Military Medicine International Journal of amsus raising the bar: extremity trauma care guest editors
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affect other quality of life metrics. Of the 30 veterans from the Vietnam War that were evaluated, 22% of respondents used prostheses for ambulation, and used them for an average of 7.7 hours per day, at mean time from injury of 27.5 years. Seventy percent were employed outside of their homes. The study group had lower physical functioning score on the Short Form-36 (SF-36) compared to a matched control group, but there was no signi ficant difference between the groups in terms of pain, social functioning, general, emotional, and mental health. SMs with BTFA from recent con flicts appear to have bet- ter health status, prosthesis adaptation, and mobility compared to SMs from prior con flicts. In a follow-up to their previous study, Dougherty et al (2012) 8 compared outcomes between 23 individuals with BTFA injured during the Vietnam War and 10 SMs who sustained BTFA during OEF, OIF, and OND. The OEF, OIF, OND group reported better health status, more frequent prosthesis usage, a greater number of prosthetic devices used, and mobility compared to the Vietnam group. However, the two groups reported similar quality of life. The greater number of prosthetic devices used is likely an indication of both the frequency of prosthetic care pro- vided to the younger SMs and the provision of prostheses to allow participation in multiple speci fic training and recre- ational activities. In the same year, Paul et al 9 reported on a retrospective analysis of outcomes from 25 Indian civilians with multiple limb amputation. In 12 patients with BTFA, 8 with bilateral transtibial amputation and 5 with mixed combination of the two levels of amputations, the authors found that there was no signi ficant difference in the activities of daily living scores across groups. However, function was signi ficantly greater for prosthesis users than nonusers, and this difference was greater for the BTFA group than other groups. The authors concluded that successful prosthetic rehabilitation appeared *Department of Rehabilitation, Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Bethesda MD 20889-5611. †Extremity Trauma and Amputation Center of Excellence, 2748 Worth Road, Suite 29, Fort Sam Houston, TX 78234. ‡Center for the Intrepid, Department of Rehabilitation Medicine, Brooke Army Medical Center, 3551 Roger Brooke Drive, Joint Base San Antonio, Fort Sam Houston, TX 78234. doi: 10.7205/MILMED-D-15-00546 MILITARY MEDICINE, Vol. 181, November/December Supplement 2016 55
achievable independent of amputation level, although the small sample size limits the strength of their conclusion. The largest study of war-related bilateral lower extremity amputations, published by Ebrahimzadeh et al, 10 found that SMs with BTFA have similar well-being and functioning as individuals with other amputations. The study included 291 Iran –Iraq War (1980–1988) veterans, and the Persian version of the SF-36 questionnaire was used to assess impact of ampu- tation on health-related quality of life. The authors devised an ordinal grouping system based on the number of major joints impaired, grouping individuals with BTFA and hip disarticula- tion into a single group (Group V). This group comprised 25% of the study population, and the authors did not find the Type V groups to have different SF-36 scores than other groups; it is unclear if their finding is applicable specifically to the BTFA cohort due to their grouping system. The lack of literature on gait and function of young, otherwise healthy SMs with BTFA is notable. Furthermore, all mentioned studies compare the rehabilitation outcomes between prosthetic and nonprosthetic groups. There is no liter- ature describing benchmarks of rehabilitation or outcomes in the prosthetic BTFA group. As the literature has established the general favorable rehabilitation outcome in BTFA group, it is of vital interest for rehabilitation specialists to under- stand reasonable expectations and de ficits of those who had achieved prosthetic ambulation in this group. The purpose of this study was to characterize physical recovery in SMs with BTFA, using objective and self-reported measures collected at two functional evaluations within the first year of independent ambulation with prostheses. METHODS
Ten SMs with combat-related bilateral transfemoral and/or knee disarticulation amputations, secondary to blast injury, participated in a large cross-sectional, longitudinal study of SMs with amputation. Institutional approval was provided by the local institutional review board and written informed con- sent was obtained before data collection. SMs were enrolled at the time they achieved the ability to independently ambu- late without using assistive devices (all participated at zero- month time point) and then at follow-up evaluation within the next year. Inclusion criteria: age 18 to 45 years old; presence of BTFA; ability to walk independently without the use of an assistive device for at least 30 feet; ability to walk continu- ously for a minimum of 5 minutes; and visual analog scale pain score less than 4 out of 10. Exclusion criteria: moderate or severe traumatic brain injury; cardiac or pulmonary prob- lems that limited physical activity; and post-traumatic stress disorder or other psychological condition that would be wors- ened by participation in the study. As a result of blast injuries, there were numerous comorbidities that did not preclude par- ticipation. SMs sustained any combination of additional inju- ries including trauma to one of both upper extremities (including amputation at transhumeral and/or transradial and/or multiple digits), abdominal and groin injuries (some requiring colosto- mies), tympanic membrane injury, as well as mild head trauma. SMs completed all testing with their daily-use prostheses, consisting of microprocessor-controlled or mechanical pros- thetic knee units and energy storing and return feet (Table I). Data are reported on the following tests and questionnaires: 6-Minute Walk Test (6MWT), Stair Assessment Index (SAI), TABLE I
Demographics Participants Age (Years)
Time of Initial and Follow-Up Visit (Days From Injury) Knee Type at Initial and Follow-Up Visit Height at Initial and Follow-Up Visit (cm) Weight at Initial and Follow-Up Visit (kg) 1 24 313 Cleg
175.5 73.1
410 3R80
173.5 74.8
2 30 343 3R80 180
83.1 464
CLeg 177.5
82.6 3 26 227 CLeg
176 57.5
404 3R80
171.5 57 4 25 203
Rheo 182
70.8 384
Plie 182
75.9 5 21 410 CLeg
169 84.2
526 3R80
164 86.2
6 31 381 Genium 171.5
75.8 428
Genium 169
75.4 7 22 210 CLeg
174.5 85.1
335 CLeg
174.5 84.9
8 27 453 CLeg 169.5
84.1 753
X2 175.5
92.2 9 23 404 X2 179 83.1 501
X2 172
83.5 10 29 580 CLeg
174 87.5
672 Genium
168.5 88.2
Average (SD) 25.8 (3.4) 357.1 (121.7) 175.1 (4.4) 78.4 (9.2) 493.5 (147.9) 172.9 (5.4) 79.7 (10.5) MILITARY MEDICINE, Vol. 181, November/December Supplement 2016 56 Outcomes of Service Members With Bilateral TF/KD Amputations Timed Stair Ascent (TSA), Lower Extremity Functional Scale (LEFS), and Activity- Speci fic Balance Confidence (ABC) Scale. Scripted instructions were read to each SM for respective tasks. The 6MWT is frequently used to assess aerobic fitness,
endurance, and mobility. 11,12
Age-based normative times have been established in military and civilian personnel, 11,13,14 and
the 6MWT is suggested as a reproducible measure of exercise tolerance. 15,16 The SMs were instructed to walk as far as pos- sible in 6 minutes and the total distance walked was recorded. The SAI assesses functional ability while ascending or descending one flight of stairs. Scores range from 0 to 13 based on ability to perform the task, how the task is executed, and level of upper extremity support required. 17 Zero signi fies inability to negotiate stairs and 13 represents reciprocal gait without use of a rail or assistive device. Ascent and descent are scored independently. For the TSA, SMs were timed while safely ascending 11 stairs. They were required to touch each stair on ascent and completed 5 trials (with 1-minute rest in between). Time began when their foot hit the first stair and stopped when both feet were on the top platform. Timed stair climbing is often used as an objective measure of mobility and power, and has established test –retest reliability in older adults. 18,19
SMs were instructed to touch every step to the top of the staircase as quickly and as safely possible, turn around, and come back to the bottom. It was documented if the SMs needed to use the handrail, if needed, for safety. Every subject performed 5 trials with 1 minute of rest between trials. The LEFS questionnaire, completed by SMs, involves a list of 20 activities that are rated on a scale from 0 (unable or dif ficult to perform) to 4 (able to perform without diffi- culty). This tool has been used in various patient populations to assess and track a person ’s ability to perform everyday tasks. It is often used as a baseline measure, and through- out the course of rehabilitation, to monitor progress and set functional goals. 20 The ABC Scale is a self-report instrument used to evalu- ate an individual ’s balance confidence and fear of falling during functional activities. 21 It has demonstrated reliability and validity in older adults who have sustained an amputa- tion; however, the psychometric properties of this instrument have not been speci fically examined in younger adults fol- lowing a traumatic amputation. 22 The ABC Scale has 16 items representing balance/functional activities, and the participant is asked to rate his/her con fidence level in performing these tasks (using a scale of 0 –100, with 0 = no confidence and 100 = complete con fidence). The response to the following pertinent question is reported: “Do you or would you have any dif
ficulty at all with going up or down 10 steps (about one
flight of stairs)?” Normality was determined using the Shapiro –Wilk test with a threshold value of p ≤ 0.05. Between-session differ- ences were evaluated using paired t tests for normally dis- tributed data (participant height, participant weight, 6MWT, stair ascent time, and ABC score) whereas nonparametric data were assessed using the Wilcoxon signed-rank test. Sig- ni ficance was again set at p ≤ 0.05. Effect sizes (Cohen’s d) were determined for performance measures. RESULTS
The SMs had an average (SD) age of 25.5 (3.4) and time from injury of 352.4 (119.6) days at enrollment. It is impor- tant to note that the time to independent ambulation, as de fined in the inclusion criteria of the study, was variable for the subject group (range = 203 –580 days). The follow-up FIGURE 1. Results of the 6MWT show participants were able to cover a signi ficantly greater distance (m) at the follow-up visit (*p = 0.005). FIGURE 2. Average method of stair ascent (left) and descent (right) as measured by SAI (Buell et al 29 ) improved (increased) at follow-up visits for the six participants that completed stair functionality testing. MILITARY MEDICINE, Vol. 181, November/December Supplement 2016 57 Outcomes of Service Members With Bilateral TF/KD Amputations evaluation was completed on average 135 (47 –300) days after initial evaluation. Although leg length can be readily modi fied
for individuals with bilateral amputation, height did not signi
ficantly differ between sessions ( p = 0.386); all but one participant was either the same height or slightly shorter at the final visit. Weight did not change between sessions ( p = 0.452) with all but two SMs staying within 2.0 kg of initial weight. All SMs completed LEFS and 6MWT testing. Only 6 of 10 SM completed stair testing at both initial and final visits, and only those with initial and follow-up stair function data were included. At the follow-up visit, all SMs were able to cover signi fi- cantly more distance within 6 minutes ( p = 0.005, d = 0.76). On average, SMs gained 135.3 (70.1) m between sessions (Fig. 1). The mean distance traveled in 6MWT at the final collection of this study was 389 (94) m. Average SAI ascent scores were 5.3 (4.0) initially and 7.0 (4.4) at follow-up, but the difference was not signi ficant ( p = 0.102, d = 0.40; Fig. 2). The average SAI descent scores did not increase signi ficantly between sessions (3.5 [3.4]– 3.8 [3.7]; p = 0.66, d = 0.09; Fig. 2). There was no signi ficant change ( p = 0.247, d = −0.49; Fig. 3) in mean time to ascend stairs between initial and final visits. The initial self-reported value of LEFS scores was reported as 3.0 (0.9) with a final value of 3.5 (0.5), which was not statistically signi ficant ( p = 0.059, d = 0.66). Mean balance con fidence during stair ascent increased from 69.2% (19.7) on a 0 to 100% scale at the first visit to 76.8% (21.1) at the final visit; the difference was not statis- tically signi ficant ( p = 0.34, d = 0.36; Fig. 4). DISCUSSION Longitudinal outcomes data are lacking for individuals who have experienced BTFA. Functional outcomes data can play a valuable role in clinical treatment planning as data can be used to objectively track recovery over time and identify factors that may in fluence the rehabilitation process. Many SMs with BTFAs are able to return to functional community ambulation but require more time than uninjured individuals to complete gait-related tasks. Therefore, the data presented provide insight into the functional abilities of SMs with BTFA at the point of independent ambulation and progress during the first year of rehabilitation. As a group, initially these SMs with BTFA demonstrated large de
ficits in the 6MWT compared to uninjured controls. However, mobility did improve over the course of rehabilita- tion as seen in the increase in distance traveled during the 6MWT. In fact, the average distance traveled increased from 327.8 (75.0) to 388.5 (93.8), which was much closer to the 452 (141) m previously reported for those with unilateral TFA. 23
were tested earlier in the rehabilitation process, relative to those with unilateral TFA who were on average 2.3 years ’ postamputation. 23 The average distance of SMs with BTFA at follow-up was still much less than the distance traveled by uninjured controls: 761 (87) m. 23 These results provide a 6MWT milestone for those with BTFA. Many aspects of mobility did not improve beyond the point of independent ambulation. Although subjective ABC score signi ficantly improved, objective improvement was not observed in the SAI during ascent or decent, the LEFS, or the TSA. Ascending stairs requires greater strength and motion than level-ground walking, 24 and not surprisingly, several SMs were unable to complete the task at initial assessment. The lack of statistically signi ficant changes in the SAI score, the ABC score, and the LEFS score shows the dif ficulty of completing important functional tasks in FIGURE 3. Although completion times varied between participants, the average time to ascend 11 stairs improved (decreased) by an average of 6.4 (11.9) seconds at the follow-up visit. FIGURE 4. Average stair ambulation con fidence score, as recorded by ABC evaluation, was signi ficantly greater at the final visit (*p = 0.034). MILITARY MEDICINE, Vol. 181, November/December Supplement 2016 58 Outcomes of Service Members With Bilateral TF/KD Amputations individuals with BTFA. Dif ficulty with stairs is well docu- mented in those with lower extremity amputations. De Laat et al
25 reported that in unilateral TFA and knee disarticula- tion group, the success rate of achieving independent stair ambulation after outpatient rehabilitation is 60% without rail and 16% without handrail. Hobara et al 24 demonstrated that time from injury has a positive correlation with the SAI in unilateral TFA, but published literature relies on patient report rather than direct observation with patients that were more than 17 years postamputation. We see a trend in decreasing time required to ascend stairs in SAI, but not in the time required to descend stairs. The ABC and LEFS questions combine stair ascent and descent within the same questions, so we cannot determine if these instruments also re flect different trends between ascending and descending stairs observed in SAI. There are several possible explana- tions for our findings. The improvement of stair ascent time may be indicative of gains in strength, balance, coordination, and motor control suf ficient to achieve the task more rap- idly. Descending stairs poses greater risk of injurious falls, 26 and individuals with BTFA must rely on resistance in the prosthetic knee to control the lowering from 1 step to the next. Therefore, the lack of SAI improvement during descent of stairs may be in fluenced by comorbidities, e.g., muscular de ficits, or inherent prosthetic limitations contributing to mistrust of the prosthesis. In addition, the lack of statistically signi
ficant improvement in these assessments over time indi- cates that the ability to navigate stairs in individuals with BTFA may plateau early without any signi ficant improve- ment overtime. These
findings have practical impact in guiding rehabili- tative therapies and prosthetic design. During the first year of independent ambulation, although efforts may have been made to improve safety or quality of movement, there were no systematic improvements over time during stair ambula- tion. Clearly, individuals with BTFA demonstrate de ficits in
physical performance relative to their able-bodied counter- parts.
7 However, in the 6MWT, these SMs performed close to civilians with unilateral transfemoral amputations. These findings, combined with the fact that this generation of SMs report con fidence in stair negation and are wearing and walk- ing in their prostheses more than the previous generations of SMs,
8 might suggest that clinicians should realign rehabilita- tion paradigms for those with BTFA. Training emphasis may be better placed on other movements required for daily living. Although stairs negotiation is limited, expectations can be increased in the area of community distance ambulation. Prosthetic development should focus on incorporating these seen restrictions into new devices. Progress remains hopeful as the prosthetic industry is incorporating new materials and advanced prosthetic technology into current designs. 27,28 These advances will likely further increase expectations in terms of rapid recovery rates, quality of life measures, and ability to return to occupation and leisure activities despite high-level injuries such as BTFA. Several limitations should be considered when interpreting the results of this study. First, there are inherent differences between the study population and the general population. Military SMs are generally in better physical condition than their civilian counterparts. In addition, the heterogeneity and complexity of injuries sustained by SMs differ from amputa- tions incurred by civilians. Injuries sustained from improvised explosive device blasts are rarely con fined to the severed extrem- ity and result in injury of varying severity to adjacent body parts. Any comorbidities can impact the rehabilitation pro- cess, likely adding variability to study results thereby in flu-
encing the ability to detect changes over time. Also, the SMs were treated in a military treatment facility that is highly spe- cialized in the rehabilitation of traumatic war injuries. They Yüklə 2,47 Mb. Dostları ilə paylaş:
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