Schnall,B. L., Chen, Y. T., Bell, E. M., Wolf, E. J., & Wilken, J. M. (2016). Functional outcomes of Service members with bilateral transfemoral and knee disarticulation amputations resulting from trauma. Military Medicine, 181(S4), 55-60. doi: 10.7205/MILMED-D-15-00546

It is important to quantify performance measures during rehabilitation in an effort to determine reasonable expectations and trends that may influence the rehabilitation process. A study was pursued to observe changes in function over the rehabilitation period in patients in patients with transfemoral amputation and knee disarticulation.  Over the rehabilitation period from date of independent ambulation to discharge (median 135 days) patients were able to achieve functional community ambulation skills, were able to cover a greater distance during a 6-minute walk test, and exhibited higher confidence scores during stair ambulation. The change in scores for stair ascent and descent did not change significantly. These results show that while stair negotiation appears to plateau early, confidence builds despite absence of functional gains over time, suggesting that clinicians can realign rehabilitation paradigms to shift focus towards community distance ambulation once safe stair ascent and descent is achieved.

Tennent,D. J., Hylden, C. M., Johnson, A. E., Burns, T. C., Wilken, J. M., & Owens, J. G. (2017). Blood flow restriction training after knee arthroscopy: A randomized controlled pilot study. Clinical Journal of Sports Medicine, 27(3), 245-252. doi: 10.1097/JSM.0000000000000377

Blood flow restriction training is a method used within a rehabilitation environment to partially restrict blood flow during exercises, which is theorized to increase improvements in muscle size and strength.  In a novel study, our team evaluated the effects of blood flow restriction training following knee arthroscopy and observed improvements in strength, muscular hypertrophy, function, and patient-reported measures when compared with the same exercise program performed without blood flow restriction.  Further study will determine if this rehabilitation intervention can benefit patients who have sustained severe extremity trauma.

Oliver, R., Schoonover, C., Tu, T., Turner, S., Cancio, J., & Yancosek, K. (2017). Prosthesis thesis: A task oriented approach to motor learning. OT Practice, 22(8), 14-16

When undertaking a new activity the brain and body adapt to the use of new motor patterns inherent in that activity.  As such, one goal of therapy is for the body to incorporate the prosthesis into any new movement strategies being learned. “Prosthesis thesis” is a rehabilitation concept that allows the patient to create a meaningful project over the course of therapeutic care.   Using the prosthesis thesis intervention occurs at a juncture of care to help transition to the advanced phase of prosthetic training, where smoother, more automatic, and well-coordinated movements are practiced.  Case examples of successful outcomes document how the principles of neuroplasticity are utilized within a clinical setting to master desired functional skills.

Diebal-Lee, A. R., Kuenzi, R. S., & Rábago, C. A. (2017). Return to running following a knee disarticulation amputation: A case report. International Journal of Sports Physical Therapy, 12(4), 655-669

Rehabilitative training in proper running mechanics using advanced prosthetic devices is an integral and essential aspect of a rehabilitation intervention, and can effectively alter limb mechanics that improve performance and prevent injury to the intact limb. A three-week run training intervention for an individual with knee disarticulation changed an asymmetrical foot strike pattern to a symmetrically loaded non-rearfoot strike pattern.⁴This intervention enabled the patient to double his pain-free run mileage from 5 km to 10 km and improve his run time, contributing to his goal to participate in a triathlon. Additionally, the load placed on his intact limb decreased to near normal, reducing additional load on the non-injured limb that can lead to arthritic change over time.

Highsmith MJ, Andrews CR,Millman C, Fuller A, Kahle JT, Klenow TD, Lewis KL, Bradley RC, Orriola JJ.Gait Training Interventions for Lower Extremity Amputees: A SystematicLiterature Review. Technology & Innovation 18(2), 99-113, 2016.

Therapeutic interventions using both treadmill-based and overground training methods have been shown to be effective at improving gait. These include in-shoe auditory feedback, verbal and tactile cueing, early weight-bearing, the use of walking aids, and combined physical therapy and psychological awareness training.  Gait lab analysis is an integral part of documenting changes associated with these clinical interventions that can assess energy efficiency, gait symmetry, and techniques used to negotiate direction changes and uneven terrain.

Rabago, C. A. & Wilken,J. M. (2016). The prevalence of gait deviations in individuals withtrans-tibial amputation. Military Medicine, 11(12), 30-37. doi:10.1371/journal.pone.0166815

Patients with transtibial amputation, who exhibit decreased prosthetic ankle power generation during push off, do not appear to elicit compensations in the intact limb, knee, and hip, suggesting that interventions, such as powered prostheses, may not greatly influence improved energy efficiency for these patients. These individuals do, however, exhibit changes in knee and hip compensation in the prosthetic limb that are typically used to control the knee during stance, which may influence energy efficiency.

RussellEsposito, E., Choi, H. S., Wilken, J. M., & Darter, B. J. (2017). Canreal-time visual feedback during gait retraining reduce metabolic demand forindividuals with transtibial amputation. Public Library of Science One, 12(2).doi:10.1371/journal.pone.0171786

An intervention effort using a single-session of gait retraining through visual feedback in a computer-assisted virtual reality environment successfully decreased center of mass sway and quadriceps activity in a group of patients with transtibial amputation. However these changes did not significantly affect metabolic rate during walking, and metabolic rate was not different than that of a control group.

Darter,B. J., Bastian, A. J., Wolf, E. J., Husson, E. M., Labrecque, B. A., &Hendershot, B. D. (2017). Locomotor adaptability in persons with unilateraltranstibial amputation. PloS one, 12(7), e0181120. doi:10.1371/journal.pone.0181120

A follow-on study observed that reactive changes and locomotor adaptation in response to a challenging and novel walking condition utilizing a split-belt treadmill were similar in persons with transtibial amputation compared to those without an amputation. Overall, our results suggest persons with transtibial amputation have the capacity to modify locomotor strategies to meet the demands of most ambulation challenges imposed by an amputation and use of a prosthetic limb when the individual is young, active, and/or has extensive access to rehabilitative care.

RussellEsposito, E., Rábago, C. A., & Wilken, J. M. (2017). The influence oftraumatic transfemoral amputation on metabolic cost across walking speeds.Prosthetics and Orthotics International, (June). doi: 10.1177/0309364617708649

Interventions to lower metabolic costs of walking may be more relevant in individuals with transfemoral and bilateral lower-limb amputation as they utilize more pronounced biomechanical compensations to ambulate, and compensations during gait produce increased loads on the body that may reduce efficiency. Significantly decreased energy efficiency was observed in a group of patients with transfemoral amputation, even though they walked at a slower pace.  When compared to a control group, these individuals also exhibited a 44%-47% greater metabolic rate and cost, a 24-33% greater heart rate, and a 24%-35% greater perceived exertion. Of note, this transfemoral amputation group was relatively young, physically fit, and had extensive access to rehabilitative care.  The metabolic cost of walking fell within the ranges of an older or presumably less fit group, suggesting that young, active individuals with transfemoral amputation can benefit from prosthetic and other rehabilitative regimens designed to improve energy efficiency.

MengelkochLJ, Kahle JT, Highsmith MJ. Energy Costs & Performance of Transfemoral Amputees and Non-Amputees During Walking and Running: A Pilot Study. ProsthetOrthot Int, 2016;(epub ahead of print):1-8

To determine how different prosthetic foot devices affect energy cost for patients with transfemoral amputation, patients were tested with three prosthetic feet: a conventional foot (solid-ankle cushioned heel (SACH)); an energy storing and return foot (Renegade); and a running-specific energy storing and return foot (Nitro). Energy costs were greater and ambulatory performance was lower for transfemoral amputees compared to matched, non-amputee controls and did not differ between prosthetic foot conditions.

Ebrahimi,A., Goldberg, S. R., Wilken, J. M., & Stanhope, S. J. (2017). Constituent Lower Extremity Work (CLEW) approach: A novel tool to visualize joint andsegment work. Gait Posture, 56(Jul), 49-53. Doi

The use of gait evaluation to assess a patient’s response to training following injury can be an integral part of developing an individualized therapeutic program.  New avenues are being developed for how gait evaluation can enhance the clinical information gained during a gait assessment.  One example can be found in the Constituent Lower Extremity Work (CLEW) approach, a novel tool developed to visualize and interpret cyclic tasks performed by the lower extremity, taking into account movements at the hip, knee, ankle, and distal foot to come up a mechanical cost of transport.

Salinas, M. M., Wilken, J.M., & Dingwell, J. B. (2017). How humans use visual optic flow to regulatestepping during walking. Gait Posture, 57(Sep), 15-20.doi:10.1016/j.gaitpost.2017.05.002

Gait analysis and training within a laboratory environment is challenged by lack of a “real world” environment in which to assess a patient’s ability to navigate obstacles encountered in daily life.  When a patient pays attention to walking, as in a therapeutic or laboratory environment, they are less distracted, which doesn’t accurately reflect the patient’s ability to ambulate safely when everyday distractions are present.  Treadmill analysis within a virtual reality environment has the advantage of being able to create a moving visual surrounding that more accurately resembles a real world environment.  To assess the contribution of “optic flow” researchers utilized a virtual reality environment to assess gait reactions during walking under five conditions:  blank screen, static screen, or three speeds with a moving screen. When visual information was removed, individuals appeared to walk more cautiously. Optic flow influenced both how quickly humans corrected stride speed deviations and how successful they were at minimizing stride speed and treadmill position variability. These findings provide greater understanding of how advanced technologies can be used to create clinical interventions that more accurately resembles a real world situation.

Hendershot,B. D., Mahon, C. E., & Pruziner, A. L. (2016). A comparison ofkinematic-based gait event detection methods in a self-paced treadmillapplication. Journal of Biomechanics, 49(16), 4146-4149. doi:10.1016/j.jbiomech.2016.10.046

Finally, the use of self-paced treadmills is allowing for a more individualized method of training on a treadmill within rehabilitation clinics.  To assure methodologies used in biomechanical analyses during treadmill ambulation are applicable to self-paced treadmills a study was pursued to validate kinematic-based algorithms currently being used in our laboratories.  Results indicate that common kinematic-based gait event detection methods are applicable to self-paced treadmill applications and may be robust for both asymptomatic and pathological gait patterns.

Golyski,P. R., & Hendershot, B. D. (2017). A computational algorithm forclassifying step and spin turns using pelvic center of mass trajectory and footposition. Journal of Biomechanics, 54, 96-100. doi:10.1016/j.jbiomech.2017.01.02

Less than optimal turning strategies used by a patient may predispose an individual to stumbles or falls during walking activities.  Turning transitions are difficult to assess, and are typically observed through subjective and time consuming visual ratings.  A novel biomechanical analysis using pelvic center of mass trajectory (pCOM) and time-distance parameters was developed to quantitatively identify turning strategies during gait.  This assessment can be implemented in place of time-consuming and subjective visual observations, and provides a new platform for classifying and possibly optimizing turning strategies used by patients during walking transitions.

KahleJT, Klenow TD, Sampson W, Highsmith MJ. The Effect of Transfemoral InterfaceDesign On Gait Speed and Risk of Falls. Technology & Innovation, 18(2),167-173, 2016.

To begin a strength and walking program, the use of an effective prosthesis is imperative. There is collective agreement that ongoing research is needed to develop appropriate intervention strategies that can decrease fall risk, however these interventions should also consider the impact of the prosthetic interface.  This is particularly important in individuals with transfemoral amputation, where walking capacity and balance confidence are especially compromised.  Researchers have found that a high-fidelity interface socket improved walking capacity and balance confidence in higher-functioning patients with transfemoral amputation when compared with use of an ischial ramus containment socket. These results suggest that the less cumbersome walls and subischial trimlines of a high-fidelity interface socket might optimize freedom of movement and improved walking capacity that may lead to a decreased risk for falls. 

Andrews,A. M., Pruziner, A. L., Deehl, C., & Rogers, R. L. (2016). Core temperaturein service members with and without traumatic amputations during a prolongedendurance event. Military Medicine, 181(S4), 61-65. doi:10.7205/MILMED-D-15-00515

Many active duty service members return to combat operations that take place in harsh environmental conditions.   Anecdotal information from patients suggested that individuals with amputation reported feeling hotter and experiencing more profuse sweating during activity.  Researchers postulated that the decreased body surface area and increased energy needs during running and other athletic activities may increase heat production and risk of heat injury for individuals with amputations.  To address these possible health safety concerns a series of studies was undertaken to compare core temperature changes between individuals with and without amputation during strenuous military activities.  One such study monitored core body temperature during the Bataan Memorial Death March, a 26.2 mile road march that mimics the extended marching frequently performed by many operational military forces.  No significant differences in core temperature were noted, nor did any subjects reach the threshold for increased risk of heat stroke.  The pace selected by those individuals with amputation was slower, and may have attenuated core temperature increases.

Harper, N., Wilken, J. M.,& Neptune, R. (2017). Muscle Function and Coordination of Stair Ascent.Journal of Biomechanics. (Aug). doi: 10.1115/1.4037791

Stair ascent is an activity of daily living and necessary for maintaining independence in community environments. Navigating stairs, particular during ascent, has traditionally been a challenge for individuals following amputation or severe extremity trauma. Numerous muscle groups are involved in successful stair climbing, to include the knee extensors, ankle plantarflexors, hip extensors, and hip abductors. If an injury affects one of more of these muscle groups, compensatory movements occur that can lead to secondary musculoskeletal injury.

Melcer,T., Pyo, J., Walker, J., Quinn, K., Lebedda, M., Neises, K., Nguyen, C., &Galarneau, M. (2017). Rehabilitation and multiple limb amputations: A clinicalreport of patients injured in combat. JRRD, 53(6), 1045-1060

Rehabilitation programs for service members with amputation and extremity trauma are comprehensive.  In a subset of patients who obtained their care at a military amputee care center, patients engaged in daily rehabilitation therapy, par­ticularly for the six to nine month period immediately following injury, and continued on a several times a week basis for an average of 18 months.  Functional outcomes assessments documented the program’s effectiveness in improving physical and psychosocial functioning.

Butowicz,C. M., Dearth, C. L., & Hendershot, B. D. (2017). Impact of Traumatic LowerExtremity Injuries Beyond Acute Care: Movement-Based Considerations forResultant Longer Term Secondary Health Conditions. Advances in Wound Care,6(8), 269-278, doi: 10.1089/wound.2016.0714

Of particular importance and relevance to the long-term care of our young patients is the need to understand and ultimately eliminate the secondary health complications that our patients are at a pronounced and progressively increased risk for developing.  There is a limited, but growing, body of evidence relating movement abnormalities to altered musculoskeletal demands that may lead to the development of longer term secondary conditions in this population. Especially important from a research and therapeutic intervention perspective is determining the impact of altered movement patterns and other modifiable risk factors that can increase mechanical loading of the spine and lower extremities, potentially resulting in cumulative effects over time.  Therefore, developing effective early intervention strategies that can prevent or minimize these deleterious secondary health effects is critical to the program of care of individuals with limb loss.

Farrokhi,S., Mazzone, B., Yoder, A., Grant, K., & Wyatt, M. (2016). A narrativereview of the prevalence and risk factors associated with development of kneeosteoarthritis after traumatic unilateral lower limb amputation. MilitaryMedicine, 181(S4), 38-44. doi: 10.7205/MILMED-D-15-00510

Evidence compiled in a recent review supports that young military Service members with traumatic unilateral lower limb amputations may be at increased risk for developing knee osteoarthritis (OA) compared to nonamputees.  Potential risk factors include chronic knee pain, obesity, abnormal knee joint mechanics, muscle weakness, prior knee trauma, and altered activity levels. Therefore, preservation of intact limb function through prevention of factors that place an individual at risk for development of OA is an important component of rehabilitative care.

Melcer, T., Walker, J.,Bhatnagar, V., Richard, E., Sechriest, V. F. II, & Galarneau, M. (2017). Acomparison of four-year health outcomes following combat amputation and limbsalvage. PLOS ONE, 12(1), e0170569. doi: 10.1371/journal.pone.0170569

A four-year study in service members showed a small but significant increase in the prevalence of osteoarthritis one to two years after traumatic extremity injury, with no additional change during years three and four. Approximately 20% of the late amputation and limb salvage groups in the present study, however, had an osteoarthritis diagnosis by age 25 to 35 years, compared to about 14% of individuals age 25-65 without amputation. These data suggest that extremity trauma patients may be at increased risk for OA as they age.

Miller,R. H., Krupenevich, R. L., Pruziner, A. L., Wolf, E. J., & Schnall, B. L.(2017). Medial Knee Joint Contact Force in the Intact Limb during Walking inRecently Ambulatory Service Members with Unilateral Limb Loss: A Cross-sectionalStudy. PeerJ, 5, e2960. doi: 10.7717/peerj.2960

Knee joint forces and loading rates in the intact limb of individuals with above knee and below knee amputations are significantly greater during walking than are the limbs of individuals without amputation.   As walking reflects joint loading experienced in daily life, this supports a “mechanical overloading'' hypothesis for the risk of developing knee OA in the intact limb of limb loss subjects.

Krupenevich,R. L., Pruziner, A. L., & Miller, R. H. (2017). Knee Joint Loading duringSingle-Leg Forward Hopping. Medicine and science in sports and exercise, 49(2),327-332. doi: 10.1249/MSS.0000000000001098

Individuals with unilateral amputation often hop on the intact limb to maneuver over very short distances. There is a substantial increase in knee joint loading during hopping, suggesting that, overtime, these high impact loads could potentially increase knee osteoarthritis risk.

Farrokhi,S., Mazzone, B., Schneider, M., Gombatto, S., Mayer, J., Highsmith, M. J.,& Hendershot, B. (2017). Biopsychosocial risk factors associated withchronic low back pain after lower limb amputation. Medical Hypotheses, 108,1-9. doi: 10.1016/j.mehy.2017.07.030

The biopsychosocial model of low back pain is likely influenced or amplified by lower limb amputation.  Components of this model that are supported by the literature include biological (i.e. increased pain sensitivity), psychological (i.e. ineffective coping strategies, pain catastrophizing), and social (i.e. smoking, alcohol consumption) factors.  There are also other contributors to low back pain that include biomechanical (i.e. increased spinal loading) and lifestyle (i.e. weight gain, physical activity level) factors that might be modifiable with targeted rehabilitation interventions.

HighsmithMJ, Kahle JT, Miro RM, Cress ME, Quillen WS, Carey SL, Dubey RV, MengelkochLJ.  Concurrent Validity of theContinuous Scale-Physical Functional Performance -10 (CS-PFP-10) Test inTransfemoral Amputees. Technology & Innovation 18(2), 185-191, 2016.

The Continuous Scale-Physical Functional Performance-10 (CS-PFP-10) test consists of 10 standardized daily living tasks that evaluate overall physical functional performance and performance in functional domains that include upper body strength, upper body flexibility, lower body strength, balance and coordination, and endurance.  A study was pursued to determine the concurrent validity of the CS-PFP-10 test and its lower extremity functional domains in comparison to measures that have established validity for use in persons with transfemoral amputation.  Results showed that the lower limb and balance domains of the CS-PFP-10 are valid measures to assess the physical functional performance of TFA patients.

HighsmithMJ, Kahle JT, Kaluf B, Miro RM, Mengelkoch LJ, Klenow TD. PsychometricEvaluation of the Hill Assessment Index (HAI) and Stair Assessment Index (SAI)in High-Functioning Transfemoral Amputees. Technology & Innovation 18(2),193-201, 2016.

The hill assessment index and stair assessment index were developed to objectively evaluate ramp and stair gait.  A study was pursued to determine the validity and reliability of these tests in a sample of persons with unilateral transfemoral amputation using microprocessor prosthetic knee systems.  The hill assessment index showed moderate to excellent sensitivity and specificity, and good to adequate reliability. The stair assessment index showed excellent to good reliability,  suggesting that these clinical assessments are reliable outcome measures for assessing ambulation on ramps and stairs.

Sheean,A. J., Schmitz, M. R., Ward, C. L., Barrow, A. E., Tennent, D. J., Roach, C.J., Burns, T. C., & Wilken, J. M. (2017). Assessment of disability relatedto femoroacetabular impingement syndrome by use of the Patient-Reported OutcomeMeasure Information System (PROMIS) and objective measures of physicalperformance. American Journal of Sports Medicine, 45(11), 2476-2482. doi:10.1177/0363546517708793

Assessment tools need to be sensitive enough to detect changes in function in individuals with lower limb pathology.  The Patient-Reported Outcomes Measurement System (PROMIS) was developed to characterize outcomes among patients with specific musculoskeletal conditions.  In determining the assessment capability of this tool researchers used the PROMIS to assess differences between patients with femoroacetabular impingement and asymptomatic controls.  The PROMIS self-report assessment was responsive to FAI-associated debility and may be used to objectively assess surgical or other rehabilitative outcomes.  These results suggest that the PROMIS might be a way to practically and quickly incorporate this self-assessment tool into routine clinical practice.

Resnik, L., Borgia. M.,Silver, B., & Cancio, J. (2017). Systematic review of measures of physicalfunction and activity limitation for persons with limb trauma and amputation.Archives of Physical Medicine and Rehabilitation, (17). doi10.1016/j.apmr.2017.01.015

There are numerous tools utilized to assess functional outcomes following injury of the upper extremity.  A systematic review was pursued to identify outcome measures used in studies of persons with traumatic upper limb injury and/or amputation, and to evaluate the focus, content, and psychometric properties of each measure. The mostly highly rated performance measures included 2 amputation-specific measures: the Activities Measure for Upper Limb Amputees, and the University of New Brunswick Test of Prosthetic Function skill and spontaneity subscales.  In addition 2 non-amputation-specific measures – the Box and Block Test and modified Jebsen-Taylor Hand Function Test were highly rated.  The most highly-rated self-report measures were: Disabilities of the Arm, Shoulder and Hand; Patient Rated Wrist Evaluation; QuickDASH; Hand Assessment Tool; International Osteoporosis Foundation Quality of Life Questionnaire; and Patient Rated Wrist Evaluation functional recovery subscale. While the self-assessment tools were not amputation specific, all were considered suitable for both an amputee and non-amputee population.

Baumann,M. L., Cancio, J. M., & Yancosek, K. E. (2017). The Suitcase PackingActivity: A new evaluation of hand function. Journal of Hand Therapy, (17).doi: 10.1016/j.jht.2017.02.002

Another potential tool is the suitcase packing activity, which was developed to provide a measure of bimanual and unilateral hand function. Conceptualized to be occupation based, the tool allows for assessment of hand function by participation in the goal-directed activity of packing a suitcase.  As study evaluating the psychometric properties of this assessment tool demonstrated good to excellent interrater reliability, good to excellent test-retest reliability, and acceptable concurrent validity when compared against other currently utilized assessment tools. These results show that the suitcase packing assessment tools is a simple, low-cost, valid, and reliable tool for assessing bimanual and unilateral hand function, and shows promise in contributing to evidence-based practice by providing a quality, composite measure of hand function.

Cancio,J., Oliver, R. M., & Yancosek, K. E. (2017). Functional capacityevaluation-military: Program description and case series. Military Medicine,182(1), 1658-1664. doi: 10.7205/MILMED-D-16-00072

A functional capacity evaluation quantifies an individual’s capacity to perform activities related to employment.  Military activities differ significantly from typical activities encountered in civilian jobs.  To address this need, a functional capacity evaluation was developed for use in a military population, and included seventeen activities such as shooting, dragging, pushing, lifting, high/low crawling, and other military relevant tasks.  These tasks were assessed in 3 individuals with limb reconstruction who were using an ankle foot orthosis to assist with lower extremity function.  The Functional Capacity Evaluation – Military (FCE-M) is fully described in this article, and provides a systematic method to assess performance of military tasks.⁶⁶ Follow-on research is planned to standardize and perform psychometric testing, with hopes that in the future this tool can provide a means of assessing a Service member’s ability to return to full duty.

Sposato,L., Yancosek, K., Lospinoso, J. & Cancio, J. (2017). Psychosocial reactionsto upper extremity limb salvage: A cross-sectional study. Journal of HandTherapy. S0894-1130(17):30151-5. doi: 10.1016/j.jht.2017.05.020

Available studies indicate that individuals with lower extremity limb salvage are at risk for poor psychosocial outcomes.   In an initial study investigating outcomes related to upper extremity limb salvage researchers observed similar outcomes.  Worse psychosocial adaptation was associated with lower education, being less than 6 months post-injury, being older than 23 years, and having more pain. Dominant hand injuries were found to influence poor adaptation on the Reactions to Impairment and Disability Inventory subscale.  Studies assessing outcomes following limb salvage procedures, particularly psycho-social factors that can affect successful reintegration into the community, are needed.

Woodruff,S., Galarneau, M., Sack, D., McCabe, C., & Dye, J. (2017). Combat amputees'health-related quality of life and psychological outcomes: A brief report fromthe Wounded Warrior Recovery Project. Journal of trauma and acute care surgery,82(3), 592-595.

Conversely, a recent study in an amputee population suggests that when assessed over 5 years postinjury, on average, amputees have unique physical and functional limitations, yet do not report greater depression or PTSD symptoms than others seriously injured in combat. These findings suggest that state-of-the-art integrated amputee care that includes support networks and emphasis on adjustment and psychological health following an amputation procedure may increase successful coping and adjustment.  The reasons behind differing psycho-social outcomes between amputation and limb salvage procedures may be due to the delays experienced in returning to the fullest level of function possible, and deserves further study. 

HillO, Bulathsinhala L, Eskridge SL, Quinn K, Stinner DJ. (2016). Descriptivecharacteristics and amputation rates with use of Intrepid Dynamic ExoskeletonOrthosis.  Military Medicine, 181, 77-80.

High level functional activities are often challenging for individuals with amputation and/or severe limb trauma.  Individuals who choose limb preservation surgery are often prescribed ankle-foot orthoses (AFOs) to decrease pain and improve ambulatory function on level ground, uneven surfaces, and slopes and stairs.  An advanced orthotic bracing solution, the “Intrepid Dynamic Exoskeletal Orthosis” (IDEO), was developed by a CFI prosthetist specifically for young, active military patients who have undergone limb preservation.  The most common injury for which 624 Service members were prescribed an IDEO between 2009 and 2014 occurred at or surrounding the ankle joint, and over 80% avoided amputation within a one-year time period.

HighsmithMJ, Nelson LM, Carbone NT, Klenow TD, Kahle JT, Hill OT, Maikos JT, Kartel MS,Randolph BJ. Outcomes Associated With the Intrepid Dynamic Exoskeletal Orthosis(IDEO): A Systematic Review of the Literature. Military Medicine.181(11/12):69-76, 2016.

Modification to existing orthoses, such as the IDEO, may optimize functional outcomes. Evidence collected during a systematic literature review supports this, suggesting that strut stiffness is a patient preference that should be considered during the orthotic prescription process. Another factor that might affect orthotic performance is the location of the bending axis on the strut. With this in mind, several studies were pursued to compare functional outcomes of three AFO designs that differed in location of the bending axis of the strut (high, middle, low). Building on previous work that assessed function related to bending axis location during walking, participants ran overground while wearing a passive-dynamic AFO with posterior struts manufactured with central (middle) and off-centered (high and low) bending axes. Half of patients preferred the middle bending axis, four preferred low and two preferred high, suggesting that individual preferences and abilities should be considered when fabricating an AFO.

Brown,S. E., Russell Esposito, E., & Wilken, J. M. (2017). The effect of anklefoot orthosis alignment on walking in individuals treated for traumatic lowerextremity injuries. Journal of Biomechanics, 16(61), 51-57. doi:10.1016/j.jbiomech.2017.06.037

An additional aspect of orthotic design related to patient comfort appears to be the degree of flexion built into the orthosis.  Plantar flexion alignment of the AFO (compared to neutral and dorsiflexed) resulted in earlier center of pressure progression and a resulting decrease in both internal knee extensor moment and quadriceps and soleus muscle activity, with 8/12 patients preferring this plantar flexion alignment.

Ikeda,A. J., Fergason, J. R., & Wilken, J. M. (2017). Effects of altering heelwedge properties on gait with the Intrepid Dynamic Exoskeletal Orthosis. Prosthetics and Orthotics International,(Sep). doi: 10.1177/0309364617728116

Patients walked over level ground in the IDEO and six different heel wedges (soft or firm durometer, and 1, 2, or 3 cm height), which also incorporate a slight degree of plantar flexion. Patients preferred durometer and height that produced mechanics similar to able-bodied individuals.  Changing wedge height and durometer is a simple, straightforward way to alter loading of the foot with great potential to improve an individual’s gait.

Hsu,J. R., Owens, J. G., DeSanto, J., Fergason, J. R., Kuhn, K. M., Potter, B. K.,Stinner, D. J., Sheu, R. G., Waggoner, S. L., Wilken, J. M., Huang, Y.,Scharfstein, D. O., & MacKenzie, E. J. (2017). Patient Response to anIntegrated Orthotic and Rehabilitation Initiative for Traumatic Injuries: ThePRIORITI-MTF Study. Journal ofOrthopaedic Trauma, 31(1), 56-62. doi: 10.1097/BOT.0000000000000795

Evidence supports that use of the IDEO, combined with the Return to Run physical therapy program, can decrease pain, improve agility, power, and speed, and may allow return to duty in a population of high-functioning patients. The successful outcomes observed in a series of clinical studies led to a prospective multi-site clinical trial, as described in this publication. It is our hope that this study will eventually provide generalizable outcomes for this unique program, and evidence-based support for implementing this multidisciplinary intervention across the nation.

HighsmithMJ, Kahle JT, Klenow TD, Andrews CR, Lewis KL, Bradley RC, Ward JM, Orriola JJ,Highsmith JT. Interventions to Manage Residual Limb Ulceration Due ToProsthetic Use in Individuals with Lower Extremity Amputation: A SystematicReview of the Literature. Technology & Innovation 18(2), 115-123, 2016.

Ulcers or pressure sores are among the more common skin conditions in prosthetic users.  This can occur from shear forces, humidity, and moisture at the skin-socket interface.  Prevention is key, however evidence from a meta-analysis suggests that continued prosthetic use is a viable option to manage a residual limb with minor early stage ulceration in a compliant patient lacking comorbidities that may delay healing. Conversely, prosthetic discontinuance is also a viable method of residual limb ulcer healing in the presence of multiple comorbidities that may delay healing.³¹ Therefore, it is clinically important to study factors within a socket that can prevent detrimental movement that can lead to skin damage.

KahleJT, Klenow TD, Highsmith MJ. Comparative Effectiveness of an AdjustableTransfemoral Prosthetic Interface Accommodating Volume Fluctuation: Case Study.Technology & Innovation, 18(2), 167-173, 2016.

The standard of care socket interface doesn’t offer inherent adjustability. A case analysis compared a non-adjustable transfemoral socket to a novel adjustable transfemoral socket interface, and noted that the adjustable socket produced superior subjective and performance outcomes. There is a critical need for further study into advanced technologies that might optimize the stump-socket interface.

LuraDJ, Wernke MW, Carey SL, Kahle JT, Miro RM, Highsmith MJ. Crossover study ofamputee stair ascent and descent biomechanics using Genium and C-Leg prostheseswith comparison to non-amputee control. Gait Posture. 58, 103-107, 2017.

The Genium knee offers a more advanced sensor array than the C-leg, and improvements in perceived function have been observed.  When comparing the two knee systems during stair ascent the Genium knee decreased deficiency in gait patterns by enabling gait patterns that more closely resembled non-amputees.  Further comparative studies will contribute greatly to understanding how a particular prosthetic device responds to specific physical challenges, leading to optimized prosthetic prescription for our patients.

Pickle,N. T., Silverman, A. K., Wilken, J. M., & Fey, N. P. (2017). Segmentalcontributions to sagittal-plane whole-body angular momentum when using poweredcompared to passive ankle-foot prostheses on ramps. IEEE InternationalConference on Rehabilitation Robotics, (Jul), 609-1614. doi:10.1109/ICORR.2017.8009478

The contributions of individual body segments to overall whole body mechanics throughout the gait cycle may yield further insights, specifically for people with transtibial amputation using powered prostheses. When comparing passive with powered ankle prostheses, a powered prosthesis generated more normative biomechanics in the trunk during prosthetic leg push-off when negotiating inclines, and resembles more closely the biomechanical function of the soleus muscle. There was little or no difference, however, between the passive and powered prostheses at declines of -5° and -10°, suggesting that neither passive nor active prostheses replicate soleus function on declines.

Rabago,C. A., Whitehead, J. M., & Wilken, J. M. (2016). Evaluation of a poweredankle-foot prosthesis during slope ascent gait. Public Library of Science One,181(S4), 30-37. doi: 10.1671/journal.pone.0166815

An additional study comparing powered and passive ankle prostheses on knee mechanics when walking up an incline found that use of a powered ankle prosthesis increased ankle plantarflexion and push-off power when transitioning off the prosthetic limb. This contributed to decreased intact limb knee extensor power production, lessening demand on the intact limb knee.

HighsmithMJ, Klenow TD, Kahle JT, Wernke MW, Carey SL, Miro RM, Lura DJ. Effects of theGenium Microprocessor Knee System on Knee Moment Symmetry During Hill Walking.Technology & Innovation 18(2), 151-157, 2016.

Use of the Genium microprocessor knee system by individuals with transfemoral amputation reportedly improves knee kinematics during walking on both flat surfaces and hills. Given the improved kinematics associated with hill walking, researchers sought to assess the impact of the Genium on knee mechanics. When ambulating on a five degree ramp, the Genium knee system improved knee moment symmetry during both incline and decline walking compared with C-Leg. Results of this work suggest that the Genium microprocessor knee system may be a desirable intervention for patients with transfemoral limb loss who range in function from high-functioning community ambulators to older amputees who walk slower and require more consistent knee performance.

KahleJT, Highsmith MJ, Schaepper H, Johannesson A, Orendurff MS, Kaufman K. Predicting Walking Ability Following Lower Limb Amputation: An UpdatedSystematic Literature Review. Technology & Innovation 18(2), 125-137, 2016.

Determining the appropriate prosthetic prescription and functional level potential is an important aspect of care for patients with amputation.  Little is known about which factors might best predict the best outcomes when prescribing a prosthesis.  In a recent meta-analysis moderate to strongly supported predictive factors of prosthetic candidacy were determined to be etiology, physical fitness, pre-amputation living status, amputation level, age, physical fitness, and comorbidities. These factors are supported in an earlier literature review and should be strongly considered in a complete history and physical examination by a multidisciplinary team.

HighsmithMJ, Kahle JT, Lewandowski A, Klenow TD, Orriola JJ, Miro RM, Hill OT,Raschke  SU, Orendurff MS, Highsmith JT,Sutton BS. Economic Evaluations of Interventions for Transtibial Amputees: AScoping Review of Comparative Studies. Technology & Innovation 18(2),85-98, 2016.

As the cost of prosthetic devices becomes higher with increasing technology, economic analyses of prosthetic interventions are needed in order to determine value related to device provision and maintenance, outcomes, and health. A recent review sought to formulate evidence statements related to prosthetic interventions for persons with transtibial amputation from an economic evaluation perspective based solely on comparative studies. The findings concluded with moderate confidence that specific weight-bearing and total-contact sockets for transtibial amputees are functionally and economically equivalent in the short term when costs, delivery time, and all stakeholder perspectives are considered.  Long-term socket outcomes are relatively unexplored, and further research in this area is needed to optimize prosthetic prescription recommendations.

HighsmithMJ, Kahle JT, Miro RM, Cress ME, Lura DJ, Quillen WS, Carey SL, Dubey RV,Mengelkoch LJ. Functional performance differences between the Genium and C-Legprosthetic knees and intact knees. J Rehabil Res Dev. 53(6), 753-766, 2016.

Engineering advancements incorporated into the Genium microprocessor knee include a sagittal knee moment sensor, angle sensor, and gyroscope, which have the potential to increasingly replicate normal knee motion. Comparisons were made to assess functional outcomes between the advanced knee prosthesis Genium and the C-Leg, prescribed frequently for our patients. Genium use improved upper-body flexibility, balance, and endurance domain scores compared with the C-Leg.  Only in the endurance domain did Genium users score sig­nificantly lower than nonamputees. Regardless of knee condition, subjects with transfemoral amputation did not equal or surpass nonamputees in any functional domain, suggesting room for continued technological improvements in prosthetic knee functional parameters.

HighsmithMJ, Kahle JT, Wernke MM, Carey SL, Miro RM, Lura DJ, Sutton BS. Effects of theGenium Knee System on Functional Level, Stair Ambulation, Perceptive andEconomic Outcomes in Transfemoral Amputees. Technology & Innovation 18(2),139-150, 2016.

This study noted that the laboratory determined benefits of the Genium over the C-leg were supported by common clinical benefits.  Use of the Genium improved stair walking performance, multi-directional stepping, functional level, and perceived function. In this group of community ambulators with transfemoral amputation the Genium was preferred, suggesting that while more costly, the significant improvements in functional performance were worth the additional cost.

HighsmithMJ, Kahle JT, Miro RM, Lura DJ, Carey SL, Wernke MW, Kim SH, Quillen WS.Differences in Military Obstacle Course Performance Between ThreeEnergy-Storing and Shock Adapting Prosthetic Feet in High-FunctioningTranstibial Amputees: A Double-Blind, Randomized Control Trial. MilitaryMedicine. 181(11/12):45-54, 2016.

Military Service members with transtibial amputation function at a level beyond basic ambulation. As many injured Service members would like to return to high-performance activities commensurate with return to duty, efforts are ongoing to demonstrate which prosthetic feet maximize this possibility. A field-based study compared three prosthetic feet (Ossur Variflex, Endolite Elite Blade, and Ossur Re-Flex Rotate) during performance on an obstacle course.  While no clear differences in prosthetic feet emerged during obstacle course completion individual task performance, perceived effort, and preference resulted in trends of slight performance improvement with and preference for Elite Blade,⁴² a dual function energy-storing and return foot combined with vertical shock absorption. Controls completed the obstacle course faster and with less effort than individuals with amputation regardless of prosthetic foot, suggesting further advances in prosthetic technologies are needed to optimize high level performance activities.

HighsmithMJ, Kahle JT, Miro RM, Mengelkoch LJ. Bioenergetic Differences During Walkingand Running in Transfemoral Amputee Runners Using Articulating andNon-Articulating Knee Prostheses. Technology & Innovation, 18(2), 159-165,2016

Running is an activity that is part of military service and, as such, is an important goal of many Service members.  For transfemoral amputees running presents a challenge in that they have lost knee function.  Some distance runners with transfemoral amputation prefer to run with a prosthesis that has a non-articulating knee joint, as they feel that it controls knee buckling that can occur with an articulating knee mechanism.  A study comparing outcomes between articulating and non-articulating running prostheses noted decreased energy expenditure, lower perceived exertion, faster self-selected walking and running speeds, and a subjective preference for the articulated knee condition. These findings suggest that for trained runners with transfemoral amputation a running prosthesis with an articulating knee may be preferred.

RandolphBJ, Nelson LM, Highsmith MJ. A Review of Unique Considerations for FemaleVeterans With Amputation. Military Medicine. 181(11/12):66-68, 2016.

Dissatisfaction with prosthetic fit and appearance tends to be higher in the female population living with limb loss. A recent review provides an overview of considerations unique to female Veterans with amputation.These include the need for smaller componentry that suits a smaller frame size, a need to adapt to changes that occur during pregnancy, and the higher occurrence of osteoporosis as a woman ages. These factors need to be taken into account if treatment strategies are to be successful and gaps in commercially available products and research are going to be appropriately identified. Defining the population of women Veterans with amputation and their needs is the next step in generating research priorities for this population.

Resnik,L., Cancio, J., Klinger, S., Latlief, G., Sasson, N., & Smurr-Walters, L.(2017). Predictors of retention and attrition in a study of an advanced upperlimb prosthesis: Implications for adoption of the DEKA Arm. Disability andRehabilitation Assistive Technology, (April), 1-5. doi:10.1080/17483107.2017.1304585

The DEKA Gen 3 arm is a novel upper limb prosthesis recently approved by the Food and Drug Administration, and features enhanced ability to perform the complex movements required to increase dexterity and movement quality. As a step to identify and target the most appropriate candidates for prescription of the DEKA Arm prescription a home study was undertaken.  Results from this study, for which completion of the home use study was a reasonable proxy for participant willingness to adopt the device, found that those most likely to be successful adopters were already using a personal prosthesis and were free of pre-existing musculoskeletal problems.  Further work is ongoing to optimize function of the DEKA arm and other available prosthetic devices for the upper extremity.

Stacy,M. R., & Dearth, C. L. (2017). Multimodality imaging approaches forevaluating traumatic extremity injuries: Implications for military medicine.Advances in Wound Care, 6(7), 241-251, doi: 10.1089/wound.2016.0716

Traumatic extremity injuries require rapid diagnosis and treatment to facilitate optimal patient outcomes.  A variety of imaging modalities are available for non-invasive assessment following extremity trauma, and include ultrasound,  computed tomography (CT), magnetic resonance imaging (MRI), and radiotracer imaging with SPECT and PET.  A recent review describes the advantages and disadvantages to each.  Disadvantages that include exposure to radiation, high cost, non-portability, long image acquisition times, and other challenges support a continued clinical need for noninvasive quantitative imaging techniques that are capable of providing rapid objective assessments of residual limb health at the time of initial presentation, as well as after various forms of medical treatment.

RussellEsposito, E., Stinner, D. J., Fergason, J. R., & Wilken, J. M. (2017). Gaitbiomechanics following lower extremity trauma: Amputation vs. reconstruction.Gait Posture, 54(May), 167-173. doi: 10.1016/j.gaitpost.2017.02.016

Surgical advances have substantially improved outcomes for individuals who have undergone limb reconstruction surgery, and there is a growing body of knowledge to inform clinicians and patients on functional expectations when considering amputation or limb reconstruction.   A recent study comparing functional outcomes between patients with amputation and limb reconstruction found that the reconstruction group exhibited less ankle power and range of motion while the amputee group exhibited lower knee flexor and extensor moments and power generation.⁶ This suggests that surgical interventions that preserve or improve ankle function can play a role in the decision to choose limb preservation over amputation.

Ranz,E. C., Wilken, J. M., Gajewski, D. A., & Neptune, R. R. (2017). Theinfluence of limb alignment and transfemoral amputation technique on musclecapacity during gait. Computer Methods in Biomechanical and BiomedicalEngineering, 20(11), 1167-1174. doi: 10.1080/10255842.2017.1340461

Advanced musculoskeletal modeling techniques suggest that femur length may have little effect if surgical procedures are employed that preserved muscle tension.  In a musculoskeletal modeling study looking at the influence of various surgical options, muscle wrap techniques had little effect on muscle capacity, while muscle tension had the greatest influence. This analysis suggests that myodesis stabilization, which allows for greater muscle tension, may provide superior hip muscle balance and function compared to myoplasty stabilization or when leaving muscles unattached.

KahleJT, Highsmith MJ, Kenney J, Ruth T, Lunseth PA, Ertl J. The Effectiveness ofthe Bone Bridge Transtibial Amputation Technique: A Systematic Review ofHigh-Quality Evidence. Prosthet Orthot Int, 2016;(epub ahead of print):1-8

An ongoing debate exists as to whether the ERTL bone bridging procedure, which creates a boney bridge between the distal tibia and fibula following amputation, contributes to a more efficient platform in the total-surface-bearing socket.  A comprehensive systematic review undertaken in FY17 reported that current level III evidence supports a bone bridge technique as an equivalent option to the non-bone bridge transtibial amputation technique, and suggests that formal level I and II clinical trials will need to be undertaken to answer this question sufficiently to make a recommendation that can guide clinical practice.

HighsmithJT, Weinstein DA, Highsmith MJ, Etzkorn JR. Biopsy 1-2-3 in DermatologicSurgery: Improving Smartphone Use to Avoid Wrong-site Surgery. Technology &Innovation 18(2), 203-206, 2016.

With the increasing need to provide care for patients who are geographically dispersed, advanced communication capabilities may increasingly provide a real-time universal “tele-health” platform for interface between clinicians and patients.  A case report described a step-by-step procedure that a patient can use to relay photographic images related to their care to their clinicians through use of a Smartphone.¹⁸   In this case the information was limited to a potential biopsy site, however the potential exists to utilize photos sent by the patient as requested by the provider to assist in the medical care of a patient.  It is possible that use of a photo that would come from the patient’s own smartphone device may not violate privacy acts and, as such, might facilitate care provided when patients are remote from a clinic, and placed within the medical record to document care.

AlMuderis M, Bosley BA, Florschutz AV, Lunseth PA, Klenow TD, Highsmith MJ, KahleJT. Radiographic Assessment of Extremity Osseointegration for the Amputee.Technology & Innovation 18(2), 211-216, 2016.

The current standard of care for persons with limb loss is use of an artificial limb with a socket attached to prosthetic limb components.  Though significant technological advances have been made in prosthetic technologies, the stump-socket interface remains a clinical challenge.  Problems include limb volume changes over time and during activities, sweating, suspension techniques, pain, and skin breakdown.  The surgical practice of osseointegration offers a new and exciting option for patients for whom the use of an artificial limb is challenging.  This procedure is in its infancy, and offers a rich environment for investigation that builds on previous work in the field of joint replacement surgery. 

A recent study utilized a modification of the radiographic zonal analysis (Gruen zones) used in orthopedic intramedullary implant evaluation to address the need for a common reference standard for osseointegration in an amputated extremity.  This OGA Zonal analysis, developed by a team of clinicians in Australia who are one of the pioneers of the osseointegration technique, provides a method for observing changes in extremity bone resulting from an osseointegrated implant.¹⁹   This provides a radiographic standard that can contribute to optimizing this procedure, with the hopes that osseointegration might become as successful for patients with amputation as intramedullary joint replacement has for individuals with debilitating arthritic change.

Greising,S. M., Dearth, C. L., & Corona, B. T. (2016). Regenerative and rehabilitativemedicine:  A necessary synergy forfunctional recovery from volumetric muscle loss injury. Cells Tissues Organs,202(3-4), 237-249. doi: 10.1159/000444673

Clinical observations and the existing literature suggests that traditional physical therapy does not significantly restore muscle strength or limb function in patients with volumetric muscle loss (VML). An emerging field of research, “regenerative rehabilitation”, is investigating the potential for synergizing regenerative and rehabilitative therapies to restore limb and muscle function following VML.  Currently there is no standard of care related to rehabilitative therapies for patients with VML, though emerging therapies are in various stages of development or clinical testing.  A recent review highlighted current clinical strategies of rehabilitation in patients with VML, and presented a summary of generalizable preclinical findings that may lead to evidence-based opportunities for multidisciplinary collaboration between these clinical and research fields.

Dziki,J. L., Giglio, R. M., Sicari, B. M., Wang, D. S., Gandhi, R. M., Londono, R.,Dearth, C. L. & Badylak, S. F. (2017). The effect of mechanical loadingupon extracellular matrix bioscaffold-mediated skeletal muscleremodeling. Tissue Engineering Part A. (epub ahead of print) doi:https://doi.org/10.1089/ten.tea.2017.0011

Mounting evidence suggests that site-appropriate loading of implanted extracellular matrix (ECM) bioscaffolds and the surrounding skeletal muscle microenvironment could enhance the development of functional muscle tissue.  A mouse hind limb unloading VML model was used to evaluate the effect of mechanical loading after ECM implantation, and showed that myoblast chemotaxis and differentiation and isometric torque production was positively influenced by mechanical loading.⁹  This work supports the importance of incorporating a multidisciplinary approach that emphasizes rehabilitation following surgical regenerative medicine interventions.  Future studies are planned to further explore these phenomenon and others, all in an effort optimize the restoration of tissue form and function following extremity trauma.