Military Medicine International Journal of amsus raising the bar: extremity trauma care guest editors
Yüklə 2,47 Mb. Pdf görüntüsü
|
|
however, it may bear consideration in future studies. Accommodation with study feet was 7 days per component in this study and 21 days with the duplicate socket. Socket accommodation was consistent with other transtibial studies who also reported 21 days. 34 In terms of feet components, the 7-day accommodation utilized here was substantially longer than the 30-minute accommodation 35 used in some foot studies, but notably shorter than the 4 weeks 30,36
used in others. There is no agreed on accommodation time for prosthetic componentry. Thus, confounding related to a lack of full accommodation can never be completely ruled out; however, we were con fident subjects were proficient in the use of all study feet at the point of assessment. Unlike other prosthetic considerations discussed thus far, the prosthetic foot design was the independent variable. One of the study ’s hypotheses was that foot mass would have been a key variable to impact function. The Vari flex is an ESR foot shown to improve stride length and bioenergetic ef ficiency during ambulation, stair ascent kinetics, and to reduce fatigue. The other two feet studied incorporated both ESR and additional functions. The Elite Blade also incorpo- rates vertical shock absorption and the Re-Flex Rotate incor- porates vertical shock and torsional force absorption. These two additional features engineered into the Re-Flex Rotate increase component mass by 13% to 21% compared with the Vari flex and Elite Blade, respectively ( p ≤ 0.05). Despite the signi ficant difference in mass between com- ponents, the 1.4% to 5.6% difference between prosthetic feet in overall OC completion time was not statistically signi fi- cant. However, in two speci fic tasks, climbing the chain-link fence and the sprint finish, use of the Elite Blade resulted in an 11.4% (compared to Vari flex; chain-link fence) and a 10.6% (compared to Vari flex and Re-Flex Rotate) reduced completion time ( p ≤ 0.05). Although component mass may have been a factor, it is unlikely to have been the sole factor for the difference. Because the Elite Blade ’s energy storage and return capabilities, kinetics, ambulatory ef ficiency, and other factors have yet to be studied, it is not possible to determine which of these or other attributes of the Elite- Blade provide an advantage for these speci fic tasks. How- ever, the addition of vertical shock function to an ESR foot has been shown to provide biomechanical advantages during stair climbing and in ambulatory ef ficiency and may have played a role. 13,27
Also noteworthy in terms of individual task function is the fact that use of the Re-Flex Rotate resulted in increased task completion time compared with the Vari flex (10.6%; p ≤ 0.05). As previously mentioned, while evidence sup- ports improved lower extremity stair-climbing kinetics and improved gait ef ficiency when ESR and vertical shock absorption are combined, authors were unable to locate evidence to suggest ambulatory speed increases with fur- ther addition of torsional force absorption. Conversely, dur- ing circular turning maneuvers, 1 report shows addition of a torsion adapter results in comparable movement speed. 37 These data suggest that some combination of additional component mass or the increased control needed to utilize the torsion adapter element of the Re-Flex Rotate, resulted in a decreased sprint time following a period of rigorous task completion. There are, however, clinical reports of bene fits of torsional absorption in terms of favorable bene- fits to skin of the residual limb that may be preferable despite potential limitations to functional performance. 38 The Re-Flex Rotate stood out in individual tasks com- pared with controls. Although control subjects completed the OC faster (31 –35%; p ≤ 0.05), and completed 13/17 tasks faster ( p ≤ 0.05) than TTA regardless of foot condition, con- trols were signi ficantly faster than TTA when using Re-Flex Rotate for completing the culvert and angle tube obstacles (16.7% and 46.0%, respectively; p ≤ 0.05). These two tasks were not signi ficantly different than controls when TTA used Elite Blade and Vari flex feet. The culvert obstacle requires ducking to crawl through a concrete culvert (3 ft or 0.9 m diameter × 8 ft or 2.4 m length), standing up out of the first culvert, turning 180°, ducking and crawling through a second culvert (identical size). The angle tube is a plastic pipe (com- parable size to the culvert obstacle) that must be crawled through after climbing upward into the pipe (3.8 ft or 1.2 m from the ground). The pipe is angled on a 4° incline so the subject exits the pipe 0.2 m higher than the start (4.7 ft or 1.4 m elevation). It is not clear how the Re-Flex Rotate may challenge function while crawling through the culverts unless perhaps the user is attempting to accept body weight through a transversely rigid foot that is rotating and thus requiring additional effort and time to control. In addition, on the culvert obstacle, the stand and turn maneuver may require added time and effort to control as does the climb into and landing from the angle tube obstacle. Nevertheless, use of the Elite Blade and Vari flex did not result in sig- ni ficant time delays compared to controls as the Re-Flex Rotate foot condition did. Perceptively, there were no signi ficant differences between prosthetic feet. Vari flex and Elite Blade yielded RPE (median) of 18.5/20, whereas Re-Flex Rotate yielded 18/20 immediately following OC completion. Although the Re-Flex Rotate ’s median RPE was lower, it yielded the same RPE range as Vari flex (15–20), whereas Elite Blade yielded the lowest MILITARY MEDICINE, Vol. 181, November/December Supplement 2016 52 Energy-Storing and Shock-Adapting Prosthetic Feet in Transtibial Amputees RPE range at 13 to 20. Although no foot condition emerged as a clear overall advantage in this test battery, the Elite Blade yielded multiple trends of improvement which were given con firmation by being selected by half of study sub- jects while blinded to condition. Interestingly, more than twice as many participants preferred the Re-Flex Rotate rela- tive to Vari flex despite trends of performance advantages favoring Vari flex. Considering other potential benefits of the Re-Flex Rotate, perhaps TTA are willing to trade nonsigni fi- cant differences in performance for greater comfort with this component. This finding is consistent with evidence-based practice, which places as much emphasis on patient prefer- ence as it does empirical evidence. LIMITATIONS Although there were no skin-related or performance com- plaints to suggest suspension issues, suspension was not controlled and could be a factor related to performance. Study feet were not blinded during training and accommoda- tion as study personnel felt it was important to train subjects on individual attributes of the feet. This could have led to some level of kinesthetic or other familiarity with the com- ponents that cued subjects to identi fication even while masked during testing. This could potentially be con firmed
in future studies, however, the success of masking was not assessed. Also impacting results may have been the choice to acclimate subjects with study feet in a singular, extended time block as opposed to individually acclimating and then assessing with each foot. Finally, there are multiple statisti- cal modeling approaches available to analyze these data. For instance, the OC used in this study could be viewed as a single task or as individual obstacle tasks. The primary hypothesis for this study sought to address overall perfor- mance. Thus, multitest correction was not incorporated into the analysis. Incorporation of multitest correction may have resulted in minor differences between prosthetic feet in indi- vidual obstacle outcomes, but would have been unlikely to impact overall outcomes. CONCLUSIONS This study has quanti fied performance differences between highly mobile TTAs with optimized prosthetic componentry and able-bodied controls in a never before studied field OC
environment. This could assist in determining the potential for retention of already trained soldiers following TTA. 6,31 Ultimately, nonamputee SWAT team members completed a military equivalent OC signi ficantly faster and with less effort than a group of high-functioning transtibial amputees regardless of prosthetic foot condition. There were no clear differences in prosthetic feet when completing the OC; how- ever, individual task performance, perceptive measures, and preference resulted in trends showing a slight improvement in performance with and preference for the Elite Blade, which is a dual function ESR foot combined with vertical shock absorption. Ultimately, patient preference should be regarded highly during foot selection and prescription. Understanding how to maximally improve performance in such functional tasks may allow soldiers to best sustain physical
fitness, return to their military occupational spe- cialty and possibly in-theater duty. Data from this study have identi fied trends in the tested prosthetic feet to assist in optimizing performance in these activities, which can reduce wasteful costs associated with the current practice of trial- and-error foot selection based on anecdotal evidence. ACKNOWLEDGMENTS We wish to thank Ms. Kaitlin Lostroscio for assistance processing study data and Mr. Steven Springer for assistance with subject recruitment. Sheriff David Gee, Maj Alan Hill, and Sgt. Edmond Shea of the Hillsborough County Sheriff ’s Department provided vital assistance with facility access, training, and safety monitoring throughout study activities. This project was funded by the U.S. Department of Defense, Congressionally Directed Medi- cal Research Program (DOD-CDMRP) Project No. W81XWH-112-0170 (U.S.F. Grant No. 10193006). REFERENCES 1. Stansbury LG, Lalliss SJ, Branstetter JG, Bagg MR, Holcomb JB: Amputations in U.S. military personnel in the current con flicts in Afghanistan and Iraq. J Orthop Trauma 2008; 22(1): 43 –6. 2. Potter BK, Scoville CR: Amputation is not isolated: an overview of the US Army Amputee Patient Care Program and associated amputee inju- ries. J Am Acad Orthop Surg 2006; 14(10 Spec No.): S188 –90. 3. Krueger CA, Wenke JC, Ficke JR: Ten years at war: comprehen- sive analysis of amputation trends. J Trauma Acute Care Surg 2012; 73(6 Suppl 5): S438 –44. 4. Stansbury LG, Branstetter JG, Lalliss SJ: Amputation in military trauma surgery. J Trauma 2007; 63(4): 940 –4.
5. Kaluf B: Evaluation of mobility in persons with limb loss using the amputee mobility predictor and the prosthesis evaluation questionnaire — mobility subscale: a six month retrospective chart review. J Prosthet Orthot 2014; 26(2): 70 –6.
6. Stinner DJ, Burns TC, Kirk KL, Ficke JR: Return to duty rate of ampu- tee soldiers in the current con flicts in Afghanistan and Iraq. J Trauma 2010; 68(6): 1476 –9. 7. Hofstad C, Linde H, Limbeek J, Postema K: Prescription of prosthetic ankle-foot mechanisms after lower limb amputation. Cochrane Database Syst Rev 2004(1): CD003978. 8. Menard MR, Murray DD: Subjective and objective analysis of an energy-storing prosthetic foot. J Prosthet Orthot 1989; 1: 220 –30. 9. Nielsen DH, Shurr DG, Golde JC, Meier K: Comparison of energy cost and gait ef ficiency during ambulation in below-knee amputees using different prosthetic feet: a preliminary report. J Prosthet Orthot 1988; 1: 24 –31. 10. Torburn L, Powers CM, Guiterrez R, Perry J. Energy expenditure during ambulation in dysvascular and traumatic below-knee amputees: a comparison of five prosthetic feet. J Rehabil Res Dev 1995; 32(2): 111 –9.
11. Torburn L, Perry J, Ayyappa E, Shan field SL: Below-knee amputee gait with dynamic elastic response prosthetic feet: a pilot study. J Rehabil Res Dev 1990; 27(4): 369 –84. 12. Macfarlane PA, Nielsen DH, Shurr DG, Meier K: Perception of walk- ing dif ficulty by below-knee amputees using a conventional prosthetic foot. J Prosthet Orthot 1991; 3: 150 –61.
13. Yack H, Nielsen D, Shurr D: Kinetic patterns during stair ascent of patients with trans-tibial amputations wearing three different prostheses. J Prosthet Orthot 1999; 3: 57 –62.
MILITARY MEDICINE, Vol. 181, November/December Supplement 2016 53 Energy-Storing and Shock-Adapting Prosthetic Feet in Transtibial Amputees 14. Mengelkoch LJ, Kahle JT, Highsmith MJ: Energy costs and perfor- mance of transtibial amputees and non-amputees during walking and running. Int J Sports Med 2014; 35(14): 1223 –8.
15. Seymour R, Engbretson B, Kott K, et al: Comparison between the C-leg microprocessor-controlled prosthetic knee and non-microprocessor con- trol prosthetic knees: a preliminary study of energy expenditure, obsta- cle course performance, and quality of life survey. Prosthet Orthot Int 2007; 31(1): 51 –61.
16. Adams J, Roberts J, Simms K, Cheng D, Hartman J, Bartlett C: Mea- surement of functional capacity requirements to aid in development of an occupation-speci fic rehabilitation training program to help fire- fighters with cardiac disease safely return to work. Am J Cardiol 2009; 103(6): 762 –5. 17. Harman EA, Gutekunst DJ, Frykman PN, et al: Prediction of simulated battle field physical performance from field-expedient tests. Mil Med 2008; 173(1): 36 –41.
18. Kuyk T, Elliott JL, Biehl J, Fuhr PS: Environmental variables and mobility performance in adults with low vision. J Am Optom Assoc 1996; 67(7): 403 –9.
19. Mahoney J, Euhardy R, Carnes M: A comparison of a two-wheeled walker and a three-wheeled walker in a geriatric population. J Am Geriatr Soc 1992; 40(3): 208 –12.
20. Means KM, O ’Sullivan PS: Modifying a functional obstacle course to test balance and mobility in the community. J Rehabil Res Dev 2000; 37(5): 621 –32. 21. Nindl BC, Leone CD, Tharion WJ, et al: Physical performance responses during 72 h of military operational stress. Med Sci Sports Exerc 2002; 34(11): 1814 –22. 22. Webster JS, Cottam G, Gouvier WD, Blanton P, Beissel GF, Wofford J: Wheelchair obstacle course performance in right cerebral vascular accident victims. J Clin Exp Neuropsychol 1989; 11(2): 295 –310. 23. Bishop PA, Fielitz LR, Crowder TA, Anderson CL, Smith JH, Derrick KR: Physiological determinants of performance on an indoor military obstacle course test. Mil Med 1999; 164(12): 891 –6. 24. Meier MR, Hansen AH, Gard SA, McFadyen AK: Obstacle course: users ’ maneuverability and movement efficiency when using Otto Bock C-Leg, Otto Bock 3R60, and CaTech SNS prosthetic knee joints. J Rehabil Res Dev 2012; 49(4): 583 –96. 25. Pandorf CE, Nindl BC, Montain SJ, et al: Reliability assessment of two militarily relevant occupational physical performance tests. Can J Appl Physiol 2003; 28(1): 27 –37. 26. Borg GA: Psychophysical bases of perceived exertion. Med Sci Sports Exerc 1982; 14(5): 377 –81.
27. Hsu M, Nielsen DH, Yack HJ, Shurr DG: Physiological measurements of walking and running in people with transtibial amputations with 3 different prostheses. J Orthop Sports Phys Ther 1999; 29(9): 526 –33.
28. Cohen J (editor): Statistical Power Analysis for the Behavioral Sci- ences, Ed 2. Hillsdale, NJ, Erlbaum, 1988. 29. Krueger CA, Wenke JC, Ficke JR: Ten years at war: comprehen- sive analysis of amputation trends. J Trauma Acute Care Surg 2012; 73(6 Suppl 5): S438 –44.
30. Perry J, Boyd LA, Rao SS, Mulroy SJ: Prosthetic weight acceptance mechanics in transtibial amputees wearing the Single Axis, Seattle Lite, and Flex Foot. IEEE Trans Rehabil Eng 1997; 5(4): 283 –9.
31. Kishbaugh D, Dillingham TR, Howard RS, Sinnott MW, Belandres PV: Amputee soldiers and their return to active duty. Mil Med 1995; 160(2): 82 –84.
32. Pandorf CE, Harman EA, Frykman PN, Patton JF, Mello RP, Nindl BC: Correlates of load carriage and obstacle course performance among women. Work 2002; 18(2): 179 –189.
33. Blough DK, Hubbard S, McFarland LV, Smith DG, Gambel JM, Reiber GE: Prosthetic cost projections for servicemembers with major limb loss from Vietnam and OIF/OEF. J Rehabil Res Dev 2010; 47(4): 387
–402. 34. Klute GK, Berge JS, Biggs W, Pongnumkul S, Popovic Z, Curless B: Vacuum-assisted socket suspension compared with pin suspension for lower extremity amputees: effect on fit, activity, and limb volume. Arch Phys Med Rehabil 2011; 92(10): 1570 –5. 35. Underwood HA, Tokuno CD, Eng JJ: A comparison of two prosthetic feet on the multi-joint and multi-plane kinetic gait compensations in individuals with a unilateral trans-tibial amputation. Clin Biomech (Bristol, Avon) 2004; 19(6): 609 –16.
36. Zmitrewicz RJ, Neptune RR, Walden JG, Rogers WE, Bosker GW: The effect of foot and ankle prosthetic components on braking and propulsive impulses during transtibial amputee gait. Arch Phys Med Rehabil 2006; 87(10): 1334 –9. 37. Segal AD, Orendurff MS, Czerniecki JM, Shofer JB, Klute GK: Local dynamic stability of amputees wearing a torsion adapter compared to a rigid adapter during straight-line and turning gait. J Biomech 2010; 43(14): 2798 –803.
38. Cummings S, Highsmith MJ, Kahle JT, et al: Interdisciplinary Man- agement of Patients with Complex Lower Extremity Amputation. Orga- nized Session(OS2). Joint AAOP/APTA programming at the National Meeting: American Academy of Orthotists and Prosthetists. Atlanta, GA. Available at http://opsolutions.us/encyclopedia; accessed July 21, 2016. MILITARY MEDICINE, Vol. 181, November/December Supplement 2016 54 Energy-Storing and Shock-Adapting Prosthetic Feet in Transtibial Amputees MILITARY MEDICINE, 181, 11/12:55, 2016 Functional Outcomes of Service Members With Bilateral Transfemoral and Knee Disarticulation Amputations Resulting From Trauma Barri L. Schnall, MPT*; MAJ Yin-Ting Chen, MC USA*; Elizabeth M. Bell, BS*†; Erik J. Wolf, PhD*†; Jason M. Wilken, PT, PhD†‡ ABSTRACT As longitudinal studies for those with bilateral transfemoral amputation (BTFA) or knee disarticulation (KD) are lacking, it is important to quantify performance measures during rehabilitation in an effort to determine reasonable expectations and trends that may in fluence the rehabilitation process. At initial evaluation (date of first independent ambulation) and follow up (median 135 [range = 47 –300] days later), 10 participants with BTFA/KD completed 6 minute walk testing and Activity Speci fic Balance Confidence and Lower Extremity Functional Scale questionnaires. Of these, six participants also completed stair ambulation; ascent time and stair assessment index (SAI) scores were calculated. Patients utilized their prescribed prostheses at each visit. Participants were able to cover a sig- ni ficantly greater distance (135.3 [70.1] m) in 6 minutes at the follow-up visit (*p = 0.005). The change in SAI scores for stair ascent and descent was not statistically signi ficant ( p = 0.247). Stair ambulation confidence scores were signif- icantly greater at the final visit (*p = 0.034). Stair negotiation appears to plateau early; however, confidence builds despite absence of functional gains over time. Service members with BTFAs/KDs are able to achieve functional com- munity ambulation skills. Thus, this investigation suggests that clinicians can realign rehabilitation paradigms to shift focus towards community distance ambulation once safe stair ascent and descent is achieved. INTRODUCTION Recent con flicts in Iraq and Afghanistan have resulted in a cohort of individuals who have survived multiple limb ampu- tation. The total percent of troops with multiple limb injury increased steadily throughout Operation Iraqi Freedom (OIF), Operation Enduring Freedom (OEF), and Operation New Dawn (OND). 1
alence of multiple limb amputation is 30%, of which bilateral transfemoral amputation (BTFA) were most common (27%). 1 –3
and require complex surgical and rehabilitative care. 4 –7 Despite the increased prevalence of BTFAs compared to prior con flicts, the body of literature characterizing this injury group is mini- mal compared to that of persons with unilateral lower extrem- ity limb loss. One of first long-term follow-up studies of military service members (SMs) with BTFA was published by Dougherty in 1999, and the results were encouraging in terms of their adap- tation of prosthesis, employment, and general well-being. 7 The presence of BTFA severely affects function but may not Yüklə 2,47 Mb. Dostları ilə paylaş:
|