction survey (CSS), and prosthesis satisfaction was measured by the OPUS client satisfaction with device (CSD), and the Trinity Amputation and Prosthetic Experience Scale satisfaction scales. The Quality of Care index, developed for this study, assessed care quality. The study included 808 baseline participants and 585 follow-up participants. Satisfaction with prosthetic limb care is associated with device satisfaction and receipt of care within the prior year. Veterans receiving amputation care within the VA or DOD received better care quality scores than those receiving prosthetic care outside of the VA or DOD. Findings from this study can serve as benchmarks for future work on care satisfaction and quality of amputation rehabilitative care.

Butowicz, C.M., Silfies, S.P., Vendemia, J., Farrokhi, S., & Hendershot, B.D. (2019). Characterizing and understanding the low back pain experience among persons with lower limb loss. Pain Medicine, 21(5), 1068–1077. doi: https://doi.org/10.1093/pm/pnz293

This cross sectional study characterizes and compares the impact of lower limb loss and development of chronic low back pain (cLBP) on psychosocial factors and the relationship between these factors and low back pain–related functional disability. The study recruited 33 male subjects with traumatic unilateral limb loss. The presence of cLBP was highly correlated with pain intensity and moderately correlated with self-reported functional disability and impact, suggesting that perceived functional impairments are associated with pain perception. The findings of this study should be considered during the development of rehabilitative strategies to treat secondary musculoskeletal conditions within this population.

Goldman, S. M., Valerio, M. S., Janakiram, N. B., & Dearth, C. L. (2020). COX-2 inhibition does not alter wound healing outcomes of a volumetric muscle loss injury treated with a biologic scaffold. Journal of Tissue Engineering & Regenerative Medicine, 2020, 1-10. https://doi.org/10.1002/term.3144

This experimental design study was designed to test the hypothesis that COX-2 inhibition impairs BS-mediated functional outcomes in the context of a well-defined VML injury model. Preclinical and clinical investigations aimed at repairing volumetric muscle loss (VML) injuries have largely utilized biologic scaffolds (BS) as a potential therapeutic intervention. Given the known roles of Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) on cyclooxygenase (COX) signaling and of COX signaling on macrophage polarization and myogenesis, it is plausible that prescription of NSAIDs could alter BS-mediated VML repair. To study the effect of COX-2 inhibition on BS-mediated repair of VML, an established rat model of VML was acutely treated with BS with and without adjunct administration of Mavacoxib, a COX-2 specific inhibitor. The results of this study suggest that surgeons could add these agents to their clinical care analgesics armamentarium without having to worry about negatively impacting the outcome of BS-mediated repairs of VML injuries and suggests further investigation should be given to the prescription of NSAIDs for pain management of VML cases.

Cancio, J.M., Jones, K.A., Stanley, B., Truax, C., & Nuelle, J. A. V. (2020). Design and fabrication of the Cubital Tunnel Control Orthosis (CTCO). Journal of Hand Therapy. 2020 Aug 24;S0894-1130(20)30119-8. doi: 10.1016/j/jht.2020.05.005

These case series demonstrated a novel orthosis to treat cubital tunnel syndrome that provided greater user comfort and investigated the effect of compliance. Subjects claimed greater comfort and compliance with the wear schedule. They also demonstrated improvements in grip strength, pain, and QuickDASH scores. This demonstrates the importance user centered design and customization for orthotic devices. This provides clinicians with alternative orthotic designs for cubital tunnel syndrome.

Jones, K.A., Cancio, J.M., Stanely, B., Truax, C., & Gower, J.T. (2020). Design and fabrication of the radial and ulnar wrist articulating control orthoses. Journal of Hand Therapy, 34, 2021, 47-52. https://doi.org/10.1016/j.jht.2019.11.003

The purpose of study was to describe two orthoses that allow targeted rest and recovery of involved anatomical structure(s) while preserving function of surrounding uninvolved structures in patients who have overuse or traumatic injury at the radial or ulnar aspect of the wrist. This study described the fabrication of the Ulnar-Wrist Articulating Control Orthosis (U-WACO) and the Radial Wrist Articulating Control Orthosis (R-WACO) and presents case examples for each orthosis. This case series suggests that the U-WACO and R-WACO designs may improve comfort, compliance, and functional ability to complete daily tasks while allowing targeted rest and recovery of involved anatomical structure(s) at the radial and ulnar aspects of the wrist due to overuse or trauma.

Hendershot, B.D. & Bazrgari, B. (2020). Evolution of fatigue damage in the L5-S1 disc resulting from walking exposures among persons with lower limb loss. Annals of Biomedical Engineering, 28 Feb 2020. doi: 10.1007/s10439-020-02481-5

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 count. Assuming similar activity across groups (10,000 steps per day), times to failure were not different between persons with and without limb loss. 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.

Tenan, M. S., Galvin, J. W., Mauntel, T. C., Tokish, J. M., MOTION Collaborative, & Dickens, J. F. (2021). Generating the American Shoulder and Elbow Surgeons score using multivariable predictive models and computer adaptive testing to reduce survey burden. The American Journal of Sports Medicine, 1-9. doi: 10.1177/0363546520987240

This study established a valid predictive model of the American Shoulder and Elbow Surgeons (ASES) scores using a nonlinear combination of the Patient Reported Outcomes Measurement Information System (PROMIS) computer adaptive tests (CATs) domains for physical function and pain. The PROMIS predictive models approximate the ASES score within 13-14 points, which is 7 points more accurate than the ASES MCID/SCB for our model. Our ASES-index algorithm can be used to decrease patient survey burden by 11 questions and provide a reliable ASES analog to clinicians. This is an important first step in promoting the use of standardized patient reported outcome measures across musculoskeletal conditions within the DOD. Our model enables clinicians to obtain the information contained within an ASES score with fewer survey questions and therefore lower patient survey fatigue and higher response rates. This tool will allow clinical researchers to switch to measuring PROMIS physical function and pain interference in current and future studies while still allowing for correlation and comparison to prior studies based upon the legacy ASES scores.

Bhakta, K., Camargo, J., Kunapuli, P., Childers, W. L., & Young, A. (2020). Impedance control strategies for enhancing sloped and level walking capabilities for individuals with transfemoral amputation using a powered multi-joint prosthesis. Military Medicine, 185, 490-499. doi:10.1093/milmed/usz229

The purpose of this study was to validate an impedance control strategy for a powered knee and ankle prosthesis that would assist individuals in performing common locomotion tasks, such as level walking and ascending/descending slopes. Three subjects with limb loss walked on a treadmill and four subjects with limb loss walked on a ramp circuit to test whether a dual powered knee and ankle prosthesis could generate appropriate device joint kinematics across users. Investigators found that tuning 2–3 subject-specific parameters per ambulation mode was necessary to render individualized assistance. This work presents a strategy that requires minimal tuning for a powered knee and ankle prosthesis that scales across a nominal range of both walking speeds and ramp slopes and successfully recognizes and adapts to different phases of gait and terrains. This study is a step toward restoring function after amputation.

Lee, S. E., Kilpatrick, C., Kang, I., Hsu, H., Childers, W. L., & Young, A. (2020). Investigating the impact of the user interface for a powered hip orthosis on metabolic cost and user comfort: A preliminary study. Journal of Prosthetics and Orthotics, 33(2), 133-140. doi: 10.1097/JPO.0000000000000311

The aim of this study was to design and evaluate a novel user interface for a powered hip orthosis. We hypothesized that our interface design would reduce metabolic costs, reduce skin irritation, increase user comfort, and reduce pain during ambulation when compared with an off-the-shelf (OTS) interface. This study demonstrated the importance of using a custom made interface between the user and the exoskeleton. The novel and user-specific interface reduced metabolic cost, pain, and skin irritation in treadmill walking in people without a gait pathology. Having an interface between the human and an exoskeleton that can conform/adapt to maximize loaded area and offload to anatomical structures is critical to success of exoskeleton developments. This study demonstrates the importance of interface adjustability for exoskeleton design and will influence future work in exoskeletons designed for prolonged field care applications.

Harper, N., Wilken, J. M., & Neptune, R. (2020). Muscle contributions to balance control during amputee and non-amputee stair ascent. Journal of Biomechanical Engineering, 2020 May 29. doi: 10.1115/1.4047387

This study used data collected on subjects ascending stairs and then modeled muscle contributions to measurements of dynamic balance. Muscular compensation strategies were found in people with amputations ascending stairs that were related to the properties of the prosthetic foot. The authors recommend this be considered in the design of prosthetic feet for stair ascent. This research further demonstrates the differences in the mechanical requirements for different tasks of daily living and how this is influenced by prosthesis design. Prosthetic feet could be better optimized for stair ascent to reduce altered muscle coordination

Cancio, J. M., Orr, A., Eskridge, S., Shannon, K., Mazzone, B., & Farrokhi, S. (2020). Occupational therapy practice patterns for military Service members with upper limb amputation. Military Medicine, 185, 444-450. doi:10.1093/milmed/usz341

The purpose of this retrospective observational study was to identify OT practice patterns for U.S. Military Service Members treated in Military Treatment Facilities, who have sustained various levels of deployment-related upper limb amputation. Service Members within 24 hours of unilateral upper limb amputation (partial hand and proximal), occurring between January 2001 and December 2014 were identified. The findings of this study suggest Service Members with upper limb amputation utilize OT services often within the first year after injury and those who have sustained amputation proximal to the elbow received more therapy visits than their below elbow counterparts during months 4 to 12. Therapists should be prepared to provide prosthetic training, therapeutic activities, and therapeutic exercise to increase function during the first year following upper limb amputation. Further research is needed to determine details on types and frequency of therapy utilization and recommended therapy strategies.

Mazzone B., Farrokhi, S., Hendershot, B., McCabe, C., & Watrous, J. (2020). Prevalence of low back pain and relationship to mental health symptoms and quality of life after a deployment-related lower limb amputation. Spine, 45(19), 1368–1375. doi: 10.1097/BRS.0000000000003525

The objective of this study was to assess the prevalence and association of low back pain with psychosocial factors in Service Members with amputations. Seventy-nine subjects with lower limb amputation were included in the analysis. This study reported that individuals with amputations and recurrent low back pain reported higher post-traumatic stress disorder (PTSD) symptom severity compared to those without low back pain. Presence of recurrent low back pain after amputation appears to be associated with more severe PTSD and depression symptoms as well as lower quality of life.

Baquet, A., Mazzone, B., Yoder, A., Farrokhi, S. (2020). Rearfoot strike landing pattern run retraining to prevent recurrent calf strains in a US Navy Service member. Physical Therapy in Sport, 41, 64-70. doi: 10.1016/j.ptsp.2019.11.004

The goal of this study was to identify rehabilitative techniques that can attenuate load/risk for injury during running and/or load carriage activities, and enhance full participation in high-level sporting activities. This was a case study evaluating a 40 year old Navy Service member who had a 7-year history of recurrent calf strains. After 8 sessions of run retraining for 2 weeks the subject reported increased running frequency without further episodes of calf strain, along with improvements in running mechanics and self-reported function up to 6-months post training. The outcomes of this case report suggest that movement-based interventions may be a viable treatment option of chronic calf strains.

Butowicz, C.M., Krupenevich, R.L., Acasio, J.C., Dearth, C.L., & Hendershot, B.D. (2020). Relationships between mediolateral trunk-pelvic motion, hip strength, and knee joint moments during gait among persons with lower limb amputation. Clinical Biomechanics, 71, 160-166. doi: https://doi.org/10.1016/j.clinbiomech.2019.11.009

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 movements; however, it is unclear how these are inter-related post-amputation. This study compared 24 males with unilateral lower limb loss with 8 uninjured controls. 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. Therapists need to consider and educate individuals with limb loss that repeated exposures to altered mechanics of movement (e.g., knee or trunk motion/loads) contribute to an increased risk for joint degeneration and pain following lower limb amputation.

Sgromolo, N. M., Cancio, J. M., & Rhee, P. C. (2020). Safety and efficacy of blood flow restriction therapy after operative management of distal radius fractures: A randomized controlled study. Journal of Wrist Surgery, 9(4), 345-352. doi: 10.1055/s-0040-1712504

This study investigated the effect of using Blood Flow Restriction Therapy for distal radius fracture therapy by comparing clinical outcome measures between groups that received (N=5) and did not receive (N=4) this therapy. This study demonstrated that Blood Flow Restriction Therapy may be safely applied to people with distal radius fractures with the potential to reduce pain and improve patient outcomes. More studies with a larger n are required to validate these finding.

Wasser, J. G., Acasio, J. C., Hendershot, B. D., & Miller, R. H. (2020). Single-leg forward hopping exposures adversely affect knee joint health among persons with unilateral lower limb loss: A predictive model. Journal of Biomechanics, 109(26), Article 109941. https://doi.org/10.1016/j.jbiomech.2020.109941

Single-leg hopping is an atypical, yet convenient, method of ambulation for individuals with unilateral lower limb loss. While hopping is generally discouraged by therapists, many patients report hopping, and the potential deleterious effects of frequent hopping on knee joint health remains unclear. We aimed to compare knee joint mechanics between single-leg hopping and walking at self-selected paces among 32 individuals with unilateral lower limb loss, and estimated the associated probability of knee cartilage failure. 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. Understanding the impact of single-leg hopping is vital for future clinical guidelines and will allow clinicians to better direct patient care, without increasing the risk for future damage of articular cartilage.

Lynall, R. C., Campbell, K. R., Mauntel, T. C., Blackburn, J. T., & Mihalik, J. P. (2020). Single-legged hop and single-legged squat balance performance in recreational athletes with a history of concussion. Journal of Athletic Training, 55(5), 488–493. doi: 10.4085/1062-6050-185-19

Lingering dynamic balance-control deficits after concussion may contribute to an increased musculoskeletal injury risk. This study compared balance in 15 subjects who previously concussed and 15 control subjects. Subjects jumped off a 30-cm box, landed on a single limb, and attempted to achieve a stable position as quickly as possible. Participants also performed single-legged squats while standing on a force plate. Time to stabilization (TTS; time for the normalized ground reaction force to stabilize after landing) was calculated during the single legged hop, and center-of-pressure path and speed were calculated during single-legged squats. The concussion group demonstrated a longer TTS than the control group during the single-legged hop on the non-dominant leg. The results of this study suggest that neuromuscular deficits currently not assessed after concussion may linger.

Scheiber, Kurapaty, Goldman, S. M., Dearth, C. L., Liacouras, & Souza (2020). Suturable mesh better resists early laparotomy failure in a cyclic ball-burst model. Hernia, 24, 559–565. https://doi.org/10.1007/s10029-020-02133-6

The objective of this study was to determine whether incorporating a mid-weight polypropylene mesh material into a hollow-bore surgical suture material would effectively increase the force distribution at the suture–tissue interface and potentially help prevent early laparotomy dehiscence in an ex vivo model. A cyclic stress ball-burst model was used to compare suturable mesh (DuraMesh™) to conventional suture. A custom 3D-printed ball-burst test apparatus was used to fatigue the repair on a MTS Bionix Load Frame. The tissue was repetitively stressed at a physiological force of 15–120 N cycled at a rate of 0.25 Hz for a total of 1000 repetitions, followed by a load to failure, and the maximal force was recorded. This ex vivo study suggests that using rational suture design to improve force distribution at the suture–tissue interface may be a viable strategy for preventing the suture pull-through that drives incisional hernia.

Webster, J., Scholten, J., Young, P., & Randolph, B. J. (2020). Ten-year outcomes of a systems-based approach to longitudinal amputation care in the US Department of Veteran Affairs. Federal Practitioner. 2020 Aug; 37(8): 360–367.doi:10.12788/fp.0024

The Amputation System of Care (ASoC) provides specialized expertise in amputation rehabilitation incorporating the latest practices in medical management, rehabilitation, and artificial limbs in order to minimize disability and to enable the highest level of social, vocational, and recreational success for veterans with amputation. The ASoC serves veterans with limb amputation from any etiology. Between 2009 and 2019, the VA experienced a 34% increase in the number of veterans with amputation who received care. During the same 10-year period, the percentage of veterans with major limb amputation seen in an outpatient amputation specialty clinic each year increased from 4.8 to 26%. This VA amputation care program serves as a model of amputation care that can be utilized outside the federal sector and has the potential to serve as a systems-based example for providing longitudinal care to other populations.

Russell Esposito, E., Ruble, M. D., Ikeda, A. J., & Wilken, J. M. (2020). The effect of custom carbon ankle-foot orthosis alignment on roll-over shape and center of pressure velocity. Prosthetics and Orthotics International, 2020, 1-7. doi: 10.1177/0309364620971407

The aim of this randomized cross-over study with a control group comparison study was to investigate the effects of the sagittal plane ankle-foot orthosis alignment on rollover shape and center of pressure velocity in individuals with lower limb reconstructions. Twelve individuals with lower limb reconstruction who used a custom carbon ankle-foot orthosis and 12 uninjured controls underwent gait analysis. Ankle-foot orthosis users were tested in their clinically-provided ankle foot orthosis alignment, with an alignment that was 3° more plantarflexed, and with an alignment that was 3° more dorsiflexed. Components of roll-over shape and center of pressure velocity were calculated from heel strike on the ankle-foot orthosis limb to contralateral heel strike. Roll-over shape radius was not significantly different from controls. Aligning the ankle-foot orthosis in more dorsiflexion than clinically provided resulted in a smaller peak center of pressure velocity that occurred later in stance. The results of this study suggest that individuals using custom carbon ankle-foot orthoses can accommodate 3° alterations in the dorsiflexion or plantarflexion alignment giving clinicians a range of positions to work with to meet a person's specific needs.

Yepson, H., Mazzone, B., Eskridge, S., Shannon, K., Awodele, E., & Farrokhi, S. (2020). The influence of tobacco use, alcohol consumption, and weight gain on development of secondary musculoskeletal injury after lower limb amputation. Archives of Physical Medicine and Rehabilitation. doi: 10.1016/j.apmr.2020.04.022

The objective of this retrospective cohort study was to evaluate whether tobacco use, alcohol consumption, and weight gain are associated with the diagnosis of overuse musculoskeletal injuries within the first 12 months following lower limb amputation. The study consisted of 641 Service members with a deployment-related lower limb amputation. Service members reporting tobacco use in the first three months after amputation were nearly twice as likely to be diagnosed with a lower limb musculoskeletal injury in months 4 to 12 after amputation. Service members reporting alcohol consumption within the first three months after amputation were more than twice as likely to be diagnosed with at least one overuse musculoskeletal injury in months 4-12 after amputation. The results of this study suggest that the development of secondary overuse musculoskeletal injury appears to be related to tobacco use and alcohol consumption, but not weight gain.

Mauntel, T. C., Marshall, S. W., Hackney, A. C., Pietrosimone, B. G., Cameron, K. L., Peck, K. Y., Trump, J. R., & Padua, D. A. (2020). Trunk and lower extremity movement patterns, stress fracture risk factors, and biomarkers of bone turnover in military trainees. Journal of Athletic Training, 55(7), 724–732. doi: 10.4085/1062-6050-134-19

The objective of this cross-sectional study was to determine how lower extremity stress fractures (SFx) influence bone metabolism. Understanding how SFx risk factors influence bone metabolism may help to optimize risk mitigation strategies. Forty-five men who completed Cadet Basic Training were included in the study. The findings of this study provide insight into how SFx risk factors influence bone health. This information can help future researchers to develop future guidance for SFx risk-mitigation strategies.

Mauntel, T. C, Cameron, Pietrosimone, Marshall, Hackney, & Padua (2021). Validation of a commercially available markerless motion capture system for trunk and lower extremity kinematics during a jump-landing assessment. Journal of Athletic Training, 56(2), 177–190. doi: 10.4085/1062-6050-0023.20

Field-based, portable motion capture systems can help identify individuals at greater musculoskeletal injury risk. Microsoft Kinect based markerless motion capture systems may be able to serve this purpose; however, these systems are generally not automated, require significant data post-processing, and not commercially available. Thus, this study sought to validate a commercially available markerless motion capture system against the gold-standard of 3D motion tracking. Moderate agreement exist between markerless and stereophotogrammetric motion capture systems. The markerless motion capture system is limited in its abilities to accurately calculate small(er) joint angles, which may have important implications for injury risk. Thus, markerless motion capture systems should be used with caution for identifying small differences in joint kinematics. Kinect based markerless motion capture systems can correctly identify differences in gross movement patterns and thus may aid clinicians in identifying individuals at increased risk of injury. Validated Kinect based markerless motion capture systems can efficiently screen large numbers of individuals and identify individuals with gross movement errors who may benefit from a more robust and in-depth biomechanical screening assessment which can optimize MSKI risk assessment screenings in the DOD.

Goldman, S. M., Feng, J. P., & Corona, B. T. (2020). Volumetric muscle loss disrupts length-dependent architectural and functional characteristics of skeletal muscle. Connective Tissue Research, 62(1), 72-82. doi: 10.1080/03008207.2020.1789608

Volumetric muscle loss (VML) injury is destructive; however, the impact on muscle architecture, a primary determinant of function, is uncharacterized. To that end, architectural and functional effects of VML were assessed in a rat tibialis anterior (TA) muscle model 4 weeks post-injury. These findings raise the importance of augmenting length-dependent muscle properties to optimize functional recovery after VML injury. Study identifies interventions that modulate serial sarcomere number as an area for further investigation towards improved VML outcomes